NCLEX Select All That Apply Practice Exam 9
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?
The loss of gastric fluid via nasogastric suction or vomiting causes metabolic alkalosis as a result of the loss of hydrochloric acid; this results in an alkalotic condition. Options 3 and 4 deal with respiratory problems. Option 1 relates to acidosis.
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?
Kussmaul's respirations are abnormally deep, regular, and increased in rate. In apnea, respirations cease for several seconds. In bradypnea, respirations are regular but abnormally slow. In hyperpnea, respirations are labored and increased in depth and rate
Which nursing interventions are appropriate for a client recovering from surgery for retinal detachment? Select all that apply.
Please select 4 correct answers
An eye patch or shield is applied to protect the eye and prevent any further detachment. Educating the client regarding symptoms is necessary because the client is at risk for subsequent retinal detachment. Positioning, activity restrictions, and eye patches hinder the client in the performance of activities of daily living, and the client needs the nurse's assistance with these activities. Eye medications are prescribed postoperatively, and hemorrhage is also a risk post surgery. Coughing is not encouraged because this can increase intraocular pressure and harm the client.
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?
Postural blood pressure changes occur in the client with hyponatremia. Dry mucous membranes and intense thirst are seen in clients with hypernatremia. A slow, bounding pulse is not indicative of hyponatremia. In a client with hyponatremia, a rapid thready pulse is noted.
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?
Children should not be given herbal therapies, especially in the home and without professional supervision. There are no general contraindications for the clients described in options 1, 2, and 4.
A nurse is caring for an infant with a diagnosis of tetralogy of Fallot. The infant suddenly becomes cyanotic and the oxygen saturation reading drops to 60%. Choose the interventions that the nurse should perform. Select all that apply.
Please select 4 correct answers
The child who is cyanotic with oxygen saturations dropping to 60% is having a hypercyanotic episode. Hypercyanotic episodes often occur among infants with tetralogy of Fallot, and they may occur among infants whose heart defect includes the obstruction of pulmonary blood flow and communication between the ventricles. If a hypercyanotic episode occurs, the infant is placed in a knee-chest position immediately. The registered nurse is notified, who will then contact the health care provider. The knee-chest position improves systemic arterial oxygen saturation by decreasing venous return so that smaller amounts of highly saturated blood reach the heart. Toddlers and children squat to get into this position and relieve chronic hypoxia. There is no reason to call a code blue unless respirations cease. Additional interventions include administering 100% oxygen by face mask, morphine sulfate, and intravenous fluids, as prescribed.
A nurse is collecting data on a client with severe preeclampsia. Choose the findings that would be noted in severe preeclampsia. Select all that apply.
Please select 3 correct answers
Severe preeclampsia is characterized by blood pressure higher than 160/110 mmHg, proteinuria 3+ or higher, and oliguria. Seizures (convulsions) are present in eclampsia and are not a characteristic of severe preeclampsia. Muscle cramps and contractions are not findings noted in severe preeclampsia, although the client is monitored for these occurrences.
A nurse is monitoring a client with Graves' disease for signs of thyrotoxicosis (thyroid storm). Which of the following signs and symptoms, if noted in the client, will alert the nurse to the presence of this crisis? Select all that apply.
Please select 3 correct answers
Thyrotoxic crisis (thyroid storm) is an acute, potentially life-threatening state of extreme thyroid activity that represents a breakdown in the body's tolerance to a chronic excess of thyroid hormones. The clinical manifestations include fever greater than 100° F, severe tachycardia, flushing and sweating, and marked agitation and restlessness. Delirium and coma can occur.
A nurse is monitoring a group of clients for acid-base imbalances. Which clients are at highest risk for metabolic acidosis? Select all that apply.
Please select 3 correct answers
Diabetes mellitus, malnutrition, and renal failure lead to metabolic acidosis because of the increasing acids in the body. Options 1, 2, and 5 are respiratory problems, not metabolic, and result in either respiratory acidosis or respiratory alkalosis.
The nurse should understand regulations of nursing practice as put forth by the Nurse Practice Act. Identify the statement which is incorrect.
The Nurse Practice Act is a series of statutes enacted by the federal government in order to regulate the practice of nursing. The Nurse Practice Act is a series of statutes enacted by each state legislature in order to regulate the practice of nursing in that particular state. All the other statements are true and correct.
The Boards of Nursing have the right to revoke, deny, or suspend any license to practice as a practical/vocational nurse within their jurisdiction. There are several causes or actions which are considered to be causes for disciplinary action by the Board of Nursing. Identify the cause for disciplinary action which is incorrect.
Informing your supervisor that you cannot assume nursing duties until sufficient preparation for the specific duty has been provided. It is the nurse’s responsibility to inform the supervisor of an inappropriate assignment. The nurse should let the supervisor know that they are uncomfortable performing these duties until they have been prepared to handle them. The supervisor may then make a more appropriate assignment. All the other statements are correct and are reasons for the Board of Nursing to take disciplinary action towards the nurse.
A nurse is planning assignments for the upcoming shift. Which of the following would be the most appropriate assignment for the nursing assistant?
Assist a diabetic client on bedrest with a bed bath. This would be the MOST appropriate assignment to give to the nursing assistant with the information which has been provided. It would be inappropriate for the nursing assistant to record the vital signs in the medical chart. Since the patient requiring feeding had a stroke three days earlier, there is a greater risk of choking and/or aspiration of food material. The Alzheimer’s patient may be confused and may have the potential for difficulties in regards to bathroom assistance.
Vitamin K is typically given during the immediate post delivery period to the healthy newborn infant. The IM injection is administered in the vastus lateralis muscle of the infant’s thigh. What is the MOST appropriate response for the nurse to give if questioned by the parents about the reason for the injection?
“This is a Vitamin K injection. Infants are deficient in Vitamin K for the first 5- 8 days of life. Vitamin K helps their blood clot. This injection is administered to all healthy newborns to help their blood clot better.” Telling the parents that the injection is for their child’s own good is an unprofessional explanation. It is untrue that infants do not feel pain. They are able to feel pain and discomfort. Telling the parents that the injection is a “necessary evil” creates a negative view of the procedure and again an unprofessional explanation. This would not be the most appropriate answer. The last response is an example of the nurse assuming that the parents do not wish for their child to receive the injection. The parents simply asked for its purpose and an explanation of why it needed to be given.
A nurse has received orders to administer a RhoGAM injection IM to a postpartum patient. Which situation is NOT a contraindication for administration of this injection?
Administration of the injection within 72 hours after delivery. The injection is given to an Rh-negative mother to prevent isoimmunization from the possibility of exposure to Rh-positive blood. Exposure can occur not only through delivery of an Rh-positive infant but also by transfusion, amniocentesis, chorionic villus sampling, abdominal injury or trauma, bleeding during pregnancy, and termination of a pregnancy. The injection should never be administered to an Rh-positive patient, a patient with an elevated temperature, or a patient with a history of an allergic reaction to preparations containing human immunoglobulins. The injection should never be administered to a newborn.
A nursing student is asked by her nursing instructor to explain and give an example of Erik Erikson’s Identity vs. Role Confusion psychosocial development stage. The MOST appropriate answer would be:
"This stage occurs in adolescence (12-20 years), when the adolescent is confused about who he is. An example is when the adolescent obtains a tattoo, which he feels shows the world who he really is.” The school age child (6-12 years) is in the stage or psychosocial crisis of “industry vs. inferiority”. In early adulthood (20-35 years), they are experiencing the “intimacy vs. isolation” stage or crisis. In middle adulthood (35-65 years), they are experiencing the “generativity vs. stagnation” stage or crisis.
The nurse is assessing a multigravida, 36 weeks gestation for symptoms of pregnancy-induced hypertension and preeclampsia. The nurse should give priority to assessing the client for:
The nurse should pay close attention to swelling in the client with preeclampsia. Facial swelling indicates that the client’s condition is worsening and blood pressure will be increased. Answer B is not related to the question; therefore, it is incorrect. Answer C is incorrect because ankle edema is expected in pregnancy. Diminished reflexes are associated with the use of magnesium sulfate, which is the treatment of preeclampsia; therefore, answer D is incorrect.