NCLEX-RN | QB2 | Practice Exam #4 (50 questions)

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

 

1. Situation: During the morning endorsement, the outgoing nurse informed the nursing staff that Regina, 5 years old, was given Flurazepam (Dalmane) 15 mg at 10:00pm because she had trouble going to sleep. Before approaching Regina, the nurse read the observation of the night nurse.Q. Regina is a high school teacher. Which of these information LEAST communicate attention and care for her needs for information about her medicine?

• Guided by a medication teaching plan go over with her the purpose, indications and special instructions, about the medication and provide her a checklist
• Provide a drug literature
• Have an informal conversation about the medication and its effects
• Ask her what time she would like to watch the informative video about the medication

2. Situation: Developing countries such as the Philippines suffer from high infant and child mortality rates. Thus, as a management to the existing problem, the WHO and UNICEF launched the IMCI. An ear discharge that has been present for more than 14 days can be classified as:

• Complicated ear infection
• Acute ear infection
• Chronic ear infection
• Mastoiditis

3. The nurse is giving a report to an unlicensed assistive personnel (UAP) who will be caring for a client who has hand restraints (safety devices). The nurse instructs the UAP to check the skin integrity of the restrained hands how frequently?

• Every 2 hours
• Every 3 hours
• Every 4 hours
• Every 30 minutes

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4. The nurse is caring for a client who takes ibuprofen for pain. The nurse is gathering information on the client's medication history, and determines it is necessary to contact the health care provider (HOP) if the client is also taking which medications? Select all that apply. 1.Warfarin. 2.Glimepiride. 3.Amlodipine. 4.Simvastatin. 5.Hydrochlorothiazide

• 1,2,3
• 3,4,5
• 1,2,3,4
• 2,4,5

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5. Situation : Overpopulation is one problem in the Philippines that case economic drain. Most Filipinos are against in legalizing abortion. As a nurse, Mastery of contraception is needed to contribute to the society and economic growth.Dana chooses to use COC as her family planning method, what is the danger sign of COC you would ask her to report?

• A stuffy or runny nose
• Arthritis like symptoms
• Slight weight gain
• Migraine headache

6. The nurse is caring for a new mother. The mother asks why her baby has lost weight since he was born. The best explanation of the weight loss is:

• The baby is dehydrated.
• The baby is hypoglycemic.
• The baby is allergic to the formula the mother is giving him.
• A loss of 10% is normal in the first week due to meconium stools.

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7. When teaching the family of a client with schizophrenia, the nurse should provide which information?

• Relapse can be prevented if the client takes the medication.
• Support is available to help family members meet their own needs.
• Improvement should occur if the client has a stimulating environment.
• Stressful family situations can precipitate a relapse in the client.

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8. Arubellla titer result of a 1-day postpartum client is less than 1:8, and a rubella virus vaccine is prescribed to be administered before discharge. The nurse provides which information to the client about the vaccine? Select all that apply. 1.Breast-feeding needs to be stopped for 3 months. 2.Pregnancy needs to be avoided for 1 to 3 months. 3.The vaccine is administered by the subcutaneous route. 4.Exposure to immunosuppressed individuals needs to be avoided. 5.A hypersensitivity reaction can occur if the client has an allergy to eggs. 6.The area of the injection needs to be covered with a sterile gauze for 1 week.

• 2,3,4,5
• 1,2,3,4
• 3,4,5
• 2,3,5

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9. A healthy patient is in doctor s office for a pre-operative visit before a total replacement. The nurse interviewing the patient charts the following medications: aspirin 81 mg once a day, vitamin E 260 international units once a day, and unknown amount of a herbal supplement once a day, based on the patient's medication list which of the following labs would be important pre-operatively?

• Prostate specific antigen(PSA)
• Blood glucose
• Creatine phosphokinaseisoenzymes (CPK enzymes)
• Prothrombin time

10. The client is admitted to the unit after a motor vehicle accident with a temperature of 102F rectally. The most likely explanations for the elevated temperature is that:

• There was damage to the hypothalamus.
• He has an infection from the abrasions to the head and face.
• He will require a cooling blanket to decrease the temperature.
• There was damage to the frontal lobe of the brain.

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11. The nurse is caring for a client who has exophthalmos associated with her thyroid disease. What is the cause of exophthalmos?

• Fluid edema in the retro-orbital tissues which force the eyes to protrude
• Impaired vision, which causes the client to squint in order to see
• Increased eye lubrication, which makes the client blink less
• Decrease in extraocular eye movements, which results in the "thyroid stare”

12. Situation: Susan is a patient in the clinic where you work She is inquiring about pregnancy.Kevin, Susan's husband, tells you that he is considering vasectomy. After the birth of their new child. Vasectomy involves the incision of which organ?

• The testes
• The vas deferens
• The epididymis
• The scrotum

13. The client with Alzheimers disease is being assisted with activities of daily living when the nurse notes that the client uses her toothbrush to brush her hair. The nurse is aware that the client is exhibiting:

• Agnosia
• Apraxia
• Anomia
• Aphasia

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14. Which of the following medications would the patient be instructed to stop 2 weeks prior the surgery?

• Anti arrhythmic
• Antifungal
• Antidiabetics
• antiplatelet

15. Jose is tn danger of respiratory arrest following the administration of a narcotic analgesic. An arterial blood gas value is obtained. Nurse Oliver would expect the paco2 to be which of the following values?

• 15 mm Hg
• 30 mm Hg
• 40 mm Hg
• 80 mm Hg

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16. The doctor orders 2% nitroglycerin ointment in a 1-inch dose every 12 hours. Proper application of nitroglycerin ointment includes:

• Rotating application sites
• Limiting applications to the chest
• Rubbing it into the skin
• Covering it with a gauze dressing

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17. In a mother s class, you discuss proper breastfeeding technique. Which of these is a sign that the baby has "lactated on" the breast property?

• The baby takes shallow, rapid sucks
• The mother does not feel nipple pain
• The babys mouth is only partly open
• Only the mother's nipple is inside the baby's mouth

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18. Which of the following can you visualize in intravenous pyelogram (IVP )?

• bladder
• bladder and kidney
• bladder, kidney , ureter
• bladder and ureter

19. The client is admitted to the ER with multiple rib fractures on the right. The nurses assessment reveals that an area over the right clavicle is puffy and that there is a crackling noise with palpation. The nurse should further assess the client for which of the following problems?

• Flail chest
• Subcutaneous emphysema
• Infiltrated subclavian IV
• Pneumothorax

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20. A patient is admitted to the hospital with a cerebrovascular accident, accident, right hemiplegia, and expressive aphasia. With a nursing diagnosis of impaired verbal communication, what is the BEST term goal for this patient?

• Learn to speak clearly within 30 days
• Communicate effectively within one week
• Have all needs anticipated by staff daily
• Make basic needs known daily

21. The nursing intervention that Is most important in a patient on IV Morphine?

• Monitor for hypertension
• Monitor for decreased respirations
• Monitor for cardiac rates
• Monitor for hyperglycemia

22. The nursing a 15 year old patient who is being admitted due to an exacerbation of bronchial asthma. The nurse should give PRIORITY to asking if the patient has history of?

• Indoor allergies
• Intubation
• Chest trauma
• Co sack virus

23. Which of the following is TRUE in postural drainage?

• Patient assumes position for 10 to 15 minutes
• Should last only for 60 minutes
• Done best PC
• An independent nursing action

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24. The client would be experiencing a typical symptom of Meniere's disease if, before an attack, he experienced:

• A severe headache
• Blurred vision
• Nausea
• A feeling of inner ear fullness

25. Mrs. Cruz uses a cane for assistance in walking. Which of the following statements is true about a cane or other assistive devices?

• A walker is a better choice than a cane.
• The cane should be used on the affected side
• The cane should be used on the unaffected side
• A client with osteoarthritis should be encouraged to ambulate without the cane

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26. A client with a T6 injury six months ago develops facial flushing and a BP of 210/106. After elevating the head of the bed which is the most appropriate nursing action?

• Notify the physician.
• Assess the client for a distended bladder.
• Apply ordered oxygen via nasal cannula.
• Increase the IV fluids.

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27. Situation: Mr. Baldo , 36 years old patient complaints of fatigue, weight loss, and low-grade fever. He also has pain his fingers, elbows, and ankles.Q. Which of the following elements shows that the client does not understand the cause of exacerbation of system lupus erythematosus (SLE)?

• " I need to stay away from sunlight"
• "I don't have to worry if I get a strep, throat"
• "I need to work on managing stress in life."
• "i don't have to worry about changing my diet"

28. A client with AIDS has a viral load of 200 copies per ml. The nurse should interpret this finding as:

• The client is at risk for opportunistic diseases.
• The client is no longer communicable.
• The clients viral load is extremely low so he is relatively free of circulating virus.
• The clients T-cell count is extremely low.

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29. The nurse receives a call from a client concerned about eliminating brown-colored urine after taking nitrofurantoin for a urinary tract infection. The nurse should make which appropriate response?

• "Continue taking the medication; the brown urine occurs and is not harmful”
• "Take magnesium hydroxide with your medication to lighten the urine color."
• "Take magnesium hydroxide with your medication to lighten the urine color."
• "Decrease your medication to half the dose, because your urine is too concentrated.”

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30. The nurse is providing care for a female client with a history of schizophrenia who's experiencing hallucinations. The physician orders 200 mg of haloperidol (Haldol) orally or l.M. every 4 hours as needed. What is the nurse's best action?

• Administer the haloperidol orally if the client agrees to take it.
• Call the physician to clarify whether the haloperidol should be given orally or l.M.
• Call the physician to clarify the order because the dosage is too high.
• Withhold haloperidol because it may worsen hallucinations.

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31. Situation: Leukemia is the most common type of childhood cancer. Acute Lymphoid Leukemia is the cause of almost 1/3 of all cancer that occurs in children under age 15.Q. The survival rate for Acute Lymphoid Leukemia is approximately:

• 25%
• 40%
• 75%
• 95%

32. A client with myocardial infarction suddenly becomes tachycardic, shows signs of air hunger, and begins coughing frothy, pink-tinged sputum. Which finding would the nurse anticipate when auscultating the client's breath sounds?

• Stridor
• Crackles
• Scattered rhonchi
• Diminished breath sounds

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33. As a result of fractured ribs, the client may develop:

• Scoliosis
• Paradoxical respiration
• Obstructive lung-disease
• Herniation of the diaphragm

34. Methylergonovine is prescribed for a client with postpartum hemorrhage. Before administering the medication, the nurse should contact the health care provider who prescribed the medication if which condition is documented in the client's medical history?

• Hypotension
• Hypothyroidism
• Diabetes mellitus
• Peripheral vascular disease

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35. An elderly patient with severe degenerative joint disease comes to the clinic for routine follow up of pain management The patient reports that over the past month, the pain has begun to increase in severity. The patient requests an increase in dosage of the pain medication. The nurse recognize that this is MOST likely due to:

• Drug addiction
• Drug tolerance
• An improvement in condition
• Lack of efficacy of the current medication

36. The following are true with regards to aspect of the sick role except

• One should be held responsible for his condition
• One is excused from his societal role
• One is obliged to get well as soon as possible
• One is obliged to seek competent help

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37. A client with a diagnosis of HPV is at risk for which of the following?

• Hodgkins lymphoma
• Cervical cancer
• Multiple myeloma
• Ovarian cancer

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38. The infant of a substance-abusing mother is at risk for developing a sense of which of the following?

• Mistrust
• Shame
• Guilt
• Inferiority

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39. A patient is scheduled for a total hip arthroplasty. The preoperative nurse reviews the chest and notes the following: serum potassium level of 2.8 mEq/l, AB positive blood type, and elevated ST Segments on the electrocardiogram (ECG). Which of the following would be the MOST appropriate action for the nurse to do next?

• Report abnormal diagnostic results to the surgeon
• Review the patient consent for the surgical procedure
• Educate the patient on the risk factors and side-effects of the surgery
• Ensure that the patient has a post-surgery physical therapy order

40. When evaluating an arterial blood gas from a male client with a subdural hematoma, the nurse notes the PaCO2 is 30 mm Hg. Which of the following responses best describes the result?

• Appropriate; lowering carbon dioxide (CO2) reduces intracranial pressure (ICP)
• Emergent; the client is poorly oxygenated
• Significant; the client has alveolar hypoventilation
• Normal

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41. He wants to influence the customary way of thinking and behaving that is shared by the members of the department Which of the following terms refer to this?

• Organizational chart
• Cultural network
• Organizational structure
• Organizational culture

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42. To monitor the frequency of the uterine contraction during labor, the right technique is to time the contraction

• From the beginning of one contraction to the end of the same contraction
• From the beginning of one contraction to the beginning of the next contraction
• From the end of one contraction to the beginning of the next contraction
• From the deceleration of one contraction to the acme of the next contraction

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43. The nurse is caring for a client who is receiving a blood transfusion and is complaining of a cough. The nurse checks the client's vital signs, which include temperature of 97.2 T (36.2 °C), pulse of 108 beats per minute, blood pressure of 152/ 76 mm Hg, respiratory rate of 24 breaths per minute, and an oxygen saturation level of 95% on room air. The client denies pain at this time. Based on this information, what initial action should the nurse take?

• Collect a urine sample for analysis.
• Place the client in an upright position.
• Compare current data to baseline data.
• Slow the rate of the blood transfusion.

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44. What is the priority care for a client with a dementia resulting from AIDS?

• Planning for remotivational therapy
• Arranging for long term custodial care
• Providing basic intellectual stimulation
• Assessing pain frequently

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45. Which oxygen delivery system would the nurse apply that would provide the highest concentrations of oxygen to the client?

• Venturi mask
• Partial rebreather mask
• Non-rebreather mask
• Simple face mask

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46. To maintain the cleanliness of the bag and its contents, which of the following must the nurse do?

• Wash his/her hands before and after providing nursing care to the family members
• In the care of family members, as much as possible, use only articles taken from the bag
• Put on an apron to protect her uniform and fold it with the right side out before putting it back into the bag.
• At the end of the visit, fold the lining on which the bag was placed, ensuring that the contaminated side is on the outside.

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47. A home care nurse visits a patient with a new-below-the knee amputation. The site of the incision is red, warm and tender with purulent yellow drainage. The patient has a new prescription for cephalexin (Keflex) and oxycodone(oxycontin). What would the nurse instruct the patient to do FIRST?

• Take oxycodone as soon as possible
• Take cephalexin as soon as possible
• Wash the incision site and apply bacitracin cream
• Wash the incision site and apply hydrocortisone

48. The nursing theorist who developed transcultural nursing theory is:

• Florence Nightingale
• Madeleine Leininger
• Albert Moore
• Sr. Callista Roy

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49. Freud postulated that child adopts parental standards and traits through

• Imitation
• Introjection
• Identification
• Regression

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50. Which of the following is not an example of alteration of perception?

• ideas of reference
• flight of ideas
• illusion
• hallucination

 

NCLEX-RN | QB2 | Practice Exam #4 (50 questions)