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

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

Drinking a glass of wine just before retiring to bed

Eating a large meal 1 hour before bedtime

Consuming a small glass of warm milk at bedtime

Performing mild exercises 30 minutes before going to bed

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

Explanation

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

2. 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)?

Elevated blood pressure

Negative urinary protein

Facial edema

Increased respirations

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

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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3. 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.

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

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

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

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

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

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.

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

Reflects electrical impulse beginning at the SA node

Indicated electrical impulse beginning at the AV node

Reflects atrial muscle depolarization

Identifies ventricular muscle depolarization

Has duration of normally 0.11 seconds or less.

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.

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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5. 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):

Prone

Side-lying

Supine

Fowler’s

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

Explanation

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

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

Extended time to fall asleep

Falling asleep at inappropriate times

Difficulty staying asleep

Feeling tired after a night’s sleep

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.

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

Administration of syrup of ipecac

Gastric lavage

Activated charcoal and a saline cathartic

Hemodialysis

Administration of Flumazenil

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.

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

Barbiturates deprive people of NREM sleep

Barbiturates deprive people of REM sleep

When the barbiturates are discontinued, the NREM sleep increases.

When the barbiturates are discontinued, the REM sleep increases.

Nightmares are often an adverse effect when discontinuing barbiturates.

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.

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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9. 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.

Monitor maternal vital signs every 2 hours

Notify the physician if respirations are less than 12 per minute

Monitor renal function and cardiac function closely

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

Monitor deep tendon reflexes hourly

Monitor I and O’s hourly

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

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.

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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10. 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:

Chronic stress

Severe anxiety

Generalized pain

Excessive caffeine

Chronic depression

Environmental noise

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.

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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