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- The nurse is caring for a client with emphysema. Which of the following nursing interventions are most appropriate? Select all that apply.
- Reduce fluid intake to less than 2,000 ml/day.
- Teach client pursed –lip breathing.
- Administer low flow oxygen.
- Keep the client in a supine position as much as possible.
- Encourage alternating activity with rest periods.
- The nurse is planning care for a client with hyperthyroidism. Which of the following nursing interventions is appropriate? Select all that apply.
- Provide small, well balanced meals throughout the day.
- Apply prescribed eye drops, as necessary.
- Encourage rest periods.
- Provide a warm environment for comfort.
- Encourage family and friends to visit the client
- A nurse is teaching a class on Gastroesophageal Reflux Disease (GERD). A client complains his GERD causes a burning sensation halfway between the navel and breastbone. Which of the following instructions should the nurse recommend when teaching this client? Select all that apply.
- Maintain a normal body weight
- Sleep in a low fowler’s position and don’t eat at night.
- Decrease frequency of meal.
- Avoid caffeine.
- Avoid spicy foods.
- Wear loose fitting clothing
- A nurse is caring for a client with diabetes insipidus, the client is diagnosed with a tumor and a decreased level of the anti-diuretic hormone. Which of the following interventions should be included in the plan of care? Select all that apply.
- Encourage fluids.
- Restrict fluids.
- Collect a 24 hour urine specimen.
- Encourage intake of coffee or tea.
- Monitor intake and output.
- Take a daily weight.
- A nurse is caring for a client with delirium tremors. The client is violent and agitated. The physician orders a vest restraint and bilateral soft wrist restraints. The client is disoriented to time and place but is able to state name. Which of the following actions should be performed by the nurse? Select all that apply.
- Secure all loose ties to the side rail.
- Position the vest restraint so the straps are crossed in the front.
- Position the vest restraint so the straps are crossed in the back.
- Perform range of motion every 4 hours.
- Offer toileting every 2 hours.
- Tie the bilateral wrist restraints in a double loop secure knot.
- The home care nurse provides medication instructions to an older hypertensive client who is taking lisinopril (Prinivil), 40 mg orally daily. Which statements should be included in the teaching plan? Select all that apply.
- Instruct the client to avoid sudden position changes.
- Advise the client to report eye and lip swelling immediately.
- Teach the client to avoid salt substitutions.
- Teach the client to avoid dairy products.
- A decrease in the white blood cell count is normal at the beginning of therapy and no cause for concern.
- A client with type 2 diabetes mellitus is prescribed metoprolol I.V. for mild hypertension. Which nursing interventions should be carried out? Select all that apply.
- Mix the medication with 100 ml normal saline and infuse over 60 minutes.
- Know this medication is compatible with meperidine hydrochloride.
- Monitor heart rate and blood pressure carefully.
- Monitor blood glucose levels closely.
- Monitor for sinus bradycardia.
- A nurse is assessing a client who has a rash on his left lower thigh and left foot. Which questions should the nurse ask in order to gain further information about the client’s rash? Select all that apply.
- When did the rash start?
- Do you drink alcohol?
- How old are you?
- Do you have allergies?
- Have you traveled outside the country?
- A 55 year old male client arrives to the emergency department. He is diagnosed with left ventricular dysfunction. The nurse caring for this client is aware which of the following are signs of left sided heart failure? Select all that apply.
- Paroxysmal nocturnal dyspnea
- S4 heart sounds
- Right upper quadrant pain
- A 28-year-old female is brought to the Emergency Department with complaints of her “heart beating out of her chest.” She is diaphoretic and her BP is 135/90. The cardiac monitor shows an inferior wall myocardial infarction (MI). Which of the following ECG changes is associated with a MI? Select all that apply.
- Prolonged PR-interval
- U wave
- Repolarization of Purkinje fibers
- T wave inversion
- ST segment elevation
- Pathologic Q wave
- A client prescribed lisinopril asks the nurse about the potential adverse reactions. Which of the following are related to the adverse effect of an angiotensin-converting-enzyme (ACE) inhibitor? Select all that apply.
- A nurse is teaching a class about cardiac disease. The daughter of a client diagnosed with hypertension asks about the risk factors. Which of the following should be included as the risk factors for primary hypertension? Select all that apply.
- Closed head injury
- Diabetes mellitus
- Oral contraceptives
- High intake of sodium
- A nurse is caring for a client who recently had a cystoscopy to remove the bladder. The client now has an ileal conduit. What assessment by the nurse would indicate the client is developing complications? Select all that apply.
- Sharp abdominal pain with rigidity
- Dusky appearance of the stoma
- Urine output greater than 30 ml/hr
- Mucus shreds in the urine collection bag
- Stoma edema during the first 24 hours after surgery
- The nurse is caring for a client who is immunosuppressed and at risk for infections. Which of the following activities should be included in the discharge teaching plan?
- Avoid shaving with a straight razor
- Increase intake of fresh vegetables
- Avoid contact sports
- Treat a fever with over the counter medicines
- Wash hands frequently
- Avoid crowded places
- A client with testicular cancer is prescribed cisplatin (Platinol). Which of the following should the nurse monitor? Select all that apply.
- Urine output
- Hematocrit (HCT)
- Blood urea nitrogen (BUN)
- Magnesium level
- Creatinine level
- Which of the following are finding common in neonates born with esophageal atresia? Select all that apply.
- Decreased production of saliva
- Inadequate swallow
- Inability to cough
- The client with Crohn’s disease has a nursing diagnosis of acute pain. Which of the following should the nurse expect to be part of the care plan? Select all that apply
- Lactulose therapy
- High fiber diet
- High protein milkshakes
- Corticosteroid therapy
- Antidiarrheal medications
- A nurse is caring for a client with a stage 3 pressure ulcer on the back of the right thigh. Which of the following are characteristics of a stage 3 pressure? Select all that apply.
- The ulcer looks like a blister
- There is partial thickness skin loss of the epidermis
- Sinus tracts have developed
- There is full thickness skin loss
- The skin is intact
- The medical surgical nurse is working with an unlicensed assistive personnel (UAP). The nurse has delegated the UAP to care for a client with human immunodeficiency virus (HIV). Which statement by the UAP indicates a correct understanding of the HIV transmission process? Select all that apply.
- “I will implement contact precautions for all care.”
- “I do not need to wear any personal protective equipment because I am not at low risk for occupational exposure.”
- “I will wash my hands after toileting the client.”
- “I will wear a mask if the client has a cough from a viral infection”
- “I will wear a mask, gown, and gloves if I will come in contact with splattering blood or body fluids.”
- A nurse is caring for a client with rheumatoid arthritis. The client asks the nurse about nonpharmacologic interventions that could be implemented. Which measures should the nurse educate the client on? Select all that apply.
- Using assistive devices at all times
- Massaging inflamed joints
- Applying splints in times of increased inflammation
- Removing splints in times of increased inflammation
- Utilizing range of motion exercises
1.Correct answers B, C – Pursed lip breathing is one of the simplest ways to control shortness of breath. It provides a quick and easy way to slow your pace of breathing, making each breath more effective. Low flow oxygen should be administered because a client with emphysema has chronic hypercapnia and a hypoxic respiratory drive. Fluid intake should be increased to 3,000 ml/day, if not contraindicated to thin out mucous secretions and facilitate their removal. The client should be placed in a high Fowler’s position to improve ventilation.
2. Correct answer A, B, C – The conjunctivae should be moistened with isotonic eye drops especially if the client has exophthalmos. Small, well balanced meals will satisfy the increased appetite seen in hyperthyroidism. The nurse should encourage rest periods throughout the day. Frequent visitors may disrupt sufficient rest. Clients with hyperthyroidism should not be placed in warm environments due to heat intolerance.
3. Correct answers: A, D, E, F – To reduce gastric reflux, the nurse should instruct the client to sleep with his upper body elevated; maintain a normal body weight or lose weight. Clients should wear loose fitting clothing, avoid spicy foods and drink items low in caffeine. When sitting or asleep the client should be in a semi-fowler’s or upright position.
4. Correct answers A, E, F – Low levels of anti-diuretic hormone will cause the kidneys to excrete too much water. Urine volume will increase leading to dehydration and a fall in blood pressure. Low levels of anti-diuretic hormone may indicate damage to the hypothalamus or pituitary gland. Diabetes inspidus is a condition where you either make too little anti-diuretic hormone (usually due to a tumor, trauma or inflammation of the pituitary or hypothalamus), or where the kidneys are insensitive to it. Diabetes insipidus is associated with increased thirst and urine production. Nursing interventions should include monitoring daily weights. Clients with diabetes insipidus should also be encouraged to drink fluids to prevent dehydration. However coffee, tea, and other fluids with caffeine should be avoided because they have a diuretic effect. Collecting a 24 hour urine specimen is not required.
5. Correct answers: B, E – Restraints must not be used for coercion, punishment, discipline, or staff convenience. They are implemented as a safety precaution, clients require frequent and assessment to determine when the restraints can be removed. Toileting and range of motion exercises should be performed every 2 hours while a client is in restraints. Cotton fabric vest is crisscrossed in front of person and ends tie to bed or wheelchair. Restraints should never be tied to the side rail.
6. Correct answers A, B, C – Lisinopril is an ACE inhibitor used to treat high blood pressure. It may also be used to treat heart failure in combination with other drugs. It can cause orthostatic hypotension, low blood pressure, edema and inflammation of the blood vessels. Clients taking this medication should be advised to change position slowly to decrease orthostatic hypotension. Facial swelling should be reported immediately as this drug may cause angioedema. The client should also report signs and symptoms of infection as the drug may decrease white blood cell count. Salt substitutes should be avoided as they are linked to increased potassium levels that may precipitate lightheadedness. Dairy products can be consumed as client desires.
7. Correct answers are B, C, D, E – Metoprolol is used for the treatment of hypertension and angina pectoris; also the prevention of myocardial infarction. This medication can be given undiluted and given by direct injection. This medication is compatible with meperidine or morphine. The client’s blood glucose levels should be monitored closely as metoprolol can mask signs of hypoglycemia. The development of heart blocks or bradycardia can occur with the use of metoprolol so client’s vital signs should be monitored carefully. Do not administer this medication if the heart rate is less than 60.
8. Correct answer A, D, E – The nurse should assess when the rash began and what the rash looks like. The nurse also should ask about allergies which can produce a rash. Traveling outside the country exposes the client to new environments and foods which can contribute to a rash. The client’s age and whether they consume alcohol will not provide additional information about the rash or its cause.
9. Correct answer A, B, C – Signs and symptoms of left sided heart failure include non productive cough, fatique, orthopnea, paroxysmal nocturnal dyspnea and crackles. There will also be S3 and S4 heart sounds and cool pale skin. Jugular venous distention, hepatomegaly, and right upper quadrant pain are all signs of right sided heart failure.
10. Correct answers C, E, F – Myocardial infarction is the irreversible damage of myocardial tissue caused by prolonged ischemia and hypoxia. ST segment elevation, T wave inversion, and pathologic Q wave are all signs of the tissue ischemia that occurs. The presence of a U wave may be seen on a normal ECG; it represents the repolarization of the Purkinje fibers. A prolonged PR interval is associated with first degree heart block.
11. Correct answers C, D, E – Dizziness, headache, and hypotension are all common adverse effects of angiotensin-converting-enzyme (ACE) inhibitors. Lisinopril may cause diarrhea, not constipation. Lisinopril is not known to cause hyperthyroidism.
12. Correct answer C, E – Family history, obesity, stress, high intake of sodium are all risk factors for primary hypertension. Diabetes mellitus, head injury, and oral contraceptives are risk factors for secondary hypertension.
13. Correct answer A and B – Clients complaining of sharp abdominal pain with rigidity may be experiencing peritonitis. A dusky appearance of the stoma indicates a decrease blood supply, the stoma should be beefy red. A urine output of greater than 30 ml/hr is a sign of adequate renal perfusion and is a normal finding. Mucous membranes are used to create the conduit, mucous in the urine is expected. Stomal edema is a normal finding during the first 24 hours after surgery.
14. Correct answers E, F Immunocompromised patients are at high risk for opportunistic infections. The client should wash hands frequently because hand washing is the best way to prevent the spread of infection. An immunosuppressed client should also avoid crowded places or people who are sick because of a reduced ability to fight infection. Fresh fruit and vegetables should also be avoided because they can harbor bacteria that can’t be easily removed by washing. Signs and symptoms of infection such as fever, cough, and sore throat should be reported to the physician immediately.
15. Correct answers A, B, D, F – Cisplatin is a neoplastic agent. Adverse reactions to cisplatin include ototoxicity and nephrotoxicity. The nurse must monitor the client’s hearing. The client should also report any hearing loss or tinnitus. The client should be adequately hydrated before administration of the drug. Signs of nephrotoxicity include decreased urine output and elevated BUN and creatinine levels. Cisplatin does not affect hematocrit or serum magnesium levels.
16. Correct answers B, C, E – Cyanosis, coughing, and choking occur when fluid from the blind pouch is aspirated into the trachea. Saliva production doesn’t decrease in neonates born with esophageal atresia. The ability to swallow isn’t affected by this disorder.
17. Correct answers D, E – Corticosteroids, such as prednisone, reduce the signs and symptoms of diarrhea, pain, and bleeding by decreasing inflammation. Anti-diarrheals such as diphenoxylate (Lomotil) treat diarrhea by decreasing peristalsis. Lactulose is used to treat chronic constipation and would aggravate the symptoms. A high fiber diet and milk products are contraindicated in clients with Chron’s disease because they cause diarrhea.
18. Correct answers C, D – Full thickness skin loss, undermining, and sinus tracts are characteristics of a stage 3 pressure ulcer. A stage 2 pressure ulcer involves partial thickness loss of dermis presenting as a shallow open ulcer with a red/pink wound bed, without slough. A stage 2 pressure ulcer may appear intact or open/ruptured serum filled blister. Stage 1 pressure ulcer demonstrates the skin being intact with non-blanchable redness of a localized area, usually over a bony prominence.
19. Correct answers C, E – Human immunodeficiency virus (HIV), the virus that causes acquired immunodeficiency syndrome (AIDS), is transmitted through sexual contact and exposure to infected blood or blood components and perinatally from mother to neonate. HIV has been isolated from blood, semen, vaginal secretions, saliva, tears, breast milk, cerebrospinal fluid, amniotic fluid, and urine and is likely to be isolated from other body fluids, secretions, and excretions. Standard precautions are used for any known or anticipated contact the blood or body fluids. If a healthcare worker may be exposed to splattering blood or body fluids a mask, googles, or a face shield should be worn. Hand washing should be done before and after toileting any clients. HIV is not transmitted in droplet form unless there is blood present in the sputum.
20. Correct answers C, E – Rheumatoid arthritis (RA) is an inflammatory disorder of unknown origin that primarily involves the synovial membrane of the joints. A physical therapy program including range of motion exercises will prevent loss of joint function. Assistive devices should not be used all the time but only as needed. Clients need to be instructed not to massage inflamed joints or over bony prominences which can further increase inflammation.
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