NCLEX Select All That Apply Practice Exam 7

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.

Accepted Answer

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

Answer

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.

Accepted Answer

Uterine enlargement

Answer

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)?

Accepted Answer

Elevated blood pressure

Answer

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.

Accepted Answer

Monitor renal function and cardiac function closely

Answer

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.

Accepted Answer

Reflects electrical impulse beginning at the SA node

Answer

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.

NCLEX Practice Test

NCLEX Practice Test

NCLEX Select All That Apply Practice Exam 7