QB2 | Practice Exam #3 -> answers with explanation - Free NCLEX Exam Practice

NCLEX-RN | QB2 | Practice Exam #3 (50 questions)

All 50 questions are randomized each time you take the test, and do not appear in the same order.

 

1. The type of anxiety that leads to personality disorganization is:

• Mild
• moderate
• severe
• panic

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2. Situation: Some equipments and materials in our hospital are color coded, this is to increase the safety and proficiency of rendering patients care.Q. If a nurse has been ordered to prepare a spinal set gauge 16, the nurse knew that the color for that spinal set is coded at:

• Red
• Pink
• Yellow
• Blue

3. Mr. Duffy is admitted to the CCll with a diagnosis of R/O Ml. He presented in the ER with a typical description of pain associated with an Ml, and is now cold and clammy, pale and dyspneic. He has an IV of D5W running, and is complaining of chest pain. Oxygen therapy has not been started, and he is not on the monitor. He is frightened.Q. You did the initial assessment on Mr. Kaplan when he came to your unit. What classical signs and symptoms did you note?

• fruity-smelling breath.
• Weakness, anorexia, pruritus
• Polyuria, polydipsia, polyphagia
• Ruddy complexion

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4. Situation: You are actively practicing nurse who just finished your Graduate Studies. You earned the value of Research and would like to utilize the knowledge and skills gained in the application of research to Nursing service. The following questions apply to research.Q. Which type of research Inquiry investigates the issue of human complexity (e.g. understanding the human expertise)

• Logical position
• Naturalistic inquiry
• Positivism
• Quantitative Research

5. Situation: As a beginner in research, you are aware that sampling is an essential element of the research process.Q. What is the most important characteristics of a sample?

• Randomization
• Appropriate location
• Appropriate number
• Representativeness

6. Nurse Monette recognizes that the focus of environmental (MILIEU) therapy is to:

• Manipulate the environment to bring about positive changes in behavior
• Allow the clients freedom to determine whether or not they will be involved in activities
• Role play life events to meet individual needs
• Use natural remedies rather than drugs to control behavior

7. Situation: Nette, a nurse palpates the abdomen of Mrs. Medina, a primigravida. She is unsure of the date of her last menstrual period. Leopold's Maneuver is done. The obstetrician told mat she appears to be 20 weeks pregnant. If Mrs. Medina comes to you for check-up on June 2, her EDO is June 11, what do you expect during assessment?

• Fundic ht 2 fingers below xyphoid process, engaged
• Cervix close, uneffaced, FH-midway between the umbilicus and symphysis pubis
• Cervix open, fundic ht. 2 fingers below xyphoid process, floating
• Fundal height at least at the level of the xyphoid process, engaged

8. Nurse Sarah is caring for clients on the surgical floor and has just received report from the previous shift Which of the following clients should the nurse see first?

• A 35-year-old admitted three hours ago with a gunshot wound; 1.5 cm area of dark drainage noted on the dressing.
• A 43-year-old who had a mastectomy two days ago; 23 ml of serosanguinous fluid noted in the Jackson-Pratt drain.
• A 59-year-old with a collapsed lung due to an accident; no drainage noted in the previous eight hours.
• A 62-year-old who had an abdominal-perineal resection three days ago; client complaints of chills.

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9. A murmur is heard at the second left intercostal space along the left sternal border. Which valve area is this?

• Aortic
• Pulmonic
• Mitral
• Tricuspid

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10. On admission to the psychiatric unit, the client is trembling and appears fearful. The nurses initial response should be to:

• Give the client orientation materials and review the unit rules and regulations
• Introduce him/her and accompany the client to the clients room
• Take the client to the day room and introduce her to the other clients
• Ask the nursing assistant to get the client's vital signs and complete the admission search

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11. A parent brings their teenage child the pediatricians office. The parent reports that the patient frequently complains of abdominal bloating and stomach pain after eating and also has a chronic sore throat. The patient's labs show hypokalemia.Which of the following diagnosis should the nurse anticipate?

• Anorexia nervosa
• Bulimia
• Morbid obesity
• Impulsive behavior

12. The normal umbilical cord is composed of:

• 2 arteries and 1 vein
• 2 veins and 1 artery
• 2 arteries and 2 veins
• none of the above

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13. A client is admitted to the mental health unit after an attempted suicide by hanging. The nurse can best ensure client safety by which action?

• Requesting that a peer remain with the client at all times
• Removing the client's clothing and placing the client in a hospital gown
• Assigning to the client a staff member who will remain with the client at all times
• Admitting the client to a seclusion room where all potentially dangerous articles are removed

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14. The nurse enters a clients room and finds that the wastebasket is on fire. The nurse immediately assists the client out of the room. What is the next nursing action?

• Call for help.
• Extinguish the fire.
• Activate the fire alarm.
• Confine the fire by closing the room door.

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15. Which of the following is the meaning of PRN?

• When advice
• Immediately
• When necessary
• Now

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16. Pressure ulcer risk factors include:

• Immobility and inactivity.
• Fecal and urinary incontinence.
• Decreased mental status.
• All of the above.

17. As an epidemiologist, the nurse is responsible for reporting cases or notifiable diseases. What law mandates reporting cases of notifiable diseases?

• Act 3573
• RA.3753
• RA 1054
• RA 1045

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18. A client with pneumacystis carinn pneumonia is receiving Methotrexate. The rationale for administering leucovorin calcium to a client receiving Methotrexate is to:

• Treat anemia
• Create a synergistic effect
• increase the number of white blood cells
• Reverse drug toxicity

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19. A client with rheumatoid arthritis is receiving injections of Myochrysine (gold sodium thiomalate). Before administering the clients medication the nurse should:

• Prevention of nausea and vomiting
• Treatment of micro-metastasis
• Eradication of bone pain
• Prevention of therapy-induced anemia

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20. A bacteria which causes diphtheria is also known as?

• Amoeba
• Cholera
• Klebs-loeffler bacillus
• Spirochete

21. A client with a diagnosis of depression who has attempted suicide says to the nurse, "I should have died. I've always been a failure. Nothing ever goes right for me." Which response by the nurse demonstrates therapeutic communication?

• "You have everything to live for"
• "Why do you see yourself as a failure?"
• "Feeling like this is all part of being depressed"
• "You've been feeling like a failure for a while?"

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22. Situation: Please respond as a professional nurse in the other health situations through the following question.Q. The rationales for using a prostaglandin gel for a client prior to the induction of labor is to:

• Soften and efface the cervix
• Numb cervical pain receptors
• Prevent cervical lacerations
• Stimulate uterine contractions

23. A patient has multiple sclerosis and complains of overwhelming fatigue. The nurse would be MOST correct in instruction the patient to:

• Conserve energy during activities of daily living
• Increase muscle strength through aerobic exercise
• Ignore fatigue and keep working
• Increase early afternoon intake of caffeine

24. SITUATION: Devon, A registered nurse, witnessed an old woman hit by a motorcycle while crossing a train railway. The old woman fell at the railway. Devon rushed at the scene.Q. The old woman told Devon that she has osteoporosis; Devon knew that all of the following factors would contribute to osteoporosis except:

• Hypothyroidism
• End stage renal disease
• Cushing's Disease
• Taking Furosemide and Phenytoin.

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25. A schizophrenic client states, I hear the voice of King Tut Which response by the nurse would be most therapeutic?

• "I don't hear the voice, but I know you hear what sounds like a voice."
• "You shouldn't focus on that voice."
• "Don't worry about the voice as long as it doesn't belong to anyone real"
• "King Tut has been dead for years"

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26. A client comes to the outpatient mental health clinic 2 days after being discharged from the hospital. The client was given a 1-week supply of clozapine (Clozaril). The nurse reviews information about clozapine with the client Which client statement indicates an accurate understanding of the nurse's teaching about this medication?

• "I need to call my doctor in 2 weeks for a checkup.”
• "I need to keep my appointment here at the hospital this week for a blood test”
• I can drink alcohol with this medication.
• "I can take over-the-counter sleeping medication if I have trouble sleeping."

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27. An infection that the patient acquires in the hospital is called:

• A local infection
• An endogenous infection
• A nosocomial infection
• A secondary infection

28. The newly licensed nurse has been asked to perform a procedure that he feels unqualified to perform. The nurses best response at this time is to:

• Attempt to perform the procedure.
• Refuse to perform the procedure and give a reason for the refusal.
• Request to observe a similar procedure and then attempt to complete the procedure.
• Agree to perform the procedure if the client is willing.

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29. In this stage of illness, the person accepts or rejects a professionals suggestion. The person also becomes passive and may regress to an earlier stage.

• Symptom Experience
• Assumption of sick role
• Medical care contact
• Dependent patient role

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30. Situation: Nette, a nurse palpates the abdomen of Mrs. Medina, a primigravida. She is unsure of the date of her last menstrual period. Leopold's Maneuver is done. The obstetrician told mat she appears to be 20 weeks pregnant. Q. The nurse assesses the woman at 20 weeks gestation and expects the woman to report:

• Spotting related to fetal implantation
• Symptoms of diabetes as human placental lactogen is released
• Feeling fetal kicks
• Nausea and vomiting related HCG production

31. The nurse is caring for a client admitted with acute laryngotracheobronchitis (LTB). Because of the possibility of complete obstruction of the airway which of the following should the nurse have available?

• Intravenous access supplies
• Emergency intubation equipment
• intravenous fluid-administration pump
• Supplemental oxygen

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32. Situation: You are assigned to take care of a group of patients across the lifespan.The use of interpersonal decision making psychomotor skills and application of knowledge expected in the role of a licensed healthcare professional in the context of public health welfare and safety as an example of?

• Delegation
• Supervision
• Responsibility
• Competence

33. A client is to have a hysterosalpingogram. In this procedure, the physician will be able to determine which of the following?

• Whether or not the ovaries are maturing properly.
• If the endometrium is fully vascularized.
• If the cervix is incompetent.
• Whether or not the fallopian tubes are obstructed.

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34. When assessing the urinary output of a client who has had extracorporeal lithotripsy the nurse can expect to find:

• Cherry-red urine that gradually becomes clearer
• Orange-tinged urine containing particles of calculi
• Dark red urine that becomes cloudy in appearance
• Dark smoky-colored urine with high specific gravity

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35. A child/boy in the emergency-department, oriented, crying and open his eyes spontaneously, the child move as responding to pain, based on Glasgow Coma Scale, the child scores at:

• 15
• 13
• 11
• 9

36. SITUATION: a 20 year old college student was rushed to the ER of PGH after he fainted during their ROTO 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. Peritonitis may occur in ruptured appendix and may cause serious problems which are: l.Hypovolemia, electrolyte imbalance. 2.Elevated temperature, weakness and diaphoresis. 3.Nausea and vomiting, rigidity of the abdominal wall. 4.Pallor and eventually shock

• 1 and 2
• 2 and 3
• 1,2,3
• All of the above

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37. When assessing a newborn suspected of having Down syndrome, nurse Rey would expect to observe:

• long thin fingers
• Large, protruding ears
• Hypertonic neck muscles
• Simian lines on the hands

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38. Which assessment finding indicates circulatory constriction in a male client with a newly applied long leg cast?

• Blanching or cyanosis of legs
• Complaints of pressure or tightness
• inability to move toes
• Numbness of toes

39. When documenting information in a clients medical record, the nurse should:

• erase any errors.
• use a #2 pencil
• leave one line blank before each new entry.
• end each entry with the nurse's signature and title.

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40. She checks the documentary requirements for the applicants for staff nurse position. Which one is NOT necessary?

• Certificate of previous employment
• Record of related learning experience (RLE)
• Membership to accredited professional organization
• Professional identification card

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41. The amniotic fluid of a client has a greenish tint. The nurse interprets this to be the result of which of the following?

• Lanugo
• Hydramnio
• Meconium
• Vernix

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42. The nurse is caring for a client receiving Capoten (captopril). The nurse should be alert for adverse reactions to the drug which include:

• Increased red cell count
• Decreased sodium level
• Decreased white cell count
• Increased calcium level

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43. The nurse is caring for child admitted with viral pneumonia. Which of the following nursing diagnoses should receive PRIORITY?

• Nutrition altered: less than body requirements
• Ineffective airway clearance
• Fluid volume deficit
• Risk for injury

44. Situation: Rose seeks psychiatric consultation because of intense fear of flying in an airplane which has greatly affected her chances of success in her job.Q. The most common defense mechanism used by phobic client is:

• Supression
• Rationalization
• Denial
• Displacement

45. The client is receiving heparin for thrombophlebitis of the left lower extremity. Which of the following drugs reverses the effects of heparin?

• Cyanocobalamine
• Protamine sulfate
• Streptokinase
• Sodium warfarin

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46. A client with an abdominal cholecystectomy returns from surgery with a Jackson-Pratt drain. The chief purpose of the Jackson-Pratt drain is to:

• Prevent the need for dressing changes
• Reduce edema at the incision
• Provide for wound drainage
• Keep the common bile duct open

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47. A client has an order for one unit of whole blood. What is a correct nursing action?

• Initiate an IV with 5% dextrose in water (D5W) to maintain a patent access site
• Initiate the transfusion within 30 minutes of receiving the blood
• Monitor the clients vital signs for the first 5 minutes
• Monitor the client's vital signs for the first 5 minutes

48. A patient presents with a productive cough with a moderate amount of while Frothy sputum and dispend. The patient is anxious and the nurse notices on assessment that the patient is using accessory muscle including intercostals spaces to breathe and has jugular vein distention. The patient has a history of hypertension and heart failure. What should the nurse administer FIRST?

• Digoxin (lanoxin) toimprovethe abilityof the heart topump effectively
• Oxygen therapy to combathypoxemia
• Furosemide (lasix) to reduce blood volume and pulmonary congestion
• Morphine sulface(Duramorph) to reduce anxiety

49. A nurse is evaluating a patient 5 days after a right total hip replacement. Which of the following goals is appropriate for the patient?

• Maintain hip abduction without dislocation
• Rest with legs elevate while sitting
• Tie shoes and put on undergarments without assistive devices
• Perform scissors-like leg exercise daily

50. The nurse is assisting a health care provider (HOP) examining a 3-week-old infant with developmental dysplasia of the hip. What test or sign should the nurse expect the HOP to assess?

• Babinski's sign
• The Moro reflex
• Ortolani's maneuver
• The palmar-plantar grasp

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NCLEX-RN | QB2 | Practice Exam #3 (50 questions)