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Home NCLEX Practice Questions

 NCLEX Practice Questions

NCLEX Select All That Apply Practice Exam

4 (20 Questions)
By

Matt Vera, BSN, R.N.

October 30, 2014

2
 ADVERTISEMENT

Feeling confident in answering Select All That Apply Questions (SATA) yet? Here are 20
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For true success ask yourself these four questions: Why? Why not? Why not me? Why not
now? – James Allen

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.

Questions

 EXAM MODE
 PRACTICE MODE
 TEXT MODE

In Text Mode: All questions and answers are given for reading and answering at your own
pace. You can also copy this exam and make a print out.
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 Chvostek’s 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 Trousseau’s 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 Cushing’s 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 Cushing’s 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 face-forward 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
client’s 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 client’s 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 husband’s 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.

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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 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.

7. Answer: 3.

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.
8. Answers: 1, 2, 4, and 5.

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.

9. Answers: 1, 2, 4, and 5.

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.

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 bodyweight 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 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.

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.
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Matt Vera, BSN, R.N.

https://nurseslabs.com

Matt Vera is a registered nurse with a bachelor of science in nursing since 2009 and is currently
working as a full-time writer and editor for Nurseslabs. During his time as a student, he knows how
frustrating it is to cram on difficult nursing topics and finding help online is near to impossible. His
situation drove his passion for helping student nurses through the creation of content and lectures
that is easy to digest. Knowing how valuable nurses are in delivering quality healthcare but limited in
number, he wants to educate and inspire students in nursing. As a nurse educator since 2010, his
goal in Nurseslabs is to simplify the learning process, breakdown complicated topics, help motivate
 learners, and look for unique ways of assisting students in mastering core nursing concepts
effectively.

2 COMMENTS

1. lizzy May 15, 2015 at 5:14 AM

Clarification for # 14…US law states that a car seat in a face-forward position is
used if the child is 3 years old and above.

Reply

2. Linsey Mackey December 9, 2015 at 7:12 AM

Questions 8 & 9 are the same questions

Reply

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