NCLEX Select All That Apply Practice Exam 4

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A nurse is providing a list of instructions to a client who is scheduled to have an electroencephalogram (EEG). Choose the instructions that the nurse places on the list. Select all that apply.

Please select 3 correct answers

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Pre-procedure instructions include informing the client that the procedure is painless. The procedure requires no dietary restrictions other than avoidance of cola, tea, and coffee on the morning of the test. These products have a stimulating effect and should be avoided. The hair should be washed the evening before the test, and gels, hairsprays, and lotion should be avoided. The client is informed that the test will take 45 minutes to 2 hours and that medications are usually not withheld before the test.

The nurse is providing discharge teaching to the client who was given a prescription for nifedipine (Adalat) for blood pressure management. Which instructions should the nurse include? Select all that apply.

Please select 4 correct answers

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Nifedipine is a calcium-channel blocker. Its therapeutic outcome is to decrease blood pressure. Its method of action is blockade of the calcium channels in vascular smooth muscle, promoting vasodilation. Side effects that can occur early in therapy include reflex tachycardia (palpitations) and first-dose hypotension, leading to orthostatic hypotension. Weight should be checked regularly to monitor for early signs of heart failure. Also the client is taught to take his or her own pulse. Nifedipine does not affect serum calcium levels. Increased water intake is not indicated in the client with cardiovascular disease.

A nurse is providing teaching regarding the prevention of Lyme disease to a group of teenagers going on a hike in a wooded area. Which of the following points should the nurse include in the session? Select all that apply.

Please select 4 correct answers

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Measures to prevent tick bites focus on covering the body as completely as possible and spraying insect repellent containing DEET on the skin and clothing. Long sleeves and pants tucked into the socks along with closed shoes will offer some protection. Light-colored clothing should be worn so that ticks would be easily visible. Hikers should not sit directly on the ground and should cover the ground with an item such as a blanket. Ticks should be removed with tweezers.

A nurse is reinforcing instructions to a client following a total laryngectomy about caring for the stoma. Choose the instructions that the nurse provides to the client. Select all that apply.

Please select 4 correct answers

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The client with a stoma should be instructed to wash the stoma daily with a washcloth. Soaps, cotton swabs, or tissues should be avoided because their particles may enter and obstruct the airway. The client should be instructed to avoid applying alcohol to a stoma because it is both drying and irritating. A thin layer of petroleum jelly applied to the skin around the stoma helps prevent cracking. The client is instructed to protect the stoma from water.

A nurse is reviewing the health records of assigned clients. The nurse plans care knowing that which client is at risk for fluid volume deficit?

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Causes of a fluid volume deficit include vomiting, diarrhea, conditions that cause increased respirations or increased urinary output, insufficient intravenous fluid replacement, draining fistulas, ileostomy, and colostomy. A client with cirrhosis, CHF, or decreased kidney function is at risk for fluid volume excess.

A nurse is told in report that a client has a positive Chvostek's sign. What other data would the nurse expect to find on data collection? Select all that apply.

Please select 4 correct answers

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A positive Chvostek's sign is indicative of hypocalcemia. Other signs and symptoms include tachycardia, hypotension, paresthesias, twitching, cramps, tetany, seizures, positive Trousseau's sign, diarrhea, hyperactive bowel sounds, and a prolonged QT interval.

A nurse lawyer provides an education session to the nursing staff regarding client rights. A nurse asks the lawyer to describe an example that may relate to invasion of client privacy. A nursing action that indicates a violation of this right is:

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Invasion of privacy takes place when an individual's private affairs are intruded on unreasonably. Threatening to place a client in restraints constitutes assault. Performing a surgical procedure without consent is an example of battery. Not allowing a client to leave the hospital constitutes false imprisonment.

A nurse notes in the medical record that a client with Cushing's syndrome is experiencing fluid overload. Which interventions should be included in the plan of care? Select all that apply.

Please select 4 correct answers

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The client with Cushing's syndrome experiencing fluid overload should be maintained on a high-potassium and low-sodium diet. Decreased sodium intake decreases renal retention of sodium and water. Monitoring weight, intake, output, and extremities for edema are all appropriate interventions for such a nursing diagnosis.

A nurse notes in the medical record that a client with Cushing's syndrome is experiencing fluid overload. Which interventions should be included in the plan of care? Select all that apply.

Please select 4 correct answers

Correct! Wrong!

The client with Cushing's syndrome experiencing fluid overload should be maintained on a high-potassium and low-sodium diet. Decreased sodium intake decreases renal retention of sodium and water. Monitoring weight, intake, output, and extremities for edema are all appropriate interventions for such a nursing diagnosis.

Which instruction should the nurse provide to the client with diabetes mellitus receiving acarbose (Precose)? Select all that apply.

Please select 4 correct answers

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The mechanism of action of acarbose is a delay in absorption of dietary carbohydrates, thereby reducing the rise in blood glucose after a meal. To accomplish this, the medication must be taken with each meal. Because of its bacterial fermentation of unabsorbed carbohydrates in the colon, side effects such as borborygmus, cramps, abdominal distention, and flatulence can occur. The medication also can affect absorption of iron, leading to symptoms (shortness of breath, tiredness) of anemia.

A nurse prepares a list of home care instructions for the parents of a child who has a plaster cast applied to the left forearm. Choose the instructions that would be included on the list. Select all that apply.

Please select 3 correct answers

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While the cast is drying, the palms of the hands are used to lift the cast. If the fingertips are used, indentations in the cast could occur and cause constant pressure on the underlying skin. Small toys and sharp objects are kept away from the cast, and no objects (including padded objects) are placed inside of the cast because of the risk of altered skin integrity. A heating pad is not applied to the cast or fingers. Cold fingers could indicate neurovascular impairment, and the HCP should be notified. The extremity is elevated to prevent swelling, and the HCP is notified immediately if any signs of neurovascular impairment develop.

A nurse reinforces instructions to the mother of a child who has been hospitalized with croup. Which of the following statements, if made by the mother, would indicate the need for further instruction?

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Cough syrups and cold medicines are not to be given, because they may dry and thicken secretions. During a croup attack, the child can be taken to a cool basement or garage. Acetaminophen is used if a fever develops. Adequate hydration of 500 to 1000 mL of fluids daily is important for thinning secretions.

The nurse would anticipate the use of which medications in the treatment of the client with heart failure? Select all that apply.

Please select 3 correct answers

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Medications recommended for treatment of heart failure include diuretics, cardiac glycosides such as digoxin (Lanoxin), PDE inhibitors, and ACE inhibitors. Clients in heart failure do not need anticoagulants or anticholinergics.

The parent of a toddler asks a nurse when it is safe to place the car safety seat in a face-forward position. Which of the following is the best nursing response?

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The transition point for switching to the forward-facing position is defined by the manufacturer of the convertible car safety seat, but it is generally at a body weight of 9 kg (20 lb) and an age of 1 year. Options 2, 3, and 4 are incorrect.

A pregnant woman has a positive history of genital herpes, but she has not had lesions during her pregnancy. The nurse plans to provide which of the following information to the client?

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If herpetic genital lesions are present at the time of delivery, a cesarean delivery will be necessary to reduce the risk of infecting the neonate. In the absence of herpetic genital lesions, a vaginal delivery may be indicated, unless there are other reasons for performing a cesarean delivery. Maternal isolation is not necessary, but potentially exposed neonates should be cultured on the day of delivery.

Which of these clients are most likely to develop fluid (circulatory) overload? Select all that apply.

Please select 4 correct answers

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Clients with cardiac, respiratory, renal, or liver diseases and older and very young clients cannot tolerate an excessive fluid volume. The risk of fluid (circulatory) overload exists with these clients

An unconscious client who is bleeding profusely is brought to the emergency department after a serious accident. Surgery is required immediately to save the client's life. With regard to informed consent for the surgical procedure, which of the following is the best action?

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Generally there are only two instances in which the informed consent of an adult client is not needed. One instance is when an emergency is present and delaying treatment for the purpose of obtaining informed consent would result in injury or death to the client. The second instance is when the client waives the right to give informed consent. Options 1, 2, and 3 are inappropriate.

When caring for a 3-year-old child, the nurse should provide which toy for this child?

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Toys for the toddler must be strong, safe, and too large to swallow or place in the ear or nose. Toddlers need supervision at all times. Push-pull toys, large balls, large crayons, trucks, and dolls are some appropriate toys. A puzzle with large pieces only may be appropriate. A farm set and a golf set may contain items that the child could swallow.

When the nurse is collecting data from the older adult, which of the following findings would be considered normal physiological changes? Select all that apply.

Please select 3 correct answers

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Anatomical changes to the eye affect the individual's visual ability, which leads to potential problems with activities of daily living. Light adaptation and visual fields are reduced. Respiratory rates are usually unchanged. The heart rate decreases, and the heart valves thicken. Age-related changes that affect the urinary tract increase an older client's susceptibility to urinary tract infections. Short-term memory may decline with age, but long-term memory is usually maintained. Changes in sleep patterns are consistent, age-related changes. Older persons experience an increased incidence of awakening after sleep onset.

Which data indicates to the nurse that a client may be experiencing ineffective coping?

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Coping mechanisms are behaviors that are used to decreased stress and anxiety. In response to a death, ineffective coping is manifested by an extreme behavior that in some instances may be harmful to the individual, physically, psychologically, or both. Option 1 is indicative of a behavior that identifies an ineffective coping behavior as part of the grieving process. The remaining options identify effective coping behaviors.

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