NCLEX Select All That Apply Practice Exam 9 (10 Questions)

1. A pregnant woman has a positive history of genital herpes. but she has not had lesions during her pregnancy. The nurse plans to provide which of the following information to the client?

“You will be isolated from your newborn after delivery.”

“There is little risk to your baby during your pregnancy. birth. and after delivery.”

“Vaginal deliveries can reduce neonatal infection risks. even if you have an active lesion at birth.”

“You will be evaluated at the time of delivery for herpetic genital tract lesions. If they are present. a cesarean delivery will be needed.”

If herpetic genital lesions are present at the time of delivery. a cesarean delivery will be necessary to reduce the risk of infecting the neonate. In the absence of herpetic genital lesions. a vaginal delivery may be indicated. unless there are other reasons for performing a cesarean delivery. Maternal isolation is not necessary. but potentially exposed neonates should be cultured on the day of delivery.

Explanation

If herpetic genital lesions are present at the time of delivery. a cesarean delivery will be necessary to reduce the risk of infecting the neonate. In the absence of herpetic genital lesions. a vaginal delivery may be indicated. unless there are other reasons for performing a cesarean delivery. Maternal isolation is not necessary. but potentially exposed neonates should be cultured on the day of delivery.

2. Which data indicates to the nurse that a client may be experiencing ineffective coping?

Constantly neglects personal grooming

Visits her husband’s grave once a month

Visits the senior citizens’ center once a month

Frequently looks at snapshots of her husband and family

Coping mechanisms are behaviors that are used to decreased stress and anxiety. In response to a death. ineffective coping is manifested by an extreme behavior that in some instances may be harmful to the individual. physically. psychologically. or both. Option 1 is indicative of a behavior that identifies an ineffective coping behavior as part of the grieving process. The remaining options identify effective coping behaviors.

Explanation

Coping mechanisms are behaviors that are used to decreased stress and anxiety. In response to a death. ineffective coping is manifested by an extreme behavior that in some instances may be harmful to the individual. physically. psychologically. or both. Option 1 is indicative of a behavior that identifies an ineffective coping behavior as part of the grieving process. The remaining options identify effective coping behaviors.

3. An unconscious client who is bleeding profusely is brought to the emergency department after a serious accident. Surgery is required immediately to save the client's life. With regard to informed consent for the surgical procedure. which of the following is the best action?

Call the nursing supervisor to initiate a court order for the surgical procedure.

Try calling the client’s spouse to obtain telephone consent before the surgical procedure.

Ask the friend who accompanied the client to the emergency department to sign the consent form.

Transport the client to the operating department immediately. as required by the health care provider without obtaining an informed consent.

Generally there are only two instances in which the informed consent of an adult client is not needed. One instance is when an emergency is present and delaying treatment for the purpose of obtaining informed consent would result in injury or death to the client. The second instance is when the client waives the right to give informed consent. Options 1. 2. and 3 are inappropriate.

Explanation

Generally there are only two instances in which the informed consent of an adult client is not needed. One instance is when an emergency is present and delaying treatment for the purpose of obtaining informed consent would result in injury or death to the client. The second instance is when the client waives the right to give informed consent. Options 1. 2. and 3 are inappropriate.

4. When caring for a 3-year-old child. the nurse should provide which toy for this child?

A puzzle

A wagon

A golf set

A farm set

Toys for the toddler must be strong. safe. and too large to swallow or place in the ear or nose. Toddlers need supervision at all times. Push-pull toys. large balls. large crayons. trucks. and dolls are some appropriate toys. A puzzle with large pieces only may be appropriate. A farm set and a golf set may contain items that the child could swallow.

Explanation

Toys for the toddler must be strong. safe. and too large to swallow or place in the ear or nose. Toddlers need supervision at all times. Push-pull toys. large balls. large crayons. trucks. and dolls are some appropriate toys. A puzzle with large pieces only may be appropriate. A farm set and a golf set may contain items that the child could swallow.

5. A nurse prepares a list of home care instructions for the parents of a child who has a plaster cast applied to the left forearm. Choose the instructions that would be included on the list. Select all that apply.

Use the fingertips to lift the cast while it is drying.

Keep small toys and sharp objects away from the cast.

Use a padded ruler or another padded object to scratch the skin under the cast if it itches.

Place a heating pad on the lower end of the cast and over the fingers if the fingers feel cold.

Contact the health care provider if the child complains of numbness or tingling in the extremity.

Elevate the extremity on pillows for the first 24 to 48 hours after casting to prevent swelling.

While the cast is drying. the palms of the hands are used to lift the cast. If the fingertips are used. indentations in the cast could occur and cause constant pressure on the underlying skin. Small toys and sharp objects are kept away from the cast. and no objects (including padded objects) are placed inside of the cast because of the risk of altered skin integrity. A heating pad is not applied to the cast or fingers. Cold fingers could indicate neurovascular impairment. and the HCP should be notified. The extremity is elevated to prevent swelling. and the HCP is notified immediately if any signs of neurovascular impairment develop.

Explanation

While the cast is drying. the palms of the hands are used to lift the cast. If the fingertips are used. indentations in the cast could occur and cause constant pressure on the underlying skin. Small toys and sharp objects are kept away from the cast. and no objects (including padded objects) are placed inside of the cast because of the risk of altered skin integrity. A heating pad is not applied to the cast or fingers. Cold fingers could indicate neurovascular impairment. and the HCP should be notified. The extremity is elevated to prevent swelling. and the HCP is notified immediately if any signs of neurovascular impairment develop.

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6. A nurse reinforces instructions to the mother of a child who has been hospitalized with croup. Which of the following statements. if made by the mother. would indicate the need for further instruction?

“I will give my child cough syrup if a cough develops.”

“During an attack. I will take my child to a cool location.”

“I will give acetaminophen (Tylenol) if my child develops a fever.”

“I will be sure that my child drinks at least three to four glasses of fluids every day.”

Cough syrups and cold medicines are not to be given. because they may dry and thicken secretions. During a croup attack. the child can be taken to a cool basement or garage. Acetaminophen is used if a fever develops. Adequate hydration of 500 to 1000 mL of fluids daily is important for thinning secretions.

Explanation

Cough syrups and cold medicines are not to be given. because they may dry and thicken secretions. During a croup attack. the child can be taken to a cool basement or garage. Acetaminophen is used if a fever develops. Adequate hydration of 500 to 1000 mL of fluids daily is important for thinning secretions.

7. The parent of a toddler asks a nurse when it is safe to place the car safety seat in a face-forward position. Which of the following is the best nursing response?

When the toddler weighs 20 lb and is 1 year old

When the weight of the toddler is more than 40 lb

The seat should not be placed in a face-forward position unless there are safety locks in the car.

The seat should never be placed in a face-forward position because of the risk of the child unbuckling the harness.

The transition point for switching to the forward-facing position is defined by the manufacturer of the convertible car safety seat. but it is generally at a bodyweight of 9 kg (20 lb) and an age of 1 year. Options 2. 3. and 4 are incorrect.

Explanation

The transition point for switching to the forward-facing position is defined by the manufacturer of the convertible car safety seat. but it is generally at a bodyweight of 9 kg (20 lb) and an age of 1 year. Options 2. 3. and 4 are incorrect.

8. Which of these clients are most likely to develop fluid (circulatory) overload? Select all that apply.

A premature infant

A 101-year-old man

A client on renal dialysis

A client with diabetes mellitus

A 29-year-old woman with pneumonia

A client with congestive heart failure

Clients with cardiac. respiratory. renal. or liver diseases and older and very young clients cannot tolerate an excessive fluid volume. The risk of fluid (circulatory) overload exists with these clients

Explanation

Clients with cardiac. respiratory. renal. or liver diseases and older and very young clients cannot tolerate an excessive fluid volume. The risk of fluid (circulatory) overload exists with these clients

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9. When the nurse is collecting data from the older adult. which of the following findings would be considered normal physiological changes? Select all that apply.

Increased heart rate

Decline in visual acuity

Decreased respiratory rate

Decline in long-term memory

Increased susceptibility to urinary tract infections

Increased incidence of awakening after sleep onset

Anatomical changes to the eye affect the individual’s visual ability. which leads to potential problems with activities of daily living. Light adaptation and visual fields are reduced. Respiratory rates are usually unchanged. The heart rate decreases. and the heart valves thicken. Age-related changes that affect the urinary tract increase an older client’s susceptibility to urinary tract infections. Short-term memory may decline with age. but long-term memory is usually maintained. Changes in sleep patterns are consistent. age-related changes. Older persons experience an increased incidence of awakening after sleep onset.

Explanation

Anatomical changes to the eye affect the individual’s visual ability. which leads to potential problems with activities of daily living. Light adaptation and visual fields are reduced. Respiratory rates are usually unchanged. The heart rate decreases. and the heart valves thicken. Age-related changes that affect the urinary tract increase an older client’s susceptibility to urinary tract infections. Short-term memory may decline with age. but long-term memory is usually maintained. Changes in sleep patterns are consistent. age-related changes. Older persons experience an increased incidence of awakening after sleep onset.

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10. The nurse would anticipate the use of which medications in the treatment of the client with heart failure? Select all that apply.

Diuretics

Anticoagulants

Anticholinergics

Cardiac glycosides

Phosphodiesterase (PDE) inhibitors

Angiotensin-converting enzyme (ACE) inhibitors

Medications recommended for treatment of heart failure include diuretics. cardiac glycosides such as digoxin (Lanoxin). PDE inhibitors. and ACE inhibitors. Clients in heart failure do not need anticoagulants or anticholinergics.

Explanation

Medications recommended for treatment of heart failure include diuretics. cardiac glycosides such as digoxin (Lanoxin). PDE inhibitors. and ACE inhibitors. Clients in heart failure do not need anticoagulants or anticholinergics.

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