NCLEX Select All That Apply Practice Exam 6 (10 Questions)

1. A nurse is assisting with collecting data from an African-American client admitted to the ambulatory care unit who is scheduled for a hernia repair. Which of the following information about the client is of least priority during the data collection?

Respiratory

Psychosocial

Neurological

Cardiovascular

The psychosocial data is the least priority during the initial admission data collection. In the African-American culture. it is considered intrusive to ask personal questions during the initial contact or meeting. Additionally. respiratory. neurological. and cardiovascular data include physiological assessments that would be the priority.

Explanation

The psychosocial data is the least priority during the initial admission data collection. In the African-American culture. it is considered intrusive to ask personal questions during the initial contact or meeting. Additionally. respiratory. neurological. and cardiovascular data include physiological assessments that would be the priority.

2. A nurse is assigned to care for four clients. When planning client rounds. which client would the nurse check first?

A client on a ventilator

A client in skeletal traction

A postoperative client preparing for discharge

A client admitted on the previous shift who has a diagnosis of gastroenteritis

The airway is always a high priority. and the nurse first checks the client on a ventilator. The clients described in options 2. 3. and 4 have needs that would be identified as intermediate priorities.

Explanation

The airway is always a high priority. and the nurse first checks the client on a ventilator. The clients described in options 2. 3. and 4 have needs that would be identified as intermediate priorities.

3. A nurse is caring for a client after thyroidectomy and notes that calcium gluconate is prescribed for the client. The nurse determines that this medication has been prescribed to:

Treat thyroid storm.

Prevent cardiac irritability.

Treat hypocalcemic tetany.

Stimulate the release of parathyroid hormone.

121

Explanation

121

4. A nurse is caring for a client with a nasogastric tube that is attached to low suction. The nurse monitors the client closely for which acid-base disorder that is most likely to occur in this situation?

Metabolic acidosis

Metabolic alkalosis

Respiratory acidosis

Respiratory alkalosis

The loss of gastric fluid via nasogastric suction or vomiting causes metabolic alkalosis as a result of the loss of hydrochloric acid; this results in an alkalotic condition. Options 3 and 4 deal with respiratory problems. Option 1 relates to acidosis.

Explanation

The loss of gastric fluid via nasogastric suction or vomiting causes metabolic alkalosis as a result of the loss of hydrochloric acid; this results in an alkalotic condition. Options 3 and 4 deal with respiratory problems. Option 1 relates to acidosis.

5. A nurse is caring for a client with a healthcare-associated infection caused by methicillin-resistant Staphylococcus aureus who is on contact precautions. The nurse prepares to provide colostomy care to the client. Which of the following protective items will be required to perform this procedure?

Gloves and a gown

Gloves and goggles

Gloves. a gown. and goggles

Gloves. a gown. and shoe protectors

Goggles are worn to protect the mucous membranes of the eye during interventions that may produce splashes of blood. body fluids. secretions. and excretions. In addition. contact precautions require the use of gloves. and a gown should be worn if direct client contact is anticipated. Shoe protectors are not necessary.

Explanation

Goggles are worn to protect the mucous membranes of the eye during interventions that may produce splashes of blood. body fluids. secretions. and excretions. In addition. contact precautions require the use of gloves. and a gown should be worn if direct client contact is anticipated. Shoe protectors are not necessary.

6. A nurse is assigned to care for a client with a peripheral IV infusion. The nurse is providing hygiene care to the client and would avoid which of the following while changing the client's hospital gown?

Using a hospital gown with snaps at the sleeves

Disconnecting the IV tubing from the catheter in the vein

Checking the IV flow rate immediately after changing the hospital gown

Putting the bag and tubing through the sleeve. followed by the client’s arm

The tubing should not be removed from the IV catheter. With each break in the system. there is an increased chance of introducing bacteria into the system. which can lead to infection. Options 1 and 4 are appropriate. The flow rate should be checked immediately after changing the hospital gown. because the position of the roller clamp may have been affected during the change.

Explanation

The tubing should not be removed from the IV catheter. With each break in the system. there is an increased chance of introducing bacteria into the system. which can lead to infection. Options 1 and 4 are appropriate. The flow rate should be checked immediately after changing the hospital gown. because the position of the roller clamp may have been affected during the change.

7. A nurse is assigned to care for a client admitted to the hospital after sustaining an injury from a house fire. The client attempted to save a neighbor involved in the fire but. in spite of the client's efforts. the neighbor died. Which action would the nurse take to enable the client to work through the meaning of the crisis?

Identifying the client’s ability to function

Identifying the client’s potential for self-harm

Inquiring about the client’s feelings that may affect coping

Inquiring about the client’s perception of the cause of the neighbor’s death

The client must first deal with feelings and negative responses before the client is able to work through the meaning of the crisis. Option 3 pertains directly to the client’s feelings. Options 1. 2. and 4 do not directly address the client’s feelings.

Explanation

The client must first deal with feelings and negative responses before the client is able to work through the meaning of the crisis. Option 3 pertains directly to the client’s feelings. Options 1. 2. and 4 do not directly address the client’s feelings.

8. The nurse is caring for a client after a supratentorial craniotomy in which a large tumor was removed from the left side. Choose the positions in which the nurse can safely place the client. Select all that apply.

On the left side

With the neck flexed

Supine on the left side

With extreme hip flexion

In a semi-Fowler’s position

With the head in a midline position

Clients who have undergone supratentorial surgery should have the head of the bed elevated 30 degrees to promote venous drainage from the head. The client is positioned to avoid extreme hip or neck flexion. and the head is maintained in a midline. neutral position. If a large tumor has been removed. the client should be placed on the nonoperative side to prevent the displacement of the cranial contents.

Explanation

Clients who have undergone supratentorial surgery should have the head of the bed elevated 30 degrees to promote venous drainage from the head. The client is positioned to avoid extreme hip or neck flexion. and the head is maintained in a midline. neutral position. If a large tumor has been removed. the client should be placed on the nonoperative side to prevent the displacement of the cranial contents.

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9. A nurse is admitting a client with a possible diagnosis of chronic bronchitis. The nurse collects data from the client and notes that which of the following signs supports this diagnosis? Select all that apply.

Scant mucus

Early onset cough

Marked weight loss

Purulent mucus production

Mild episodes of dyspnea

Key features of pulmonary emphysema include dyspnea that is often marked. late cough (after onset of dyspnea). scant mucus production. and marked weight loss. By contrast. chronic bronchitis is characterized by an early onset of cough (before dyspnea). copious purulent mucus production. minimal weight loss. and milder severity of dyspnea.

Explanation

Key features of pulmonary emphysema include dyspnea that is often marked. late cough (after onset of dyspnea). scant mucus production. and marked weight loss. By contrast. chronic bronchitis is characterized by an early onset of cough (before dyspnea). copious purulent mucus production. minimal weight loss. and milder severity of dyspnea.

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10. A nurse is assisting with planning care for a client with an internal radiation implant. Which of the following should be included in the plan of care? Select all that apply.

Wearing gloves when emptying the client’s bedpan

Keeping all linens in the room until the implant is removed

Wearing a film (dosimeter) badge when in the client’s room

Wearing a lead apron when providing direct care to the client

Placing the client in a semiprivate room at the end of the hallway

A private room with a private bath is essential if a client has an internal radiation implant. This is necessary to prevent the accidental exposure of other clients to radiation. The remaining options identify interventions that are necessary for a client with a radiation device.

Explanation

A private room with a private bath is essential if a client has an internal radiation implant. This is necessary to prevent the accidental exposure of other clients to radiation. The remaining options identify interventions that are necessary for a client with a radiation device.

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