NCLEX Select All That Apply Practice Exam 4 (20

Questions)
1. 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.
1. Cola is acceptable to drink on the day of the test.
2. Tea and coffee are restricted on the day of the test.
3. The test will take between 45 minutes and 2 hours.
4. The hair should be washed the evening before the test.
5. All medications need to be withheld on the day of the test.
6. A nothing-by-mouth (NPO) status is required on the day of the test.
2. 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.
1. Increase water intake.
2. Increase calcium intake.
3. Take pulse rate each day.
4. Weigh at the same time each day.
5. Palpitations may occur early in therapy.
6. Be careful when rising from sitting to standing.
3. 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.
1. Tuck pant legs into socks.
2. Wear closed shoes when hiking.
3. Apply insect repellent containing DEET.
4. Cover the ground with a blanket when sitting.
5. Remove attached ticks by grasping with thumb and forefinger.
6. Wear long sleeves and long pants in dark colors when in high-risk areas.
4. 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.
1. Protect the stoma from water.
2. Soaps should be avoided near the stoma.
3. Wash the stoma daily using a washcloth.

4. Use diluted alcohol on the stoma to clean it.

5. Apply a thin layer of petroleum jelly to the skin surrounding the stoma.
6. Use soft tissues to clean any secretions that accumulate around the stoma.
5. 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?
1. The client with cirrhosis
2. The client with a colostomy
3. The client with decreased kidney function
4. The client with congestive heart failure (CHF)
6. A nurse is told in report that a client has a positive Chvosteks sign. What other data
would the nurse expect to find on data collection? Select all that apply.
1. Coma
2. Tetany
3. Diarrhea
4. Possible seizure activity
5. Hypoactive bowel sounds
6. Positive Trousseaus sign
7. 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:
1. Threatening to place a client in restraints
2. Performing a surgical procedure without consent
3. Taking photographs of the client without consent
4. Telling the client that he or she cannot leave the hospital
8. A nurse notes in the medical record that a client with Cushings syndrome is
experiencing fluid overload. Which interventions should be included in the plan of care?
Select all that apply.
1. Monitoring daily weight
2. Monitoring intake and output
3. Maintaining a low-potassium diet
4. Monitoring extremities for edema
5. Maintaining a low-sodium diet
9. A nurse notes in the medical record that a client with Cushings syndrome is
experiencing fluid overload. Which interventions should be included in the plan of care?
Select all that apply.

1. Monitoring daily weight

2. Monitoring intake and output
3. Maintaining a low-potassium diet
4. Monitoring extremities for edema
5. Maintaining a low-sodium diet
10. Which instruction should the nurse provide to the client with diabetes mellitus receiving
acarbose (Precose)? Select all that apply.
1. Take the medication at bedtime.
2. Take the medication with each meal.
3. Take the medication on an empty stomach.
4. Side effects include abdominal bloating and flatus.
5. Take some form of glucose if hypoglycemia occurs.
6. Report symptoms such as shortness of breath or tiredness.
11. 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.
1. Use the fingertips to lift the cast while it is drying.
2. Keep small toys and sharp objects away from the cast.
3. Use a padded ruler or another padded object to scratch the skin under the cast if it itches.
4. Place a heating pad on the lower end of the cast and over the fingers if the fingers feel cold.
5. Contact the health care provider if the child complains of numbness or tingling in the
extremity.
6. Elevate the extremity on pillows for the first 24 to 48 hours after casting to prevent swelling.
12. 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?
1. I will give my child cough syrup if a cough develops.
2. During an attack, I will take my child to a cool location.
3. I will give acetaminophen (Tylenol) if my child develops a fever.
4. I will be sure that my child drinks at least three to four glasses of fluids every day.
13. The nurse would anticipate the use of which medications in the treatment of the client
with heart failure? Select all that apply.
1. Diuretics
2. Anticoagulants
3. Anticholinergics
4. Cardiac glycosides
5. Phosphodiesterase (PDE) inhibitors
6. Angiotensin-converting enzyme (ACE) inhibitors

14. The parent of a toddler asks a nurse when it is safe to place the car safety seat in a faceforward position. Which of the following is the best nursing response?
1. When the toddler weighs 20 lb and is 1 year old
2. When the weight of the toddler is more than 40 lb
3. The seat should not be placed in a face-forward position unless there are safety locks in the
car.
4. The seat should never be placed in a face-forward position because of the risk of the child
unbuckling the harness.
15. 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?
1. You will be isolated from your newborn after delivery.
2. There is little risk to your baby during your pregnancy, birth, and after delivery.
3. Vaginal deliveries can reduce neonatal infection risks, even if you have an active lesion at
birth.
4. You will be evaluated at the time of delivery for herpetic genital tract lesions. If they are
present, a cesarean delivery will be needed.
16. Which of these clients are most likely to develop fluid (circulatory) overload? Select all
that apply.
1. A premature infant
2. A 101-year-old man
3. A client on renal dialysis
4. A client with diabetes mellitus
5. A 29-year-old woman with pneumonia
6. A client with congestive heart failure
17. An unconscious client who is bleeding profusely is brought to the emergency
department after a serious accident. Surgery is required immediately to save the clients
life. With regard to informed consent for the surgical procedure, which of the following is
the best action?
1. Call the nursing supervisor to initiate a court order for the surgical procedure.
2. Try calling the clients spouse to obtain telephone consent before the surgical procedure.
3. Ask the friend who accompanied the client to the emergency department to sign the consent
form.
4. Transport the client to the operating department immediately, as required by the health care
provider without obtaining an informed consent.
18. When caring for a 3-year-old child, the nurse should provide which toy for this child?

1. A puzzle
2. A wagon
3. A golf set
4. A farm set
19. 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.
1. Increased heart rate
2. Decline in visual acuity
3. Decreased respiratory rate
4. Decline in long-term memory
5. Increased susceptibility to urinary tract infections
6. Increased incidence of awakening after sleep onset
20. Which data indicates to the nurse that a client may be experiencing ineffective coping?
1. Constantly neglects personal grooming
2. Visits her husbands grave once a month
3. Visits the senior citizens center once a month
4. Frequently looks at snapshots of her husband and family

Answers and Rationale

1. Answers: 2, 3, and 4.
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.
2. Answers: 3, 4, 5, and 6.
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.
3. Answers: 1, 2, 3, and 4.
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.
4. Answers: 1, 2, 3, and 5.
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.
5. Answer 2.
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.
6. Answers: 2, 3, 4 and 6.
A positive Chvosteks sign is indicative of hypocalcemia. Other signs and symptoms include
tachycardia, hypotension, paresthesias, twitching, cramps, tetany, seizures, positive Trousseaus
sign, diarrhea, hyperactive bowel sounds, and a prolonged QT interval.
7. Answer: 3.
Invasion of privacy takes place when an individuals 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.
8. Answers: 1, 2, 4, and 5.
The client with Cushings syndrome experiencing fluid overload should be maintained on a highpotassium 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.
9. Answers: 1, 2, 4, and 5.
The client with Cushings syndrome experiencing fluid overload should be maintained on a highpotassium 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.
10. Answers: 2, 4, 5, and 6.
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.

11. Answers: 2, 5, and 6.

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.
12. Answer: 1.
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.
13. Answers: 1, 4, 5, and 6.
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.
14. Answer: 1.
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 body weight of 9 kg (20 lb) and an age of
1 year. Options 2, 3, and 4 are incorrect.
15. Answer: 4.
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.
16. Answers: 1, 2, 3, and 6.
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
17. Answer: 4.
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.
18. Answer: 2.
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.
19. Answers: 2, 5, and 6.
Anatomical changes to the eye affect the individuals 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 clients 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.
20. Answer: 1
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.