NCLEX Select All That Apply Practice Exam 6
Which of the following nursing diagnoses would be appropriate for a client with heart failure? Select all that apply.
HF is a result of structural and functional abnormalities of the heart tissue muscle. The heart muscle becomes weak and does not adequately pump the blood out of the chambers. As a result, blood pools in the left ventricle and backs up into the left atrium, and eventually into the lungs. Therefore, greater amounts of blood remain in the ventricle after contraction thereby decreasing cardiac output. In addition, this pooling leads to thrombus formation and ineffective tissue perfusion because of the decrease in blood flow to the other organs and tissues of the body. Typically, these clients have an ejection fraction of less than 50% and poorly tolerate activity. Activity intolerance is related to a decrease, not increase, in cardiac output. Gas exchange is impaired. However, the decrease in cardiac output triggers compensatory mechanisms, such as an increase in sympathetic nervous system activity.
When caring for a client with a central venous line, which of the following nursing actions should be implemented in the plan of care for chemotherapy administration? Select all that apply.
Please select 4 correct answers
A major concern with intravenous administration of cytotoxic agents is vessel irritation or extravasation. The Oncology Nursing Society and hospital guidelines require frequent evaluation of blood return when administering vesicant or non vesicant chemotherapy due to the risk of extravasation. These guidelines apply to peripheral and central venous lines. In addition, central venous lines may be long-term venous access devices. Thus, difficulty drawing or aspirating blood may indicate the line is against the vessel wall or may indicate the line has occlusion. Having the client cough or move position may change the status of the line if it is temporarily against a vessel wall. Occlusion warrants more thorough evaluation via x-ray study to verify placement if the status is questionable and may require a declotting regimen.
A 20-year old college student has been brought to the psychiatric hospital by her parents. Her admitting diagnosis is borderline personality disorder. When talking with the parents, which information would the nurse expect to be included in the client’s history? Select all that apply.
Please select 3 correct answers
When assessing a client diagnosed with impulse control disorder, the nurse observes violent, aggressive, and assaultive behavior. Which of the following assessment data is the nurse also likely to find? Select all that apply.
Please select 3 correct answers
A client with an impulse control disorder who displays violent, aggressive, and assaultive behavior generally functions well in other areas of his life. The degree of aggressiveness is typically out of proportion with the stressor. Such a client commonly has a history of parental alcoholism and a chaotic family life, and often verbalizes sincere remorse and guilt for the aggressive behavior.
Which of the following nursing interventions are written correctly? (Select all that apply.)
It is specific in what to do and when.
The nurse is monitoring a client receiving peritoneal dialysis and nurse notes that a client’s outflow is less than the inflow. Select actions that the nurse should take.
Please select 4 correct answers
If outflow drainage is inadequate, the nurse attempts to stimulate outflow by changing the client’s position. Turning the client to the other side or making sure that the client is in good body alignment may assist with outflow drainage. The drainage bag needs to be lower than the client’s abdomen to enhance gravity drainage. The connecting tubing and the peritoneal dialysis system is also checked for kinks or twisting and the clamps on the system are checked to ensure that they are open. There is no reason to contact the physician.
The nurse is caring for a hospitalized client who has chronic renal failure. Which of the following nursing diagnoses are most appropriate for this client? Select all that apply.
Please select 3 correct answers
Appropriate nursing diagnoses for clients with chronic renal failure include excess fluid volume related to fluid and sodium retention; imbalanced nutrition, less than body requirements related to anorexia, nausea, and vomiting; and activity intolerance related to fatigue. The nursing diagnoses of impaired gas exchange and pain are not commonly related to chronic renal failure.
The nurse is assessing a child diagnosed with a brain tumor. Which of the following signs and symptoms would the nurse expect the child to demonstrate? Select all that apply.
Please select 3 correct answers
Head tilt, vomiting, and lethargy are classic signs assessed in a child with a brain tumor. Clinical manifestations are the result of location and size of the tumor.
The nurse is caring for a client with a T5 complete spinal cord injury. Upon assessment, the nurse notes flushed skin, diaphoresis above the T5, and a blood pressure of 162/96. The client reports a severe, pounding headache. Which of the following nursing interventions would be appropriate for this client? Select all that apply.
Please select 4 correct answers
The client has signs and symptoms of autonomic dysreflexia. The potentially life-threatening condition is caused by an uninhibited response from the sympathetic nervous system resulting from a lack of control over the autonomic nervous system. The nurse should immediately elevate the HOB to 90 degrees and place extremities dependently to decrease venous return to the heart and increase venous return from the brain. Because tactile stimuli can trigger autonomic dysreflexia, any constrictive clothing should be loosened. The nurse should also assess for distended bladder and bowel impaction, which may trigger autonomic dysreflexia, and correct any problems. Elevated blood pressure is the most life-threatening complication of autonomic dysreflexia because it can cause stroke, MI, or seizures. If removing the triggering event doesn’t reduce the client’s blood pressure, IV antihypertensives should be administered. A fan shouldn’t be used because cold drafts may trigger autonomic dysreflexia.
A client admitted to the psychiatric unit claims to be the Son of God and insists that he will not be kept away from his followers. The most likely explanation for the client’s delusion is:
Delusions of grandeur are associated with low self-esteem. Answer A is incorrect because conversion is expressed as sensory or motor deficits. Answers B and C can cause an increase in the client’s delusions but do not explain their purpose; therefore, they are incorrect.
A client with a bowel resection and anastomosis returns to his room with an NG tube attached to intermittent suction. Which of the following observations indicates that the nasogastric suction is working properly?
Nasogastric suction decompresses the stomach and leaves the abdomen soft and nondistended. Answer B is incorrect because it does not relate to the effectiveness of the NG suction. Answer C is incorrect because it relates to peristalsis, not the effectiveness of the NG suction. Answer D is incorrect because it relates to wound healing, not the effectiveness of the NG suction.
The nurse is teaching the client with insulin-dependent diabetes the signs of hypoglycemia. Which of the following signs is associated with hypoglycemia?
Tremulousness is an early sign of hypoglycemia. Answers B, C, and D are incorrect because they are symptoms of hyperglycemia.
Which of the following symptoms is associated with exacerbation of multiple sclerosis?
The most common sign associated with exacerbation of multiple sclerosis is double vision. Answers A, B, and D are not associated with a diagnosis of multiple sclerosis; therefore, they are incorrect.
Which of the following conditions is most likely related to the development of renal calculi?
Gout and renal calculi are the result of increased amounts of uric acid. Answer B is incorrect because it does not contribute to renal calculi. Answers C and D can result from decreased calcium levels. Renal calculi are the result of excess calcium; therefore, answers C and D are incorrect.
A client with AIDS is admitted for treatment of wasting syndrome. Which of the following dietary modifications can be used to compensate for the limited absorptive capability of the intestinal tract?
Providing small, frequent meals will improve the client’s appetite and help reduce nausea. Answer A is incorrect because it does not compensate for limited absorption. Foods and beverages containing live cultures are discouraged for the immune-compromised client; therefore, answer B is incorrect. Answer C is incorrect because forcing fluids will not compensate for limited absorption of the intestine.
The treatment protocol for a client with acute lymphatic leukemia includes prednisone, methotrexate, and cimetidine. The purpose of the cimetidine is to:
A common side effect of prednisone is gastric ulcers. Cimetidine is given to help prevent the development of ulcers. Answers A, B, and C do not relate to the use of cimetidine; therefore, they are incorrect.