NCLEX Select All That Apply Practice Exam 7 (10 Questions)

1. The nurse is preparing a teaching plan for a client who is undergoing cataract extraction with intraocular implant. Which home care measures will the nurse include in the plan? Select all that apply.

To avoid activities that require bending over

To contact the surgeon if eye scratchiness occurs

To place an eye shield on the surgical eye at bedtime

That episodes of sudden severe pain in the eye is expected

To contact the surgeon if a decrease in visual acuity occurs

To take acetaminophen (Tylenol) for minor eye discomfort

After eye surgery. some scratchiness and mild eye discomfort may occur in the operative eye and is usually relieved by mild analgesics. If the eye pain becomes severe. the client should notify the surgeon because this may indicate hemorrhage. infection. or increased intraocular pressure. The nurse would also instruct the client to notify the surgeon of purulent drainage. increased redness. or any decrease in visual acuity. The client is instructed to place an eye shield over the operative eye at bedtime to protect the eye from injury during sleep and to avoid activities that increase intraocular pressure such as bending over.

Explanation

After eye surgery. some scratchiness and mild eye discomfort may occur in the operative eye and is usually relieved by mild analgesics. If the eye pain becomes severe. the client should notify the surgeon because this may indicate hemorrhage. infection. or increased intraocular pressure. The nurse would also instruct the client to notify the surgeon of purulent drainage. increased redness. or any decrease in visual acuity. The client is instructed to place an eye shield over the operative eye at bedtime to protect the eye from injury during sleep and to avoid activities that increase intraocular pressure such as bending over.

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2. A nurse is caring for a client with diabetic ketoacidosis and documents that the client is experiencing Kussmaul's respirations. Based on this documentation. which of the following did the nurse most likely observe?

Respirations that cease for several seconds

Respirations that are regular but abnormally slow

Respirations that are labored and increased in depth and rate

Respirations that are abnormally deep. regular. and increased in rate

Kussmaul’s respirations are abnormally deep. regular. and increased in rate. In apnea. respirations cease for several seconds. In bradypnea. respirations are regular but abnormally slow. In hyperpnea. respirations are labored and increased in depth and rate.

Explanation

Kussmaul’s respirations are abnormally deep. regular. and increased in rate. In apnea. respirations cease for several seconds. In bradypnea. respirations are regular but abnormally slow. In hyperpnea. respirations are labored and increased in depth and rate.

3. A nurse is caring for a group of clients who are taking herbal medications at home. Which of the following clients should be instructed not to take herbal medications?

A 60-year-old male client with rhinitis

A 24-year-old male client with a lower back injury

A 10-year-old female client with a urinary tract infection

A 45-year-old female client with a history of migraine headaches

Children should not be given herbal therapies. especially in the home and without professional supervision. There are no general contraindications for the clients described in options 1. 2. and 4.

Explanation

Children should not be given herbal therapies. especially in the home and without professional supervision. There are no general contraindications for the clients described in options 1. 2. and 4.

4. A nurse is monitoring a group of clients for acid-base imbalances. Which clients are at highest risk for metabolic acidosis? Select all that apply.

Severely anxious client

Pneumonia client

Diabetic mellitus client

Malnourished client

Asthma client

Renal failure client

Diabetes mellitus. malnutrition. and renal failure lead to metabolic acidosis because of the increasing acids in the body. Options 1. 2. and 5 are respiratory problems. not metabolic. and result in either respiratory acidosis or respiratory alkalosis.

Explanation

Diabetes mellitus. malnutrition. and renal failure lead to metabolic acidosis because of the increasing acids in the body. Options 1. 2. and 5 are respiratory problems. not metabolic. and result in either respiratory acidosis or respiratory alkalosis.

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5. A nurse is monitoring a client with Graves' disease for signs of thyrotoxicosis (thyroid storm). Which of the following signs and symptoms. if noted in the client. will alert the nurse to the presence of this crisis? Select all that apply.

Bradycardia

Fever

Sweating

Agitation

Pallor

Thyrotoxic crisis (thyroid storm) is an acute. potentially life-threatening state of extreme thyroid activity that represents a breakdown in the body’s tolerance to a chronic excess of thyroid hormones. The clinical manifestations include fever greater than 100° F. severe tachycardia. flushing and sweating. and marked agitation and restlessness. Delirium and coma can occur.

Explanation

Thyrotoxic crisis (thyroid storm) is an acute. potentially life-threatening state of extreme thyroid activity that represents a breakdown in the body’s tolerance to a chronic excess of thyroid hormones. The clinical manifestations include fever greater than 100° F. severe tachycardia. flushing and sweating. and marked agitation and restlessness. Delirium and coma can occur.

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6. Which nursing interventions are appropriate for a client recovering from surgery for retinal detachment? Select all that apply.

Monitor for hemorrhage.

Administer eye medications.

Maintain the eye patch or shield.

Assist with activities of daily living.

Encourage coughing and deep breathing.

Educate regarding symptoms of retinal detachment.

An eye patch or shield is applied to protect the eye and prevent any further detachment. Educating the client regarding symptoms is necessary because the client is at risk for subsequent retinal detachment. Positioning. activity restrictions. and eye patches hinder the client in the performance of activities of daily living. and the client needs the nurse’s assistance with these activities. Eye medications are prescribed postoperatively. and hemorrhage is also a risk post surgery. Coughing is not encouraged because this can increase intraocular pressure and harm the client.

Explanation

An eye patch or shield is applied to protect the eye and prevent any further detachment. Educating the client regarding symptoms is necessary because the client is at risk for subsequent retinal detachment. Positioning. activity restrictions. and eye patches hinder the client in the performance of activities of daily living. and the client needs the nurse’s assistance with these activities. Eye medications are prescribed postoperatively. and hemorrhage is also a risk post surgery. Coughing is not encouraged because this can increase intraocular pressure and harm the client.

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7. A nurse is caring for a client with leukemia and notes that the client has poor skin turgor and flat neck and hand veins. The nurse suspects hyponatremia. What additional signs would the nurse expect to note in this client if hyponatremia is present?

Intense thirst

Slow bounding pulse

Dry mucous membranes

Postural blood pressure changes

Postural blood pressure changes occur in the client with hyponatremia. Dry mucous membranes and intense thirst are seen in clients with hypernatremia. A slow. bounding pulse is not indicative of hyponatremia. In a client with hyponatremia. a rapid thready pulse is noted.

Explanation

Postural blood pressure changes occur in the client with hyponatremia. Dry mucous membranes and intense thirst are seen in clients with hypernatremia. A slow. bounding pulse is not indicative of hyponatremia. In a client with hyponatremia. a rapid thready pulse is noted.

8. The nurse is preparing a teaching plan for a client who is undergoing cataract extraction with intraocular implant. Which home care measures will the nurse include in the plan? Select all that apply.

To avoid activities that require bending over

To contact the surgeon if eye scratchiness occurs

To place an eye shield on the surgical eye at bedtime

That episodes of sudden severe pain in the eye is expected

To contact the surgeon if a decrease in visual acuity occurs

To take acetaminophen (Tylenol) for minor eye discomfort

After eye surgery. some scratchiness and mild eye discomfort may occur in the operative eye and is usually relieved by mild analgesics. If the eye pain becomes severe. the client should notify the surgeon because this may indicate hemorrhage. infection. or increased intraocular pressure. The nurse would also instruct the client to notify the surgeon of purulent drainage. increased redness. or any decrease in visual acuity. The client is instructed to place an eye shield over the operative eye at bedtime to protect the eye from injury during sleep and to avoid activities that increase intraocular pressure such as bending over.

Explanation

After eye surgery. some scratchiness and mild eye discomfort may occur in the operative eye and is usually relieved by mild analgesics. If the eye pain becomes severe. the client should notify the surgeon because this may indicate hemorrhage. infection. or increased intraocular pressure. The nurse would also instruct the client to notify the surgeon of purulent drainage. increased redness. or any decrease in visual acuity. The client is instructed to place an eye shield over the operative eye at bedtime to protect the eye from injury during sleep and to avoid activities that increase intraocular pressure such as bending over.

Submit

9. A nurse is collecting data on a client with severe preeclampsia. Choose the findings that would be noted in severe preeclampsia. Select all that apply.

Oliguria

Seizures

Contractions

Proteinuria 3+

Muscle cramps

Blood pressure 168/116 mm Hg

Severe preeclampsia is characterized by blood pressure higher than 160/110 mmHg. proteinuria 3+ or higher. and oliguria. Seizures (convulsions) are present in eclampsia and are not a characteristic of severe preeclampsia. Muscle cramps and contractions are not findings noted in severe preeclampsia. although the client is monitored for these occurrences.

Explanation

Severe preeclampsia is characterized by blood pressure higher than 160/110 mmHg. proteinuria 3+ or higher. and oliguria. Seizures (convulsions) are present in eclampsia and are not a characteristic of severe preeclampsia. Muscle cramps and contractions are not findings noted in severe preeclampsia. although the client is monitored for these occurrences.

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10. A nurse is caring for an infant with a diagnosis of tetralogy of Fallot. The infant suddenly becomes cyanotic and the oxygen saturation reading drops to 60%. Choose the interventions that the nurse should perform. Select all that apply.

Call a code blue.

Notify the registered nurse.

Place the infant in a prone position.

Prepare to administer morphine sulfate.

Prepare to administer intravenous fluids.

Prepare to administer 100% oxygen by face mask.

The child who is cyanotic with oxygen saturations dropping to 60% is having a hypercyanotic episode. Hypercyanotic episodes often occur among infants with tetralogy of Fallot. and they may occur among infants whose heart defect includes the obstruction of pulmonary blood flow and communication between the ventricles. If a hypercyanotic episode occurs. the infant is placed in a knee-chest position immediately. The registered nurse is notified. who will then contact the health care provider. The knee-chest position improves systemic arterial oxygen saturation by decreasing venous return so that smaller amounts of highly saturated blood reach the heart. Toddlers and children squat to get into this position and relieve chronic hypoxia. There is no reason to call a code blue unless respirations cease. Additional interventions include administering 100% oxygen by face mask. morphine sulfate. and intravenous fluids. as prescribed.

Explanation

The child who is cyanotic with oxygen saturations dropping to 60% is having a hypercyanotic episode. Hypercyanotic episodes often occur among infants with tetralogy of Fallot. and they may occur among infants whose heart defect includes the obstruction of pulmonary blood flow and communication between the ventricles. If a hypercyanotic episode occurs. the infant is placed in a knee-chest position immediately. The registered nurse is notified. who will then contact the health care provider. The knee-chest position improves systemic arterial oxygen saturation by decreasing venous return so that smaller amounts of highly saturated blood reach the heart. Toddlers and children squat to get into this position and relieve chronic hypoxia. There is no reason to call a code blue unless respirations cease. Additional interventions include administering 100% oxygen by face mask. morphine sulfate. and intravenous fluids. as prescribed.

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