NCLEX-RN
SELECT ALL THAT APPLY-QUESTIONS AND ANSWERS
Written and compiled by DocStewart for ExamsWithAnswers
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,NCLEX-SELECT ALL THAT APPLY-QUESTIONS AND ANSWERS
1. 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.
1. Call a code blue.
2. Notify the registered nurse.
3. Place the infant in a prone position.
4. Prepare to administer morphine sulfate.
5. Prepare to administer intravenous fluids.
6. Prepare to administer 100% oxygen by face mask.
Answers: 2, 4, 5, and 6.
The child who is cyanotic with oxygen saturations dropping to 60% is having a hypercyanotic episode. Hypercyanotic
episodes often occur among infants with tetralogy of Fallot, and they may occur among infants whose heart defect
includes the obstruction of pulmonary blood flow and communication between the ventricles. If a hypercyanotic episode
occurs, the infant is placed in a knee-chest position immediately. The registered nurse is notified, who will then contact
the health care provider. The knee-chest position improves systemic arterial oxygen saturation by decreasing venous
return so that smaller amounts of highly saturated blood reach the heart. Toddlers and children squat to get into this
position and relieve chronic hypoxia. There is no reason to call a code blue unless respirations cease. Additional
interventions include administering 100% oxygen by face mask, morphine sulfate, and intravenous fluids, as prescribed.
37
2. A nurse enters a client’s room and notes that the client’s lawyer is present and that the client is
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preparing a living will. The living will requires that the client’s signature be witnessed, and the client asks
1
the nurse to witness the signature. Which of the following is the appropriate nursing action?
1. Decline to sign the will.
2. Sign the will as a witness to the signature only.
3. Call the hospital lawyer before signing the will.
, 4. Sign the will, clearly identifying credentials and employment agency.
Answers: 1
Living wills are required to be in writing and signed by the client. The client’s signature either must be witnessed by
specified individuals or notarized. Many states prohibit any employee from being a witness, including a nurse in a facility
in which the client is receiving care.
3. 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
Answer: 2 and 3.
Research demonstrate that the occurrence of SIDS is reduced with these two positions.
4. 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.
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
5. 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
6. 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.
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
7
the aggressive behavior.
Page
SELECT ALL THAT APPLY-QUESTIONS AND ANSWERS
Written and compiled by DocStewart for ExamsWithAnswers
www.stuvia.com/user/ExamsWithAnswers
[Pick the date]
,NCLEX-SELECT ALL THAT APPLY-QUESTIONS AND ANSWERS
1. 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.
1. Call a code blue.
2. Notify the registered nurse.
3. Place the infant in a prone position.
4. Prepare to administer morphine sulfate.
5. Prepare to administer intravenous fluids.
6. Prepare to administer 100% oxygen by face mask.
Answers: 2, 4, 5, and 6.
The child who is cyanotic with oxygen saturations dropping to 60% is having a hypercyanotic episode. Hypercyanotic
episodes often occur among infants with tetralogy of Fallot, and they may occur among infants whose heart defect
includes the obstruction of pulmonary blood flow and communication between the ventricles. If a hypercyanotic episode
occurs, the infant is placed in a knee-chest position immediately. The registered nurse is notified, who will then contact
the health care provider. The knee-chest position improves systemic arterial oxygen saturation by decreasing venous
return so that smaller amounts of highly saturated blood reach the heart. Toddlers and children squat to get into this
position and relieve chronic hypoxia. There is no reason to call a code blue unless respirations cease. Additional
interventions include administering 100% oxygen by face mask, morphine sulfate, and intravenous fluids, as prescribed.
37
2. A nurse enters a client’s room and notes that the client’s lawyer is present and that the client is
Page
Page
preparing a living will. The living will requires that the client’s signature be witnessed, and the client asks
1
the nurse to witness the signature. Which of the following is the appropriate nursing action?
1. Decline to sign the will.
2. Sign the will as a witness to the signature only.
3. Call the hospital lawyer before signing the will.
, 4. Sign the will, clearly identifying credentials and employment agency.
Answers: 1
Living wills are required to be in writing and signed by the client. The client’s signature either must be witnessed by
specified individuals or notarized. Many states prohibit any employee from being a witness, including a nurse in a facility
in which the client is receiving care.
3. 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
Answer: 2 and 3.
Research demonstrate that the occurrence of SIDS is reduced with these two positions.
4. 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.
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
5. 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
6. 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.
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
7
the aggressive behavior.
Page
