NCLEX Select All That Apply Practice Exam 5

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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:

Please select 3 correct answers

Correct!Wrong!

The client is displaying paranoid behaviours, which necessitates a matter of fact approach that is nonjudgmental and accepting the client’s statements and show the nurses willingness to actively listen. The last three do not contribute to a therapeutic nurse client relationship.

Which nursing interventions will assist in reducing pressure points that may lead to pressure ulcers? Check all that apply:

Please select 4 correct answers

Correct!Wrong!

Elevating the head of the bed to 30 degrees or less will decrease the chance of ulcer development from shearing forces. When placing the client in a side lying position, use the 30 degree lateral inclined position. Do not place the client on their trochanter. Avoid donuts which promote ischemia. Don’t massage bony prominences as this causes capillary break down and injury leading to pressure ulcers.

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:

Please select 3 correct answers

Correct!Wrong!

Medications must be evaluated in terms of their potential for increasing the intraocular pressure. Ophthalmic drops are often prescribed for glaucoma and clients should know how to administer them correctly. Diabetes is a risk factor and its mgmt is important in helping slow POAG. An increase in intraocular pressure could cause further damage to a patient with POAG. The questions states the client is already diagnosed, POAG is painless and not correlated to BP.

A nurse understands that a patient may experience pain during peritoneal dialysis because of which of the following? Select all that apply:

Please select 2 correct answers

Correct!Wrong!

Rapid outflow doesn’t cause pain, warming helps with discomfort and the dialysate does not infiltrate the circulation.

The nurse is evaluating a client’s response to hemodialysis. Which lab results will indicate the dialysis was effective? Select all that apply:

Please select 3 correct answers

Correct!Wrong!

Primary action of hemodialysis is to clear nitrogenous waste products.

The nurse understands that the following clinical findings are indications for dialysis. Select all that apply:

Please select 4 correct answers

Correct!Wrong!

Indications for dialysis include volume overload, weight gain, hyperkalemia, metabolic acidosis, and rising BUN (normally 10-20 mg/dL) and Cr (normally 0.5-1.5 mg/dL) levels, along with decreased urinary creatinine clearance. The K level is hyperkalemic, the BUN is normal.

The nurse is assessing a client who had a fractured femur repaired with an external fixator device. Which assessment finding would cause the nurse concern regarding the development of compartment syndrome? Select all that apply:

Please select 3 correct answers

Correct!Wrong!

Paresthesia, edema, and leg pain unrelieved by analgesics are classic indicators of the development of compartmental syndrome. With a femur fracture the will be edema, a decrease in rate is not an indication of pressure, a decrease in pulse strength is. Anger can be due to immobility, and the pins do not usually cause pain, but this may be a sign of infection.

The nurse is preparing discharge for a patient with GERD. What would be important for the nurse to include in this teaching plan? Select all that apply:

Please select 4 correct answers

Correct!Wrong!

This will all help neutralize stomach acid. Drinking lots with meals and eating before bed will exacerbate the problem.

The nurse is preparing a client for cardiac catheterization. Which nursing interventions are necessary in preparing the client for this procedure. Select all that apply:

Please select 4 correct answers

Correct!Wrong!

In cardiac catheterization contrast dye is injected into the coronary artery and provides info on patency. Informed consent must be signed prior to any invasive procedure. The physician is responsible for explaining the procedure, the nurse can reinforce. Patient would be NPO 6-18 hours prior. An ECG would be done, but measures electrical not blood flow. Peripheral pulses is important afterwards. Shellfish is an indicator of an allergy to the medium injected.

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