NCLEX Select All That Apply Practice Exam 5 — Questions and Answers

Question 1: The nurse notes that a client is quite suspicious during an assessment interview and believes that her family is under investigation by the CIA. What would the appropriate nursing interventions be with this client? Select all that apply:

Use active listening skills to seek information from the client. (Correct answer)
Encourage the client to describe the problem as she sees it. (Correct answer)
Ask the client to tell you exactly what she thinks is happening. (Correct answer)
Tell the client that she is delusional and you can help her.
Explain to the client that most people are not investigated by the CIA.
Reassure the client that you are not with the CIA.

Correct answer: Use active listening skills to seek information from the client.

When a client is experiencing delusions, the most appropriate nursing intervention is to establish trust and understand their perception of reality without directly challenging or reinforcing the delusion. Using active listening and encouraging the client to describe their experience validates their feelings and helps the nurse gather more information, fostering a therapeutic relationship.

Question 2: Which nursing interventions will assist in reducing pressure points that may lead to pressure ulcers? Check all that apply:

Position the client directly on the trochanter when side lying.
Avoid use of donut type devices. (Correct answer)
Massage bony prominences.
Elevate the HOB no more than 30 degrees when possible (Correct answer)
When the client is side lying, use the 30 degree lateral inclined position. (Correct answer)
Avoid uninterrupted sitting in a chair or wheelchair. (Correct answer)

Correct answer: Avoid use of donut type devices.

Donut-type devices are contraindicated for pressure ulcer prevention because they can create a concentrated area of pressure around the hole, leading to tissue ischemia and actually increasing the risk of pressure ulcer development in that area. Effective interventions focus on pressure redistribution and reducing shear forces.

Question 3: The nurse is evaluating a client recently diagnosed with primary open angle glaucoma (POAG). What will an important nursing action be? Select all that apply:

Review meds the client is currently on to determine whether any of them cause an increased intraocular pressure as a side effect. (Correct answer)
Determine whether the client has any sudden loss of vision accompanied by pain.
Discuss with the client the importance of controlling blood pressure to decrease the potential loss of peripheral vision.
Instruct the client to take analgesics as soon as any discomfort occurs in the eye and to notify clinic if pain is not relieved.
Have the client demonstrate the use of eye drops. (Correct answer)
Assess the client for chronic diseases such as diabetes. (Correct answer)

Correct answer: Review meds the client is currently on to determine whether any of them cause an increased intraocular pressure as a side effect.

Certain medications, such as corticosteroids, anticholinergics, and some antidepressants, can increase intraocular pressure (IOP) and exacerbate glaucoma. Therefore, reviewing the client's current medication list is a critical nursing action to identify and potentially modify any medications that could negatively impact their glaucoma management. This helps prevent further vision loss.

Question 4: A nurse understands that a patient may experience pain during peritoneal dialysis because of which of the following? Select all that apply:

Warming the dialysate
Too rapid installation (Correct answer)
Infiltration of the solution into the bloodstream
Accumulation of dialysate solution under the diaphragm (Correct answer)
Too rapid outflow of the dialysate.

Correct answer: Too rapid installation

Pain during peritoneal dialysis can be caused by the rapid infusion of dialysate into the peritoneal cavity. This rapid influx can stretch the peritoneum quickly, leading to discomfort or cramping. Other causes of pain include accumulation of dialysate under the diaphragm or peritonitis.

Question 5: The nurse is evaluating a client’s response to hemodialysis. Which lab results will indicate the dialysis was effective? Select all that apply:

Serum potassium level decreases from 5.4 to 4.6 mEq/L (Correct answer)
Cr decreases from 1.6 to 0.8 mg/dL (Correct answer)
Hgb increases from 10-12 g/dL
WBC increase from 5000 to 8000/mm^3
BUN decreases from 110 to 90 mg/dL (Correct answer)

Correct answer: Serum potassium level decreases from 5.4 to 4.6 mEq/L

Hemodialysis is effective in removing waste products and excess electrolytes from the blood. A decrease in serum potassium from a hyperkalemic level (5.4 mEq/L) to a normal range (4.6 mEq/L) indicates effective removal of potassium. Similarly, a decrease in creatinine and BUN levels signifies effective removal of nitrogenous waste products, indicating successful dialysis.

Question 6: The nurse understands that the following clinical findings are indications for dialysis. Select all that apply:

Volume overload (Correct answer)
BUN 18 mg/dL
K 5.2 mEq/L (Correct answer)
Decreased creatinine clearance.
Metabolic acidosis (Correct answer)
Cr 5.0 mg/dL (Correct answer)

Correct answer: Volume overload

Indications for dialysis include severe fluid volume overload unresponsive to diuretics, significant electrolyte imbalances (like hyperkalemia, e.g., K 5.2 mEq/L if symptomatic or rapidly rising), severe metabolic acidosis, and high levels of uremic toxins as indicated by elevated BUN and creatinine (e.g., Cr 5.0 mg/dL). These conditions signify the kidneys' inability to maintain homeostasis.

Question 7: The nurse is assessing a client who had a fractured femur repaired with an external fixator device. Which assessment finding would cause the nurse concern regarding the development of compartment syndrome? Select all that apply:

Decrease in pulse rate in affected leg.
Paresthesia distal to area of injury. (Correct answer)
Toes on affected leg cool to touch and edematous. (Correct answer)
Complaints that pins are hurting.
Complaints of leg pain unrelieved by analgesics or repositioning. (Correct answer)
Client angry and calling loudly to the nurse every ten minutes.

Correct answer: Paresthesia distal to area of injury.

Compartment syndrome is a serious condition caused by increased pressure within a muscle compartment, leading to compromised circulation and nerve function. Paresthesia (numbness or tingling) distal to the injury is a classic 'P' sign (pain, pallor, pulselessness, paresthesia, paralysis) and an early indicator of nerve compression and ischemia, requiring immediate intervention.

Question 8: The nurse is preparing discharge for a patient with GERD. What would be important for the nurse to include in this teaching plan? Select all that apply:

Elevate the HOB. (Correct answer)
Decrease intake of caffeine. (Correct answer)
Discuss strategies for weight loss if overweight. (Correct answer)
Increase fluid intake with meals.
Take ranitidine (Zantac) at hs. (Correct answer)
Eat a bedtime snack of milk and protein.

Correct answer: Elevate the HOB.

Elevating the head of the bed (HOB) by 6-8 inches helps to prevent reflux of stomach acid into the esophagus by using gravity. This is a key non-pharmacological intervention for managing GERD symptoms, especially at night. Other important teaching points include dietary modifications, weight loss, and proper medication administration.

Question 9: The nurse is preparing a client for cardiac catheterization. Which nursing interventions are necessary in preparing the client for this procedure. Select all that apply:

Verify consent has been signed. (Correct answer)
Explain procedure to client. (Correct answer)
Provide clear liquid, no caffeine diet.
Evaluate peripheral pulses.
Obtain a 12 lead ECG (Correct answer)
Obtain history of shellfish allergy. (Correct answer)

Correct answer: Verify consent has been signed.

Before any invasive procedure like a cardiac catheterization, it is a critical nursing responsibility to ensure that informed consent has been properly obtained and signed by the client. This confirms that the client understands the procedure, risks, and benefits, and has agreed to it voluntarily. Other important pre-procedure steps include client education, assessing allergies, and evaluating peripheral pulses.

Question 10: The physician has prescribed Cytoxan (cyclophosphamide) for a client with nephrotic syndrome. The nurse should:

Encourage the client to drink extra fluids (Correct answer)
Request a low-protein diet for the client
Request a low-protein diet for the client
Bathe the client using only mild soap and water
Provide additional warmth for swollen, inflamed joints

Correct answer: Encourage the client to drink extra fluids

Cytoxan (cyclophosphamide) is an alkylating agent that can cause hemorrhagic cystitis, a serious bladder inflammation, due to the accumulation of its toxic metabolites in the bladder. Encouraging extra fluid intake helps to dilute these metabolites and promote their excretion, thereby reducing the risk of bladder toxicity and protecting the urinary tract.

Question 11: The nurse is caring for a client with detoxification from alcohol. Which medication is used in the treatment of alcohol withdrawal?

Antabuse (disulfiram)
Romazicon (flumazenil)
Dolophine (methadone)
Ativan (lorazepam) (Correct answer)

Correct answer: Ativan (lorazepam)

Benzodiazepines like Ativan (lorazepam) are the first-line treatment for acute alcohol withdrawal syndrome. They help to reduce the hyperexcitability of the central nervous system caused by alcohol cessation, thereby preventing or managing symptoms such as tremors, agitation, hallucinations, and seizures. Lorazepam is particularly useful due to its intermediate half-life and availability in various forms.

Question 12: A client with insulin-dependent diabetes takes 20 units of NPH insulin at 7 a.m. The nurse should observe the client for signs of hypoglycemia at:

8 a.m.
10 a.m.
3 p.m. (Correct answer)
5 a.m.

Correct answer: 3 p.m.

NPH insulin is an intermediate-acting insulin with a peak action typically occurring 4 to 12 hours after administration. If administered at 7 a.m., the client is most likely to experience the peak effect and thus signs of hypoglycemia between 11 a.m. and 7 p.m. Therefore, 3 p.m. falls within this peak window, making it the critical time for observation.

Question 13: The licensed practical nurse is assisting the charge nurse in planning care for a client with a detached retina. Which of the following nursing diagnoses should receive priority?

Alteration in comfort
Alteration in mobility (Correct answer)
Alteration in skin integrity
Alteration in O2 perfusion

Correct answer: Alteration in mobility

For a client with a detached retina, the primary goal is to prevent further retinal detachment and preserve vision. Any sudden head or eye movements, or increased intraocular pressure from physical exertion, can worsen the condition. Therefore, prioritizing 'Alteration in mobility' is crucial to enforce bed rest and activity restrictions, minimizing risk and promoting healing.

Question 14: The primary purpose for using a CPM machine for the client with a total knee repair is to help:

Prevent contractures
Promote flexion of the artificial joint (Correct answer)
Decrease the pain associated with early ambulation
Alleviate lactic acid production in the leg muscles

Correct answer: Promote flexion of the artificial joint

A Continuous Passive Motion (CPM) machine is used after total knee repair to gently and continuously move the knee joint. Its primary purpose is to prevent stiffness and scar tissue formation, thereby promoting and maintaining the range of motion, particularly flexion, of the artificial joint. This helps in early rehabilitation and improves long-term joint function.

Question 15: Which of the following statements reflects Kohlberg’s theory of the moral development of the preschool-age child?

Obeying adults is seen as correct behavior.
Showing respect for parents is seen as important.
Pleasing others is viewed as good behavior.
Behavior is determined by consequences. (Correct answer)

Correct answer: Behavior is determined by consequences.

According to Kohlberg's theory, preschool-age children are in the preconventional stage of moral development. In this stage, behavior is primarily determined by external consequences, meaning actions are judged as right or wrong based on whether they lead to punishment or reward. They lack an understanding of abstract moral principles or societal rules.

Question 16: A toddler with otitis media has just completed antibiotic therapy. A recheck appointment should be made to:

Determine whether the ear infection has affected her hearing
Make sure that she has taken all the antibiotic
A document that the infection has completely cleared (Correct answer)
Obtain a new prescription in case the infection recurs

Correct answer: A document that the infection has completely cleared

After completing antibiotic therapy for otitis media, a recheck appointment is essential to ensure the infection has completely cleared. This follow-up confirms the effectiveness of the treatment and helps prevent potential complications such as recurrent infections, chronic middle ear fluid, or long-term hearing impairment. It also helps to avoid antibiotic resistance if the infection persists.

NCLEX Select All That Apply Practice Exam 5

The nurse notes that a client is quite suspicious during an assessment interview and believes that her family is under investigation by the CIA.
What would the appropriate nursing interventions be with this client? Select all that apply: