NCLEX Select All That Apply

A nurse is admitting a client with a possible diagnosis of chronic bronchitis. The nurse collects data from the client and notes which of the following signs supports this diagnosis? Select all that apply.

A nurse, assigned to a client with emphysema, is providing shift report. Which nursing interventions would be appropriate to include? Select all that apply.

A nurse is assigned to care for a client with a peripheral IV infusion. The nurse is providing hygiene care to the client and would avoid which of the following while changing the client’s hospital gown?

A nurse is caring for a client who underwent surgical repair of a detached retina in the right eye. Which nursing interventions should the nurse perform? Select all that apply.

A nurse is planning care for a client with hyperthyroidism. Which nursing interventions are appropriate? Select all that apply.

A nurse is assisting with planning care for a client with an internal radiation implant. Which of the following should be included in the plan of care? Select all that apply.

The nurse is caring for a client after a supratentorial craniotomy in which a large tumor was removed from the left side. Choose the positions in which the nurse can safely place the client. Select all that apply.

A client has a tumor of the posterior pituitary gland. A nurse planning care should include which nursing interventions? Select all that apply.

A nurse is caring for a client with a healthcare-associated infection caused by methicillin-resistant Staphylococcus aureus who is on contact precautions. The nurse prepares to provide colostomy care to the client. Which of the following protective items will be required to perform this procedure? Select all that apply.

A nurse is caring for a client with a hiatal hernia. The client complains of abdominal and sternal pain after eating. The pain makes it difficult for the client to sleep. Which instructions should the nurse recommend when teaching this client? Select all that apply.

A nurse is caring for a client with diabetic ketoacidosis and documents that the client is experiencing Kussmaul’s respirations. Based on this documentation, which of the following did the nurse most likely observe?

Which nursing interventions are appropriate for a client recovering from surgery for retinal detachment? Select all that apply.

A nurse is caring for a client with leukemia and notes that the client has flat neck and hand veins. The nurse suspects hyponatremia. What additional signs would the nurse expect to note in this client if hyponatremia is present?

A nurse is caring for a group of clients who are taking herbal medications at home. Which of the following clients should be instructed not to take herbal medications?

A nurse is caring for an infant with a diagnosis of tetralogy of Fallot. The infant suddenly becomes cyanotic and the oxygen saturation reading drops to 60%. Choose the interventions that the nurse should perform. Select all that apply.

A nurse is collecting data on a client with severe preeclampsia. Choose the findings that would be noted in severe preeclampsia. Select all that apply.

A nurse is monitoring a client with Graves’ disease for signs of thyrotoxicosis (thyroid storm). Which of the following signs and symptoms, if noted in the client, will alert the nurse to the presence of this crisis? Select all that apply.

A nurse is monitoring a group of clients for acid-base imbalances. Which clients are at highest risk for metabolic acidosis? Select all that apply.

The nurse is preparing a teaching plan for a client who is undergoing cataract extraction with intraocular implant. Which home care measures will the nurse include in the plan? Select all that apply.

A nurse is teaching a client with left leg weakness to walk with a cane. The nurse should include which nursing points about safe cane use in the client teaching? Select all that apply.

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.

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.

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.

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.

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? Select all that apply.

A nurse is told in a 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.

A nurse lawyer provides an education session for the nursing staff regarding client rights. A nurse asks the lawyer to describe an example that may relate to the invasion of client privacy. A nursing action that indicates a violation of this right is? Select all that apply.

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.

While providing care to a married client, the nurse notes multiple blue, purple, and yellow ecchymotic areas on the arms and trunk. When the nurse asks about these bruises, the client responds, “I tripped.” What actions should the nurse take? Select all that apply.

Which instruction should the nurse provide to the client with diabetes mellitus receiving acarbose (Precose)? Select all that apply.

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.

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? Select all that apply.

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

The nurse is providing care for a client who has had a stroke. Since the onset of symptoms, the client has been experiencing left-sided hemianopsia. Which nursing interventions would be appropriate? Select all that apply.

A nurse is caring for a client who is disoriented to time, place, and person and is attempting to get out of bed and pull out an intravenous (I.V.) line that is supplying hydration and antibiotics. The client has a vest restraint and bilateral soft wrist restraints. Which nursing actions would be appropriate? Select all that apply.

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

A client has just been diagnosed with terminal cancer and is being transferred to home hospice care. The client’s daughter tells the nurse, “I don’t know what to say to my mother if she asks me if she’s going to die.” Which responses by the nurse would be appropriate? Select all that apply.

When caring for a 3-year-old child, the nurse should provide which toys for this child? Select all that apply.

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.

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

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:

Which nursing interventions will assist in reducing pressure points that may lead to pressure ulcers? Select all that apply:

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.

A nurse understands that a patient may experience pain during peritoneal dialysis because of which of the following? Select all that apply.

The nurse is evaluating a client’s response to hemodialysis. Which lab results will indicate the dialysis was effective? Select all that apply.

The nurse understands that the following clinical findings are indications for dialysis. Select all that apply.

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.

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.

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.

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.