NCLEX Sata (Select All That Apply) Practice Questions

1. 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

Evaluating the client’s response to antidiarrheal medications

Maintaining intake and output records

Obtaining the client’s weight.

The nurse can delegate the following basic care activities to the unlicensed assistant: providing skin care following bowel movements, maintaining intake and output records, and obtaining the client’s weight. Assessing the client’s bowel sounds and evaluating the client’s response to medication are registered nurse activities that cannot be delegated.

Explanation

The nurse can delegate the following basic care activities to the unlicensed assistant: providing skin care following bowel movements, maintaining intake and output records, and obtaining the client’s weight. Assessing the client’s bowel sounds and evaluating the client’s response to medication are registered nurse activities that cannot be delegated.

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2. 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.

Prothrombin time.

Platelet count.

Hemoglobin

Complete Blood Count

White Blood Cell Count

Prothrombin time, partial thromboplastin time, and platelet count are all included in coagulation studies. The hemoglobin level, though important information prior to an invasive procedure like liver biopsy, does not assess coagulation.

Explanation

Prothrombin time, partial thromboplastin time, and platelet count are all included in coagulation studies. The hemoglobin level, though important information prior to an invasive procedure like liver biopsy, does not assess coagulation.

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3. Which statements accurately describe the action of angiotensin-converting enzyme (ACE) inhibitors? (Select All That Apply)

Increase blood pressure

Block the conversion of angiotensin I to angiotensin II

Promote sodium and water retention

Dilate blood vessels

ACE inhibitors lower blood pressure by blocking angiotensin II formation and promoting vasodilation. They don't increase blood pressure or encourage sodium and water retention.

Explanation

ACE inhibitors lower blood pressure by blocking angiotensin II formation and promoting vasodilation. They don't increase blood pressure or encourage sodium and water retention.

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4. 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

Auscultation of bowel sounds

Presence of chest pain.

Presence of peripheral edema

Color of nail beds

A respiratory assessment, which includes auscultation of breath sounds and assessing the color of the nail beds, is a priority for clients with pneumonia. Assessing for the presence of chest pain is also an important respiratory assessment as chest pain can interfere with the client’s ability to breathe deeply. Auscultating bowel sounds and assessing for peripheral edema may be appropriate assessments, but these are not priority assessments for the patient with pneumonia.

Explanation

A respiratory assessment, which includes auscultation of breath sounds and assessing the color of the nail beds, is a priority for clients with pneumonia. Assessing for the presence of chest pain is also an important respiratory assessment as chest pain can interfere with the client’s ability to breathe deeply. Auscultating bowel sounds and assessing for peripheral edema may be appropriate assessments, but these are not priority assessments for the patient with pneumonia.

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5. What are potential signs of digoxin toxicity? (Select All That Apply)

Nausea and vomiting

Bradycardia

Visual disturbances

Hyperactivity

Digoxin toxicity symptoms include gastrointestinal disturbances, bradycardia, and visual disturbances. Hyperactivity is not associated with digoxin toxicity.

Explanation

Digoxin toxicity symptoms include gastrointestinal disturbances, bradycardia, and visual disturbances. Hyperactivity is not associated with digoxin toxicity.

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6. 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.

Hypertension.

Headaches.

The symptoms consistent with a diagnosis of polycythemia vera include:

Increased clotting time: Polycythemia vera can lead to an increased risk of blood clot formation due to elevated levels of red blood cells.

Hypertension: Elevated red blood cell counts can increase blood viscosity, leading to hypertension (high blood pressure).

Headaches: Increased blood viscosity and blood volume can lead to headaches due to increased pressure within blood vessels.

Explanation

The symptoms consistent with a diagnosis of polycythemia vera include:

Increased clotting time: Polycythemia vera can lead to an increased risk of blood clot formation due to elevated levels of red blood cells.

Hypertension: Elevated red blood cell counts can increase blood viscosity, leading to hypertension (high blood pressure).

Headaches: Increased blood viscosity and blood volume can lead to headaches due to increased pressure within blood vessels.

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

Ineffective tissue perfusion related to decreased peripheral blood flow secondary to decreased cardiac output.

Activity intolerance related to increased cardiac output.

Decreased cardiac output related to structural and functional changes.

Impaired gas exchange related to decreased sympathetic nervous system activity.

HF is a result of structural and functional abnormalities of the heart tissue muscle. The heart muscle becomes weak and does not adequately pump the blood out of the chambers. As a result, blood pools in the left ventricle and backs up into the left atrium, and eventually into the lungs. Therefore, greater amounts of blood remain in the ventricle after contraction thereby decreasing cardiac output. In addition, this pooling leads to thrombus formation and ineffective tissue perfusion because of the decrease in blood flow to the other organs and tissues of the body. Typically, these clients have an ejection fraction of less than 50% and poorly tolerate activity. Activity intolerance is related to a decrease, not increase, in cardiac output. Gas exchange is impaired. However, the decrease in cardiac output triggers compensatory mechanisms, such as an increase in sympathetic nervous system activity.

Explanation

HF is a result of structural and functional abnormalities of the heart tissue muscle. The heart muscle becomes weak and does not adequately pump the blood out of the chambers. As a result, blood pools in the left ventricle and backs up into the left atrium, and eventually into the lungs. Therefore, greater amounts of blood remain in the ventricle after contraction thereby decreasing cardiac output. In addition, this pooling leads to thrombus formation and ineffective tissue perfusion because of the decrease in blood flow to the other organs and tissues of the body. Typically, these clients have an ejection fraction of less than 50% and poorly tolerate activity. Activity intolerance is related to a decrease, not increase, in cardiac output. Gas exchange is impaired. However, the decrease in cardiac output triggers compensatory mechanisms, such as an increase in sympathetic nervous system activity.

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8. 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.

Head is tilted down while inhaling the medication

Client waits 5 minutes between puffs.

Mouth is rinsed with water following administration

Client lies supine for 15 minutes following administration.

The inhaler is held upright to ensure that the medication is properly dispersed and reaches the lungs effectively. Rinsing the mouth with water following administration helps to prevent any potential side effects such as oral thrush or hoarseness caused by the corticosteroid drug.

Explanation

The inhaler is held upright to ensure that the medication is properly dispersed and reaches the lungs effectively. Rinsing the mouth with water following administration helps to prevent any potential side effects such as oral thrush or hoarseness caused by the corticosteroid drug.

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9. 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.”

“It is important that I isolate myself from family when possible.”

“I should use paper tissues to cough in and dispose of them properly.”

“I can use regular plate and utensils whenever I eat.”

The client's statements that indicate understanding of the nurse's instructions are: "I should always cover my mouth and nose when sneezing." This demonstrates awareness of the importance of respiratory hygiene in preventing the spread of TB. "I should use paper tissues to cough in and dispose of them properly." This shows understanding of the need to contain respiratory secretions and dispose of them safely. "I can use regular plate and utensils whenever I eat." This indicates awareness that TB is not transmitted through food or utensils, and there is no need for special precautions in this regard.

Explanation

The client's statements that indicate understanding of the nurse's instructions are: "I should always cover my mouth and nose when sneezing." This demonstrates awareness of the importance of respiratory hygiene in preventing the spread of TB. "I should use paper tissues to cough in and dispose of them properly." This shows understanding of the need to contain respiratory secretions and dispose of them safely. "I can use regular plate and utensils whenever I eat." This indicates awareness that TB is not transmitted through food or utensils, and there is no need for special precautions in this regard.

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10. What are common manifestations of hypoglycemia in a diabetic client? (Select All That Apply)

Bradycardia

Polyuria

Diaphoresis

Shakiness

Common signs of hypoglycemia include diaphoresis and shakiness. Bradycardia and polyuria are not typical manifestations and may suggest other issues.

Explanation

Common signs of hypoglycemia include diaphoresis and shakiness. Bradycardia and polyuria are not typical manifestations and may suggest other issues.

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

Thirst

Palpitations

Diaphoresis

Slurred speech

Hyperventilation

Palpitations, an adrenergic symptom, occur as the glucose levels fall; the sympathetic nervous system is activated and epinephrine and norepinephrine are secreted causing this response. Diaphoresis is a sympathetic nervous system response that occurs as epinephrine and norepinephrine are released. Slurred speech is a neuroglycopenic symptom; as the brain receives insufficient glucose, the activity of the CNS becomes depressed.

Explanation

Palpitations, an adrenergic symptom, occur as the glucose levels fall; the sympathetic nervous system is activated and epinephrine and norepinephrine are secreted causing this response. Diaphoresis is a sympathetic nervous system response that occurs as epinephrine and norepinephrine are released. Slurred speech is a neuroglycopenic symptom; as the brain receives insufficient glucose, the activity of the CNS becomes depressed.

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12. Which interventions promote safety for a client receiving anticoagulant therapy? (Select All That Apply)

Encourage a diet rich in green leafy vegetables

Use a soft-bristled toothbrush for oral care

Administer subcutaneous injections

Implement fall precautions

To enhance safety, anticoagulant clients should avoid trauma, including using a soft toothbrush, receiving subcutaneous rather than intramuscular injections, and implementing fall precautions.

Explanation

To enhance safety, anticoagulant clients should avoid trauma, including using a soft toothbrush, receiving subcutaneous rather than intramuscular injections, and implementing fall precautions.

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13. Which factors contribute to a patient's risk for pressure ulcers? (Select All That Apply)

Poor nutrition

Moisture and humidity

Age over 65

High body mass index (BMI)

Pressure ulcer risk factors include poor nutrition, moisture, and advanced age. While high BMI might be a protective factor, it doesn't contribute to the risk.

Explanation

Pressure ulcer risk factors include poor nutrition, moisture, and advanced age. While high BMI might be a protective factor, it doesn't contribute to the risk.

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14. 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

Headache

Orthopnea

Gout

Weight loss

Polycythemia vera, a condition in which too many RBCs are produced in the blood serum, can lead to an increase in the hematocrit and hypervolemia, hyperviscosity, and hypertension. Subsequently, the client can experience dizziness, tinnitus, visual disturbances, headaches, or a feeling of fullness in the head. The client may also experience cardiovascular symptoms such as heart failure (shortness of breath and orthopnea) and increased clotting time or symptoms of an increased uric acid level such as painful swollen joints (usually the big toe). Hearing loss and weight loss are not manifestations associated with polycythemia vera.

Explanation

Polycythemia vera, a condition in which too many RBCs are produced in the blood serum, can lead to an increase in the hematocrit and hypervolemia, hyperviscosity, and hypertension. Subsequently, the client can experience dizziness, tinnitus, visual disturbances, headaches, or a feeling of fullness in the head. The client may also experience cardiovascular symptoms such as heart failure (shortness of breath and orthopnea) and increased clotting time or symptoms of an increased uric acid level such as painful swollen joints (usually the big toe). Hearing loss and weight loss are not manifestations associated with polycythemia vera.

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

Sweating

Low PCO2

Retinopathy

Acetone breath

Elevated serum bicarbonate

Metabolic acidosis initiates respiratory compensation in the form of Kussmaul respirations to counteract the effects of ketone buildup, resulting in a lowered PCO2. A fruity odor to the breath (acetone breath) occurs when the ketone level is elevated in ketoacidosis.

Explanation

Metabolic acidosis initiates respiratory compensation in the form of Kussmaul respirations to counteract the effects of ketone buildup, resulting in a lowered PCO2. A fruity odor to the breath (acetone breath) occurs when the ketone level is elevated in ketoacidosis.

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