NCLEX-RN | QB2 | Practice Exam #1 (50 questions)
All 50 questions are randomized each time you take the test, and do not appear in the same order.
1. Which action should nurse Marian include in the care plan for a 2 month old with heart failure?
- Feed the infant when he cries.
- Allow the infant to rest before feeding.
- Bathe the infant and administer medications before feeding.
- Weigh and bathe the infant before feeding.
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2. Nurse John develops methods for data gathering. Which of the following criteria of a good instrument refers to the ability of the instrument to yield the same results upon its repeated administration?
- Validity
- Specificity
- Sensitivity
- Reliability
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3. Situation: Lizbeth 20 year-old college student is brought to the hospital by her mother who states that for the past week her behavior has become very strange. She has become more and more withdrawn - Diagnosis: Schizophrenia Catatonic.Q. When Lizbeth become agitated, the therapeutic approach of the nurse is one that is:
- Authoritarian and directive
- Related casual and friendly
- Permissive and comforting
- Calm and firm but not threatening
4. Which hematocrit value is expected in a dehydrated male client?
- 0.67
- 0.36
- 0.5
- 0.45
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5. Situation: Clients with Bipolar disorder receives a very high nursing attention due to the increasing rate of suicide related to illness.Q. The physician orders lithium carbonate (Lithonate) for a client who's in the manic phase of bipolar disorder. During lithium therapy, the nurse should watch for which adverse reactions?
- Anxiety, restlessness, and sleep disturbance
- Nausea, diarrhea, tremor, and lethargy
- Constipation, lethargy, and ataxia
- Weakness, tremor, and urine retention
6. A 6-year-old with cerebral palsy functions at the level of an 18-month-old. Which finding would support that assessment?
- She dresses herself.
- She pulls a toy behind her.
- She can build a tower of eight blocks.
- She can copy a horizontal or vertical line
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7. Situation: Salome, 80 year old widow, has been observed to be irritable, demanding and speaking louder than usual. She would prefer to be alone and take her meals by herself, minimized receiving visitors at home and no longer bothers to answer telephone calls because of deterioration of her hearing. 'She was brought by her daughter to, the Geriatic clinic for assessment and treatment. Q.The daughter understood, the following ways to assist Salome meet her needs and avoiding which of the following:
- Using short simple sentences
- Speaking distinctly and slowly
- Speaking at eye level and having the client's attention
- Allowing her to take her meals alone
8. Before weaning a client from a ventilator, which assessment parameter is most important for the nurse to review?
- fluid intake for the past 24 hours
- baseline arterial blood gas (ABG) levels
- prior outcomes of weaning
- electrocardiogram (ECG) results
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9. Which of the following interventions is the key to increasing the survival rates of clients with lung cancer?
- Early bronchoscopy
- Early detection
- High-dose chemotherapy
- Smoking cessation
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10. On the second day of hospitalization for ventriculoperitoneal shunt revision, a child with spina bifida developed hives, itching and wheezing. The nurse should determine if the patient has been exposed to:
- Peanuts
- Strawberries
- Latex
- Eggs
11. A nurse is suctioning fluids from a client through an endotracheal tube. During the suctioning procedure, the nurse notes on the monitor that the heart rate decreases. Which of the following is the most appropriate nursing intervention?
- Ensure that the suction is limited to 15 seconds
- Continue to suction
- Hold the procedure and re-oxygenate the client
- Notify the physician immediately.
12. During surgery, the patient has the following intake and output: intravenous fluid 650cc, intravenous antibiotic 50cc, I unit of packed red blood cells (PRBC) 350cc,nasogastric output 120ccf estimated blood loss 80cc, and urine in the Foley catheter 240cc. What is the patient's total output?
- 120cc
- 200cc
- 240cc
- 440cc
13. In dystocia, the nurse assesses: 1.contractions dropping intensity and frequency. 2.progress of labor. 3.vaginal exam. 4.abdominal palpation and fetal position
- 1,2 and 3
- 1,2,3 and 4
- 2,3 and 4
- 1,3, and 4
14. A client is scheduled to have a descending colostomy. Hes very anxious and has many questions regarding the surgical procedure, care of stoma, and lifestyle changes. It would be most appropriate for the nurse to make a referral to which member of the health care team?
- Social worker
- registered dietician
- occupational therapist
- enterostomal nurse therapist
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15. The client with an abdominal aortic aneurysm is admitted in preparation for surgery. Which of the following should be reported to the doctor?
- An elevated white blood cell count
- An abdominal bruit
- A negative Babinski reflex
- Pupils that are equal and reactive to light
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16. Ventilation means:
- Movement of air in and out of the chest.
- Movement of air out of the chest.
- Movement of air in the chest.
- None of the above.
17. An adolescent with cystic fibrosis has an order for pancreatic enzyme replacement The nurse knows that the medication should be given:
- At bedtime
- With meals and snacks
- Twice daily
- Daily in the morning
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18. 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.
- 1,2,3,5
- 2,3,4,5
- 1,3,5
- 1,2,4,5
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19. The nurse is developing a plan of care for a client with a newly created ileostomy. The priority nursing diagnosis for this client is:
- Risk for deficient fluid volume related to excessive fluid loss from ostomy
- Disturbed body image related to presence of ostomy
- Risk for impaired skin integrity related to irritation from ostomy appliance
- Deficient knowledge of ostomy care related to unfamiliarity with information resources
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20. A complete blood count is commonly performed before a Joe goes into surgery. What does this test seek to identify?
- Potential hepatic dysfunction indicated by decreased blood urea nitrogen (BUN) and creatinine levels
- Low levels of urine constituents normally excreted in the urine
- Abnormally low hematocrit (HCT) and hemoglobin (Hb) levels
- Electrolyte imbalance that could affect the bloods ability to coagulate properly
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21. Situation: Mental Retardation is an increasingly common childhood disorder that impairs learning.Q. The onset of mental retardation is before the child reaches what particular age?
- 17
- 16
- 15
- 18
22. A client with a fractured tibia has a plaster-of-Paris cast applied to immobilize the fracture. Which action by the nurse indicates understanding of a plaster-of-Paris cast? The nurse:
- Handles the cast with the fingertips
- Petals the cast
- Dries the cast with a hair dryer
- Allows 24 hours before bearing weight
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23. Nurse Trish suggests a crisis intervention group to a client experiencing a developmental crisis. These groups are successful because the:
- Crisis intervention worker is a psychologist and understands behavior patterns
- Crisis group supplies a workable solution to the client's problem
- Client is encouraged to talk about personal problems
- Client is assisted to investigate alternative approaches to solving the identified problem
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24. A client hospitalized for treatment of congestive heart failure is to be discharged with a prescription for Digitek (digoxin) 0.25mg daily. Which of the following statements indicates that the client needs further teaching?
- I win need to take the medication at the same time each day.
- I can prevent stomach upset by taking the medication with an antacid.
- I can help prevent drug toxicity by eating foods containing fiber.
- I will need to report visual changes to my doctor.
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25. Which of the following is the most common symptom of myocardial infarction?
- Chest pain
- Dyspnea
- Edema
- Palpitations
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26. The nurse observes that a client with a potential for violence is agitated, pacing up and down the hallway, and is making aggressive and belligerent gestures at other clients. Which statement would be most appropriate to make to this client?
- "You need to stop that behavior now."
- "You will need to be placed in seclusion."
- "You seem restless; tell me what is happening."
- "You will need to be restrained if you do not change your behavior."
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27. The country where SHUSHURUTU originated:
- China
- Egypt
- India
- Babylonia
28. A client is admitted to the emergency department with complaints of crushing chest pain that radiates to the left jaw. After obtaining a stat electrocardiogram the nurse should:
- Obtain a history of prior cardiac problems
- Begin an IV using a large-bore catheter
- Administer oxygen at 2L per minute via nasal cannula
- Perform pupil checks for size and reaction to light
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29. A 4 year-old hospitalized child begins to have a seizure while playing with hard plastic toys in the hallway. Of the following nursing actions, which one should the nurse do first?
- Place the child in the nearest bed
- Administer IV medication to slow down the seizure
- Place a padded tongue blade in the child's mouth
- Remove the child s toys from the immediate area
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30. Skin turgor is:
- Decrease sensation in extremities due to nerves system disease.
- Collection of fluids inside the tissue.
- Elasticity by lifting and pulling the skin on an extremity.
- None of the above.
31. The nurse collects a urine specimen preoperatively from a child with epispadias who is scheduled for surgical repair When analyzing the results of the urinalysis, which should the nurse most likely expect to?
- Hematuria
- Proteinuria
- Bacteriuria
- Glucosuria
32. The wail unit is not functioning; You then try to use the portable suction equipment available. How much pressure of suction equipment is needed to prevent trauma to mucus membrane and air ways in case of portable suction units?
- 2-5 mmHg
- 5-10 mmHg
- 10-15 mmHg
- 15-25 mmHg
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33. On the second postpartum day, a client complains of burning on urination, urgency, and frequency of urination. A urinalysis indicates the presence of a urinary tract infection. The nurse instructs the client regarding measures to take for the treatment of the infection. Which client statement indicates to the nurse the need for further instruction?
- "I need to urinate frequently through out the day"
- "The prescribed medication must be taken until it is finished"
- "My fluid intake should be increased to at least 3000 ml daily"
- "Foods and fluids that will increase urine alkalinity should be consumed."
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34. Rocky has started taking haloperidol (Haldol). Which of the following instructions is most appropriate for Ricky before taking haloperidol?
- Should report feelings of restlessness or agitation at once
- Use a sunscreen outdoors on a year-round basis
- Be aware you'll feel increased energy taking this drug
- None
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35. How much Vit A should be given to 6-11 months old Infants who is experiencing Vit. A deficiency?
- 200,000 III
- 400.000 III
- 100,000 IU
- 50,000 IU
36. The nurse is preparing to administer an injection to a six-month-old when she notices a white dot in the infants right pupil. The nurse should:
- Report the finding to the physician immediately.
- Record the finding and give the infants injection.
- Recognize that the finding is a variation of normal.
- Check both eyes for the presence of the red reflex.
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37. The health care providers prescription reads levothyroxine, 150 mcg orally daily. The medication label reads levothyroxine, 0.1 mg per tablet The nurse should administer how many tablet(s) to the client?
- 1.5 tablets
- 2 tablets
- 3 tablets
- 0.5 tablet
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38. Cyrill with severe head trauma sustained in a car accident is admitted to the intensive care unit Thirty-six hours later, the client's urine output suddenly rises above 200 ml/hour, leading the nurse to suspect diabetes insipidus. Which laboratory findings support the nurse's suspicion of diabetes insipidus?
- Above-normal urine and serum osmolality levels
- Below-normal urine and serum osmolality levels
- Above-normal urine osmolality level, below-normal serum osmolality level
- Below-normal urine osmolality level, above-normal serum osmolality level
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39. While Obtaining the pre-operative history of a patient schedules for cosmetic surgery the most valuable skill at the nurse disposal is:
- knowledge of the procedure
- Time management skills
- Listening skills
- Empathy
40. The nurse is planning to talk to the client with an antisocial personality disorder. What would be the most therapeutic approach?
- Provide external controls.
- Reinforce the clients self-concept.
- Give the client opportunities to test reality.
- Gratify the client's inner needs.
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41. A pregnant client age 32 asks the nurse why her doctor has recommended a serum alpha fetoprotein. The nurse should explain that the doctor has recommended the test:
- Because it is a state law
- To detect cardiovascular defects
- Because of her age
- To detect neurological defects
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42. Which of the following groups are considered to be at highest risk for suicide?
- Adolescents, men over age 45, and persons who have made previous suicide attempts
- Teachers, divorced persons, and substance abusers
- Alcohol abusers, widows, and young married men
- Depressed persons, physicians, and persons living in rural areas
43. Situation: After an abdominal surgery, the circulating and scrub nurses have critical responsibility about sponge and Instrument count.Q. Like any nursing interventions, counts should be documented. To whom does the scrub nurse report any discrepancy of country so that immediate 'and appropriate action in instituted?
- Anesthesiologist
- Surgeon
- Or nurse supervisor
- Circulating nurse
44. Mrs. Hogan, a 43-year-old woman, is admitted to your unit for cholecystectomy.Q. During an acute myocardial infarct (Ml):
- A patient may have a normal appearing ECG.
- Chest pain will always be present.
- A targeted history is rarely useful in making the diagnosis of MI.
- The chest pain is rarely described as crushing, pressing, or heavy.
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45. Which pattern of nursing care involves the care given by a group of paraprofessional workers led by a professional nurse who take care of patients with the same disease conditions and are located geographically near each other?
- Case method
- Modular nursing
- Nursing case management
- Team nursing
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46. Situation: Mr. Ramos is a 60 year old male client admitted to the hospital with the diagnosis of pneumonia. He complains of pain when coughing.Q. Upon discharge, the health teaching of the nurse to Mr. Ramos should include which of the following except:
- Avoid fatigue
- Maintain hygiene
- Maintain the usual exercise
- Avoid drafts
47. SITUATION: a 20 year old college student was rushed to the ER of PGH after he fainted during their ROTC drill. Complained of severe right iliac pain. Upon palpation of his abdomen, Ernie jerks even on slight pressure. Blood test was ordered. Diagnosis is acute appendicitis.Q. Which result of the lab test will be significant to the diagnosis?
- RBC : 4.5 TO 5 Million / cu. mm.
- Hgb : 13 to 14 gm/dl.
- Platelets : 250,000 to 500,000 cu.mm.
- WBC : 12,000 to 13,000/cu.mm
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48. A client receiving parenteral nutrition (PN) suddenly develops a fever. The nurse notifies the health care provider (HOP), and the HOP initially prescribes that the solution and tubing be changed. What should the nurse do with the discontinued materials?
- Discard them in the unit trash.
- Return them to the hospital pharmacy.
- Save them for return to the manufacturer.
- Prepare to send them to the laboratory for culture.
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49. Which specific nursing interventions are implemented in the care of a child with leukemia who is at risk for infection? Select all that apply. 1.Maintain the child in a semiprivate room. 2.Reduce exposure to environmental organisms. 3.Use strict aseptic technique for all procedures. 4.Ensure that anyone entering the child's room wears a mask. 5.Apply firm pressure to a needle-stick area for at least 10 minutes.
- 1,2,3,4,5
- 2,3,4
- 1,2,5
- 1,2,4,5
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50. When working with a male client suffering phobia about black cats. Nurse Trish should anticipate that a problem for this client would be?
- Anxiety when discussing phobia
- Anger toward the feared object
- Denying that the phobia exist
- Distortion of reality when completing daily routines
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NCLEX-RN QB2 | Practice Exam #1 - 50 questions