NCLEX Select All That Apply Practice Exam 9

Question 1

A nurse is caring for a client with a nasogastric tube that is attached to low suction. The nurse monitors the client closely for which acid-base disorder that is most likely to occur in this situation?

Accepted Answer

Metabolic alkalosis

Answer

A nasogastric tube attached to low suction continuously removes gastric secretions, which are rich in hydrochloric acid (HCl). The loss of these acidic contents leads to a decrease in hydrogen ions and a compensatory increase in bicarbonate in the body. This imbalance results in metabolic alkalosis, characterized by an elevated blood pH and bicarbonate level.

Question 2

A nurse is caring for a client with diabetic ketoacidosis and documents that the client is experiencing Kussmaul's respirations. Based on this documentation, which of the following did the nurse most likely observe?

Accepted Answer

Respirations that are abnormally deep, regular, and increased in rate

Answer

Kussmaul's respirations are a specific type of hyperventilation characterized by abnormally deep, regular, and increased rate of breathing. This pattern is a compensatory mechanism the body uses to blow off excess carbon dioxide and reduce acidosis, commonly observed in conditions like diabetic ketoacidosis (DKA) where the body is attempting to correct metabolic acidosis.

Question 3

Which nursing interventions are appropriate for a client recovering from surgery for retinal detachment? Select all that apply.

Accepted Answer

Monitor for hemorrhage.

Answer

Post-operative care for retinal detachment surgery focuses on protecting the eye and preventing complications. Monitoring for hemorrhage, administering prescribed eye medications, and maintaining the eye patch or shield are crucial for healing and preventing re-detachment. Educating the client on symptoms of re-detachment is also vital for early intervention if it recurs.

Question 4

A nurse is caring for a client with leukemia and notes that the client has poor skin turgor and flat neck and hand veins. The nurse suspects hyponatremia. What additional signs would the nurse expect to note in this client if hyponatremia is present?

Accepted Answer

Postural blood pressure changes

Answer

Hyponatremia (low sodium) often leads to fluid shifts and can cause hypovolemia or affect vascular tone. Postural blood pressure changes, or orthostatic hypotension, are a classic sign of fluid volume deficit and electrolyte imbalances, including hyponatremia. This occurs as the body struggles to maintain blood pressure upon changing positions due to reduced circulating volume or impaired vascular response.

Question 5

A nurse is caring for a group of clients who are taking herbal medications at home. Which of the following clients should be instructed not to take herbal medications?

Accepted Answer

A 10-year-old female client with a urinary tract infection

Answer

Children, especially those with active infections like a urinary tract infection, should generally avoid herbal medications unless specifically prescribed and closely monitored by a healthcare provider. Herbal remedies may interact with prescribed medications, have unknown dosages or purity, or cause adverse effects in children whose bodies metabolize substances differently than adults. It's safer to rely on conventional, evidence-based treatments for infections in children.

NCLEX Practice Test

NCLEX Practice Test

NCLEX Select All That Apply Practice Exam 9