NCLEX Select All That Apply Practice Exam 5

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:

Accepted Answer

Use active listening skills to seek information from the client.

Answer

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:

Accepted Answer

Avoid use of donut type devices.

Answer

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:

Accepted Answer

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

Answer

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:

Accepted Answer

Too rapid installation

Answer

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:

Accepted Answer

Serum potassium level decreases from 5.4 to 4.6 mEq/L

Answer

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.

NCLEX Practice Test

NCLEX Practice Test

NCLEX Select All That Apply Practice Exam 5