NCLEX Select All That Apply Practice Exam 5 (10 Questions)

1. 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

A client who is receiving continuous tube feedings

A client who requires frequent vital signs after a cardiac catheterization

The nurse must determine the most appropriate assignment on the basis of the skills of the staff member and the needs of the client. In this case. the most appropriate assignment for a nursing assistant would be to care for the client who requires frequent ambulation. The nursing assistant is skilled in this task. The client who had a cardiac catheterization will require specific monitoring in addition to that of the vital signs. Wound irrigations and tube feedings are not performed by unlicensed personnel.

Explanation

The nurse must determine the most appropriate assignment on the basis of the skills of the staff member and the needs of the client. In this case. the most appropriate assignment for a nursing assistant would be to care for the client who requires frequent ambulation. The nursing assistant is skilled in this task. The client who had a cardiac catheterization will require specific monitoring in addition to that of the vital signs. Wound irrigations and tube feedings are not performed by unlicensed personnel.

2. 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

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.

Explanation

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.

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.”

“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.”

Toddlers. with their increased mobility and developing motor skills. can reach hot water. open fires. or hot objects placed on counters and stoves above their eye level. Parents should be encouraged to remain in the kitchen when preparing a meal and reminded to use the back burners on the stove. Pot handles should be turned inward and toward the middle of the stove. Hot liquids should never be left unattended. and the toddler should always be supervised. Options 2. 3. and 4 do not reflect an adequate understanding of the principles of safety.

Explanation

Toddlers. with their increased mobility and developing motor skills. can reach hot water. open fires. or hot objects placed on counters and stoves above their eye level. Parents should be encouraged to remain in the kitchen when preparing a meal and reminded to use the back burners on the stove. Pot handles should be turned inward and toward the middle of the stove. Hot liquids should never be left unattended. and the toddler should always be supervised. Options 2. 3. and 4 do not reflect an adequate understanding of the principles of safety.

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.

A single registered nurse is responsible for providing nursing care to a group of clients.

In team nursing. nursing personnel are led by a nurse when providing care to a group of clients. Option 1 identifies functional nursing. Option 2 identifies a component of case management. Option 4 identifies primary nursing.

Explanation

In team nursing. nursing personnel are led by a nurse when providing care to a group of clients. Option 1 identifies functional nursing. Option 2 identifies a component of case management. Option 4 identifies primary nursing.

5. 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.

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.

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.

Explanation

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.

6. 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.

Maintain the client in a flat position.

Restrict fluid intake for a period of 2 hours.

Monitor the client’s ability to move the extremities.

Inspect the puncture site for swelling, redness, and drainage.

Maintain the client on a nothing-by-mouth (NPO) status for 24 hours.

Following a lumbar puncture. the client remains flat in bed for 6 to 24 hours. depending on the health care provider’s prescriptions. A liberal fluid intake (not NPO status) is encouraged to replace cerebrospinal fluid removed during the procedure. unless contraindicated by the client’s condition. The nurse checks the puncture site for redness and drainage. and monitors the client’s ability to void and move the extremities.

Explanation

Following a lumbar puncture. the client remains flat in bed for 6 to 24 hours. depending on the health care provider’s prescriptions. A liberal fluid intake (not NPO status) is encouraged to replace cerebrospinal fluid removed during the procedure. unless contraindicated by the client’s condition. The nurse checks the puncture site for redness and drainage. and monitors the client’s ability to void and move the extremities.

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7. 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

Kissing

Inhalation

Gastrointestinal

Direct contact with an infected individual

Sexual contact with an infected individual

Anthrax is caused by Bacillus anthracis. and it can be contracted through the digestive system. abrasions in the skin. or inhalation. It cannot be spread from person to person.

Explanation

Anthrax is caused by Bacillus anthracis. and it can be contracted through the digestive system. abrasions in the skin. or inhalation. It cannot be spread from person to person.

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8. 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

Failure to teach the client adequately

Increased need to protect the client

Excessive bumetanide administration

Lack of follow-up nursing actions

To prove malpractice against a nurse. the plaintiff must prove that the nurse owed a duty to the client. that the nurse breached the duty. and that as a result harm was caused to person or property. The client has an increased risk of hypotension (option 2) because hypotension is a common adverse effect of bumetanide. this is the second dose within 4 hours. and the client has heart failure. The client can prove that the nurse did not protect him by failing to provide adequate teaching and perform correct and timely nursing interventions (options 3. 4. and 6) after administering the bumetanide. After the first 15-minute check. the nurse should continue increased client monitoring to ensure client compliance with safety measures. Replacing fluid volume is not the issue; furthermore. the goal of therapy is to reduce total body fluid. No data indicate that the dose of bumetanide. a loop diuretic. was excessive. However. because this medication can cause hypotension. especially after a repeat dose. the nurse should instruct the client to remain in bed and provide him with a urinal. It may be difficult for the client to prove that the second dose of bumetanide caused the injury.

Explanation

To prove malpractice against a nurse. the plaintiff must prove that the nurse owed a duty to the client. that the nurse breached the duty. and that as a result harm was caused to person or property. The client has an increased risk of hypotension (option 2) because hypotension is a common adverse effect of bumetanide. this is the second dose within 4 hours. and the client has heart failure. The client can prove that the nurse did not protect him by failing to provide adequate teaching and perform correct and timely nursing interventions (options 3. 4. and 6) after administering the bumetanide. After the first 15-minute check. the nurse should continue increased client monitoring to ensure client compliance with safety measures. Replacing fluid volume is not the issue; furthermore. the goal of therapy is to reduce total body fluid. No data indicate that the dose of bumetanide. a loop diuretic. was excessive. However. because this medication can cause hypotension. especially after a repeat dose. the nurse should instruct the client to remain in bed and provide him with a urinal. It may be difficult for the client to prove that the second dose of bumetanide caused the injury.

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9. A nurse has reinforced instructions to the client with hyperparathyroidism regarding home care measures related to exercise. Which statement by the client indicates a need for further instruction? Select all that apply.

“I enjoy exercising but I need to be careful.”

“I need to pace my activities throughout the day.”

“I need to limit playing football to only the weekends.”

“I should gauge my activity level by my energy level.”

“I should exercise in the evening to encourage a good sleep pattern.”

The client should be instructed to avoid high-impact activity or contact sports such as football. Exercising late in the evening may interfere with restful sleep. The client with hyperparathyroidism should pace activities throughout the day and plan for periods of uninterrupted rest. The client should plan for at least 30 minutes of walking each day to support calcium movement into the bones. The client should be instructed to use energy level as a guide to activity.

Explanation

The client should be instructed to avoid high-impact activity or contact sports such as football. Exercising late in the evening may interfere with restful sleep. The client with hyperparathyroidism should pace activities throughout the day and plan for periods of uninterrupted rest. The client should plan for at least 30 minutes of walking each day to support calcium movement into the bones. The client should be instructed to use energy level as a guide to activity.

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10. A nurse in a medical unit is caring for a client with heart failure. The client suddenly develops extreme dyspnea. tachycardia. and lung crackles. and the nurse suspects pulmonary edema. The nurse immediately notifies the registered nurse and expects which interventions to be prescribed? Select all that apply.

Administering oxygen

Inserting a Foley catheter

Administering furosemide (Lasix)

Administering morphine sulfate intravenously

Transporting the client to the coronary care unit

Placing the client in a low Fowler’s side-lying position

Pulmonary edema is a life-threatening event that can result from severe heart failure. In pulmonary edema the left ventricle fails to eject sufficient blood. and pressure increases in the lungs because of the accumulated blood. Oxygen is always prescribed. and the client is placed in a high Fowler’s position to ease the work of breathing. Furosemide. a rapid-acting diuretic. will eliminate accumulated fluid. A Foley catheter is inserted to accurately measure output. Intravenously administered morphine sulfate reduces venous return (preload). decreases anxiety. and reduces the work of breathing. Transporting the client to the coronary care unit is not a priority intervention. In fact. this may not be necessary at all if the client’s response to treatment is successful.

Explanation

Pulmonary edema is a life-threatening event that can result from severe heart failure. In pulmonary edema the left ventricle fails to eject sufficient blood. and pressure increases in the lungs because of the accumulated blood. Oxygen is always prescribed. and the client is placed in a high Fowler’s position to ease the work of breathing. Furosemide. a rapid-acting diuretic. will eliminate accumulated fluid. A Foley catheter is inserted to accurately measure output. Intravenously administered morphine sulfate reduces venous return (preload). decreases anxiety. and reduces the work of breathing. Transporting the client to the coronary care unit is not a priority intervention. In fact. this may not be necessary at all if the client’s response to treatment is successful.

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