NCLEX SATA 1-5. A Complete and Comprehensive Select All That Apply Questions and Answers.

NCLEX SATA 11. A patient is admitted to the same day surgery unitfor liver biopsy. Which of the following laboratory testsassesses coagulation? Select all that apply.1. Partial thromboplastin time.2. Prothrombin time.3. Platelet count.4. Hemoglobin5. Complete Blood Count6. White Blood Cell Count2. A patient is admitted to the hospital with suspectedpolycythemia vera. Which of the following symptoms isconsistent 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 ametered dose inhaler (MDI) to administer aCorticosteroid drug. Which of the following clientactions 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 medication3. Client waits 5 minutes between puffs.4. Mouth is rinsed with water following administration5. Client lies supine for 15 minutes following administration.4. The nurse is teaching a client with polycythemia veraabout potential complications from this disease. Whichmanifestations would the nurse include in the client’steaching plan? Select all that apply.1. Hearing loss2. Visual disturbance3. Headache4. Orthopnea5. Gout6. Weight loss5. Which of the following would be priority assessmentdata to gather from a client who has been diagnosedwith pneumonia? Select all that apply.1. Auscultation of breath sounds2. Auscultation of bowel sounds3. Presence of chest pain.4. Presence of peripheral edema5. Color of nail beds6. The nurse is teaching a client who has beendiagnosed with TB how to avoid spreading the diseaseto family members. Which statement(s) by the clientindicate(s) that he has understood the nursesinstructions? Select all that apply.1. “I will need to dispose of my old clothing when I returnhome.”2. “I should always cover my mouth and nose whensneezing.”3. “It is important that I isolate myself from family whenpossible.”4. “I should use paper tissues to cough in and dispose ofthem 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 shouldexpect. Select all that apply.1. Thirst2. Palpitations3. Diaphoresis4. Slurred speech5. Hyperventilation8. Which adaptations should the nurse caring for aclient with diabetic ketoacidosis expect the client toexhibit? Select all that apply:1. Sweating2. Low PCO23. Retinopathy4. Acetone breath5. Elevated serum bicarbonate9. When planning care for a client with ulcerative colitiswho is experiencing symptoms, which client careactivities can the nurse appropriately delegate to aunlicensed assistant? Select all that apply.1. Assessing the client’s bowel sounds2. Providing skin care following bowel movements3. Evaluating the client’s response to antidiarrhealmedications4. Maintaining intake and output records5. Obtaining the client’s weight.10. Which of the following nursing diagnoses would beappropriate for a client with heart failure? Select allthat apply.1. Ineffective tissue perfusion related to decreased peripheralblood flow secondary to decreased cardiac output.2. Activity intolerance related to increased cardiac output.3. Decreased cardiac output related to structural andfunctional changes.4. Impaired gas exchange related to decreased sympatheticnervous system activity.11. When caring for a client with a central venous line,which of the following nursing actions should beimplemented in the plan of care for chemotherapyadministration? Select all that apply.1. Verify patency of the line by the presence of a blood returnat regular intervals.2. Inspect the insertion site for swelling, erythema, ordrainage.3. Administer a cytotoxic agent to keep the regimen onschedule even if blood return is not present.4. If unable to aspirate blood, reposition the client andencourage the client to cough.5. Contact the health care provider about verifying placementif the status is questionable.12. A 20-year old college student has been brought tothe psychiatric hospital by her parents. Her admittingdiagnosis is borderline personality disorder. Whentalking with the parents, which information would thenurse expect to be included in the client’s history?Select all that apply.1. Impulsiveness2. Lability of mood3. Ritualistic behavior4. psychomotor retardation5. Self-destructive behavior13. When assessing a client diagnosed with impulsecontrol disorder, the nurse observes violent,aggressive, and assaultive behavior. Which of thefollowing assessment data is the nurse also likely tofind? 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 thestressor.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 hisanger.14. Which of the following nursing interventions arewritten 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 receivingperitoneal dialysis and nurse notes that a client’soutflow is less than the inflow. Select actions that thenurse should take.1. Place the client in good body alignment2. Check the level of the drainage bag3. Contact the physician4. Check the peritoneal dialysis system for kinks5. Reposition the client to his or her side.16. The nurse is caring for a hospitalized client who haschronic renal failure. Which of the following nursingdiagnoses are most appropriate for this client? Selectall that apply.1. Excess Fluid Volume2. Imbalanced Nutrition; Less than Body Requirements3. Activity Intolerance4. Impaired Gas Exchange5. Pain.17. The nurse is assessing a child diagnosed with abrain tumor. Which of the following signs andsymptoms would the nurse expect the child todemonstrate? Select all that apply.1. Head tilt2. Vomiting3. Polydipsia4. Lethargy5. Increased appetite6. Increased pulse18. The nurse is caring for a client with a T5 completespinal cord injury. Upon assessment, the nurse notesflushed skin, diaphoresis above the T5, and a bloodpressure of 162/96. The client reports a severe,pounding headache. Which of the following nursinginterventions would be appropriate for this client?Select all that apply.1. Elevate the HOB to 90 degrees2. Loosen constrictive clothing3. Use a fan to reduce diaphoresis4. Assess for bladder distention and bowel impaction5. Administer antihypertensive medication6. Place the client in a supine position with legs elevated19. The nurse is evaluating the discharge teaching for aclient who has an ileal conduit. Which of the followingstatements indicates that the client has correctlyunderstood the teaching? Select all that apply.1. “If I limit my fluid intake I will not have to empty myostomy pouch as often.”2. “I can place an aspirin tablet in my pouch to decreaseodor.”3. “I can usually keep my ostomy pouch on for 3 to 7 daysbefore 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 ona client who suspects that she is pregnant and ischecking the client for probable signs ofpregnancy. Select all probable signs of pregnancy.1. Uterine enlargement2. Fetal heart rate detected by nonelectric device3. Outline of the fetus via radiography or ultrasound4. Chadwick’s sign5. Braxton Hicks contractions6. Ballottement21. A nurse is monitoring a pregnant client withpregnancy induced hypertension who is at risk forPreeclampsia. The nurse checks the client for whichspecific signs of Preeclampsia (select all that apply)?1. Elevated blood pressure2. Negative urinary protein3. Facial edema4. Increased respirations22. A nurse is caring for a pregnant client with severepreeclampsia who is receiving IV magnesium sulfate.Select all nursing interventions that apply in the carefor the client.1. Monitor maternal vital signs every 2 hours2. Notify the physician if respirations are less than 18 perminute.3. Monitor renal function and cardiac function closely4. Keep calcium gluconate on hand in case of a magnesiumsulfate overdose5. Monitor deep tendon reflexes hourly6. Monitor I and O’s hourly7. Notify the physician if urinary output is less than 30 ml perhour.23. When interpreting an ECG, the nurse would keep inmind which of the following about the P wave? Selectall that apply.1. Reflects electrical impulse beginning at the SA node2. Indicated electrical impulse beginning at the AV node3. Reflects atrial muscle depolarization4. Identifies ventricular muscle depolarization5. 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 beimplemented in the plan of care for chemotherapyadministration? Select all that apply.1. Verify patency of the line by the presence of a blood returnat regular intervals.2. Inspect the insertion site for swelling, erythema, ordrainage.3. Administer a cytotoxic agent to keep the regimen onschedule even if blood return is not present.4. If unable to aspirate blood, reposition the client andencourage the client to cough.5. Contact the health care provider about verifying placementif the status is questionable.