NCLEX Select All That Apply Practice Exam 3 (10 Questions)

1.

A nurse is monitoring a pregnant client with pregnancy induced hypertension who is at risk for Preeclampsia. The nurse checks the client for which specific signs of Preeclampsia (select all that apply)?

A.

Elevated blood pressure
B.

Negative urinary protein
C.

Facial edema
D.

Increased respirations

Correct Answer(s)
A. Elevated blood pressure
C. Facial edema

Explanation
The three classic signs of preeclampsia are hypertension, generalized edema, and proteinuria. Increased respirations are not a sign of preeclampsia.

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2.

**A nurse is caring for a pregnant client with severe preeclampsia who is receiving IV magnesium sulfate. Select all nursing interventions that apply in the care for the client.**

A.

Monitor maternal vital signs every 2 hours
B.

Notify the physician if respirations are less than 12 per minute
C.

Monitor renal function and cardiac function closely
D.

Keep calcium gluconate on hand in case of a magnesium sulfate overdose
E.

Monitor deep tendon reflexes hourly
F.

Monitor I and O’s hourly
G.

Notify the physician if urinary output is less than 30 ml per hour.

Correct Answer(s)
B. Notify the physician if respirations are less than 12 per minute
C. Monitor renal function and cardiac function closely
D. Keep calcium gluconate on hand in case of a magnesium sulfate overdose
E. Monitor deep tendon reflexes hourly
F. Monitor I and O’s hourly
G. Notify the physician if urinary output is less than 30 ml per hour.

Explanation
When caring for a client receiving magnesium sulfate therapy, the nurse would monitor maternal vital signs, especially respirations, every 30-60 minutes and notify the physician if respirations are less than 12, because this would indicate respiratory depression. Calcium gluconate is kept on hand in case of magnesium sulfate overdose, because calcium gluconate is the antidote for magnesium sulfate toxicity. Deep tendon reflexes are assessed hourly. Cardiac and renal function is monitored closely. The urine output should be maintained at 30 ml per hour because the medication is eliminated through the kidneys.

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3.

When interpreting an ECG, the nurse would keep in mind which of the following about the P wave? Select all that apply.

A.

Reflects electrical impulse beginning at the SA node
B.

Indicated electrical impulse beginning at the AV node
C.

Reflects atrial muscle depolarization
D.

Identifies ventricular muscle depolarization
E.

Has duration of normally 0.11 seconds or less.

Correct Answer(s)
A. Reflects electrical impulse beginning at the SA node
C. Reflects atrial muscle depolarization
E. Has duration of normally 0.11 seconds or less.

Explanation
In a client who has had an ECG, the P wave represents the activation of the electrical impulse in the SA node, which is then transmitted to the AV node. In addition, the P wave represents atrial muscle depolarization, not ventricular depolarization. The normal duration of the P wave is 0.11 seconds or less in duration and 2.5 mm or more in height.

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4.

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.

A.

Verify patency of the line by the presence of a blood return at regular intervals.
B.

Inspect the insertion site for swelling, erythema, or drainage.
C.

Administer a cytotoxic agent to keep the regimen on schedule even if blood return is not present.
D.

If unable to aspirate blood, reposition the client and encourage the client to cough.
E.

Contact the health care provider about verifying placement if the status is questionable.

Correct Answer(s)
A. Verify patency of the line by the presence of a blood return at regular intervals.
B. Inspect the insertion site for swelling, erythema, or drainage.
D. If unable to aspirate blood, reposition the client and encourage the client to cough.
E. Contact the health care provider about verifying placement if the status is questionable.

Explanation
A major concern with intravenous administration of cytotoxic agents is vessel irritation or extravasation. The Oncology Nursing Society and hospital guidelines require frequent evaluation of blood return when administering vesicant or non vesicant chemotherapy due to the risk of extravasation. These guidelines apply to peripheral and central venous lines. In addition, central venous lines may be long-term venous access devices. Thus, difficulty drawing or aspirating blood may indicate the line is against the vessel wall or may indicate the line has occlusion. Having the client cough or move position may change the status of the line if it is temporarily against a vessel wall. Occlusion warrants more thorough evaluation via x-ray study to verify placement if the status is questionable and may require a declotting regimen.

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5.

To assist an adult client to sleep better the nurse recommends which of the following? (Select all that apply.)

A.

Drinking a glass of wine just before retiring to bed
B.

Eating a large meal 1 hour before bedtime
C.

Consuming a small glass of warm milk at bedtime
D.

Performing mild exercises 30 minutes before going to bed

Correct Answer
C. Consuming a small glass of warm milk at bedtime

Explanation
A small glass of milk relaxes the body and promotes sleep.

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6.

The nurse recognizes that a client is experiencing insomnia when the client reports (select all that apply):

A.

Extended time to fall asleep
B.

Falling asleep at inappropriate times
C.

Difficulty staying asleep
D.

Feeling tired after a night’s sleep

Correct Answer(s)
A. Extended time to fall asleep
C. Difficulty staying asleep
D. Feeling tired after a night’s sleep

Explanation
These symptoms are often reported by clients with insomnia. Clients report nonrestorative sleep. Arising once at night to urinate (nocturia) is not in and of itself insomnia.

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7.

The nurse teaches the mother of a newborn that in order to prevent sudden infant death syndrome (SIDS) the best position to place the baby after nursing is (select all that apply):

A.

Prone
B.

Side-lying
C.

Supine
D.

Fowler’s

Correct Answer(s)
B. Side-lying
C. Supine

Explanation
Research demonstrate that the occurrence of SIDS is reduced with these two positions.

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8.

A client has a diagnosis of primary insomnia. Before assessing this client, the nurse recalls the numerous causes of this disorder. Select all that apply:

A.

Chronic stress
B.

Severe anxiety
C.

Generalized pain
D.

Excessive caffeine
E.

Chronic depression
F.

Environmental noise

Correct Answer(s)
A. Chronic stress
D. Excessive caffeine
F. Environmental noise

Explanation
Acute or primary insomnia is caused by emotional or physical discomfort not caused by the direct physiologic effects of a substance or a medical condition. Excessive caffeine intake is an example of disruptive sleep hygiene; caffeine is a stimulant that inhibits sleep. Environmental noise causes physical and/or emotional and therefore is related to primary insomnia.

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9.

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

A.

Barbiturates deprive people of NREM sleep
B.

Barbiturates deprive people of REM sleep
C.

When the barbiturates are discontinued, the NREM sleep increases.
D.

When the barbiturates are discontinued, the REM sleep increases.
E.

Nightmares are often an adverse effect when discontinuing barbiturates.

Correct Answer(s)
B. Barbiturates deprive people of REM sleep
D. When the barbiturates are discontinued, the REM sleep increases.
E. Nightmares are often an adverse effect when discontinuing barbiturates.

Explanation
Barbiturates deprive people of REM sleep. When the barbiturate is stopped and REM sleep once again occurs, a rebound phenomenon occurs. During this phenomenon, the persons dream time constitutes a larger percentage of the total sleep pattern, and the dreams are often nightmares.

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10.

Select all that apply that is appropriate when there is a benzodiazepine overdose:

A.

Administration of syrup of ipecac
B.

Gastric lavage
C.

Activated charcoal and a saline cathartic
D.

Hemodialysis
E.

Administration of Flumazenil

Correct Answer(s)
B. Gastric lavage
C. Activated charcoal and a saline cathartic
E. Administration of Flumazenil

Explanation
If ingestion is recent, decontamination of the GI system is indicated. The administration of syrup of ipecac is contraindicated because of aspiration risks related to sedation. Gastric lavage is generally the best and most effective means of gastric decontamination. Activated charcoal and a saline cathartic may be administered to remove any remaining drug. Hemodialysis is not useful in the treatment of benzodiazepine overdose. Flumazenil can be used to acutely reverse the sedative effects of benzodiazepines, though this is normally done only in cases of extreme overdose or sedation.

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