NCLEX Select All That Apply Practice Exam 7 — Questions and Answers

Question 1: The nurse is evaluating the discharge teaching for a client who has an ileal conduit. Which of the following statements indicates that the client has correctly understood the teaching? Select all that apply.

“If I limit my fluid intake I will not have to empty my ostomy pouch as often.”
“I can place an aspirin tablet in my pouch to decrease odor.”
“I can usually keep my ostomy pouch on for 3 to 7 days before changing it.” (Correct answer)
“I must use a skin barrier to protect my skin from urine.” (Correct answer)

Correct answer: “I can usually keep my ostomy pouch on for 3 to 7 days before changing it.”

For clients with an ileal conduit, proper stoma care and pouch management are essential. Modern ostomy pouches with skin barriers are designed for extended wear, typically 3 to 7 days, provided there is no leakage or skin irritation. Additionally, using a skin barrier is crucial to protect the peristomal skin from constant exposure to urine, which can cause irritation and breakdown.

Question 2: A nurse is assisting in performing an assessment on a client who suspects that she is pregnant and is checking the client for probable signs of pregnancy. Select all probable signs of pregnancy.

Uterine enlargement (Correct answer)
Fetal heart rate detected by nonelectric device
Outline of the fetus via radiography or ultrasound
Chadwick’s sign (Correct answer)
Braxton Hicks contractions (Correct answer)
Ballottement (Correct answer)

Correct answer: Uterine enlargement

Probable signs of pregnancy are objective signs observed by an examiner that strongly suggest pregnancy but can also be caused by other conditions. These include uterine enlargement, Chadwick's sign (bluish discoloration of the cervix/vagina), Braxton Hicks contractions (painless uterine contractions), and ballottement (rebound of the fetus upon palpation). Positive signs, such as fetal heart rate or visualization of the fetus, definitively confirm pregnancy.

Question 3: A nurse is monitoring a pregnant client with pregnancy induced hypertension who is at risk for Preeclampsia. The nurse checks the client for which specific signs of Preeclampsia (select all that apply)?

Elevated blood pressure (Correct answer)
Negative urinary protein
Facial edema (Correct answer)
Increased respirations

Correct answer: Elevated blood pressure

Preeclampsia is a serious pregnancy complication characterized by new-onset hypertension and proteinuria after 20 weeks of gestation. Therefore, an elevated blood pressure is a defining diagnostic criterion. Facial edema, along with edema in the hands, is also a common clinical sign, though not a diagnostic criterion itself, indicating fluid retention associated with the condition.

Question 4: A nurse is caring for a pregnant client with severe preeclampsia who is receiving IV magnesium sulfate. Select all nursing interventions that apply in the care for the client.

Monitor maternal vital signs every 2 hours
Notify the physician if respirations are less than 18 per minute.
Monitor renal function and cardiac function closely (Correct answer)
Keep calcium gluconate on hand in case of a magnesium sulfate overdose (Correct answer)
Monitor deep tendon reflexes hourly (Correct answer)
Monitor I and O’s hourly (Correct answer)
Notify the physician if urinary output is less than 30 ml per hour. (Correct answer)

Correct answer: Monitor renal function and cardiac function closely

When a client receives IV magnesium sulfate for severe preeclampsia, close monitoring is essential due to the risk of toxicity. Key nursing interventions include monitoring renal and cardiac function, as magnesium is renally excreted and can affect the heart. Hourly monitoring of deep tendon reflexes and intake/output is crucial, and calcium gluconate must be readily available as the antidote for magnesium overdose.

Question 5: When interpreting an ECG, the nurse would keep in mind which of the following about the P wave? Select all that apply.

Reflects electrical impulse beginning at the SA node (Correct answer)
Indicated electrical impulse beginning at the AV node
Reflects atrial muscle depolarization (Correct answer)
Identifies ventricular muscle depolarization
Has duration of normally 0.11 seconds or less (Correct answer)

Correct answer: Reflects electrical impulse beginning at the SA node

The P wave on an ECG represents atrial depolarization, which is the electrical activation of the atria. This electrical impulse originates in the sinoatrial (SA) node, the heart's natural pacemaker, and then spreads through the atria, causing them to contract. Therefore, a normal P wave indicates that the electrical activity is starting correctly at the SA node.

Question 6: When caring for a client with a central venous line, which of the following nursing actions should be implemented in the plan of care for chemotherapy administration? Select all that apply.

Verify patency of the line by the presence of a blood return at regular intervals. (Correct answer)
Inspect the insertion site for swelling, erythema, or drainage. (Correct answer)
Administer a cytotoxic agent to keep the regimen on schedule even if blood return is not present.
If unable to aspirate blood, reposition the client and encourage the client to cough. (Correct answer)
Contact the health care provider about verifying placement if the status is questionable. (Correct answer)

Correct answer: Verify patency of the line by the presence of a blood return at regular intervals.

Verifying blood return is a critical safety measure before administering chemotherapy through a central venous line. The presence of blood return confirms the catheter's patency and intraluminal placement, ensuring the medication will be delivered into the bloodstream and not into surrounding tissues. Administering vesicant chemotherapy without confirmed blood return could lead to severe extravasation and tissue damage.

Question 7: To assist an adult client to sleep better the nurse recommends which of the following? (Select all that apply.)

Drinking a glass of wine just before retiring to bed
Eating a large meal 1 hour before bedtime
Consuming a small glass of warm milk at bedtime (Correct answer)
Performing mild exercises 30 minutes before going to bed

Correct answer: Consuming a small glass of warm milk at bedtime

Consuming a small glass of warm milk at bedtime can promote sleep due to its tryptophan content, an amino acid that aids in serotonin and melatonin production, which are sleep-inducing neurotransmitters. The warmth can also have a calming, relaxing effect. Conversely, alcohol, large meals, and vigorous exercise before bed can disrupt sleep patterns.

Question 8: The nurse recognizes that a client is experiencing insomnia when the client reports (select all that apply):

Extended time to fall asleep (Correct answer)
Falling asleep at inappropriate times
Difficulty staying asleep (Correct answer)
Feeling tired after a night’s sleep (Correct answer)

Correct answer: Extended time to fall asleep

Insomnia is characterized by persistent difficulty initiating or maintaining sleep, leading to impaired daytime functioning. Key indicators include taking an extended time to fall asleep (sleep latency), frequent awakenings, or waking up too early and being unable to return to sleep. Feeling tired after a night's sleep is a consequence, but the core issue is the inability to achieve restorative sleep.

Question 9: The nurse teaches the mother of a newborn that in order to prevent sudden infant death syndrome (SIDS) the best position to place the baby after nursing is (select all that apply):

Prone
Side-lying (Correct answer)
Supine (Correct answer)
Fowler’s

Correct answer: Side-lying

To prevent Sudden Infant Death Syndrome (SIDS), the safest position for a baby to sleep is on their back (supine). However, after nursing, placing the baby in a side-lying position for a brief period can help reduce the risk of aspiration if they spit up, especially if the mother is still awake and observing. Once the baby is settled and no longer at risk of spitting up, they should be repositioned to supine for the remainder of sleep.

Question 10: A client develops tremors while withdrawing from alcohol. Which medication is routinely administered to lessen physiological effects of alcohol withdrawal?

Dolophine (methadone)
Klonopin (clonazepam) (Correct answer)
Narcan (Naloxone)
Antabuse (disulfiram)

Correct answer: Klonopin (clonazepam)

Klonopin (clonazepam) is a benzodiazepine, a class of medications commonly used to manage alcohol withdrawal symptoms. Benzodiazepines work by enhancing the effect of GABA, an inhibitory neurotransmitter, which helps to calm the overactive central nervous system seen in alcohol withdrawal. This reduces symptoms like tremors, anxiety, and the risk of seizures.

Question 11: A client with Type II diabetes has an order for regular insulin 10 units SC each morning. The client’s breakfast should be served within:

15 minutes
20 minutes
30 minutes (Correct answer)
45 minutes

Correct answer: 30 minutes

Regular insulin is a short-acting insulin that typically has an onset of action within 30 to 60 minutes after subcutaneous injection. To prevent hypoglycemia, it is crucial to administer regular insulin approximately 30 minutes before a meal. This timing allows the insulin to begin lowering blood glucose levels as the client starts to absorb carbohydrates from their food.

Question 12: A 10-year-old has an order for Demerol (meperidine) 35 mg IM for pain. The medication is available as Demerol 50mg per ml. How much should the nurse administer?

0.5mL
0.6mL
0.7mL (Correct answer)
0.8mL

Correct answer: 0.7mL

To calculate the correct dosage, use the formula: (Desired Dose / Available Dose) x Volume. In this case, (35 mg / 50 mg) x 1 mL = 0.7 mL. Therefore, the nurse should administer 0.7 mL of Demerol.

Question 13: Which antibiotic is contraindicated for the treatment of infections in infants and young children?

Tetracyn (tetracycline) (Correct answer)
Amoxil (amoxicillin)
Cefotan (cefotetan)
E-Mycin (erythromycin)

Correct answer: Tetracyn (tetracycline)

Tetracycline antibiotics are contraindicated in infants and young children, typically under 8 years of age, due to their adverse effects on developing teeth and bones. Tetracycline can cause permanent discoloration (yellow-gray-brown) of tooth enamel and hypoplasia, as well as reversible inhibition of bone growth.

Question 14: The chart of a client with schizophrenia states that the client has echolalia. The nurse can expect the client to:

Speak using words that rhyme
Repeat words or phrases used by others (Correct answer)
Include irrelevant details in conversation
Make up new words with new meanings

Correct answer: Repeat words or phrases used by others

Echolalia is a common symptom observed in clients with schizophrenia and other neurological or psychiatric conditions. It is characterized by the involuntary and senseless repetition of words or phrases spoken by another person. This can manifest as an immediate repetition or a delayed echo of previously heard speech.

Question 15: Which early morning activity helps to reduce the symptoms associated with rheumatoid arthritis?

Brushing the teeth
Drinking a glass of juice
Drinking a cup of coffee (Correct answer)
Brushing the hair

Correct answer: Drinking a cup of coffee

Many individuals with rheumatoid arthritis experience significant morning stiffness and pain. Drinking a cup of coffee, which contains caffeine, can help reduce these symptoms by acting as a mild stimulant and analgesic. Caffeine can improve alertness and may have some anti-inflammatory effects, helping to ease discomfort and improve mobility in the morning.

Question 16: A newborn weighed 7 pounds at birth. At 6 months of age, the infant could be expected to weigh:

14 pounds (Correct answer)
18 pounds
25 pounds
30 pounds

Correct answer: 14 pounds

A general guideline for infant growth is that babies typically double their birth weight by 5 to 6 months of age. For a newborn weighing 7 pounds at birth, doubling that weight would result in an expected weight of approximately 14 pounds by 6 months. This rapid growth indicates healthy development.

NCLEX Select All That Apply Practice Exam 7

The nurse is evaluating the discharge teaching for a client who has an ileal conduit.
Which of the following statements indicates that the client has correctly understood the teaching? Select all that apply.