Select All That Apply SATA

7/25/2019 Select All That Apply SATA

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NCLEX Select All That Apply Practice ExamNursesLabs.com

1. A patient is admitted to the same day surgery unit for liver biopsy. Which of the following laboratory tests

assesses coagulation? Select all that apply.

1. Partial thromboplastin time.

2. Prothrombin time.

3. Platelet count.

4. Hemoglobin

5. Complete Blood Count

6. White Blood Cell Count

Answer: 1, 2, and

Prothrombin time, partial thromboplastin time, and platelet count are all included in coagulation studies. he hemoglobin

le!el, though important in"ormation prior to an in!asi!e procedure li#e li!er biops$, does not assess coagulation.

2. A patient is admitted to the hospital with suspected polycythemia vera. Which of the following symptoms

is consistent with the diagnosis? Select all that apply.

1. Weight loss.

2. %ncreased clotting time.

3. H$pertension.

4. Headaches.

Answer: 2, , and !

Pol$c$themia !era is a condition in &hich the bone marro& produces too man$ red blood cells. his causes an increase in

hematocrit and !iscosit$ o" the blood. Patients can e'perience headaches, di((iness, and !isual disturbances.

Cardio!ascular e""ects include increased blood pressure and dela$ed clotting time. Weight loss is not a mani"estation o"

pol$c$themia !era.


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. "he nurse is teaching the client how to use a metered dose inhaler #$%&' to administer a (orticosteroid

drug. Which of the following client actions indicates that he is using the $%& correctly? Select all that apply.

1. he inhaler is held upright.

2. Head is tilted do&n &hile inhaling the medication3. Client &aits 5 minutes bet&een pu""s.

4. )outh is rinsed &ith &ater "ollo&ing administration

5. Client lies supine "or 15 minutes "ollo&ing administration.

Answer: 1 and !.

!. "he nurse is teaching a client with polycythemia vera about potential complications from this disease.

Which manifestations would the nurse include in the client)s teaching plan? Select all that apply.

1. Hearing loss

2. *isual disturbance

3. Headache

4. +rthopnea

5. out

6. Weight loss

Answers: 2, , ! and *.

Pol$c$themia !era, a condition in &hich too man$ -BCs are produced in the blood serum, can lead to an increase in the

hematocrit and h$per!olemia, h$per!iscosit$, and h$pertension. ubse/uentl$, the client can e'perience di((iness,

tinnitus, !isual disturbances, headaches, or a "eeling o" "ullness in the head. he client ma$ also e'perience

cardio!ascular s$mptoms such as heart "ailure 0shortness o" breath and orthopnea and increased clotting time or

s$mptoms o" an increased uric acid le!el such as pain"ul s&ollen oints 0usuall$ the big toe. Hearing loss and &eight loss

are not mani"estations associated &ith pol$c$themia !era.


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*. Which of the following would be priority assessment data to gather from a client who has been diagnosed

with pneumonia? Select all that apply.

1. uscultation o" breath sounds2. uscultation o" bo&el sounds

3. Presence o" chest pain.

4. Presence o" peripheral edema

5. Color o" nail beds

Answer: 1, , *.

respirator$ assessment, &hich includes auscultation o" breath sounds and assessing the color o" the nail beds, is a

priorit$ "or clients &ith pneumonia. ssessing "or the presence o" chest pain is also an important respirator$ assessment

as chest pain can inter"ere &ith the clients abilit$ to breathe deepl$. uscultating bo&el sounds and assessing "or

peripheral edema ma$ be appropriate assessments, but these are not priorit$ assessments "or the patient &ith

pneumonia.

+. "he nurse is teaching a client who has been diagnosed with " how to avoid spreading the disease to

family members. Which statement#s' by the client indicate#s' that he has understood the nurses

instructions? Select all that apply.

1. % &ill need to dispose o" m$ old clothing &hen % return home.

2. % should al&a$s co!er m$ mouth and nose &hen snee(ing.

3. %t is important that % isolate m$sel" "rom "amil$ &hen possible.

4. % should use paper tissues to cough in and dispose o" them properl$.

5. % can use regular plate and utensils &hene!er % eat.

Answer: 2, !, *.


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-. "he nurse is admitting a client with hypoglycemia. &dentify the signs and symptoms the nurse should

epect. Select all that apply.

1. hirst

2. Palpitations3. 7iaphoresis

4. lurred speech

5. H$per!entilation

Answer: 2, , !.

Palpitations, an adrenergic s$mptom, occur as the glucose le!els "all8 the s$mpathetic ner!ous s$stem is acti!ated and

epinephrine and norepinephrine are secreted causing this response. 7iaphoresis is a s$mpathetic ner!ous s$stem

response that occurs as epinephrine and norepinephrine are released. lurred speech is a neurogl$copenic s$mptom8 as

the brain recei!es insu""icient glucose, the acti!it$ o" the C9 becomes depressed.

/. Which adaptations should the nurse caring for a client with diabetic 0etoacidosis epect the client to

ehibit? Select all that apply:

1. &eating

2. :o& PC+2

3. -etinopath$

4. cetone breath

5. ;le!ated serum bicarbonate

Answer: 2, !.

)etabolic acidosis initiates respirator$ compensation in the "orm o"


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. When planning care for a client with ulcerative colitis who is eperiencing symptoms, which client care

activities can the nurse appropriately delegate to a unlicensed assistant? Select all that apply.

1. ssessing the clients bo&el sounds2. Pro!iding s#in care "ollo&ing bo&el mo!ements

3. ;!aluating the clients response to antidiarrheal medications

4. )aintaining inta#e and output records

5. +btaining the clients &eight.

Answer: 2, !, and *.

he nurse can delegate the "ollo&ing basic care acti!ities to the unlicensed assistant= pro!iding s#in care "ollo&ing bo&el

mo!ements, maintaining inta#e and output records, and obtaining the clients &eight. ssessing the clients bo&el sounds

and e!aluating the clients response to medication are registered nurse acti!ities that cannot be delegated.

1. Which of the following nursing diagnoses would be appropriate for a client with heart failure? Select all

that apply.

1. %ne""ecti!e tissue per"usion related todecreased peripheral blood "lo& secondar$ to decreased cardiac output.

2. cti!it$ intolerance related toincreased cardiac output.

3. 7ecreased cardiac output related tostructural and "unctional changes.

4. %mpaired gas e'change related todecreased s$mpathetic ner!ous s$stem acti!it$.

Answer: 1 and .

H> is a result o" structural and "unctional abnormalities o" the heart tissue muscle. he heart muscle becomes &ea# and

does not ade/uatel$ pump the blood out o" the chambers. s a result, blood pools in the le"t !entricle and bac#s up into

the le"t atrium, and e!entuall$ into the lungs. here"ore, greater amounts o" blood remain in the !entricle a"ter

contraction thereb$ decreasing cardiac output. %n addition, this pooling leads to thrombus "ormation and ine""ecti!e tissue


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per"usion because o" the decrease in blood "lo& to the other organs and tissues o" the bod$. $picall$, these clients ha!e

an eection "raction o" less than 5?@ and poorl$ tolerate acti!it$. cti!it$ intolerance is related to a decrease, not

increase, in cardiac output. as e'change is impaired. Ho&e!er, the decrease in cardiac output triggers compensator$

mechanisms, such as an increase in s$mpathetic ner!ous s$stem acti!it$.

11. 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.

1. *eri"$ patenc$ o" the line b$ the presence o" a blood return at regular inter!als.

2. %nspect the insertion site "or s&elling, er$thema, or drainage.

3. dminister a c$toto'ic agent to #eep the regimen on schedule e!en i" blood return is not present.

4. %" unable to aspirate blood, reposition the client and encourage the client to cough.

5. Contact the health care pro!ider about !eri"$ing placement i" the status is /uestionable.

Answer: 1, 2, !, *.

maor concern &ith intra!enous administration o" c$toto'ic agents is !essel irritation or e'tra!asation. he +ncolog$

9ursing ociet$ and hospital guidelines re/uire "re/uent e!aluation o" blood return &hen administering !esicant or non

!esicant chemotherap$ due to the ris# o" e'tra!asation. hese guidelines appl$ to peripheral and central !enous lines. %n

addition, central !enous lines ma$ be longAterm !enous access de!ices. hus, di""icult$ dra&ing or aspirating blood ma$

indicate the line is against the !essel &all or ma$ indicate the line has occlusion. Ha!ing the client cough or mo!e position

ma$ change the status o" the line i" it is temporaril$ against a !essel &all. +cclusion &arrants more thorough e!aluation

!ia 'Ara$ stud$ to !eri"$ placement i" the status is /uestionable and ma$ re/uire a declotting regimen.

12. A 23year old college student has been brought to the psychiatric hospital by her parents. 4er admitting

diagnosis is borderline personality disorder. When tal0ing with the parents, which information would the

nurse epect to be included in the client)s history? Select all that apply.


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1. %mpulsi!eness

2. :abilit$ o" mood

3. -itualistic beha!ior

4. ps$chomotor retardation5. el"Adestructi!e beha!ior

1. 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 li0ely to find? Select all

that apply.

1. he client "unctions &ell in other areas o" his li"e.

2. he degree o" aggressi!eness is out o" proportion to the stressor.

3. he !iolent beha!ior is most o"ten usti"ied b$ the stressor.

4. he client has a histor$ o" parental alcoholism and chaotic, abusi!e "amil$ li"e.

5. he client has no remorse about the inabilit$ to control his anger.

Answer: 1, 2, !.

client &ith an impulse control disorder &ho displa$s !iolent, aggressi!e, and assaulti!e beha!ior generall$ "unctions &ell

in other areas o" his li"e. he degree o" aggressi!eness is t$picall$ out o" proportion &ith the stressor. uch a client

commonl$ has a histor$ o" parental alcoholism and a chaotic "amil$ li"e, and o"ten !erbali(es sincere remorse and guilt "or

the aggressi!e beha!ior.

1!. Which of the following nursing interventions are written correctly? #Select all that apply.'

1. ppl$ continuous passi!e motion machine during da$.

2. Per"orm neuro!ascular chec#s.

3. ;le!ate head o" bed 3? degrees be"ore meals.

4. Change dressing once a shi"t.


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Answer: .

%t is speci"ic in &hat to do and &hen.

1*. "he nurse is monitoring a client receiving peritoneal dialysis and nurse notes that a client)s outflow isless than the inflow. Select actions that the nurse should ta0e.

1. Place the client in good bod$ alignment

2. Chec# the le!el o" the drainage bag

3. Contact the ph$sician

4. Chec# the peritoneal dial$sis s$stem "or #in#s

5. -eposition the client to his or her side.

Answer: 1, 2, !, *.

%" out"lo& drainage is inade/uate, the nurse attempts to stimulate out"lo& b$ changing the clients position. urning the

client to the other side or ma#ing sure that the client is in good bod$ alignment ma$ assist &ith out"lo& drainage. he

drainage bag needs to be lo&er than the clients abdomen to enhance gra!it$ drainage. he connecting tubing and the

peritoneal dial$sis s$stem is also chec#ed "or #in#s or t&isting and the clamps on the s$stem are chec#ed to ensure that

the$ are open. here is no reason to contact the ph$sician.

1+. "he nurse is caring for a hospitali5ed client who has chronic renal failure. Which of the following nursing

diagnoses are most appropriate for this client? Select all that apply.

1. ;'cess >luid *olume

2. %mbalanced 9utrition8 :ess than Bod$ -e/uirements

3. cti!it$ %ntolerance

4. %mpaired as ;'change

5. Pain.


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Answer: 1, 2, .

ppropriate nursing diagnoses "or clients &ith chronic renal "ailure include e'cess "luid !olume related to "luid and sodium

retention8 imbalanced nutrition, less than bod$ re/uirements related to anore'ia, nausea, and !omiting8 and acti!it$

intolerance related to "atigue. he nursing diagnoses o" impaired gas e'change and pain are not commonl$ related tochronic renal "ailure.

1-. "he nurse is assessing a child diagnosed with a brain tumor. Which of the following signs and symptoms

would the nurse epect the child to demonstrate? Select all that apply.

1. Head tilt

2. *omiting

3. Pol$dipsia

4. :etharg$

5. %ncreased appetite

6. %ncreased pulse

Answer: 1, 2, !.

Head tilt, !omiting, and letharg$ are classic signs assessed in a child &ith a brain tumor. Clinical mani"estations are the

result o" location and si(e o" the tumor.

1/. "he nurse is caring for a client with a "* complete spinal cord in6ury. 7pon assessment, the nurse notes

flushed s0in, diaphoresis above the "*, and a blood pressure of 1+28+. "he client reports a severe,

pounding headache. Which of the following nursing interventions would be appropriate for this client? Select

all that apply.

1. ;le!ate the H+B to ? degrees

2. :oosen constricti!e clothing

3. se a "an to reduce diaphoresis


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4. ssess "or bladder distention and bo&el impaction

5. dminister antih$pertensi!e medication

6. Place the client in a supine position &ith legs ele!ated

Answer: 1, 2, !, *.

he client has signs and s$mptoms o" autonomic d$sre"le'ia. he potentiall$ li"eAthreatening condition is caused b$ an

uninhibited response "rom the s$mpathetic ner!ous s$stem resulting "rom a lac# o" control o!er the autonomic ner!ous

s$stem. he nurse should immediatel$ ele!ate the H+B to ? degrees and place e'tremities dependentl$ to decrease

!enous return to the heart and increase !enous return "rom the brain. Because tactile stimuli can trigger autonomic

d$sre"le'ia, an$ constricti!e clothing should be loosened. he nurse should also assess "or distended bladder and bo&el

impaction, &hich ma$ trigger autonomic d$sre"le'ia, and correct an$ problems. ;le!ated blood pressure is the most li"eA

threatening complication o" autonomic d$sre"le'ia because it can cause stro#e, )%, or sei(ures. %" remo!ing the triggering

e!ent doesnt reduce the clients blood pressure, %* antih$pertensi!es should be administered. "an shouldnt be used

because cold dra"ts ma$ trigger autonomic d$sre"le'ia.

1. "he nurse is evaluating the discharge teaching for a client who has an ileal conduit. Which of the

following statements indicates that the client has correctly understood the teaching? Select all that apply.

1. %" % limit m$ "luid inta#e % &ill not ha!e to empt$ m$ ostom$ pouch as o"ten.

2. % can place an aspirin tablet in m$ pouch to decrease odor.

3. % can usuall$ #eep m$ ostom$ pouch on "or 3 to D da$s be"ore changing it.

4. % must use a s#in barrier to protect m$ s#in "rom urine.

5. % should empt$ m$ ostom$ pouch o" urine &hen it is "ull.

Answer: , !.

he client &ith an ileal conduit must learn sel"Acare acti!ities related to care o" the stoma and ostom$ appliances. he

client should be taught to increase "luid inta#e to about 3,??? ml per da$ and should not limit inta#e. de/uate "luid


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inta#e helps to "lush mucus "rom the ileal conduit. he ostom$ appliance should be changed appro'imatel$ e!er$ 3 to D

da$s and &hene!er a lea# de!elops. s#in barrier is essential to protecting the s#in "rom the irritation o" the urine. n

aspirin should not be used as a method o" odor control because it can be an irritant to the stoma and lead to ulceration.

he ostom$ pouch should be emptied &hen it is oneAthird to oneAhal" "ull to pre!ent the &eight "rom pulling the appliancea&a$ "rom the s#in.

2. A nurse is assisting in performing an assessment on a client who suspects that she is pregnant and is

chec0ing the client for probable signs of pregnancy. Select allprobable signs of pregnancy.

1. terine enlargement

2. >etal heart rate detected b$ nonelectric de!ice

3. +utline o" the "etus !ia radiograph$ or ultrasound

4. Chad&ic#s sign

5. Bra'ton Hic#s contractions

6. Ballottement

Answers:1, !, *, and +.

he probablesigns o" pregnanc$ include=

terine ;nlargement

Hegars sign or so"tening and thinning o" the uterine segment that occurs at &ee# 6.

oodells sign or so"tening o" the cer!i' that occurs at the beginning o" the 2nd month

Chad&ic#s sign or bluish coloration o" the mucous membranes o" the cer!i', !agina and !ul!a. +ccurs at &ee#

6.

Ballottement or rebounding o" the "etus against the e'aminers "ingers o" palpation

Bra'tonAHic#s contractions

Positi!e pregnanc$ test measuring "or hC.

Positi!e signs o" pregnanc$ include=


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>etal Heart -ate detected b$ electronic de!ice 0doppler at 1?A12 &ee#s

>etal Heart rate detected b$ nonelectronic de!ice 0"etoscope at 2? &ee#s +

cti!e "etal mo!ement palpable b$ the e'aminers

+utline o" the "etus !ia radiograph$ or ultrasound

21. A nurse is monitoring a pregnant client with pregnancy induced hypertension who is at ris0 for

9reeclampsia. "he nurse chec0s the client for which specific signs of 9reeclampsia #select all that apply'?

1. ;le!ated blood pressure

2. 9egati!e urinar$ protein

3. >acial edema

4. %ncreased respirations

Answer: 1 and .

he three classic signs o" preeclampsia are h$pertension, generali(ed edema, and proteinuria. %ncreased respirations are

not a sign o" preeclampsia.

22. A nurse is caring for a pregnant client with severe preeclampsia who is receiving & magnesium sulfate.

Select all nursing interventions that apply in the care for the client.

1. )onitor maternal !ital signs e!er$ 2 hours

2. 9oti"$ the ph$sician i" respirations are less than 1E per minute.

3. )onitor renal "unction and cardiac "unction closel$

4.


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Answers: , !, *, +, and -.

When caring "or a client recei!ing magnesium sul"ate therap$, the nurse &ould monitor maternal !ital signs, especiall$

respirations, e!er$ 3?A6? minutes and noti"$ the ph$sician i" respirations are less than 12, because this &ould indicate

respirator$ depression. Calcium gluconate is #ept on hand in case o" magnesium sul"ate o!erdose, because calciumgluconate is the antidote "or magnesium sul"ate to'icit$. 7eep tendon re"le'es are assessed hourl$. Cardiac and renal

"unction is monitored closel$. he urine output should be maintained at 3? ml per hour because the medication is

eliminated through the #idne$s.

2. When interpreting an ;(


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4. %" unable to aspirate blood, reposition the client and encourage the client to cough.

5. Contact the health care pro!ider about !eri"$ing placement i" the status is /uestionable.

Answer: 1, 2, !, *. maor concern &ith intra!enous administration o" c$toto'ic agents is !essel irritation or e'tra!asation. he +ncolog$

9ursing ociet$ and hospital guidelines re/uire "re/uent e!aluation o" blood return &hen administering !esicant or non

!esicant chemotherap$ due to the ris# o" e'tra!asation. hese guidelines appl$ to peripheral and central !enous lines. %n

addition, central !enous lines ma$ be longAterm !enous access de!ices. hus, di""icult$ dra&ing or aspirating blood ma$

indicate the line is against the !essel &all or ma$ indicate the line has occlusion. Ha!ing the client cough or mo!e position

ma$ change the status o" the line i" it is temporaril$ against a !essel &all. +cclusion &arrants more thorough e!aluation

!ia 'Ara$ stud$ to !eri"$ placement i" the status is /uestionable and ma$ re/uire a declotting regimen.

2*. "o assist an adult client to sleep better the nurse recommends which of the following? #Select all that

apply.'

1. 7rin#ing a glass o" &ine ust be"ore retiring to bed

2. ;ating a large meal 1 hour be"ore bedtime

3. Consuming a small glass o" &arm mil# at bedtime

4. Per"orming mild e'ercises 3? minutes be"ore going to bed

Answer: .

small glass o" mil# rela'es the bod$ and promotes sleep.

2+. "he nurse recogni5es that a client is eperiencing insomnia when the client reports #select all that

apply':

1. ;'tended time to "all asleep

2. >alling asleep at inappropriate times


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3. 7i""icult$ sta$ing asleep

4. >eeling tired a"ter a nights sleep

Answer: 1, , and !.hese s$mptoms are o"ten reported b$ clients &ith insomnia. Clients report nonrestorati!e sleep. rising once at night to

urinate 0nocturia is not in and o" itsel" insomnia.

2-. "he nurse teaches the mother of a newborn that in order to prevent sudden infant death syndrome

#S&%S' the best position to place the baby after nursing is #select all that apply':

1. Prone

2. ideAl$ing

3. upine

4. >o&lers

Answer: 2 and .

-esearch demonstrate that the occurrence o" %7 is reduced &ith these t&o positions.

2/. A client has a diagnosis of primary insomnia. efore assessing this client, the nurse recalls the numerous

causes of this disorder. Select all that apply:

1. Chronic stress

2. e!ere an'iet$

3. enerali(ed pain

4. ;'cessi!e ca""eine

5. Chronic depression

6. ;n!ironmental noise


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Answer: 1, !, and +.

cute or primar$ insomnia is caused b$ emotional or ph$sical discom"ort not caused b$ the direct ph$siologic e""ects o" a

substance or a medical condition. ;'cessi!e ca""eine inta#e is an e'ample o" disrupti!e sleep h$giene8 ca""eine is a

stimulant that inhibits sleep. ;n!ironmental noise causes ph$sical andFor emotional and there"ore is related to primar$insomnia.

2. Select all that apply to the use of barbiturates in treating insomnia:

1. Barbiturates depri!e people o" 9-;) sleep

2. Barbiturates depri!e people o" -;) sleep

3. When the barbiturates are discontinued, the 9-;) sleep increases.

4. When the barbiturates are discontinued, the -;) sleep increases.

5. 9ightmares are o"ten an ad!erse e""ect &hen discontinuing barbiturates.

Answer: 2, !, and *.

Barbiturates depri!e people o" -;) sleep. When the barbiturate is stopped and -;) sleep once again occurs, a rebound

phenomenon occurs. 7uring this phenomenon, the persons dream time constitutes a larger percentage o" the total sleep

pattern, and the dreams are o"ten nightmares.

. Select all that apply that is appropriate when there is a ben5odia5epine overdose:

1. dministration o" s$rup o" ipecac

2. astric la!age

3. cti!ated charcoal and a saline cathartic

4. Hemodial$sis

5. dministration o" >luma(enil

Answer: 2, , and *.


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%" ingestion is recent, decontamination o" the % s$stem is indicated. he administration o" s$rup o" ipecac is

contraindicated because o" aspiration ris#s related to sedation. astric la!age is generall$ the best and most e""ecti!e

means o" gastric decontamination. cti!ated charcoal and a saline cathartic ma$ be administered to remo!e an$

remaining drug. Hemodial$sis is not use"ul in the treatment o" ben(odia(epine o!erdose. >luma(enil can be used toacutel$ re!erse the sedati!e e""ects o" ben(odia(epines, though this is normall$ done onl$ in cases o" e'treme o!erdose

or sedation.

1. A +3year3old child with leu0emia is hospitali5ed and is receiving combination chemotherapy. =aboratory

results indicate that the child is neutropenic, and the nurse prepares to implement protective isolation

procedures. Which interventions would the nurse initiate? Select all that apply.

1. -estrict all !isitors.

2. Place the child on a lo&Abacteria diet.

3. Change dressings using sterile techni/ue.

4. ;ncourage the consumption o" "resh "ruits and !egetables.

5. Per"orm meticulous hand &ashing be"ore caring "or the child.

6. llo& "reshAcut "lo&ers in the room as long as the$ are #ept in a !ase &ith "resh &ater.

Answer: 2, , and *.

>or the hospitali(ed neutropenic child, "lo&ers or plants should not be #ept in the room because standing &ater and damp

soil harbor spergillus and Pseudomonas, to &hich these children are !er$ susceptible. >ruits and !egetables not peeled


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be"ore being eaten harbor molds and should be a!oided until the &hite blood cell count rises. he child is placed on a lo&A

bacteria diet. 7ressings are al&a$s changed &ith sterile techni/ue. 9ot all !isitors need to be restricted, but an$one &ho

is ill should not be allo&ed in the childs room. )eticulous hand &ashing is re/uired be"ore caring "or the child. %n

addition, glo!es, a mas#, and a go&n are &orn 0per agenc$ polic$.

2. A 1+3year3old child is brought to the emergency department by his mother with a complaint that the child

6ust eperienced a tonic3clonic sei5ure. >n arrival in the emergency department no apparent sei5ures were

occurring. "he mother states that her son is ta0ing medication for the sei5ure disorder. "he nurse plans care,

0nowing that which of the following medications are used for long3term control of tonic3clonic sei5ures?

Select all that apply.

1. 7ia(epam 0*alium

2. lpra(olam 0Gana'

3. abapentin 09eurontin

4. ;thosu'imide 0arontin

5. Carbama(epine 0egretol

6. )eth$lphenidate 0-italin

Answers: , !, and *.

)edications that are prescribed "or longAterm control o" tonicAclonic sei(ures are gabapentin, ethosu'imide, and

carbama(epine. 7ia(epam is a medication that is prescribed to halt tonicAclonic episodes, and meth$lphenidate is a

medication used to treat attention de"icit h$peracti!it$ disorder. Both o" these medications are not suitable "or longAterm

control o" a sei(ure condition. lpra(olam is a medication used to treat an'iet$.


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. A child has been diagnosed with meningococcal meningitis. Which of the following isolation techniues is

appropriate?

1. ;nteric precautions

2. 9eutropenic precautions

3. 9o precautions are re/uired as long as antibiotics ha!e been started.

4. %solation precautions "or at least 24 hours a"ter the initiation o" antibiotics

Answer: !.

)eningococcal meningitis is transmitted primaril$ b$ droplet in"ection. %solation is begun and maintained "or at least 24

hours a"ter antibiotics are gi!en. +ptions 1, 2, and 3 are incorrect.

!. A client enters the emergency department confused, twitching, and having sei5ures. 4is family states he

recently was placed on corticosteroids for arthritis and was feeling better and eercising daily. >n data

collection, he has flushed s0in, dry mucous membranes, an elevated temperature, and poor s0in turgor. 4is

serum sodium level is 1-2 m;8=. (hoose the interventions that the health care provider would li0ely

prescribe. Select all that apply.

1. )onitor inta#e and output.

2. )onitor !ital signs.

3. )aintain sodiumAreduced diet.

4. )onitor electrol$te le!els.

5. %ncrease &ater inta#e orall$.

6. dminister sodium replacements.


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Answers: 1, 2, , !, and *.

H$pernatremia is described as ha!ing a serum sodium le!el that e'ceeds 145 m;/F:. igns and s$mptoms &ould include

dr$ mucous membranes, loss o" s#in turgor, thirst, "lushed s#in, ele!ated temperature, oliguria, muscle t&itching, "atigue,

con"usion, and sei(ures. %nter!entions include monitoring "luid balance, monitoring !ital signs, reducing dietar$ inta#e o"

sodium, monitoring electrol$te le!els, and increasing oral inta#e o" &ater. odium replacement therap$ &ould not be

prescribed "or a client &ith h$pernatremia.

*. A client has died, and a nurse as0s a family member about the funeral arrangements. "he family member

refuses to discuss the issue. "he nurse)s appropriate action is to:

1. ho& acceptance o" "eelings.

2. Pro!ide in"ormation needed "or decision ma#ing.

3. uggest a re"erral to a mental health pro"essional.

4. -emain &ith the "amil$ member &ithout discussing "uneral arrangements.

Answer: !.

he "amil$ member is e'hibiting the "irst stage o" grie" 0denial, and the nurse should remain &ith the "amil$ member.

+ption 1 is an appropriate inter!ention "or the acceptance or reorgani(ation and restitution stage. +ption 2 ma$ be an

appropriate inter!ention "or the bargaining stage. +ption 3 ma$ be an appropriate inter!ention "or depression.

+. A client is scheduled for a myelogram, and the nurse provides a list of instructions to the client regarding

preparation for the procedure. Which instructions should the nurse place on the list? Select all that apply.


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1. Ie&elr$ &ill need to be remo!ed.

2. n in"ormed consent &ill need to be signed.

3. trained 'Ara$ technician per"orms the procedure.

4. he procedure &ill ta#e appro'imatel$ 45 minutes.5. li/uid diet can be consumed on the da$ o" the procedure.

6. olid "ood inta#e needs to be restricted onl$ on the da$ o" the procedure.

Answer: 1, 2, and !.

Client preparation "or a m$elogram includes instructing the client to restrict "ood and "luids "or 4 to E hours be"ore the

procedure. he client is told that the procedure ta#es about 45 minutes. n in"ormed consent is re/uired because the

procedure is in!asi!e and is there"ore per"ormed b$ the health care pro!ider. he client &ill need to remo!e e&elr$ and

metal obects "rom the chest area. he client is also told that pretest medications ma$ be prescribed "or rela'ation.

-. A client with a closed head in6ury is receiving phenytoin #%ilantin', an anticonvulsant medication. Which of

the following would indicate that the client is eperiencing side effects related to this medication? Select all

that apply.

1. ta'ia

2. edation

3. Constipation

4. Bleeding gums

5. H$pergl$cemia

6. 7ecreased platelet count


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Answers: , !, *, and +.

7ilantin causes blood d$scrasias, such as decreased platelet counts and decreased &hite blood cell counts8 it contributes

to constipation as &ell. ingi!al h$perplasia can occur, causing gums to bleed easil$, and blood glucose le!els can ele!ate

&hen ta#ing phen$toin. edation is a side e""ect o" barbiturates, not phen$toin. ta'ia is a side e""ect o" ben(odia(epines.

/. A client with carcinoma of the lung develops the syndrome of inappropriate antidiuretic hormone #S&A%4'

as a complication of the cancer. "he nurse anticipates that which of the following may be prescribed? Select

all that apply.

1. -adiation

2. Chemotherap$

3. %ncreased "luid inta#e

4. erum sodium blood le!els

5. 7ecreased oral sodium inta#e

6. )edication that is antagonistic to antidiuretic hormone 07H

Answers: 1, 2, !, and +.

Cancer is a common cause o" %7H. %n clients &ith %7H, e'cessi!e amounts o" &ater are reabsorbed b$ the #idne$

and put into the s$stemic circulation. he increased &ater causes h$ponatremia 0decreased serum sodium le!els and

some degree o" "luid retention. %7H is managed b$ treating the condition and its cause, and treatment usuall$ includes

"luid restriction, increased sodium inta#e, and a medication &ith a mechanism o" action that is antagonistic to 7H.


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odium le!els are monitored closel$, because h$pernatremia can suddenl$ de!elop as a result o" treatment. he

immediate institution o" appropriate cancer therap$ 0usuall$ either radiation or chemotherap$ can cause tumor

regression so that 7H s$nthesis and release processes return to normal.

. A client with carcinoma of the lung develops the syndrome of inappropriate antidiuretic hormone #S&A%4'

as a complication of the cancer. "he nurse anticipates that which of the following may be prescribed? Select

all that apply.

1. -adiation

2. Chemotherap$

3. %ncreased "luid inta#e

4. erum sodium blood le!els

5. 7ecreased oral sodium inta#e

6. )edication that is antagonistic to antidiuretic hormone 07H

Answers: 1, 2, ! and +.

Cancer is a common cause o" %7H. %n clients &ith %7H, e'cessi!e amounts o" &ater are reabsorbed b$ the #idne$

and put into the s$stemic circulation. he increased &ater causes h$ponatremia 0decreased serum sodium le!els and

some degree o" "luid retention. %7H is managed b$ treating the condition and its cause, and treatment usuall$ includes

"luid restriction, increased sodium inta#e, and a medication &ith a mechanism o" action that is antagonistic to 7H.

odium le!els are monitored closel$, because h$pernatremia can suddenl$ de!elop as a result o" treatment. he

immediate institution o" appropriate cancer therap$ 0usuall$ either radiation or chemotherap$ can cause tumor

regression so that 7H s$nthesis and release processes return to normal.


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1. "he clinic nurse is assisting to perform a focused data collection process on a client who is complaining

of symptoms of a cold, a cough, and lung congestion. Which of the following would the nurse include for this

type of data collection? Select all that apply.

1. uscultating lung sounds

2. +btaining the clients temperature

3. Chec#ing the strength o" peripheral pulses

4. +btaining in"ormation about the clients respirations

5. Per"orming a musculos#eletal and neurological e'amination

6. s#ing the client about a "amil$ histor$ o" an$ illness or disease

Answers: 1, 2, and !.

"ocused data collection process "ocuses on a limited or shortAterm problem, such as the clients complaint. Because the

client is complaining o" s$mptoms o" a cold, a cough, and lung congestion the nurse &ould "ocus on the respirator$

s$stem and the presence o" an in"ection. complete data collection includes a complete health histor$ and ph$sical

e'amination and "orms a baseline database. Chec#ing the strength o" peripheral pulses relates to a !ascular assessment,

&hich is not related to this clients complaints. musculos#eletal and neurological e'amination also is not related to this

clients complaints. Ho&e!er, strength o" peripheral pulses and a musculos#eletal and neurological e'amination &ould be

included in a complete data collection. :i#e&ise, as#ing the client about a "amil$ histor$ o" an$ illness or disease &ould be

included in a complete assessment.


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11. A community health nurse is conducting a teaching session about terrorism with members of the

community and discussing information regarding anthra. "he nurse tells those attending that anthra can

be transmitted via which route#s'? Select all that apply.

1. #in

2.


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Answer: 1.

oddlers, &ith their increased mobilit$ and de!eloping motor s#ills, can reach hot &ater, open "ires, or hot obects placed

on counters and sto!es abo!e their e$e le!el. Parents should be encouraged to remain in the #itchen &hen preparing a

meal and reminded to use the bac# burners on the sto!e. Pot handles should be turned in&ard and to&ard the middle o"

the sto!e. Hot li/uids should ne!er be le"t unattended, and the toddler should al&a$s be super!ised. +ptions 2, 3, and 4

do not re"lect an ade/uate understanding o" the principles o" sa"et$.

1. A licensed practical nurse is attending an agency orientation meeting about the nursing model of practice

implemented in the facility. "he nurse is told that the nursing model is a team nursing approach. "he nurse

understands that which of the following is a characteristic of this type of nursing model of practice?

1. tas# approach method is used to pro!ide care to clients.

2. )anaged care concepts and tools are used &hen pro!iding client care.

3. 9ursing sta"" are led b$ a nurse &hen pro!iding care to a group o" clients.

4. single registered nurse is responsible "or pro!iding nursing care to a group o" clients.

Answer: .

%n team nursing, nursing personnel are led b$ a nurse &hen pro!iding care to a group o" clients. +ption 1 identi"ies

"unctional nursing. +ption 2 identi"ies a component o" case management. +ption 4 identi"ies primar$ nursing.


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1!. A licensed practical nurse is planning the client assignments for the day. Which of the following is the

most appropriate assignment for the nursing assistant?

1. client &ho re/uires &ound irrigation

2. client &ho re/uires "re/uent ambulation

3. client &ho is recei!ing continuous tube "eedings

4. client &ho re/uires "re/uent !ital signs a"ter a cardiac catheteri(ation

Answer: 2.

he nurse must determine the most appropriate assignment on the basis o" the s#ills o" the sta"" member and the needs

o" the client. %n this case, the most appropriate assignment "or a nursing assistant &ould be to care "or the client &ho

re/uires "re/uent ambulation. he nursing assistant is s#illed in this tas#. he client &ho had a cardiac catheteri(ation &ill

re/uire speci"ic monitoring in addition to that o" the !ital signs. Wound irrigations and tube "eedings are not per"ormed b$

unlicensed personnel.

1*. A male client who has heart failure receives an additional dose of bumetanide as prescribed ! hours after

the daily dose. "he nurse assesses him 1* minutes after administering the medication and reminds him to

save all urine in the bathroom. "hirty minutes later the nurse finds the client on the floor, unresponsive, and

bleeding from a laceration. %etermine the issues that support the client)s malpractice claim. Select all that

apply.

1. >ailure to replace bod$ "luids

2. %ncreased ris# o" h$potension


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3. >ailure to teach the client ade/uatel$

4. %ncreased need to protect the client

5. ;'cessi!e bumetanide administration

6. :ac# o" "ollo&Aup nursing actions

Answers: 2, , !, and +.

o pro!e malpractice against a nurse, the plainti"" must pro!e that the nurse o&ed a dut$ to the client, that the nurse

breached the dut$, and that as a result harm &as caused to person or propert$. he client has an increased ris# o"

h$potension 0option 2 because h$potension is a common ad!erse e""ect o" bumetanide, this is the second dose &ithin 4

hours, and the client has heart "ailure. he client can pro!e that the nurse did not protect him b$ "ailing to pro!ide

ade/uate teaching and per"orm correct and timel$ nursing inter!entions 0options 3, 4, and 6 a"ter administering the

bumetanide. "ter the "irst 15Aminute chec#, the nurse should continue increased client monitoring to ensure client

compliance &ith sa"et$ measures. -eplacing "luid !olume is not the issue8 "urthermore, the goal o" therap$ is to reduce

total bod$ "luid. 9o data indicate that the dose o" bumetanide, a loop diuretic, &as e'cessi!e. Ho&e!er, because this

medication can cause h$potension, especiall$ a"ter a repeat dose, the nurse should instruct the client to remain in bed

and pro!ide him &ith a urinal. %t ma$ be di""icult "or the client to pro!e that the second dose o" bumetanide caused the

inur$.

1+. A nurse develops a plan of care for a client following a lumbar puncture. Which interventions should be

included in the plan? Select all that apply.

1. )onitor the clients abilit$ to !oid.

2. )aintain the client in a "lat position.


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3. -estrict "luid inta#e "or a period o" 2 hours.

4. )onitor the clients abilit$ to mo!e the e'tremities.

5. %nspect the puncture site "or s&elling, redness, and drainage.

6. )aintain the client on a nothingAb$Amouth 09P+ status "or 24 hours.

Answers: 1, 2, !, and *.

>ollo&ing a lumbar puncture, the client remains "lat in bed "or 6 to 24 hours, depending on the health care pro!iders

prescriptions. liberal "luid inta#e 0not 9P+ status is encouraged to replace cerebrospinal "luid remo!ed during the

procedure, unless contraindicated b$ the clients condition. he nurse chec#s the puncture site "or redness and drainage,

and monitors the clients abilit$ to !oid and mo!e the e'tremities.

1-. A nurse employed in an emergency department is assigned to assist with the triage of clients arriving to

the emergency department for treatment on the evening shift. "he nurse would assign the highest priority to

which of the following clients?

1. client complaining o" muscle aches, a headache, and malaise

2. client &ho t&isted her an#le &hen she "ell &hile rollerblading

3. client &ith a minor laceration on the inde' "inger sustained &hile cutting an eggplant

4. client &ith chest pain &ho states that he ust ate pi((a that &as made &ith a !er$ spic$ sauce

Answers: !.

%n an emergenc$ department, triage in!ol!es classi"$ing clients according to their need "or care, and it includes

establishing priorities o" care. he t$pe o" illness, the se!erit$ o" the problem, and the resources a!ailable go!ern the


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process. Clients &ith trauma, chest pain, se!ere respirator$ distress, cardiac arrest, limb amputation, or acute

neurological de"icits and those &ho sustained a chemical splash to the e$es are classi"ied as emergent, and these clients

are the number 1 priorit$. Clients &ith conditions such as simple "ractures, asthma &ithout respirator$ distress, "e!er,

h$pertension, abdominal pain, or renal stones ha!e urgent needs, and these clients are classi"ied as the number 2priorit$. Clients &ith conditions such as minor lacerations, sprains, or cold s$mptoms are classi"ied as non urgent, and

the$ are the number 3 priorit$.

1/. A nurse enters a client)s room and notes that the client)s lawyer is present and that the client is

preparing a living will. "he living will reuires that the client)s signature be witnessed, and the client as0s

the nurse to witness the signature. Which of the following is the appropriate nursing action?

1. 7ecline to sign the &ill.

2. ign the &ill as a &itness to the signature onl$.

3. Call the hospital la&$er be"ore signing the &ill.

4. ign the &ill, clearl$ identi"$ing credentials and emplo$ment agenc$.

Answers: 1

:i!ing &ills are re/uired to be in &riting and signed b$ the client. he clients signature either must be &itnessed b$

speci"ied indi!iduals or notari(ed. )an$ states prohibit an$ emplo$ee "rom being a &itness, including a nurse in a "acilit$

in &hich the client is recei!ing care.

1. A nurse has reinforced instructions to the client with hyperparathyroidism regarding home care

measures related to eercise. Which statement by the client indicates a need for further instruction? Select

all that apply.


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1. % eno$ e'ercising but % need to be care"ul.

2. % need to pace m$ acti!ities throughout the da$.

3. % need to limit pla$ing "ootball to onl$ the &ee#ends.

4. % should gauge m$ acti!it$ le!el b$ m$ energ$ le!el.

5. % should e'ercise in the e!ening to encourage a good sleep pattern.

Answers: and *.

he client should be instructed to a!oid highAimpact acti!it$ or contact sports such as "ootball. ;'ercising late in the

e!ening ma$ inter"ere &ith rest"ul sleep. he client &ith h$perparath$roidism should pace acti!ities throughout the da$

and plan "or periods o" uninterrupted rest. he client should plan "or at least 3? minutes o" &al#ing each da$ to support

calcium mo!ement into the bones. he client should be instructed to use energ$ le!el as a guide to acti!it$.

2. A nurse in a medical unit is caring for a client with heart failure. "he client suddenly develops etreme

dyspnea, tachycardia, and lung crac0les, and the nurse suspects pulmonary edema. "he nurse immediately

notifies the registered nurse and epects which interventions to be prescribed? Select all that apply.

1. dministering o'$gen

2. %nserting a >ole$ catheter

3. dministering "urosemide 0:asi'

4. dministering morphine sul"ate intra!enousl$

5. ransporting the client to the coronar$ care unit

6. Placing the client in a lo& >o&lers sideAl$ing position


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Answers: 1, 2, , and !.

Pulmonar$ edema is a li"eAthreatening e!ent that can result "rom se!ere heart "ailure. %n pulmonar$ edema the le"t

!entricle "ails to eect su""icient blood, and pressure increases in the lungs because o" the accumulated blood. +'$gen is

al&a$s prescribed, and the client is placed in a high >o&lers position to ease the &or# o" breathing. >urosemide, a rapidA

acting diuretic, &ill eliminate accumulated "luid. >ole$ catheter is inserted to accuratel$ measure output. %ntra!enousl$

administered morphine sul"ate reduces !enous return 0preload, decreases an'iet$, and reduces the &or# o" breathing.

ransporting the client to the coronar$ care unit is not a priorit$ inter!ention. %n "act, this ma$ not be necessar$ at all i"

the clients response to treatment is success"ul.

1. A nurse is admitting a client with a possible diagnosis of chronic bronchitis. "he nurse collects data from

the client and notes that which of the following signs supports this diagnosis? Select all that apply.

1. cant mucus

2. ;arl$ onset cough

3. )ar#ed &eight loss

4. Purulent mucus production

5. )ild episodes o" d$spnea

Answers: 2, !, and *.


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2. A nurse is assigned to care for a client admitted to the hospital after sustaining an in6ury from a house

fire. "he client attempted to save a neighbor involved in the fire but, in spite of the client)s efforts, the

neighbor died. Which action would the nurse ta0e to enable the client to wor0 through the meaning of the

crisis?

1. %denti"$ing the clients abilit$ to "unction

2. %denti"$ing the clients potential "or sel"Aharm

3. %n/uiring about the clients "eelings that ma$ a""ect coping

4. %n/uiring about the clients perception o" the cause o" the neighbors death

Answer: .

he client must "irst deal &ith "eelings and negati!e responses be"ore the client is able to &or# through the meaning o"

the crisis. +ption 3 pertains directl$ to the clients "eelings. +ptions 1, 2, and 4 do not directl$ address the clients

"eelings.

. A nurse is assigned to care for a client with a peripheral & infusion. "he nurse is providing hygiene care to

the client and would avoid which of the following while changing the client)s hospital gown?

1. sing a hospital go&n &ith snaps at the slee!es

2. 7isconnecting the %* tubing "rom the catheter in the !ein

3. Chec#ing the %* "lo& rate immediatel$ a"ter changing the hospital go&n

4. Putting the bag and tubing through the slee!e, "ollo&ed b$ the clients arm


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Answer: 2.

he tubing should not be remo!ed "rom the %* catheter. With each brea# in the s$stem, there is an increased chance o"

introducing bacteria into the s$stem, &hich can lead to in"ection. +ptions 1 and 4 are appropriate. he "lo& rate should

be chec#ed immediatel$ a"ter changing the hospital go&n, because the position o" the roller clamp ma$ ha!e been

a""ected during the change.

!. A nurse is assigned to care for four clients. When planning client rounds, which client would the nurse

chec0 first?

1. client on a !entilator

2. client in s#eletal traction

3. postoperati!e client preparing "or discharge

4. client admitted on the pre!ious shi"t &ho has a diagnosis o" gastroenteritis

Answer: 1.

he air&a$ is al&a$s a high priorit$, and the nurse "irst chec#s the client on a !entilator. he clients described in options

2, 3, and 4 ha!e needs that &ould be identi"ied as intermediate priorities.

*. A nurse is assisting with collecting data from an African3American client admitted to the ambulatory care

unit who is scheduled for a hernia repair. Which of the following information about the client is of least

priority during the data collection?


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1. -espirator$

2. Ps$chosocial

3. 9eurological

4. Cardio!ascular

Answer: 2.

he ps$chosocial data is the least priorit$ during the initial admission data collection. %n the "ricanAmerican culture, it is

considered intrusi!e to as# personal /uestions during the initial contact or meeting. dditionall$, respirator$, neurological,

and cardio!ascular data include ph$siological assessments that

&ould be the priorit$.

+. A nurse is assisting with planning care for a client with an internal radiation implant. Which of the

following should be included in the plan of care? Select all that apply.

1. Wearing glo!es &hen empt$ing the clients bedpan

2.


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the accidental e'posure o" other clients to radiation. he remaining options identi"$ inter!entions that are necessar$ "or a

client &ith a radiation de!ice.

-. "he nurse is caring for a client after a supratentorial craniotomy in which a large tumor was removed from

the left side. (hoose the positions in which the nurse can safely place the client. Select all that apply.

1. +n the le"t side

2. With the nec# "le'ed

3. upine on the le"t side

4. With e'treme hip "le'ion

5. %n a semiA>o&lers position

6. With the head in a midline position

Answers: * and +.

Clients &ho ha!e undergone supratentorial surger$ should ha!e the head o" the bed ele!ated 3? degrees to promote

!enous drainage "rom the head. he client is positioned to a!oid e'treme hip or nec# "le'ion, and the head is maintained

in a midline, neutral position. %" a large tumor has been remo!ed, the client should be placed on the nonoperati!e side to

pre!ent the displacement o" the cranial contents.

/. A nurse is caring for a client after thyroidectomy and notes that calcium gluconate is prescribed for the

client. "he nurse determines that this medication has been prescribed to:


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1. reat th$roid storm.

2. Pre!ent cardiac irritabilit$.

3. reat h$pocalcemic tetan$.

4. timulate the release o" parath$roid hormone.

Answer: .

. A nurse is caring for a client with a healthcare3associated infection caused by methicillin3resistant

Staphylococcus aureus who is on contact precautions. "he nurse prepares to provide colostomy care to the

client. Which of the following protective items will be reuired to perform this procedure?

1. lo!es and a go&n

2. lo!es and goggles

3. lo!es, a go&n, and goggles

4. lo!es, a go&n, and shoe protectors

Answer: .

oggles are &orn to protect the mucous membranes o" the e$e during inter!entions that ma$ produce

splashes o" blood, bod$ "luids, secretions, and e'cretions. %n addition, contact precautions re/uire the use o" glo!es, and

a go&n should be &orn i" direct client contact is anticipated. hoe protectors are not

necessar$.


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1. A nurse is caring for a client with a nasogastric tube that is attached to low suction. "he nurse monitors

the client closely for which acid3base disorder that is most li0ely to occur in this situation?

1. )etabolic acidosis

2. )etabolic al#alosis

3. -espirator$ acidosis

4. -espirator$ al#alosis

Answer: 2

he loss o" gastric "luid !ia nasogastric suction or !omiting causes metabolic al#alosis as a result o" the loss o"

h$drochloric acid8 this results in an al#alotic condition. +ptions 3 and 4 deal &ith respirator$ problems. +ption 1 relates to

acidosis.

11. A nurse is caring for a client with diabetic 0etoacidosis and documents that the client is eperiencing

@ussmaul)s respirations. ased on this documentation, which of the following did the nurse most li0ely

observe?

1. -espirations that cease "or se!eral seconds

2. -espirations that are regular but abnormall$ slo&

3. -espirations that are labored and increased in depth and rate

4. -espirations that are abnormall$ deep, regular, and increased in rate


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Answer: !.


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1. A nurse is caring for a client with leu0emia and notes that the client has poor s0in turgor and flat nec0

and hand veins. "he nurse suspects hyponatremia. What additional signs would the nurse epect to note in

this client if hyponatremia is present?

1. %ntense thirst

2. lo& bounding pulse

3. 7r$ mucous membranes

4. Postural blood pressure changes

Answer: !.

Postural blood pressure changes occur in the client &ith h$ponatremia. 7r$ mucous membranes and intense thirst are

seen in clients &ith h$pernatremia. slo&, bounding pulse is not indicati!e o" h$ponatremia. %n a client &ith

H$ponatremia, a rapid thread$ pulse is noted.

1!. A nurse is caring for a group of clients who are ta0ing herbal medications at home. Which of the

following clients should be instructed not to ta0e herbal medications?

1. 6?A$earAold male client &ith rhinitis

2. 24A$earAold male client &ith a lo&er bac# inur$

3. 1?A$earAold "emale client &ith a urinar$ tract in"ection

4. 45A$earAold "emale client &ith a histor$ o" migraine headaches


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Answer: .

Children should not be gi!en herbal therapies, especiall$ in the home and &ithout pro"essional super!ision. here are no

general contraindications "or the clients described in options 1, 2, and 4.

1*. A nurse is caring for an infant with a diagnosis of tetralogy of allot. "he infant suddenly becomes

cyanotic and the oygen saturation reading drops to +B. (hoose the interventions that the nurse should

perform. Select all that apply.

1. Call a code blue.

2. 9oti"$ the registered nurse.

3. Place the in"ant in a prone position.

4. Prepare to administer morphine sul"ate.

5. Prepare to administer intra!enous "luids.

6. Prepare to administer 1??@ o'$gen b$ "ace mas#.

Answers: 2, !, *, and +.

he child &ho is c$anotic &ith o'$gen saturations dropping to 6?@ is ha!ing a h$perc$anotic episode. H$perc$anotic

episodes o"ten occur among in"ants &ith tetralog$ o" >allot, and the$ ma$ occur among in"ants &hose heart de"ect

includes the obstruction o" pulmonar$ blood "lo& and communication bet&een the !entricles. %" a h$perc$anotic episode

occurs, the in"ant is placed in a #neeAchest position immediatel$. he registered nurse is noti"ied, &ho &ill then contact

the health care pro!ider. he #neeAchest position impro!es s$stemic arterial o'$gen saturation b$ decreasing !enous

return so that smaller amounts o" highl$ saturated blood reach the heart. oddlers and children s/uat to get into this

position and relie!e chronic h$po'ia. here is no reason to call a code blue unless respirations cease. dditional

inter!entions include administering 1??@ o'$gen b$ "ace mas#, morphine sul"ate, and intra!enous "luids, as prescribed.


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1+. A nurse is collecting data on a client with severe preeclampsia. (hoose the findings that would be noted

in severe preeclampsia. Select all that apply.

1. +liguria

2. ei(ures

3. Contractions

4. Proteinuria 3K

5. )uscle cramps

6. Blood pressure 16EF116 mm Hg

Answers: 1, !, and +.

e!ere preeclampsia is characteri(ed b$ blood pressure higher than 16?F11? mm Hg, proteinuria 3K or higher, and

oliguria. ei(ures 0con!ulsions are present in eclampsia and are not a characteristic o" se!ere preeclampsia. )uscle

cramps and contractions are not "indings noted in se!ere preeclampsia, although the client is monitored "or these

occurrences.

1-. A nurse is monitoring a client with


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1. Brad$cardia

2. >e!er

3. &eating

4. gitation

5. Pallor

Answers: 2, , and !.

h$roto'ic crisis 0th$roid storm is an acute, potentiall$ li"eAthreatening state o" e'treme th$roid acti!it$ that represents a

brea#do&n in the bod$s tolerance to a chronic e'cess o" th$roid hormones. he clinical mani"estations include "e!er

greater than 1??L >, se!ere tach$cardia, "lushing and s&eating, and mar#ed agitation and restlessness. 7elirium and

coma can occur.

1/. A nurse is monitoring a group of clients for acid3base imbalances. Which clients are at highest ris0 for

metabolic acidosis? Select all that apply.

1. e!erel$ an'ious client

2. Pneumonia client

3. 7iabetic mellitus client

4. )alnourished client

5. sthma client

6. -enal "ailure client


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Answers: , !, and +.

7iabetes mellitus, malnutrition, and renal "ailure lead to metabolic acidosis because o" the increasing acids in the bod$.

+ptions 1, 2, and 5 are respirator$ problems, not metabolic, and result in either respirator$ acidosis or respirator$

al#alosis.

1. "he nurse is preparing a teaching plan for a client who is undergoing cataract etraction with intraocular

implant. Which home care measures will the nurse include in the plan? Select all that apply.

1. o a!oid acti!ities that re/uire bending o!er

2. o contact the surgeon i" e$e scratchiness occurs

3. o place an e$e shield on the surgical e$e at bedtime

4. hat episodes o" sudden se!ere pain in the e$e is e'pected

5. o contact the surgeon i" a decrease in !isual acuit$ occurs

6. o ta#e acetaminophen 0$lenol "or minor e$e discom"ort

Answers: 1, , *, and +.

"ter e$e surger$, some scratchiness and mild e$e discom"ort ma$ occur in the operati!e e$e and is usuall$ relie!ed b$

mild analgesics. %" the e$e pain becomes se!ere, the client should noti"$ the surgeon because this ma$ indicate

hemorrhage, in"ection, or increased intraocular pressure. he nurse &ould also instruct the client to noti"$ the surgeon o"

purulent drainage, increased redness, or an$ decrease in !isual acuit$. he client is instructed to place an e$e shield o!er

the operati!e e$e at bedtime to protect the e$e "rom inur$ during sleep and to a!oid acti!ities that increase intraocular

pressure such as bending o!er.

2. "he nurse is preparing a teaching plan for a client who is undergoing cataract etraction with intraocular

implant. Which home care measures will the nurse include in the plan? Select all that apply.


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1. o a!oid acti!ities that re/uire bending o!er

2. o contact the surgeon i" e$e scratchiness occurs

3. o place an e$e shield on the surgical e$e at bedtime

4. hat episodes o" sudden se!ere pain in the e$e is e'pected

5. o contact the surgeon i" a decrease in !isual acuit$ occurs

6. o ta#e acetaminophen 0$lenol "or minor e$e discom"ort

Answers: 1, , *, and +.

"ter e$e surger$, some scratchiness and mild e$e discom"ort ma$ occur in the operati!e e$e and is usuall$ relie!ed b$

mild analgesics. %" the e$e pain becomes se!ere, the client should noti"$ the surgeon because this ma$ indicate

hemorrhage, in"ection, or increased intraocular pressure. he nurse &ould also instruct the client to noti"$ the surgeon o"

purulent drainage, increased redness, or an$ decrease in !isual acuit$. he client is instructed to place an e$e shield o!er

the operati!e e$e at bedtime to protect the e$e "rom inur$ during sleep and to a!oid acti!ities that increase intraocular

pressure such as bending o!er.

1. A nurse is providing a list of instructions to a client who is scheduled to have an electroencephalogram

#;;


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5. ll medications need to be &ithheld on the da$ o" the test.

6. nothingAb$Amouth 09P+ status is re/uired on the da$ o" the test.

Answers: 2, , and !.

PreAprocedure instructions include in"orming the client that the procedure is painless. he procedure re/uires no dietar$

restrictions other than a!oidance o" cola, tea, and co""ee on the morning o" the test. hese products ha!e a stimulating

e""ect and should be a!oided. he hair should be &ashed the e!ening be"ore the test, and gels, hairspra$s, and lotion

should be a!oided. he client is in"ormed that the test &ill ta#e 45 minutes to 2 hours and that medications are usuall$

not &ithheld be"ore the test.

2. "he 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.

1. %ncrease &ater inta#e.

2. %ncrease calcium inta#e.

3. a#e pulse rate each da$.

4. Weigh at the same time each da$.

5. Palpitations ma$ occur earl$ in therap$.

6. Be care"ul &hen rising "rom sitting to standing.

Answers: , !, *, and +.

9i"edipine is a calciumAchannel bloc#er. %ts therapeutic outcome is to decrease blood pressure. %ts method o" action is

bloc#ade o" the calcium channels in !ascular smooth muscle, promoting !asodilation. ide e""ects that can occur earl$ in


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therap$ include re"le' tach$cardia 0palpitations and "irstAdose h$potension, leading to orthostatic h$potension. Weight

should be chec#ed regularl$ to monitor "or earl$ signs o" heart "ailure. lso the client is taught to ta#e his or her o&n

pulse. 9i"edipine does not a""ect serum calcium le!els. %ncreased &ater inta#e is not indicated in the client &ith

cardio!ascular disease.

. A nurse is providing teaching regarding the prevention of =yme disease to a group of teenagers going on a

hi0e in a wooded area. Which of the following points should the nurse include in the session? Select all that

apply.

1. uc# pant legs into soc#s.

2. Wear closed shoes &hen hi#ing.

3. ppl$ insect repellent containing 7;;.

4. Co!er the ground &ith a blan#et &hen sitting.

5. -emo!e attached tic#s b$ grasping &ith thumb and "ore"inger.

6. Wear long slee!es and long pants in dar# colors &hen in highAris# areas.

Answers: 1, 2, , and !.

)easures to pre!ent tic# bites "ocus on co!ering the bod$ as completel$ as possible and spra$ing insect repellent

containing 7;; on the s#in and clothing. :ong slee!es and pants tuc#ed into the soc#s along &ith closed shoes &ill o""er

some protection. :ightAcolored clothing should be &orn so that tic#s &ould be easil$ !isible. Hi#ers should not sit directl$

on the ground and should co!er the ground &ith an item such as a blan#et. ic#s should be remo!ed &ith t&ee(ers.

!. A nurse is reinforcing instructions to a client following a total laryngectomy about caring for the stoma.

(hoose the instructions that the nurse provides to the client. Select all that apply.


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1. Protect the stoma "rom &ater.

2. oaps should be a!oided near the stoma.

3. Wash the stoma dail$ using a &ashcloth.

4. se diluted alcohol on the stoma to clean it.

5. ppl$ a thin la$er o" petroleum ell$ to the s#in surrounding the stoma.

6. se so"t tissues to clean an$ secretions that accumulate around the stoma.

Answers: 1, 2, , and *.

he client &ith a stoma should be instructed to &ash the stoma dail$ &ith a &ashcloth. oaps, cotton s&abs, or tissues

should be a!oided because their particles ma$ enter and obstruct the air&a$. he client should be instructed to a!oid

appl$ing alcohol to a stoma because it is both dr$ing and irritating. thin la$er o" petroleum ell$ applied to the s#in

around the stoma helps pre!ent crac#ing. he client is instructed to protect the stoma "rom &ater.

*. A nurse is reviewing the health records of assigned clients. "he nurse plans care 0nowing that which client

is at ris0 for fluid volume deficit?

1. he client &ith cirrhosis

2. he client &ith a colostom$

3. he client &ith decreased #idne$ "unction

4. he client &ith congesti!e heart "ailure 0CH>

Answer 2.

Causes o" a "luid !olume de"icit include !omiting, diarrhea, conditions that cause increased respirations or increased

urinar$ output, insu""icient intra!enous "luid replacement, draining "istulas, ileostom$, and colostom$. client &ith

cirrhosis, CH>, or decreased #idne$ "unction is at ris# "or "luid !olume e'cess.


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+. A nurse is told in report that a client has a positive (hvoste0)s sign. What other data would the nurse

epect to find on data collection? Select all that apply.

1. Coma

2. etan$

3. 7iarrhea

4. Possible sei(ure acti!it$

5. H$poacti!e bo&el sounds

6. Positi!e rousseaus sign

Answers: 2, , ! and +.

positi!e Ch!oste#s sign is indicati!e o" h$pocalcemia. +ther signs and s$mptoms include tach$cardia, h$potension,

paresthesias, t&itching, cramps, tetan$, sei(ures, positi!e rousseaus sign, diarrhea, h$peracti!e bo&el sounds, and a

prolonged M inter!al.

-. A nurse lawyer provides an education session to the nursing staff regarding client rights. A nurse as0s the

lawyer to describe an eample that may relate to invasion of client privacy. A nursing action that indicates a

violation of this right is:

1. hreatening to place a client in restraints

2. Per"orming a surgical procedure &ithout consent

3. a#ing photographs o" the client &ithout consent

4. elling the client that he or she cannot lea!e the hospital

Answer: .

%n!asion o" pri!ac$ ta#es place &hen an indi!iduals pri!ate a""airs are intruded on unreasonabl$. hreatening to place a


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client in restraints constitutes assault. Per"orming a surgical procedure &ithout consent is an e'ample o" batter$. 9ot

allo&ing a client to lea!e the hospital constitutes "alse imprisonment.

/. A nurse notes in the medical record that a client with (ushing)s syndrome is eperiencing fluid overload.

Which interventions should be included in the plan of care? Select all that apply.

1. )onitoring dail$ &eight

2. )onitoring inta#e and output

3. )aintaining a lo&Apotassium diet

4. )onitoring e'tremities "or edema

5. )aintaining a lo&Asodium diet


he client &ith Cushings s$ndrome e'periencing "luid o!erload should be maintained on a highApotassium and lo&A

sodium diet. 7ecreased sodium inta#e decreases renal retention o" sodium and &ater. )onitoring &eight, inta#e, output,

and e'tremities "or edema are all appropriate inter!entions "or such a nursing diagnosis.

. A nurse notes in the medical record that a client with (ushing)s syndrome is eperiencing fluid overload.

Which interventions should be included in the plan of care? Select all that apply.

1. )onitoring dail$ &eight2. )onitoring inta#e and output

3. )aintaining a lo&Apotassium diet

4. )onitoring e'tremities "or edema

5. )aintaining a lo&Asodium diet


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he client &ith Cushings s$ndrome e'periencing "luid o!erload should be maintained on a highApotassium and lo&A

sodium diet. 7ecreased sodium inta#e decreases renal retention o" sodium and &ater. )onitoring &eight, inta#e, output,

and e'tremities "or edema are all appropriate inter!entions "or such a nursing diagnosis.

1. Which instruction should the nurse provide to the client with diabetes mellitus receiving acarbose

#9recose'? Select all that apply.

1. a#e the medication at bedtime.

2. a#e the medication &ith each meal.

3. a#e the medication on an empt$ stomach.

4. ide e""ects include abdominal bloating and "latus.

5. a#e some "orm o" glucose i" h$pogl$cemia occurs.

6. -eport s$mptoms such as shortness o" breath or tiredness.


he mechanism o" action o" acarbose is a dela$ in absorption o" dietar$ carboh$drates, thereb$ reducing the rise in blood

glucose a"ter a meal. o accomplish this, the medication must be ta#en &ith each meal. Because o" its bacterial

"ermentation o" unabsorbed carboh$drates in the colon, side e""ects such as borbor$gmus, cramps, abdominal distention,

and "latulence can occur. he medication also can a""ect absorption o" iron, leading to s$mptoms 0shortness o" breath,

tiredness o" anemia.

11. 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. (hoose the instructions that would be included on the list. Select all that apply.

1. se the "ingertips to li"t the cast &hile it is dr$ing.

2.


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3. se a padded ruler or another padded obect to scratch the s#in under the cast i" it itches.

4. Place a heating pad on the lo&er end o" the cast and o!er the "ingers i" the "ingers "eel cold.

5. Contact the health care pro!ider i" the child complains o" numbness or tingling in the e'tremit$.

6. ;le!ate the e'tremit$ on pillo&s "or the "irst 24 to 4E hours a"ter casting to pre!ent s&elling.

Answers: 2, *, and +.

While the cast is dr$ing, the palms o" the hands are used to li"t the cast. %" the "ingertips are used, indentations in the

cast could occur and cause constant pressure on the underl$ing s#in. mall to$s and sharp obects are #ept a&a$ "rom

the cast, and no obects 0including padded obects are placed inside o" the cast because o" the ris# o" altered s#in

integrit$. heating pad is not applied to the cast or "ingers. Cold "ingers could indicate neuro!ascular impairment, and

the HCP should be noti"ied. he e'tremit$ is ele!ated to pre!ent s&elling, and the HCP is noti"ied immediatel$ i" an$ signs

o" neuro!ascular impairment de!elop.

12. A nurse reinforces instructions to the mother of a child who has been hospitali5ed with croup. Which of

the following statements, if made by the mother, would indicate the need for further instruction?

1. % &ill gi!e m$ child cough s$rup i" a cough de!elops.

2. 7uring an attac#, % &ill ta#e m$ child to a cool location.

3. % &ill gi!e acetaminophen 0$lenol i" m$ child de!elops a "e!er.

4. % &ill be sure that m$ child drin#s at least three to "our glasses o" "luids e!er$ da$.

Answer: 1.

Cough s$rups and cold medicines are not to be gi!en, because the$ ma$ dr$ and thic#en secretions.

7uring a croup attac#, the child can be ta#en to a cool basement or garage. cetaminophen is used i" a "e!er de!elops.

de/uate h$dration o" 5?? to 1??? m: o" "luids dail$ is important "or thinning secretions.

NCLEX S l t All Th t A l P ti E


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1. "he nurse would anticipate the use of which medications in the treatment of the client with heart failure?

Select all that apply.

1. 7iuretics

2. nticoagulants

3. nticholinergics

4. Cardiac gl$cosides

5. Phosphodiesterase 0P7; inhibitors

6. ngiotensinAcon!erting en($me 0C; inhibitors


)edications recommended "or treatment o" heart "ailure include diuretics, cardiac gl$cosides such as digo'in 0:ano'in,

P7; inhibitors, and C; inhibitors. Clients in heart "ailure do not need anticoagulants or anticholinergics.

1!. "he parent of a toddler as0s a nurse when it is safe to place the car safety seat in a face3forward

position. Which of the following is the best nursing response?

1. When the toddler &eighs 2? lb and is 1 $ear old

2. When the &eight o" the toddler is more than 4? lb

3. he seat should not be placed in a "aceA"or&ard position unless there are sa"et$ loc#s in the car.

4. he seat should ne!er be placed in a "aceA"or&ard position because o" the ris# o" the child unbuc#ling the harness.

Answer: 1.

he transition point "or s&itching to the "or&ardA"acing position is de"ined b$ the manu"acturer o" the con!ertible car

sa"et$ seat, but it is generall$ at a bod$ &eight o" #g 02? lb and an age o" 1 $ear. +ptions 2, 3, and 4 are incorrect.

NCLEX S l t All Th t A l P ti E


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1*. A pregnant woman has a positive history of genital herpes, but she has not had lesions during her

pregnancy. "he nurse plans to provide which of the following information to the client?

1. Nou &ill be isolated "rom $our ne&born a"ter deli!er$.

2. here is little ris# to $our bab$ during $our pregnanc$, birth, and a"ter deli!er$.

3. *aginal deli!eries can reduce neonatal in"ection ris#s, e!en i" $ou ha!e an acti!e lesion at birth.

4. Nou &ill be e!aluated at the time o" deli!er$ "or herpetic genital tract lesions. %" the$ are present, a cesarean deli!er$

&ill be needed.

Answer: !.

%" herpetic genital lesions are present at the time o" deli!er$, a cesarean deli!er$ &ill be necessar$ to reduce the ris# o"

in"ecting the neonate. %n the absence o" herpetic genital lesions, a !aginal deli!er$ ma$ be indicated, unless there are

other reasons "or per"orming a cesarean deli!er$. )aternal isolation is not necessar$, but potentiall$ e'posed neonates

should be cultured on the da$ o" deli!er$.

1+. Which of these clients are most li0ely to develop fluid #circulatory' overload? Select all that apply.

1. premature in"ant

2. 1?1A$earAold man

3. client on renal dial$sis

4. client &ith diabetes mellitus

5. 2A$earAold &oman &ith pneumonia

6. client &ith congesti!e heart "ailure

Answers: 1, 2, , and +.

Clients &ith cardiac, respirator$, renal, or li!er diseases and older and !er$ $oung clients cannot tolerate an e'cessi!e

"luid !olume. he ris# o" "luid 0circulator$ o!erload e'ists &ith these clients

NCLEX Select All That Apply Practice Exam


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1-. An unconscious client who is bleeding profusely is brought to the emergency department after a serious

accident. Surgery is reuired immediately to save the client)s life. With regard to informed consent for the

surgical procedure, which of the following is the best action?

1. Call the nursing super!isor to initiate a court order "or the surgical procedure.

2. r$ calling the clients spouse to obtain telephone consent be"ore the surgical procedure.

3. s# the "riend &ho accompanied the client to the emergenc$ department to sign the consent "orm.

4. ransport the client to the operating department immediatel$, as re/uired b$ the health care pro!ider &ithout obtaining

an in"ormed consent.

Answer: !.

enerall$ there are onl$ t&o instances in &hich the in"ormed consent o" an adult client is not needed. +ne instance is

&hen an emergenc$ is present and dela$ing treatment "or the purpose o" obtaining in"ormed consent &ould result in

inur$ or death to the client. he second instance is &hen the client &ai!es the right to gi!e in"ormed consent. +ptions 1,

2, and 3 are inappropriate.

1/. When caring for a 3year3old child, the nurse should provide which toy for this child?

1. pu((le

2. &agon

3. gol" set

4. "arm set

Answer: 2.

o$s "or the toddler must be strong, sa"e, and too large to s&allo& or place in the ear or nose. oddlers need super!ision

at all times. PushApull to$s, large balls, large cra$ons, truc#s, and dolls are some appropriate to$s. pu((le &ith large

pieces onl$ ma$ be appropriate. "arm set and a gol" set ma$ contain items that the child could s&allo&.



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1. 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.

1. %ncreased heart rate

2. 7ecline in !isual acuit$

3. 7ecreased respirator$ rate

4. 7ecline in longAterm memor$

5. %ncreased susceptibilit$ to urinar$ tract in"ections

6. %ncreased incidence o" a&a#ening a"ter sleep onset

Answers: 2, *, and +.

natomical changes to the e$e a""ect the indi!iduals !isual abilit$, &hich leads to potential problems &ith acti!ities o"

dail$ li!ing. :ight adaptation and !isual "ields are reduced. -espirator$ rates are usuall$ unchanged. he heart rate

decreases, and the heart !al!es thic#en. geArelated changes that a""ect the urinar$ tract increase an older clients

susceptibilit$ to urinar$ tract in"ections. hortAterm memor$ ma$ decline &ith age, but longAterm memor$ is usuall$

maintained. Changes in sleep patterns are consistent, ageArelated changes. +lder persons e'perience an increased

incidence o" a&a#ening a"ter sleep onset.

2. Which data indicates to the nurse that a client may be eperiencing ineffective coping?

1. Constantl$ neglects personal grooming

2. *isits her husbands gra!e once a month

3. *isits the senior citi(ens center once a month

4. >re/uentl$ loo#s at snapshots o" her husband and "amil$

Answer: 1

Coping mechanisms are beha!iors that are used to decreased stress and an'iet$. %n response to a death, ine""ecti!e



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coping is mani"ested b$ an e'treme beha!ior that in some instances ma$ be harm"ul to the indi!idual, ph$sicall$,

ps$chologicall$, or both. +ption 1 is indicati!e o" a beha!ior that identi"ies an ine""ecti!e coping beha!ior as part o" the

grie!ing process. he remaining options identi"$ e""ecti!e coping beha!iors.

1. "he nurse notes that a client is uite suspicious during an assessment interview and believes that her

family is under investigation by the (&A. What would the appropriate nursing interventions be with this

client? Select all that apply:

1. se acti!e listening s#ills to see# in"ormation "rom the client.

2. ;ncourage the client to describe the problem as she sees it.

3. s# the client to tell $ou e'actl$ &hat she thin#s is happening.

4. ell the client that she is delusional and $ou can help her.

5. ;'plain to the client that most people are not in!estigated b$ the C%.

6. -eassure the client that $ou are not &ith the C%.

Answers: 1,2,.

he client is displa$ing paranoid beha!iours, &hich necessitates a matter o" "act approach that is nonudgmental and

accepting the clients statements and sho& the nurses &illingness to acti!el$ listen. he last three do not contribute to a

therapeutic nurse client relationship.



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2. Which nursing interventions will assist in reducing pressure points that may lead to pressure ulcers?

(hec0 all that apply:

1. Position the client directl$ on the trochanter &hen side l$ing.

2. !oid use o" donut t$pe de!ices.

3. )assage bon$ prominences.

4. ;le!ate the H+B no more than 3? degrees &hen possible.

5. When the client is side l$ing, us

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