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Home NCLEX Practice Questions

 NCLEX Practice Questions

NCLEX Select All That Apply Practice Exam


1 (30 Questions)
Keep calm and select all that apply!
By

Matt Vera, BSN, R.N.

October 12, 2014

1
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Other than the usual multiple choice question formats, the NCLEX has also alternate format
questions like the Select All That Apply or SATA. Unfortunately, SATA questions are what
many test candidates fear the most. Whether you like it or not, the NCLEX will have these
type of questions. To help you prepare and at least ease the anxiety, here are 30 Select All
That Apply practice questions.

If you need help answering SATA questions, be sure to read: 12 Tips to Answer NCLEX
Select All That Apply (SATA) Questions.

If you are going through hell, keep going.


– Winston Churchill

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 patient is admitted to the same day surgery unit for liver biopsy. Which of the
following laboratory tests assesses coagulation? Select all that apply.

1. Partial thromboplastin time.


2. Prothrombin time.
3. Platelet count.
4. Hemoglobin
5. Complete Blood Count
6. White Blood Cell Count

2. 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.

1. Weight loss.
2. Increased clotting time.
3. Hypertension.
4. Headaches.

3. 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.

1. The inhaler is held upright.


2. Head is tilted down while inhaling the medication
3. Client waits 5 minutes between puffs.
4. Mouth is rinsed with water following administration
5. Client lies supine for 15 minutes following administration.

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.

1. Hearing loss
2. Visual disturbance
3. Headache
4. Orthopnea
5. Gout
6. Weight loss

5. Which of the following would be priority assessment data to gather from a client
who has been diagnosed with pneumonia? Select all that apply.

1. Auscultation of breath sounds


2. Auscultation of bowel sounds
3. Presence of chest pain.
4. Presence of peripheral edema
5. Color of nail beds

6. 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.

1. “I will need to dispose of my old clothing when I return home.”


2. “I should always cover my mouth and nose when sneezing.”
3. “It is important that I isolate myself from family when possible.”
4. “I should use paper tissues to cough in and dispose of them properly.”
5. “I can use regular plate and utensils whenever I eat.”
7. The nurse is admitting a client with hypoglycemia. Identify the signs and
symptoms the nurse should expect. Select all that apply.

1. Thirst
2. Palpitations
3. Diaphoresis
4. Slurred speech
5. Hyperventilation

8. Which adaptations should the nurse caring for a client with diabetic
ketoacidosis expect the client to exhibit? Select all that apply:

1. Sweating
2. Low PCO2
3. Retinopathy
4. Acetone breath
5. Elevated serum bicarbonate

9. When planning care for a client with ulcerative colitis who is experiencing
symptoms, which client care activities can the nurse appropriately delegate to a
unlicensed assistant? Select all that apply.

1. Assessing the client’s bowel sounds


2. Providing skin care following bowel movements
3. Evaluating the client’s response to antidiarrheal medications
4. Maintaining intake and output records
5. Obtaining the client’s weight.

10. Which of the following nursing diagnoses would be appropriate for a client
with heart failure? Select all that apply.
1. Ineffective tissue perfusion related to decreased peripheral blood flow secondary
to decreased cardiac output.
2. Activity intolerance related to increased cardiac output.
3. Decreased cardiac output related to structural and functional changes.
4. Impaired gas exchange related to decreased sympathetic nervous system activity.

11. When caring for a client with a central venous line, which of the following nursing
actions should be implemented in the plan of care for chemotherapy administration?
Select all that apply.

1. Verify patency of the line by the presence of a blood return at regular intervals.
2. Inspect the insertion site for swelling, erythema, or drainage.
3. Administer a cytotoxic agent to keep the regimen on schedule even if blood return is not
present.
4. If unable to aspirate blood, reposition the client and encourage the client to cough.
5. Contact the health care provider about verifying placement if the status is questionable.

12. A 20-year old college student has been brought to the psychiatric hospital by her
parents. Her admitting diagnosis is borderline personality disorder. When talking
with the parents, which information would the nurse expect to be included in the
client’s history? Select all that apply.

1. Impulsiveness
2. Lability of mood
3. Ritualistic behavior
4. psychomotor retardation
5. Self-destructive behavior

13. When assessing a client diagnosed with impulse control disorder, the nurse
observes violent, aggressive, and assaultive behavior. Which of the following
assessment data is the nurse also likely to find? Select all that apply.
1. The client functions well in other areas of his life.
2. The degree of aggressiveness is out of proportion to the stressor.
3. The violent behavior is most often justified by the stressor.
4. The client has a history of parental alcoholism and chaotic, abusive family life.
5. The client has no remorse about the inability to control his anger.

14. Which of the following nursing interventions are written correctly? (Select all that
apply.)

1. Apply continuous passive motion machine during day.


2. Perform neurovascular checks.
3. Elevate head of bed 30 degrees before meals.
4. Change dressing once a shift.

15. The nurse is monitoring a client receiving peritoneal dialysis and nurse notes that
a client’s outflow is less than the inflow. Select actions that the nurse should take.

1. Place the client in good body alignment


2. Check the level of the drainage bag
3. Contact the physician
4. Check the peritoneal dialysis system for kinks
5. Reposition the client to his or her side.

16. The nurse is caring for a hospitalized client who has chronic renal failure. Which
of the following nursing diagnoses are most appropriate for this client? Select all that
apply.

1. Excess Fluid Volume


2. Imbalanced Nutrition; Less than Body Requirements
3. Activity Intolerance
4. Impaired Gas Exchange
5. Pain.
17. The nurse is assessing a child diagnosed with a brain tumor. Which of the
following signs and symptoms would the nurse expect the child to demonstrate?
Select all that apply.

1. Head tilt
2. Vomiting
3. Polydipsia
4. Lethargy
5. Increased appetite
6. Increased pulse

18. The nurse is caring for a client with a T5 complete spinal cord injury. Upon
assessment, the nurse notes flushed skin, diaphoresis above the T5, and a blood
pressure of 162/96. The client reports a severe, pounding headache. Which of the
following nursing interventions would be appropriate for this client? Select all that
apply.

1. Elevate the HOB to 90 degrees


2. Loosen constrictive clothing
3. Use a fan to reduce diaphoresis
4. Assess for bladder distention and bowel impaction
5. Administer antihypertensive medication
6. Place the client in a supine position with legs elevated

19. The nurse is evaluating the discharge teaching for a client who has an ileal
conduit. Which of the following statements indicates that the client has correctly
understood the teaching? Select all that apply.

1. “If I limit my fluid intake I will not have to empty my ostomy pouch as often.”
2. “I can place an aspirin tablet in my pouch to decrease odor.”
3. “I can usually keep my ostomy pouch on for 3 to 7 days before changing it.”
4. “I must use a skin barrier to protect my skin from urine.”
5. “I should empty my ostomy pouch of urine when it is full.”

20. A nurse is assisting in performing an assessment on a client who suspects that


she is pregnant and is checking the client for probable signs
of pregnancy. Select all probable signs of pregnancy.

1. Uterine enlargement
2. Fetal heart rate detected by nonelectric device
3. Outline of the fetus via radiography or ultrasound
4. Chadwick’s sign
5. Braxton Hicks contractions
6. Ballottement

21. A nurse is monitoring a pregnant client with pregnancy


induced hypertension who is at risk for Preeclampsia. The nurse checks the client for
which specific signs of Preeclampsia (select all that apply)?

1. Elevated blood pressure


2. Negative urinary protein
3. Facial edema
4. Increased respirations

22. A nurse is caring for a pregnant client with severe preeclampsia who is receiving
IV magnesium sulfate. Select all nursing interventions that apply in the care for the
client.

1. Monitor maternal vital signs every 2 hours


2. Notify the physician if respirations are less than 18 per minute.
3. Monitor renal function and cardiac function closely
4. Keep calcium gluconate on hand in case of a magnesium sulfate overdose
5. Monitor deep tendon reflexes hourly
6. Monitor I and O’s hourly
7. Notify the physician if urinary output is less than 30 ml per hour.

23. When interpreting an ECG, the nurse would keep in mind which of the following
about the P wave? Select all that apply.

1. Reflects electrical impulse beginning at the SA node


2. Indicated electrical impulse beginning at the AV node
3. Reflects atrial muscle depolarization
4. Identifies ventricular muscle depolarization
5. Has duration of normally 0.11 seconds or less.

24. When caring for a client with a central venous line, which of the following
nursing actions should be implemented in the plan of care for chemotherapy
administration? Select all that apply.

1. Verify patency of the line by the presence of a blood return at regular intervals.
2. Inspect the insertion site for swelling, erythema, or drainage.
3. Administer a cytotoxic agent to keep the regimen on schedule even if blood return is not
present.
4. If unable to aspirate blood, reposition the client and encourage the client to cough.
5. Contact the health care provider about verifying placement if the status is questionable.

25. To assist an adult client to sleep better the nurse recommends which of the
following? (Select all that apply.)

1. Drinking a glass of wine just before retiring to bed


2. Eating a large meal 1 hour before bedtime
3. Consuming a small glass of warm milk at bedtime
4. Performing mild exercises 30 minutes before going to bed

26. The nurse recognizes that a client is experiencing insomnia when the client
reports (select all that apply):
1. Extended time to fall asleep
2. Falling asleep at inappropriate times
3. Difficulty staying asleep
4. Feeling tired after a night’s sleep

27. The nurse teaches the mother of a newborn that in order to prevent sudden infant
death syndrome(SIDS) the best position to place the baby after nursing is (select all
that apply):

1. Prone
2. Side-lying
3. Supine
4. Fowler’s

28. A client has a diagnosis of primary insomnia. Before assessing this client, the
nurse recalls the numerous causes of this disorder. Select all that apply:

1. Chronic stress
2. Severe anxiety
3. Generalized pain
4. Excessive caffeine
5. Chronic depression
6. Environmental noise

29. Select all that apply to the use of barbiturates in treating insomnia:

1. Barbiturates deprive people of NREM sleep


2. Barbiturates deprive people of REM sleep
3. When the barbiturates are discontinued, the NREM sleep increases.
4. When the barbiturates are discontinued, the REM sleep increases.
5. Nightmares are often an adverse effect when discontinuing barbiturates.
30. Select all that apply that is appropriate when there is a benzodiazepine overdose:

1. Administration of syrup of ipecac


2. Gastric lavage
3. Activated charcoal and a saline cathartic(
4. Hemodialysis
5. Administration of Flumazenil

Answers and Rationale

1. 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.

2. Answer: 2, 3, and 4

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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.

3. Answer: 1 and 4.

4. 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.

5. 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.

6. Answer: 2, 4, 5.

7. 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.

8. 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.

9. Answer: 2, 4, and 5.
The nurse can delegate the following basic care activities to the unlicensed assistant:
providing skin care following bowel movements, maintaining intake and output records, and
obtaining the client’s weight. Assessing the client’s bowel sounds and evaluating the client’s
response to medication are registered nurse activities that cannot be delegated.

10. Answer: 1 and 3.

HF is a result of structural and functional abnormalities of the heart tissue muscle. The heart
muscle becomes weak and does not adequately pump the blood out of the chambers. As a
result, blood pools in the left ventricle and backs up into the left atrium, and eventually into
the lungs. Therefore, greater amounts of blood remain in the ventricle after contraction
thereby decreasing cardiac output. In addition, this pooling leads to thrombus formation
and ineffective tissue perfusion because of the decrease in blood flow to the other organs
and tissues of the body. Typically, these clients have an ejection fraction of less than 50%
and poorly tolerate activity. Activity intolerance is related to a decrease, not increase, in
cardiac output. Gas exchange is impaired. However, the decrease in cardiac output triggers
compensatory mechanisms, such as an increase in sympathetic nervous system activity.

11. Answer: 1, 2, 4, 5.

A major concern with intravenous administration of cytotoxic agents is vessel irritation or


extravasation. The Oncology Nursing Society and hospital guidelines require frequent
evaluation of blood return when administering vesicant or non vesicant chemotherapy due
to the risk of extravasation. These guidelines apply to peripheral and central venous lines.
In addition, central venous lines may be long-term venous access devices. Thus, difficulty
drawing or aspirating blood may indicate the line is against the vessel wall or may indicate
the line has occlusion. Having the client cough or move position may change the status of
the line if it is temporarily against a vessel wall. Occlusion warrants more thorough
evaluation via x-ray study to verify placement if the status is questionable and may require a
declotting regimen.

12. Answer: 1, 2, 5.
13. Answer: 1, 2, 4.

A client with an impulse control disorder who displays violent, aggressive, and assaultive
behavior generally functions well in other areas of his life. The degree of aggressiveness is
typically out of proportion with the stressor. Such a client commonly has a history of
parental alcoholism and a chaotic family life, and often verbalizes sincere remorse and guilt
for the aggressive behavior.

14. Answer: 3.

It is specific in what to do and when.

15. Answer: 1, 2, 4, 5.

If outflow drainage is inadequate, the nurse attempts to stimulate outflow by changing the
client’s position. Turning the client to the other side or making sure that the client is in good
body alignment may assist with outflow drainage. The drainage bag needs to be lower than
the client’s abdomen to enhance gravity drainage. The connecting tubing and the peritoneal
dialysis system is also checked for kinks or twisting and the clamps on the system are
checked to ensure that they are open. There is no reason to contact the physician.

16. Answer: 1, 2, 3.

Appropriate nursing diagnoses for clients with chronic renal failure include excess fluid
volume related to fluid and sodium retention; imbalanced nutrition, less than body
requirements related to anorexia, nausea, and vomiting; and activity intolerance related
to fatigue. The nursing diagnoses of impaired gas exchange and pain are not commonly
related to chronic renal failure.

17. Answer: 1, 2, 4.
Head tilt, vomiting, and lethargy are classic signs assessed in a child with a brain tumor.
Clinical manifestations are the result of location and size of the tumor.

18. Answer: 1, 2, 4, 5.

The client has signs and symptoms of autonomic dysreflexia. The potentially life-threatening
condition is caused by an uninhibited response from the sympathetic nervous system
resulting from a lack of control over the autonomic nervous system. The nurse should
immediately elevate the HOB to 90 degrees and place extremities dependently to decrease
venous return to the heart and increase venous return from the brain. Because tactile
stimuli can trigger autonomic dysreflexia, any constrictive clothing should be loosened. The
nurse should also assess for distended bladder and bowel impaction, which may trigger
autonomic dysreflexia, and correct any problems. Elevated blood pressure is the most life-
threatening complication of autonomic dysreflexia because it can cause stroke, MI, or
seizures. If removing the triggering event doesn’t reduce the client’s blood pressure, IV
antihypertensives should be administered. A fan shouldn’t be used because cold drafts may
trigger autonomic dysreflexia.

19. Answer: 3, 4.

The client with an ileal conduit must learn self-care activities related to care of the stoma
and ostomy appliances. The client should be taught to increase fluid intake to about 3,000
ml per day and should not limit intake. Adequate fluid intake helps to flush mucus from the
ileal conduit. The ostomy appliance should be changed approximately every 3 to 7 days and
whenever a leak develops. A skin barrier is essential to protecting the skin from the irritation
of the urine. An aspirin should not be used as a method of odor control because it can be an
irritant to the stoma and lead to ulceration. The ostomy pouch should be emptied when it is
one-third to one-half full to prevent the weight from pulling the appliance away from the skin.

20. Answers: 1, 4, 5, and 6.

The probable signs of pregnancy include:


 Uterine Enlargement
 Hegar’s sign or softening and thinning of the uterine segment that occurs at week
6.
 Goodell’s sign or softening of the cervix that occurs at the beginning of the 2nd
month
 Chadwick’s sign or bluish coloration of the mucous membranes of the cervix,
vagina and vulva. Occurs at week 6.
 Ballottement or rebounding of the fetus against the examiner’s fingers of
palpation
 Braxton-Hicks contractions
 Positive pregnancy test measuring for hCG.

Positive signs of pregnancy include:

 Fetal Heart Rate detected by electronic device (doppler) at 10-12 weeks


 Fetal Heart rate detected by nonelectronic device (fetoscope) at 20 weeks AOG
 Active fetal movement palpable by the examiners
 Outline of the fetus via radiography or ultrasound

21. Answer: 1 and 3.

The three classic signs of preeclampsia are hypertension, generalized edema,


and proteinuria. Increased respirations are not a sign of preeclampsia.

22. Answers: 3, 4, 5, 6, and 7.

When caring for a client receiving magnesium sulfate therapy, the nurse would monitor
maternal vital signs, especially respirations, every 30-60 minutes and notify the physician if
respirations are less than 12, because this would indicate respiratory depression. Calcium
gluconate is kept on hand in case of magnesium sulfate overdose, because calcium
gluconate is the antidote for magnesium sulfate toxicity. Deep tendon reflexes are assessed
hourly. Cardiac and renal function is monitored closely. The urine output should be
maintained at 30 ml per hour because the medication is eliminated through the kidneys.

23. Answer: 1, 3, 5.

In a client who has had an ECG, the P wave represents the activation of the electrical
impulse in the SA node, which is then transmitted to the AV node. In addition, the P wave
represents atrial muscle depolarization, not ventricular depolarization. The normal duration
of the P wave is 0.11 seconds or less in duration and 2.5 mm or more in height.

24. Answer: 1, 2, 4, 5.

A major concern with intravenous administration of cytotoxic agents is vessel irritation or


extravasation. The Oncology Nursing Society and hospital guidelines require frequent
evaluation of blood return when administering vesicant or non vesicant chemotherapy due
to the risk of extravasation. These guidelines apply to peripheral and central venous lines.
In addition, central venous lines may be long-term venous access devices. Thus, difficulty
drawing or aspirating blood may indicate the line is against the vessel wall or may indicate
the line has occlusion. Having the client cough or move position may change the status of
the line if it is temporarily against a vessel wall. Occlusion warrants more thorough
evaluation via x-ray study to verify placement if the status is questionable and may require a
declotting regimen.

25. Answer: 3.

A small glass of milk relaxes the body and promotes sleep.

26. Answer: 1, 3, and 4.

These symptoms are often reported by clients with insomnia. Clients report nonrestorative
sleep. Arising once at night to urinate (nocturia) is not in and of itself insomnia.

27. Answer: 2 and 3.


Research demonstrate that the occurrence of SIDS is reduced with these two positions.

28. Answer: 1, 4, and 6.

Acute or primary insomnia is caused by emotional or physical discomfort not caused by the
direct physiologic effects of a substance or a medical condition. Excessive caffeine intake is
an example of disruptive sleep hygiene; caffeine is a stimulant that inhibits sleep.
Environmental noise causes physical and/or emotional and therefore is related to primary
insomnia.

29. Answer: 2, 4, and 5.

Barbiturates deprive people of REM sleep. When the barbiturate is stopped and REM sleep
once again occurs, a rebound phenomenon occurs. During this phenomenon, the persons
dream time constitutes a larger percentage of the total sleep pattern, and the dreams are
often nightmares.

30. Answer: 2, 3, and 5.

If ingestion is recent, decontamination of the GI system is indicated. The administration of


syrup of ipecac is contraindicated because of aspiration risks related to sedation. Gastric
lavage is generally the best and most effective means of gastric decontamination. Activated
charcoal and a saline cathartic may be administered to remove any remaining drug.
Hemodialysis is not useful in the treatment of benzodiazepine overdose. Flumazenil can be
used to acutely reverse the sedative effects of benzodiazepines, though this is normally
done only in cases of extreme overdose or sedation.

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 NCLEX-RN

 Select All That Apply (SATA)


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.
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1. Marcia July 3, 2019 at 8:03 PM


Very good practice questions

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