NCLEX

NCLEX Select All That Apply Practice Exam 5

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

Use active listening skills to seek information from the client.

Encourage the client to describe the problem as she sees it.

Ask the client to tell you exactly what she thinks is happening.

Tell the client that she is delusional and you can help her.

Explain to the client that most people are not investigated by the CIA.

Reassure the client that you are not with the CIA.

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

Position the client directly on the trochanter when side lying.

Avoid use of donut type devices.

Massage bony prominences.

Elevate the HOB no more than 30 degrees when possible

When the client is side lying, use the 30 degree lateral inclined position.

Avoid uninterrupted sitting in a chair or wheelchair.

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

Review meds the client is currently on to determine whether any of them cause an increased intraocular pressure as a side effect.

Determine whether the client has any sudden loss of vision accompanied by pain.

Discuss with the client the importance of controlling blood pressure to decrease the potential loss of peripheral vision.

Instruct the client to take analgesics as soon as any discomfort occurs in the eye and to notify clinic if pain is not relieved.

Have the client demonstrate the use of eye drops.

Assess the client for chronic diseases such as diabetes.

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

Warming the dialysate

Too rapid installation

Infiltration of the solution into the bloodstream

Accumulation of dialysate solution under the diaphragm

Too rapid outflow of the dialysate.

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

Serum potassium level decreases from 5.4 to 4.6 mEq/L

Cr decreases from 1.6 to 0.8 mg/dL

Hgb increases from 10-12 g/dL

WBC increase from 5000 to 8000/mm^3

BUN decreases from 110 to 90 mg/dL

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

Volume overload

BUN 18 mg/dL

K 5.2 mEq/L

Decreased creatinine clearance.

Metabolic acidosis

Cr 5.0 mg/dL

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

Decrease in pulse rate in affected leg.

Paresthesia distal to area of injury.

Toes on affected leg cool to touch and edematous.

Complaints that pins are hurting.

Complaints of leg pain unrelieved by analgesics or repositioning.

Client angry and calling loudly to the nurse every ten minutes.

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

Elevate the HOB.

Decrease intake of caffeine.

Discuss strategies for weight loss if overweight.

Increase fluid intake with meals.

Take ranitidine (Zantac) at hs.

Eat a bedtime snack of milk and protein.

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

Verify consent has been signed.

Explain procedure to client.

Provide clear liquid, no caffeine diet.

Evaluate peripheral pulses.

Obtain a 12 lead ECG

Obtain history of shellfish allergy.

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.

The physician has prescribed Cytoxan (cyclophosphamide) for a client with nephrotic syndrome. The nurse should:

Encourage the client to drink extra fluids

Request a low-protein diet for the client

Bathe the client using only mild soap and water

Provide additional warmth for swollen, inflamed joints

Correct! Wrong!

The client taking Cytoxan should increase his fluid intake to prevent hemorrhagic cystitis. Answers B, C, and D do not relate to the question; therefore, they are incorrect.

The nurse is caring for a client with detoxification from alcohol. Which medication is used in the treatment of alcohol withdrawal?

Antabuse (disulfiram)

Romazicon (flumazenil)

Dolophine (methadone)

Ativan (lorazepam)

Correct! Wrong!

Benzodiazepines are ordered for the client in alcohol withdrawal to prevent delirium tremens. Answer A is incorrect because it is a medication used in aversive therapy to maintain sobriety. Answer B is incorrect because it is used for the treatment of benzodiazepine overdose. Answer C is incorrect because it is the treatment for opiate withdrawal.

A client with insulin-dependent diabetes takes 20 units of NPH insulin at 7 a.m. The nurse should observe the client for signs of hypoglycemia at:

8 a.m.

10 a.m.

3 p.m.

5 a.m.

Correct! Wrong!

The client taking NPH insulin should have a snack midafternoon to prevent hypoglycemia. Answers A and B are incorrect because the times are too early for symptoms of hypoglycemia. Answer D is incorrect because the time is too late and the client would be in severe hypoglycemia.

The licensed practical nurse is assisting the charge nurse in planning care for a client with a detached retina. Which of the following nursing diagnoses should receive priority?

Alteration in comfort

Alteration in mobility

Alteration in skin integrity

Alteration in O2 perfusion

Correct! Wrong!

The client with a detached retina will have limitations in mobility before and after surgery. Answer A is incorrect because a detached retina produces no pain or discomfort. Answers C and D do not apply to the client with a detached retina; therefore, they are incorrect.

The primary purpose for using a CPM machine for the client with a total knee repair is to help:

Prevent contractures

Promote flexion of the artificial joint

Decrease the pain associated with early ambulation

Alleviate lactic acid production in the leg muscles

Correct! Wrong!

The primary purpose for the continuous passive-motion machine is to promote flexion of the artificial joint. The device should be placed at the foot of the client’s bed. Answers A, C, and D do not describe the purpose of the CPM machine; therefore, they are incorrect.

Which of the following statements reflects Kohlberg’s theory of the moral development of the preschool-age child?

Obeying adults is seen as correct behavior.

Showing respect for parents is seen as important.

Pleasing others is viewed as good behavior.

Behavior is determined by consequences.

Correct! Wrong!

According to Kohlberg, in the preconventional stage of development, the behavior of the preschool child is determined by the consequences of the behavior. Answers A, B, and C describe other stages of moral development; therefore, they are incorrect.

A toddler with otitis media has just completed antibiotic therapy. A recheck appointment should be made to:

Determine whether the ear infection has affected her hearing

Make sure that she has taken all the antibiotic

A document that the infection has completely cleared

Obtain a new prescription in case the infection recurs

Correct! Wrong!

The client should be assessed following completion of antibiotic therapy to determine whether the infection has cleared. Answer A would be done if there are repeated instances of otitis media; therefore, it is incorrect. Answer B is incorrect because it will not determine whether the child has completed the medication. Answer D is incorrect because the purpose of the recheck is to determine whether the infection is gone.

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NCLEX Select All That Apply Practice Exam 5

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:

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

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:

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

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

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

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:

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:

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:

The physician has prescribed Cytoxan (cyclophosphamide) for a client with nephrotic syndrome. The nurse should:

The nurse is caring for a client with detoxification from alcohol. Which medication is used in the treatment of alcohol withdrawal?

A client with insulin-dependent diabetes takes 20 units of NPH insulin at 7 a.m. The nurse should observe the client for signs of hypoglycemia at:

The licensed practical nurse is assisting the charge nurse in planning care for a client with a detached retina. Which of the following nursing diagnoses should receive priority?

The primary purpose for using a CPM machine for the client with a total knee repair is to help:

Which of the following statements reflects Kohlberg’s theory of the moral development of the preschool-age child?

A toddler with otitis media has just completed antibiotic therapy. A recheck appointment should be made to:

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