NCLEX Select All That Apply Practice Exam 8 (10 Questions)

2.

A nurse lawyer provides an education session to the nursing staff regarding client rights. A nurse asks the lawyer to describe an example that may relate to invasion of client privacy. A nursing action that indicates a violation of this right is:

Threatening to place a client in restraints
Performing a surgical procedure without consent
Taking photographs of the client without consent
Telling the client that he or she cannot leave the hospital

Correct Answer

A. Taking photographs of the client without consent

Explanation

Invasion of privacy takes place when an individual’s private affairs are intruded on unreasonably. Threatening to place a client in restraints constitutes assault. Performing a surgical procedure without consent is an example of battery. Not allowing a client to leave the hospital constitutes false imprisonment.

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3.

A nurse notes in the medical record that a client with Cushing’s syndrome is experiencing fluid overload. Which interventions should be included in the plan of care? Select all that apply.

Monitoring daily weight
Monitoring intake and output
Maintaining a low-potassium diet
Monitoring extremities for edema
Maintaining a low-sodium diet

Correct Answer(s)

A. Monitoring daily weight
A. Monitoring intake and output
A. Monitoring extremities for edema
A. Maintaining a low-sodium diet

Explanation

The client with Cushing’s syndrome experiencing fluid overload should be maintained on a high-potassium and low-sodium diet. Decreased sodium intake decreases renal retention of sodium and water. Monitoring weight. intake. output. and extremities for edema are all appropriate interventions for such a nursing diagnosis.

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4.

A nurse is reviewing the health records of assigned clients. The nurse plans care knowing that which client is at risk for fluid volume deficit?

The client with cirrhosis
The client with a colostomy
The client with decreased kidney function
The client with congestive heart failure (CHF)

Correct Answer

A. The client with a colostomy

Explanation

Causes of a fluid volume deficit include vomiting. diarrhea. conditions that cause increased respirations or increased urinary output. insufficient intravenous fluid replacement. draining fistulas. ileostomy. and colostomy. A client with cirrhosis. CHF. or decreased kidney function is at risk for fluid volume excess.

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5.

A nurse is providing teaching regarding the prevention of Lyme disease to a group of teenagers going on a hike in a wooded area. Which of the following points should the nurse include in the session? Select all that apply.

Tuck pant legs into socks.
Wear closed shoes when hiking.
Apply insect repellent containing DEET.
Cover the ground with a blanket when sitting.
Remove attached ticks by grasping with thumb and forefinger.
Wear long sleeves and long pants in dark colors when in high-risk areas.

Correct Answer(s)

A. Tuck pant legs into socks.
A. Wear closed shoes when hiking.
A. Apply insect repellent containing DEET.
A. Cover the ground with a blanket when sitting.

Explanation

Measures to prevent tick bites focus on covering the body as completely as possible and spraying insect repellent containing DEET on the skin and clothing. Long sleeves and pants tucked into the socks along with closed shoes will offer some protection. Light-colored clothing should be worn so that ticks would be easily visible. Hikers should not sit directly on the ground and should cover the ground with an item such as a blanket. Ticks should be removed with tweezers.

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6.

A nurse is providing a list of instructions to a client who is scheduled to have an electroencephalogram (EEG). Choose the instructions that the nurse places on the list. Select all that apply.

Cola is acceptable to drink on the day of the test.
Tea and coffee are restricted on the day of the test.
The test will take between 45 minutes and 2 hours.
The hair should be washed the evening before the test.
All medications need to be withheld on the day of the test.
A nothing-by-mouth (NPO) status is required on the day of the test.

Correct Answer(s)

A. Tea and coffee are restricted on the day of the test.
A. The test will take between 45 minutes and 2 hours.
A. The hair should be washed the evening before the test.

Explanation

Pre-procedure instructions include informing the client that the procedure is painless. The procedure requires no dietary restrictions other than avoidance of cola. tea. and coffee on the morning of the test. These products have a stimulating effect and should be avoided. The hair should be washed the evening before the test. and gels. hairsprays. and lotion should be avoided. The client is informed that the test will take 45 minutes to 2 hours and that medications are usually not withheld before the test.

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7.

Which instruction should the nurse provide to the client with diabetes mellitus receiving acarbose (Precose)? Select all that apply.

“Take the medication at bedtime.”
“Take the medication with each meal.”
“Take the medication on an empty stomach.”
“Side effects include abdominal bloating and flatus.”
“Take some form of glucose if hypoglycemia occurs.”
“Report symptoms such as shortness of breath or tiredness.”

Correct Answer(s)

A. “Take the medication with each meal.”
A. “Side effects include abdominal bloating and flatus.”
A. “Take some form of glucose if hypoglycemia occurs.”
A. “Report symptoms such as shortness of breath or tiredness.”

Explanation

The mechanism of action of acarbose is a delay in absorption of dietary carbohydrates. thereby reducing the rise in blood glucose after a meal. To accomplish this. the medication must be taken with each meal. Because of its bacterial fermentation of unabsorbed carbohydrates in the colon. side effects such as borborygmus. cramps. abdominal distention. and flatulence can occur. The medication also can affect absorption of iron. leading to symptoms (shortness of breath. tiredness) of anemia.

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8.

The nurse is providing discharge teaching to the client who was given a prescription for nifedipine (Adalat) for blood pressure management. Which instructions should the nurse include? Select all that apply.

“Increase water intake.”
“Increase calcium intake.”
“Take pulse rate each day.”
“Weigh at the same time each day.”
“Palpitations may occur early in therapy.”
“Be careful when rising from sitting to standing.”

Correct Answer(s)

A. “Take pulse rate each day.”
A. “Weigh at the same time each day.”
A. “Palpitations may occur early in therapy.”
A. “Be careful when rising from sitting to standing.”

Explanation

Nifedipine is a calcium-channel blocker. Its therapeutic outcome is to decrease blood pressure. Its method of action is blockade of the calcium channels in vascular smooth muscle. promoting vasodilation. Side effects that can occur early in therapy include reflex tachycardia (palpitations) and first-dose hypotension. leading to orthostatic hypotension. Weight should be checked regularly to monitor for early signs of heart failure. Also the client is taught to take his or her own pulse. Nifedipine does not affect serum calcium levels. Increased water intake is not indicated in the client with cardiovascular disease.

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9.

A nurse is told in report that a client has a positive Chvostek’s sign. What other data would the nurse expect to find on data collection? Select all that apply.

Coma
Tetany
Diarrhea
Possible seizure activity
Hypoactive bowel sounds
Positive Trousseau’s sign

Correct Answer(s)

A. Tetany
A. Diarrhea
A. Possible seizure activity
A. Positive Trousseau’s sign

Explanation

A positive Chvostek’s sign is indicative of hypocalcemia. Other signs and symptoms include tachycardia. hypotension. paresthesias. twitching. cramps. tetany. seizures. positive Trousseau’s sign. diarrhea. hyperactive bowel sounds. and a prolonged QT interval.

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10.

A nurse is reinforcing instructions to a client following a total laryngectomy about caring for the stoma. Choose the instructions that the nurse provides to the client. Select all that apply.

Protect the stoma from water.
Soaps should be avoided near the stoma.
Wash the stoma daily using a washcloth.
Use diluted alcohol on the stoma to clean it.
Apply a thin layer of petroleum jelly to the skin surrounding the stoma.
Use soft tissues to clean any secretions that accumulate around the stoma.

Correct Answer(s)

A. Protect the stoma from water.
A. Soaps should be avoided near the stoma.
A. Wash the stoma daily using a washcloth.
A. Apply a thin layer of petroleum jelly to the skin surrounding the stoma.

Explanation

The client with a stoma should be instructed to wash the stoma daily with a washcloth. Soaps. cotton swabs. or tissues should be avoided because their particles may enter and obstruct the airway. The client should be instructed to avoid applying alcohol to a stoma because it is both drying and irritating. A thin layer of petroleum jelly applied to the skin around the stoma helps prevent cracking. The client is instructed to protect the stoma from water.

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NCLEX Select All That Apply Practice Exam 8 (10 Questions)

A nurse notes in the medical record that a client with Cushing’s syndrome is experiencing fluid overload. Which interventions should be included in the plan of care? Select all that apply.

Quiz Preview

A nurse lawyer provides an education session to the nursing staff regarding client rights. A nurse asks the lawyer to describe an example that may relate to invasion of client privacy. A nursing action that indicates a violation of this right is:

A nurse notes in the medical record that a client with Cushing’s syndrome is experiencing fluid overload. Which interventions should be included in the plan of care? Select all that apply.

A nurse is reviewing the health records of assigned clients. The nurse plans care knowing that which client is at risk for fluid volume deficit?

A nurse is providing teaching regarding the prevention of Lyme disease to a group of teenagers going on a hike in a wooded area. Which of the following points should the nurse include in the session? Select all that apply.

A nurse is providing a list of instructions to a client who is scheduled to have an electroencephalogram (EEG). Choose the instructions that the nurse places on the list. Select all that apply.

Which instruction should the nurse provide to the client with diabetes mellitus receiving acarbose (Precose)? Select all that apply.

The nurse is providing discharge teaching to the client who was given a prescription for nifedipine (Adalat) for blood pressure management. Which instructions should the nurse include? Select all that apply.

A nurse is told in report that a client has a positive Chvostek’s sign. What other data would the nurse expect to find on data collection? Select all that apply.

A nurse is reinforcing instructions to a client following a total laryngectomy about caring for the stoma. Choose the instructions that the nurse provides to the client. Select all that apply.