NCLEX-SELECT ALL THAT APPLY-QUESTIONS AND ANSWERS

NCLEX-SELECT ALL THAT APPLY-QUESTIONS AND ANSWERS

• A patient is admitted to the same day surgery unit for liver biopsy. Which of the following laboratory

tests assesses coagulation? Select all that apply.

• Partial thromboplastin time.
• Prothrombin time.
• Platelet count.
• Hemoglobin
• Complete Blood Count
• White Blood Cell Count

Answer: 1, 2, and 3

Prothrombin time, partial thromboplastin time, and platelet count are all included in coagulation studies. The hemoglobin level, though important information prior to an invasive procedure like liver biopsy, does not assess coagulation.

• A patient is admitted to the hospital with suspected polycythemia vera. Which of the following symptoms

is consistent with the diagnosis? Select all that apply.

• Weight loss.
• Increased clotting time.
• Hypertension.
• Headaches.

Answer: 2, 3, and 4

Polycythemia vera is a condition in which the bone marrow produces too many red blood cells. This causes an increase in hematocrit and viscosity of the blood. Patients can experience headaches, dizziness, and visual disturbances.Cardiovascular effects include increased blood pressure and delayed clotting time. Weight loss is not a manifestation of polycythemia vera.Page 1

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• The nurse is teaching the client how to use a metered dose inhaler (MDI) to administer a Corticosteroid

drug. Which of the following client actions indicates that he is using the MDI correctly? Select all that apply.

• The inhaler is held upright.
• Head is tilted down while inhaling the medication
• Client waits 5 minutes between puffs.
• Mouth is rinsed with water following administration
• Client lies supine for 15 minutes following administration.

Answer: 1 and 4.

• The nurse is teaching a client with polycythemia vera about potential complications from this disease.

Which manifestations would the nurse include in the client’s teaching plan? Select all that apply.

• Hearing loss
• Visual disturbance
• Headache
• Orthopnea
• Gout
• Weight loss

Answers: 2, 3, 4 and 5.

Polycythemia vera, a condition in which too many RBCs are produced in the blood serum, can lead to an increase in the hematocrit and hypervolemia, hyperviscosity, and hypertension. Subsequently, the client can experience dizziness, tinnitus, visual disturbances, headaches, or a feeling of fullness in the head. The client may also experience cardiovascular symptoms such as heart failure (shortness of breath and orthopnea) and increased clotting time or symptoms of an increased uric acid level such as painful swollen joints (usually the big toe). Hearing loss and weight loss are not manifestations associated with polycythemia vera.Page 2

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• Which of the following would be priority assessment data to gather from a client who has been diagnosed

with pneumonia? Select all that apply.

• Auscultation of breath sounds
• Auscultation of bowel sounds
• Presence of chest pain.
• Presence of peripheral edema
• Color of nail beds

Answer: 1, 3, 5.

A respiratory assessment, which includes auscultation of breath sounds and assessing the color of the nail beds, is a priority for clients with pneumonia. Assessing for the presence of chest pain is also an important respiratory assessment as chest pain can interfere with the client’s ability to breathe deeply. Auscultating bowel sounds and assessing for peripheral edema may be appropriate assessments, but these are not priority assessments for the patient with pneumonia.

• The nurse is teaching a client who has been diagnosed with TB how to avoid spreading the disease to

family members. Which statement(s) by the client indicate(s) that he has understood the nurses instructions? Select all that apply.

• “I will need to dispose of my old clothing when I return home.”
• “I should always cover my mouth and nose when sneezing.”
• “It is important that I isolate myself from family when possible.”
• “I should use paper tissues to cough in and dispose of them properly.”
• “I can use regular plate and utensils whenever I eat.”

Answer: 2, 4, 5.

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• The nurse is admitting a client with hypoglycemia. Identify the signs and symptoms the nurse should

expect. Select all that apply.

• Thirst
• Palpitations
• Diaphoresis
• Slurred speech
• Hyperventilation

Answer: 2, 3, 4.

Palpitations, an adrenergic symptom, occur as the glucose levels fall; the sympathetic nervous system is activated and epinephrine and norepinephrine are secreted causing this response. Diaphoresis is a sympathetic nervous system response that occurs as epinephrine and norepinephrine are released. Slurred speech is a neuroglycopenic symptom; as the brain receives insufficient glucose, the activity of the CNS becomes depressed.

• Which adaptations should the nurse caring for a client with diabetic ketoacidosis expect the client to

exhibit? Select all that apply:

• Sweating
• Low PCO2
• Retinopathy
• Acetone breath
• Elevated serum bicarbonate

Answer: 2, 4.

Metabolic acidosis initiates respiratory compensation in the form of Kussmaul respirations to counteract the effects of ketone buildup, resulting in a lowered PCO2. A fruity odor to the breath (acetone breath) occurs when the ketone level is elevated in ketoacidosis.Page 4

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