Friday, September 2, 2016

NCLEX Select All That Apply Practice Exam 5 (15 Questions)

http://www.nclexrnlab.com/2016/09/nclex-select-all-that-apply-practice_2.html
One thing that really challenges NCLEX candidates is the so called dreadful “Select All That Apply” questions. We would like you to eliminate the words anxiety and bias on your vocabulary when it comes to (SATA) questions, so here are 15 more practice NCLEX questions to answer!
God gives every bird a worm, but he does not throw it into the nest.
– Swedish Proverb

Topics

Questions on this exam are taken from various nursing concepts.
  • Questions are formatted in multiple-response or select all that apply format.

Guidelines

Follow the guidelines below to make the most out of this exam:
  • Read each question carefully and choose the best answer.
  • You are given one minute per question. Spend your time wisely!
  • Answers and rationales are given below. Be sure to read them.
  • If you need more clarifications, please direct them to the comments section.
 NCLEX Select All That Apply Practice Exam 5 (15 Questions)
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1. The nurse notes that a client is quite suspicious during an assessment interview and believes that her family is under investigation by the CIA. What would the appropriate nursing interventions be with this client? Select all that apply:
1. Use active listening skills to seek information from the client.
2. Encourage the client to describe the problem as she sees it.
3. Ask the client to tell you exactly what she thinks is happening.
4. Tell the client that she is delusional and you can help her.
5. Explain to the client that most people are not investigated by the CIA.
6. Reassure the client that you are not with the CIA.


2. Which nursing interventions will assist in reducing pressure points that may lead to pressure ulcers? Check all that apply:
1. Position the client directly on the trochanter when side lying.
2. Avoid use of donut type devices.
3. Massage bony prominences.
4. Elevate the HOB no more than 30 degrees when possible.
5. When the client is side lying, use the 30 degree lateral inclined position.
6. Avoid uninterrupted sitting in a chair or wheelchair.


3. The nurse is evaluating a client recently diagnosed with primary open angle glaucoma (POAG). What will an important nursing action be? Select all that apply:
1. Review meds the client is currently on to determine whether any of them cause an increased intraocular pressure as a side effect.
2. Determine whether the client has any sudden loss of vision accompanied by pain.
3. Discuss with the client the importance of controlling blood pressure to decrease the potential loss of peripheral vision.
4. Instruct the client to take analgesics as soon as any discomfort occurs in the eye and to notify clinic if pain is not relieved.
5. Have the client demonstrate the use of eye drops.
6. Assess the client for chronic diseases such as diabetes.


4. A nurse understands that a patient may experience pain during peritoneal dialysis because of which of the following? Select all that apply:
1. Warming the dialysate
2. Too rapid installation
3. Infiltration of the solution into the bloodstream
4. Accumulation of dialysate solution under the diaphragm
5. Too rapid outflow of the dialysate.


5. The nurse is evaluating a client’s response to hemodialysis. Which lab results will indicate the dialysis was effective? Select all that apply:
1. Serum potassium level decreases from 5.4 to 4.6 mEq/L
2. Cr decreases from 1.6 to 0.8 mg/dL
3.Hgb increases from 10-12 g/dL
4. WBC increase from 5000 to 8000/mm^3
5. BUN decreases from 110 to 90 mg/dL


6. The nurse understands that the following clinical findings are indications for dialysis. Select all that apply:
1. Volume overload
2. BUN 18 mg/dL
3. K 5.2 mEq/L
4. Decreased creatinine clearance.
5. Metabolic acidosis
6. Cr 5.0 mg/dL


7. The nurse is assessing a client who had a fractured femur repaired with an external fixator device. Which assessment finding would cause the nurse concern regarding the development of compartment syndrome? Select all that apply:
1. Decrease in pulse rate in affected leg.
2. Paresthesia distal to area of injury.
3. Toes on affected leg cool to touch and edematous.
4. Complaints that pins are hurting.
5. Complaints of leg pain unrelieved by analgesics or repositioning.
6. Client angry and calling loudly to the nurse every ten minutes.


8. The nurse is preparing discharge for a patient with GERD. What would be important for the nurse to include in this teaching plan? Select all that apply:
1. Elevate the HOB.
2. Decrease intake of caffeine.
3. Discuss strategies for weight loss if overweight.
4. Increase fluid intake with meals.
5. Take ranitidine (Zantac) at hs.
6. Eat a bedtime snack of milk and protein.



9. The nurse is preparing a client for cardiac catheterization. Which nursing interventions are necessary in preparing the client for this procedure. Select all that apply:
1. Verify consent has been signed.
2. Explain procedure to client.
3. Provide clear liquid, no caffeine diet.
4. Evaluate peripheral pulses.
5. Obtain a 12 lead ECG
6. Obtain history of shellfish allergy.


10. The nurse has been assigned a group of cardiac clients. What would be the most important information for the nurse to check on the initial evaluation of each client? Select all that apply:
1. Presence of cardiac pain.
2. Medications taken before hospitalizations.
3. Presence of jugular vein distention.
4. Heart sounds and apical rate.
5. Presence of diaphoresis.
6. History of difficulty breathing.


11. The nurse is teaching a client about home care and treatment of venous stasis ulcers in his leg. What should be included in the nurse’s instructions? Select all that apply:
1. Dressings do not need to be changed frequently because there is minimal drainage.
2. Healing will be facilitated by wearing leg compression devices.
3. When the client is in sitting position, he should keep his legs elevated.
4. Avoid standing for long periods of time.
5. Cool packs can be applied to the ulcers to decrease inflammation.
6. Soak the affected extremity in warm water every evening.


12. A nurse knows the clinical manifestations of a client with Addison’s disease include which of the following? Select all that apply:
1. Nausea
2. Hypothermia
3. Hypertension
4. Hyperpigmentation
5. Hypotension
6. Hypernatremia


13. 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?
1. A task approach method is used to provide care to clients.
2. Managed care concepts and tools are used when providing client care.
3. Nursing staff are led by a nurse when providing care to a group of clients.
4. A single registered nurse is responsible for providing nursing care to a group of clients.


14. 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?
1. A client who requires wound irrigation
2. A client who requires frequent ambulation
3. A client who is receiving continuous tube feedings
4. A client who requires frequent vital signs after a cardiac catheterization


15. 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.
1. Failure to replace body fluids
2. Increased risk of hypotension
3. Failure to teach the client adequately
4. Increased need to protect the client
5. Excessive bumetanide administration
6. Lack of follow-up nursing actions



Answers and Rationale

1. Answers: 1,2,3.
The client is displaying paranoid behaviours, which necessitates a matter of fact approach that is nonjudgmental and accepting the client’s statements and show the nurses willingness to actively listen. The last three do not contribute to a therapeutic nurse client relationship.

2. Answers: 2, 4, 5 ,6.
Elevating the head of the bed to 30 degrees or less will decrease the chance of ulcer development from shearing forces. When placing the client in a side lying position, use the 30 degree lateral inclined position. Do not place the client on their trochanter. Avoid donuts which promote ischemia. Don’t massage bony prominences as this causes capillary break down and injury leading to pressure ulcers.

3. Answers: 1, 5, 6.
Medications must be evaluated in terms of their potential for increasing the intraocular pressure. Ophthalmic drops are often prescribed for glaucoma and clients should know how to administer them correctly. Diabetes is a risk factor and its mgmt is important in helping slow POAG. An increase in intraocular pressure could cause further damage to a patient with POAG. The questions states the client is already diagnosed, POAG is painless and not correlated to BP.

4. Answers: 2,4.
Rapid outflow doesn’t cause pain, warming helps with discomfort and the dialysate does not infiltrate the circulation.

5. Answers: 1, 2, 5.
Primary action of hemodialysis is to clear nitrogenous waste products.

6. Answers: 1, 3, 5, 6.
Indications for dialysis include volume overload, weight gain, hyperkalemia, metabolic acidosis, and rising BUN (normally 10-20 mg/dL) and Cr (normally 0.5-1.5 mg/dL) levels, along with decreased urinary creatinine clearance. The K level is hyperkalemic, the BUN is normal.

7. Answers: 2, 3, 5.
Paresthesia, edema, and leg pain unrelieved by analgesics are classic indicators of the development of compartmental syndrome. With a femur fracture the will be edema, a decrease in rate is not an indication of pressure, a decrease in pulse strength is. Anger can be due to immobility, and the pins do not usually cause pain, but this may be a sign of infection.

8. Answers: 1, 2, 3, 5.
This will all help neutralize stomach acid. Drinking lots with meals and eating before bed will exacerbate the problem.


9. Answers: 1, 2, 5, and 6. 
In cardiac catheterization contrast dye is injected into the coronary artery and provides info on patency. Informed consent must be signed prior to any invasive procedure. The physician is responsible for explaining the procedure, the nurse can reinforce. Patient would be NPO 6-18 hours prior. An ECG would be done, but measures electrical not blood flow. Peripheral pulses is important afterwards. Shellfish is an indicator of an allergy to the medium injected.

10. Answers: 1, 3, 4, and 5.
A focussed cardiac assessment is directed towards assessing physiologic symptoms (cardiac pain, JVD, heart sounds and rate, and presence of diaphoresis) that provide immediate information regarding the clients condition, which is appropriate for the nurse to do at the beginning of each shift. After the physiological parameters have been evaluated the nurse can determine history of SOB and meds.

11. Answers: 2, 3, and 4.
Healing of venous stasis ulcers in dependent on relieving the venous congestion in the extremity. Compression devices and elevation of the extremity are the most effective methods. The client should avoid standing for long periods since this increases venous stasis. Moist cool and/or warm packs are NOT used, but moist environment dressings are utilized. Dressings need to be changed as frequently as necessary because there may be excessive drainage.

12. Answers: 1, 4, and 5.
Addison’s disease is due to hypofunctioning of the adrenal cortex. The clinical manifestations have a very slow onset, and skin hyperpigmentation is a classic sign. Fatigue, nausea, weight loss, hypotension, hyponatremia, and hyperkalemia are other findings associated with the condition.

13. Answer: 3.
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.

14. Answer: 2.
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.

15. Answers: 2, 3, 4, and 6.
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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