NCLEX Select All That Apply Practice Exam 8 — Questions and Answers
Question 1: The 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.
- Auscultating lung sounds (Correct answer)
- Obtaining the client's temperature (Correct answer)
- Checking the strength of peripheral pulses
- Obtaining information about the client's respirations (Correct answer)
- Performing a musculoskeletal and neurological examination
- Asking the client about a family history of any illness or disease
Correct answer: Auscultating lung sounds
A focused data collection for cold symptoms, cough, and lung congestion primarily targets the respiratory system and general signs of infection. Auscultating lung sounds directly assesses for congestion or abnormal breath sounds, while obtaining the client's temperature checks for fever. Assessing respirations provides information on breathing effort and rate, all directly relevant to the client's presenting complaints.
Question 2: A community health nurse is conducting a teaching session about terrorism with members of the community and discussing information regarding anthrax. The nurse tells those attending that anthrax can be transmitted via which route(s)? Select all that apply.
- Skin (Correct answer)
- Kissing
- Inhalation (Correct answer)
- Gastrointestinal (Correct answer)
- Direct contact with an infected individual
- Sexual contact with an infected individual
Correct answer: Skin
Anthrax, caused by the bacterium Bacillus anthracis, can infect humans through several routes. Cutaneous anthrax occurs when spores enter through broken skin, inhalation anthrax results from breathing in spores, and gastrointestinal anthrax is contracted by consuming contaminated food or water. These are the primary and most common modes of transmission for human anthrax infections.
Question 3: The emergency room nurse is providing discharge teaching to the parents of a 2-year-old child who sustained burns from a hot cup of coffee that had been left on the kitchen counter. The nurse evaluates that the parents have correctly understood the teaching when they state which of the following?
- "We will be sure to not leave hot liquids unattended." (Correct answer)
- "I guess my child needs to understand what the word 'hot' means."
- "We will be sure that our child stays in his room when we work in the kitchen."
- "We will install a safety gate as soon as we get home so that our child can't get into the kitchen."
Correct answer: "We will be sure to not leave hot liquids unattended."
The most effective way to prevent future burn injuries from hot liquids in a 2-year-old is to eliminate the source of the hazard. Leaving hot liquids unattended on counters makes them easily accessible to curious toddlers, increasing the risk of accidental spills and burns. This statement demonstrates the parents' understanding of proactive safety measures to prevent recurrence.
Question 4: A licensed practical nurse is attending an agency orientation meeting about the nursing model of practice implemented in the facility. The nurse is told that the nursing model is a team nursing approach. The nurse understands that which of the following is a characteristic of this type of nursing model of practice?
- A task approach method is used to provide care to clients.
- Managed care concepts and tools are used when providing client care.
- Nursing staff are led by a nurse when providing care to a group of clients. (Correct answer)
- A single registered nurse is responsible for providing nursing care to a group of clients.
Correct answer: Nursing staff are led by a nurse when providing care to a group of clients.
Administering an additional dose of bumetanide, a potent diuretic, significantly increases the client's risk for hypotension and fluid volume deficit, which can lead to falls. The nurse's failure to adequately educate the client about these risks and the importance of calling for assistance, combined with a lack of immediate follow-up after administering the medication, constitutes a breach in the standard of care. These omissions directly contributed to the client's fall and injury, supporting a malpractice claim.
Question 5: 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?
- A client who requires wound irrigation
- A client who requires frequent ambulation (Correct answer)
- A client who is receiving continuous tube feedings
- A client who requires frequent vital signs after a cardiac catheterization
Correct answer: A client who requires frequent ambulation
Following a lumbar puncture, key interventions focus on preventing complications. Maintaining a flat position helps reduce the risk of post-lumbar puncture headache by minimizing CSF leakage. Monitoring the client's ability to void and move extremities assesses for potential nerve damage or spinal cord compression, while inspecting the puncture site checks for infection or CSF leakage, ensuring early detection of adverse events.
Question 6: A male client who has heart failure receives an additional dose of bumetanide as prescribed 4 hours after the daily dose. The nurse assesses him 15 minutes after administering the medication and reminds him to save all urine in the bathroom. Thirty minutes later the nurse finds the client on the floor, unresponsive, and bleeding from a laceration. Determine the issues that support the client's malpractice claim. Select all that apply.
- Failure to replace body fluids
- Increased risk of hypotension (Correct answer)
- Failure to teach the client adequately (Correct answer)
- Increased need to protect the client (Correct answer)
- Excessive bumetanide administration
- Lack of follow-up nursing actions (Correct answer)
Correct answer: Increased risk of hypotension
In an emergency department triage setting, chest pain is always considered a high-priority symptom until a life-threatening cardiac event, such as a myocardial infarction, can be ruled out. Despite the client's self-diagnosis, the nurse must prioritize symptoms that could indicate a critical condition. The other options describe less urgent or non-life-threatening conditions.
Question 7: 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.
- Monitor the client's ability to void. (Correct answer)
- Maintain the client in a flat position. (Correct answer)
- Restrict fluid intake for a period of 2 hours.
- Monitor the client's ability to move the extremities. (Correct answer)
- Inspect the puncture site for swelling, redness, and drainage. (Correct answer)
- Maintain the client on a nothing-by-mouth (NPO) status for 24 hours.
Correct answer: Monitor the client's ability to void.
Nurses should decline to witness legal documents like wills to avoid potential conflicts of interest or accusations of undue influence. Witnessing a will can compromise the nurse's professional objectivity and role, especially if the client's competency or the will's validity is later questioned. It is best practice for nurses to maintain a clear boundary and avoid involvement in such legal matters.
Question 8: 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. The nurse would assign the highest priority to which of the following clients?
- A client complaining of muscle aches, a headache, and malaise
- A client who twisted her ankle when she fell while rollerblading
- A client with a minor laceration on the index finger sustained while cutting an eggplant
- A client with chest pain who states that he just ate pizza that was made with a very spicy sauce (Correct answer)
Correct answer: A client with chest pain who states that he just ate pizza that was made with a very spicy sauce
In an emergency department, triage involves classifying clients according to their need for care, and it includes establishing priorities of care. The type of illness, the severity of the problem, and the resources available govern the process. Clients with trauma, chest pain, severe respiratory distress, cardiac arrest, limb amputation, or acute neurological deficits and those who sustained a chemical splash to the eyes are classified as emergent, and these clients are the number 1 priority. Clients with conditions such as simple fractures, asthma without respiratory distress, fever, hypertension, abdominal pain, or renal stones have urgent needs, and these clients are classified as the number 2 priority. Clients with conditions such as minor lacerations, sprains, or cold symptoms are classified as non urgent, and they are the number 3 priority.
Question 9: 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. The living will requires that the client's signature be witnessed, and the client asks the nurse to witness the signature. Which of the following is the appropriate nursing action?
- Decline to sign the will. (Correct answer)
- Sign the will as a witness to the signature only.
- Call the hospital lawyer before signing the will.
- Sign the will, clearly identifying credentials and employment agency.
Correct answer: Decline to sign the will.
Living wills are required to be in writing and signed by the client. The client's signature either must be witnessed by specified individuals or notarized. Many states prohibit any employee from being a witness, including a nurse in a facility in which the client is receiving care.
Question 10: The nurse is caring for a client who is unconscious following a fall. Which comment by the nurse will help the client become reoriented when he regains consciousness?
- “I am your nurse and I will be taking care of you today.”
- “Can you tell me your name and where you are?”
- “I know you are confused right now, but everything will be alright.”
- “You were in an accident that hurt your head. You are in the hospital.” (Correct answer)
Correct answer: “You were in an accident that hurt your head. You are in the hospital.”
When a client is regaining consciousness after a head injury, providing clear, concise, and factual information helps with reorientation. Stating 'You were in an accident that hurt your head. You are in the hospital.' provides essential details about the event, the injury, and the current location. This factual information is crucial for helping the client understand their circumstances and begin the reorientation process effectively.
Question 11: Following a generalized seizure, the nurse can expect the client to:
- Be unable to move the extremities
- Be drowsy and prone to sleep (Correct answer)
- Remember events before the seizure
- Have a drop in blood pressure
Correct answer: Be drowsy and prone to sleep
Following a generalized seizure, clients typically enter a postictal phase characterized by drowsiness, confusion, and fatigue. During this period, they are often prone to sleep as their brain recovers from the intense electrical activity of the seizure. This is a normal physiological response as the brain attempts to reset and regain normal function.
Question 12: A client with oxalate renal calculi should be taught to avoid eating:
- Strawberries (Correct answer)
- Oranges
- Apples
- Pears
Correct answer: Strawberries
Clients with oxalate renal calculi (kidney stones) should be advised to limit their intake of foods high in oxalates to prevent further stone formation. Strawberries are known to have a high oxalate content. Other foods rich in oxalates include spinach, rhubarb, chocolate, and nuts, which should also be consumed in moderation.
Question 13: A 6-year-old is diagnosed with Legg-Calve Perthes disease of the right femur. An important part of the child’s care includes instructing the parents:
- To increase the amount of dietary protein
- About exercises to strengthen affected muscles
- About relaxation exercises to minimize pain in the joints
- To prevent weight bearing on the affected leg (Correct answer)
Correct answer: To prevent weight bearing on the affected leg
Legg-Calve-Perthes disease involves avascular necrosis of the femoral head, meaning the blood supply to the hip bone is disrupted. The primary goal of treatment is to protect the femoral head from further damage and allow it to heal and remodel properly. Preventing weight bearing on the affected leg is crucial to reduce stress on the fragile bone and preserve its spherical shape.
Question 14: The nurse is assessing an infant with Hirschsprung’s disease. The nurse can expect the infant to:
- Weigh less than expected for height and age
- Have a scaphoid-shaped abdomen (Correct answer)
- Exhibit clubbing of the fingers and toes
- Have hyperactive deep tendon reflexes
Correct answer: Have a scaphoid-shaped abdomen
Hirschsprung's disease is a congenital condition where nerve cells are missing in part of the colon, leading to a functional obstruction. Infants with this condition often present with a distended abdomen due to trapped stool and gas. However, the upper abdomen may appear scaphoid (sunken) due to chronic malnutrition and lack of abdominal muscle tone from the obstruction.
Question 15: The physician has prescribed supplemental iron for a prenatal client. The nurse should tell the client to take the medication with:
- Milk, to prevent stomach upset
- Tomato juice, to increase absorption (Correct answer)
- Oatmeal, to prevent constipation
- Water, to increase serum iron levels
Correct answer: Tomato juice, to increase absorption
Iron absorption is significantly enhanced when taken with vitamin C (ascorbic acid). Tomato juice is an excellent source of vitamin C, making it an ideal beverage to consume with iron supplements to maximize their effectiveness. Taking iron with milk or antacids can actually decrease its absorption.
Question 16: The nurse is teaching a client with a history of obesity and hypertension regarding dietary requirements during pregnancy. Which statement indicates that the client needs further teaching?
- “I need to reduce my daily intake to 1,200 calories a day.” (Correct answer)
- “I need to drink at least a quart of milk a day.”
- “I shouldn’t add salt when I am cooking.”
- “I need to eat more protein and fiber each day.”
Correct answer: “I need to reduce my daily intake to 1,200 calories a day.”
During pregnancy, even with a history of obesity and hypertension, severe calorie restriction like 1,200 calories a day is generally not recommended. Such a low intake can compromise fetal growth and maternal nutritional needs, as pregnant women require adequate calories and nutrients to support both their own health and the developing fetus. This statement indicates a need for further teaching to ensure proper nutrition.
NCLEX Select All That Apply Practice Exam 8
The 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.