NCLEX Select All That Apply Practice Exam 1 — Questions and Answers

Question 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.

Partial thromboplastin time. (Correct answer)
Prothrombin time. (Correct answer)
Platelet count. (Correct answer)
Hemoglobin
Complete Blood Count
White Blood Cell Count

Correct answer: Partial thromboplastin time.

For a liver biopsy, assessing coagulation is crucial due to the risk of bleeding. Partial thromboplastin time (PTT) and Prothrombin time (PT) measure the function of different coagulation pathways, indicating how long it takes for blood to clot. A platelet count assesses the number of platelets, which are essential for forming a clot plug. Together, these tests provide a comprehensive picture of a patient's clotting ability.

Question 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.

Weight loss.
Increased clotting time. (Correct answer)
Hypertension. (Correct answer)
Headaches. (Correct answer)

Correct answer: Increased clotting time.

Polycythemia vera is characterized by an overproduction of blood cells, leading to increased blood viscosity. This can cause hypertension and headaches due to impaired blood flow and increased pressure within the circulatory system. Despite the high platelet count, platelet function can be abnormal, leading to a paradoxical increased risk of bleeding, which might be reflected as an increased clotting time in some individuals or specific tests.

Question 3: The nurse is teaching the client how to use a metered dose inhaler (MDI) to administer a Corticosteroid drug. Which of the following client actions indicates that he is using the MDI correctly? Select all that apply.

The inhaler is held upright. (Correct answer)
Head is tilted down while inhaling the medication
Client waits 5 minutes between puffs.
Mouth is rinsed with water following administration (Correct answer)
Client lies supine for 15 minutes following administration.

Correct answer: The inhaler is held upright.

When using a metered-dose inhaler (MDI), it is crucial to hold the device upright to ensure proper medication delivery. Rinsing the mouth with water after administering a corticosteroid inhaler is also essential to prevent oral candidiasis (thrush) and minimize systemic absorption of the drug. These actions optimize medication effectiveness and reduce adverse effects.

Question 4: The 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.

Hearing loss
Visual disturbance (Correct answer)
Headache (Correct answer)
Orthopnea (Correct answer)
Gout (Correct answer)
Weight loss

Correct answer: Visual disturbance

Polycythemia vera leads to increased blood viscosity, which can impair blood flow to various organs. This can cause visual disturbances and headaches due to reduced cerebral perfusion. Orthopnea can result from increased blood volume and cardiac workload, while gout is a complication due to increased cell turnover leading to elevated uric acid levels. These manifestations are important for the client to recognize as potential complications.

Question 5: Which of the following would be priority assessment data to gather from a client who has been diagnosed with pneumonia? Select all that apply.

Auscultation of breath sounds (Correct answer)
Auscultation of bowel sounds
Presence of chest pain. (Correct answer)
Presence of peripheral edema
Color of nail beds (Correct answer)

Correct answer: Auscultation of breath sounds

For a client with pneumonia, priority assessments focus on respiratory function and oxygenation. Auscultating breath sounds helps identify areas of consolidation or diminished airflow. Assessing for chest pain can indicate pleuritic inflammation, a common symptom. Observing the color of nail beds provides a quick, non-invasive indicator of peripheral perfusion and oxygen saturation, reflecting the severity of respiratory compromise.

Question 6: The nurse is teaching a client who has been diagnosed with TB 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.

“I will need to dispose of my old clothing when I return home.”
“I should always cover my mouth and nose when sneezing.” (Correct answer)
“It is important that I isolate myself from family when possible.”
“I should use paper tissues to cough in and dispose of them properly.” (Correct answer)
“I can use regular plate and utensils whenever I eat.” (Correct answer)

Correct answer: “I should always cover my mouth and nose when sneezing.”

Tuberculosis is primarily spread through airborne droplets when an infected person coughs, sneezes, or speaks. Therefore, covering the mouth and nose when sneezing and properly disposing of tissues used for coughing are crucial to prevent droplet transmission. TB is not spread through shared eating utensils, so using regular plates and utensils is acceptable, indicating correct understanding of transmission routes.

Question 7: The nurse is admitting a client with hypoglycemia. Identify the signs and symptoms the nurse should expect. Select all that apply.

Thirst
Palpitations (Correct answer)
Diaphoresis (Correct answer)
Slurred speech (Correct answer)
Hyperventilation

Correct answer: Palpitations

Hypoglycemia, or low blood sugar, triggers the sympathetic nervous system and affects brain function. Palpitations and diaphoresis (sweating) are common adrenergic symptoms as the body tries to raise blood glucose. Slurred speech is a neuroglycopenic symptom, indicating that the brain is not receiving enough glucose to function properly. These symptoms are key indicators of hypoglycemia.

Question 8: Which adaptations should the nurse caring for a client with diabetic ketoacidosis expect the client to exhibit? Select all that apply:

Sweating
Low PCO2 (Correct answer)
Retinopathy
Acetone breath (Correct answer)
Elevated serum bicarbonate

Correct answer: Low PCO2

Diabetic ketoacidosis (DKA) is characterized by metabolic acidosis. The body attempts to compensate for this acidosis through Kussmaul respirations, which are deep and rapid, leading to an increased exhalation of carbon dioxide and thus a low PCO2. The breakdown of fats for energy in DKA produces ketones, including acetone, which gives the breath a characteristic fruity or acetone odor.

Question 9: When planning care for a client with ulcerative colitis who is experiencing symptoms, which client care activities can the nurse appropriately delegate to a unlicensed assistant? Select all that apply.

Assessing the client’s bowel sounds
Providing skin care following bowel movements (Correct answer)
Evaluating the client’s response to antidiarrheal medications
Maintaining intake and output records (Correct answer)
Obtaining the client’s weight. (Correct answer)

Correct answer: Providing skin care following bowel movements

Unlicensed assistive personnel (UAP) can perform tasks that do not require nursing judgment or assessment. Providing skin care after bowel movements, maintaining accurate intake and output records, and obtaining the client's weight are all routine tasks that fall within the scope of practice for a UAP. These activities are essential for client comfort and monitoring fluid balance and nutritional status.

Question 10: When assessing the urinary output of a client who has had extracorporeal lithotripsy, the nurse can expect to find:

Cherry-red urine that gradually becomes clearer (Correct answer)
Orange-tinged urine containing particles of calculi
Dark red urine that becomes cloudy in appearance
Dark, smoky-colored urine with high specific gravity

Correct answer: Cherry-red urine that gradually becomes clearer

Extracorporeal shock wave lithotripsy (ESWL) uses shock waves to break kidney stones into smaller fragments. It is common for clients to experience hematuria (blood in the urine) immediately after the procedure due to the trauma from the shock waves and the passage of stone fragments. The urine typically appears cherry-red initially and should gradually clear as the bleeding subsides and fragments are passed.

Question 11: The physician has prescribed Cognex (tacrine) for a client with dementia. The nurse should monitor the client for adverse reactions, which include:

Hypoglycemia
Jaundice (Correct answer)
Urinary retention
Tinnitus

Correct answer: Jaundice

Tacrine (Cognex) is an acetylcholinesterase inhibitor used to treat Alzheimer's disease. A significant adverse effect of tacrine is hepatotoxicity, which can manifest as elevated liver enzymes and, in more severe cases, jaundice. Due to this risk, liver function tests are routinely monitored in clients taking tacrine, and jaundice would indicate a serious hepatic issue.

Question 12: The nurse is providing dietary teaching for a client with elevated cholesterol levels. Which cooking oil is not suggested for the client on a low-cholesterol diet?

Safflower oil
Sunflower oil
Coconut oil (Correct answer)
Canola oil

Correct answer: Coconut oil

Coconut oil is high in saturated fat, which can raise low-density lipoprotein (LDL) cholesterol levels, often referred to as 'bad' cholesterol. For clients with elevated cholesterol, it is recommended to limit saturated fat intake. Safflower, sunflower, and canola oils are generally healthier alternatives as they are higher in monounsaturated and polyunsaturated fats, which can help lower cholesterol.

Question 13: The nurse is caring for a client with stage III Alzheimer’s disease. A characteristic of this stage is:

Memory loss
Failing to recognize familiar objects (Correct answer)
Wandering at night
Failing to communicate

Correct answer: Failing to recognize familiar objects

Stage III (moderate) Alzheimer's disease is characterized by more pronounced cognitive deficits, including agnosia, which is the inability to recognize familiar objects, people, or sounds despite intact sensory function. While memory loss is present in earlier stages and communication difficulties and wandering occur in later stages, agnosia is a hallmark of the moderate stage.

Question 14: In stage III of Alzheimer’s disease, the client develops agnosia, or failure to recognize familiar objects. Answer A is incorrect because it appears in stage I. Answer C is incorrect because it appears in stage II. Answer D is incorrect because it appears in stage IV.

Take the medication 30 minutes before eating.
Report changes in appetite and weight.
Wear sunglasses to prevent cataracts.
Schedule a time to take the influenza vaccine. (Correct answer)

Correct answer: Schedule a time to take the influenza vaccine.

For older adults, especially those with chronic conditions or cognitive impairment, preventative health measures are crucial. Scheduling an annual influenza vaccine is a vital health promotion activity to protect against seasonal flu, which can lead to severe complications in this vulnerable population. This helps maintain overall health and reduce the risk of hospitalizations.

Question 15: The nurse is caring for a client with an above-the-knee amputation (AKA). To prevent contractures, the nurse should:

Place the client in a prone position 15–30 minutes twice a day (Correct answer)
Keep the foot of the bed elevated on shock blocks
Place trochanter rolls on either side of the affected leg
Keep the client’s leg elevated on two pillows

Correct answer: Place the client in a prone position 15–30 minutes twice a day

After an above-the-knee amputation (AKA), clients are at high risk for hip flexion contractures. Placing the client in a prone position for 15-30 minutes twice a day helps to stretch the hip flexor muscles and prevent this common complication. This position encourages hip extension, maintaining range of motion and facilitating future prosthetic fitting and ambulation.

Question 16: The mother of a 6-month-old asks when her child will have all his baby teeth. The nurse knows that most children have all their primary teeth by age:

12 months
18 months
24 months
30 months (Correct answer)

Correct answer: 30 months

Most children typically erupt all 20 primary (baby) teeth by the age of 30 months, or approximately 2.5 years old. While the first teeth usually appear around 6-10 months, the full set is generally complete by this later age. This developmental milestone is important for chewing, speech development, and proper alignment of permanent teeth.

NCLEX Select All That Apply Practice Exam 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.