QB2 | Practice Exam #5 -> answers with explanation - Free NCLEX Exam Practice

NCLEX-RN | QB2 | Practice Exam #5 (50 questions)

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

 

1. A 22-year-old client is being admitted with a diagnosis of brief psychotic disorder. Two weeks ago, his girlfriend broke off their engagement and cancelled the wedding. Given the Diagnosis and Statistical Manual of Mental Disorders, edition, text' revised (DSM-IV-TR) criteria for this disorder the nurse expects to find which of the following data during the interview with the client?

• Current treatment for pneumonia
• Regular use of alcohol and marijuana
• Evidence of delusions and hallucinations
• A history of chronic depression

2. The nurse caring for a client with a head injury would recognize which assessment finding as the most indicative of increased ICP?

• Vomiting
• Headache
• Dizziness
• Papilledema

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3. Temperature of refrigerator to maintain potency of measles and OPV vaccine is:

• -3c to -8c
• -15c to -25c
• +15c to +25c
• +3c to +8c

4. Situation: Blood transfusion was ordered for Andre after an episode of severe bleeding.Q. Which of the following is not expected to be done by the nurse in case of a whole blood transfusion?

• Assess the venipuncture for any signs of bleeding or hematoma
• Prepare the blood transfusion using a microdrip tubing
• Assess the patient closely for any reaction
• Make sure that the drip chamber of the IV fluid is partially filled with blood

5. The mother calls the clinic to report that her newborn has a rash on his forehead and face. Which action is most appropriate?

• Tell the mother to wash the face with soap and apply powder
• Tell her that 30% of newborns have a rash that will go away by one month of life.
• Report the rash to the doctor immediately.
• Ask the mother if anyone else in the family has had a rash in the last six months.

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6. Situation: The question with regards to the OPERATING ROOM.Q. Endoscopic minimally invasive surgery has evolved from diagnostic modality to a widespread surgical technique. What department should the nurse collaborate which is unusual in conventional surgery?

• engineering department
• x-ray department
• blood bank services
• linen section

7. Situation: Group Approach in Nursing.Q. The treatment of the family as a unit is based on the belief that the family:

• is a social system and all the members are interrelated components of that system
• as a unit of society needs the opportunity to change its own destiny
• who has therapy together will tend to remain together
• is "contaminated" by the presence of deviant member and all members need treatment

8. The nurse has been working with a laboring client and notes that she has been pushing effectively for 1 hour. What is the client's primary physiological need at this time?

• Ambulation
• Rest between contractions
• Change positions frequently
• Consume oral food and fluids

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9. The nurse is conducting allergy skin testing on a client. Which postprocedure interventions are most appropriate? Select all that apply. 1.Record site, date, and time of the test. 2.Give the client a list of potential allergens if identified. 3.Estimate the size of the wheal and document the finding. 4.Tell the client to return to have the site inspected only if there is a reaction. 5.Have the client wait in the waiting room for at least 1 to 2 hours after injection.

• 1,2
• 1,2,3,4
• 3,4,5
• 1,3,5

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10. The nurse is caring for a child in a plaster-of-Paris hip spica cast. To facilitate drying the nurse should:

• Use a small hand-held hair dryer set on medium heat.
• Place a small heater near the childs bed.
• Turn the child at least every two hours.
• Allow one side to dry before changing positions.

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11. Due to a high census it has been necessary for a number of clients to be transferred to other units within the hospital. Which client should be transferred to the postpartum unit?

• A 66-year-old female with gastroenteritis
• A 40-year-old female with a hysterectomy
• A 27-year-old male with severe depression
• A 28-year-old male with ulcerative colitis

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12. On crisis intervention, one of the important personal qualities that can enhance the nurses effectiveness is:

• Friendliness
• Flexibility
• Patience
• Consistency

13. Methylergonovine is prescribed for a woman to treat postpartum hemorrhage. Before administration of methylergonovine, what is the priority assessment?

• Uterine tone
• Blood pressure
• Amount of lochia
• Deep tendon reflexes

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14. A patient had a vitrectomy and is about to be transported to the post anesthesia care unit (PACll). The patient should be placed in which of the following positions before transport to the PACU?

• Semi-fowlers
• Prone
• Dorsal recumbent
• Sim's

15. Situation Records are vital tools in any institution and should be properly maintained for specific use and time.Q. The patient's medical record can work as a double-edged swords. When can the medical record become the doctor's/nurse worst enemy?

• When the record is voluminous
• When a medical record is subpoenaed in court
• When it is missing
• When the medical record is inaccurate, incomplete, and inadequate

16. Situation : Mrs. Cruz was admitted in the Medical Floor due to pyrosis, dyspepsia and difficulty of swallowing.Q. To avoid acid reflux, Nurse Yoshi should advise Mrs. Cruz to avoid which type of diet?

• cola, coffee and tea
• high fat, carbonated and caffeinated beverages
• beer and green tea
• lechon paksiw and bicol express

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17. A depressed client on an inpatient unit says to the nurse, My family would be better off without me." Which is the nurse's best response?

• "Have you talked to your family about this?"
• "Everyone feels this way when they are depressed"
• "You will feel better once your medication begins to work."
• "You sound very upset. Are you thinking of hurting yourself?"

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18. The nurse is caring for a client diagnosed with paranoid personality disorder who is experiencing disturbed thought processes. In formulating a nursing plan of care, which best intervention should the nurse include?

• Increase socialization of the client with peers.
• Avoid using a whisper voice in front of the client.
• Begin to educate the client about social supports in the community.
• Have the client sign a release of information to appropriate parties for assessment purposes.

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19. Every day for the past 2 weeks, a client with schizophrenia stands up during group therapy and screams, "Get out of here right now. The elevator bombs are going to explode in 3 minutes!" The next time this happens, how should the nurse respond?

• "Why do you think there is a bomb in the elevator?"
• "That is the same thing you said in yesterday's session"
• "I know you think there are bombs in the elevator, but there aren't."
• "If you have something to say you must do it according to our group rules."

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20. Included in teaching the client with tuberculosis taking INH about follow-up home care, the nurse should emphasize that a laboratory appointment for which of the following lab tests is critical?

• Liver function
• Kidney function
• Blood sugar
• Cardiac enzymes

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21. Situation : Margie has been diagnosed with Bipolar I disorder. The client demonstrates extreme psychomotor agitation, flight of ideas, loud talking and elated mood.Q. Which of the following is a suitable activity that a nurse should assign for a Manic client?

• delivering supply of linen to other rooms
• conducting a drama workshop
• engaging in activity therapy and group exercises
• painting a mural with other patients

22. The nurse in the nursing care unit is aware that one of the medical staff displays unlikely behaviors like confusion, agitation, lethargy and unkempt appearance. This behavior has been reported to the nurse manager several times, but no changes observed. The nurse should:

• Continue to report observations of unusual behavior until the problem is resolved
• Consider that the obligation to protect the patient from harm has been met by the prior reports and do nothing further.
• Discuss the situation with friends who are also nurses to get ideas.
• Approach the partner of this medical staff member with these concerns.

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23. Baby Marie was born May 23,1984. Nurse John will expect finger thumb opposition on:

• April 1985
• February 1985
• March 1985
• June 1985

24. Situation: You are assigned to take care of a group of patients across the lifespan. Preschoolers are able to see things from which of the following perspectives?

• Their peers
• Their own and their caregivers
• Their own and their mother's
• Only their own

25. The nurse is preparing to assess the uterine fundus of a client in the immediate postpartum period. After locating the fundus, the nurse notes that the uterus feels soft and boggy. Which nursing intervention is appropriate?

• Elevate the clients legs.
• Massage the fundus until it is firm.
• Ask the client to turn on her left side.
• Push on the uterus to assist in expressing clots.

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26. 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. The point of maximal impulse (PMl) is an important landmark in the cardiac exam. Which statement best describes the location of the PMI in the healthy adult?

• Base of the heart, Sth intercostal space, 7-9 cm to the left of the midsternal line.
• Base of the heart, 7th intercostal space, 7-9 cm to the left of the midsternal line.
• Apex of the heart, intercostal space, 7-9 cm to the left of the midsternal line.

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27. A client on the postpartum unit has a proctoepisiotomy. The nurse should anticipate administering which medication?

• Dulcolax suppository
• Docusate sodium [Colace)
• Methyergonovine maleate (Methergine)
• Bromocriptine sulfate (Parlodel)

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28. Twenty-four hours after an uncomplicated labor and delivery a clients WBC is 12 OOOcu/ mm. The elevation in the clients WBC is most likely an indication of:

• A normal response to the birth process
• An acute bacterial infection
• A sexually transmitted virus
• Dehydration from being NPO during labor

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29. Situation: The preoperative nurse collaborates with the client significant others, and healthcare providers.Q. An air crash occurred near the hospital leading to a surge of trauma patient. One of the last patients will need surgical amputation but there are no sterile surgical equipments. In this case, which of the following will the nurse expect?

• Equipments needed for surgery need not be sterilized if this is an emergency necessitating life saving measu
• Forwarding the trauma client to the nearest hospital that has available sterile equipment is appropriate
• The nurse will need to sterilize the item before using it to the client using the regular sterilization setting at 121 degree Celsius in 15 minutes.
• In such cases, flash sterilizer will be use at 132 degree Celsius in 3 minutes.

30. The physician has ordered sodium warfarin for the client with thrombophlebitis. The order should be entered to administer the medication at:

• "900"
• "1200"
• "1700"
• "2100"

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31. The diagnostic work-up of a client hospitalized with complaints of progressive weakness and fatigue confirm a diagnosis of myasthenia gravis. The medication used to treat myasthenia gravis is:

• Prostigmine (neostigmine)
• Atropine (atropine sulfate)
• Didronel (etidronate)
• Tensilon (edrophonium)

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32. Which of the following clients is most at risk for developing multiple myeloma?

• A 20-year-old Asian woman
• A 30-year-old White man
• A 50-year-old Hispanic woman
• A 60-year-old Black man

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33. A severely dehydrated teenager admitted to the hospital with hypotension and tachycardia undergoes evaluation for electrolyte disturbances. Her history includes anorexia nervosa and a 20-lb (9 .1 -kg) weight loss in the last month. She is 517" (1.7 m) tall and weighs 80 lb (36.3 kg). Which nursing intervention takes highest priority?

• Initiating caloric and nutritional therapy as ordered
• Instituting behavioral modification therapy as ordered
• Addressing the client's low self-esteem
• Regularly monitoring vital signs and weight

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34. A client with paranoid schizophrenia is brought to the hospital by her elderly parents. During the assessment the clients mother states Sometimes she is more than we can manage. Based on the mothers statement the most appropriate nursing diagnosis is:

• Ineffective family coping related to parental role conflict
• Care-giver role strain related to chronic situational stress
• Altered family process related to impaired social interaction
• Altered parenting related to impaired growth and development

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35. The nursing measure to relieve fetal distress due to maternal supine hypotension is:

• Place the mother on semi-fowlers position
• Put the mother on left side lying position
• Place mother on a knee chest position
• Any of the above

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36. Nurse Len should expect to administer which medication to a client with gout?

• aspirin
• furosemide (Lasix)
• colchicines
• calcium gluconate (Kalcinate)

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37. When assessing a client for an abdominal aortic aneurysm, which area of the abdomen is most commonly palpated?

• Right upper quadrant
• Directly over the umbilicus
• Middle lower abdomen to the left of the midline
• Midline lower abdomen to the right of the midline

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38. Nurse Angela knew that Stephen Lee Mu Chin, has just undergone an operation with an incision near the diaphragm. She knew that this will contribute to some complications later on. She then should develop what type of Nursing diagnosis?

• Actual
• Probable
• Possible
• Risk

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39. The home health psychiatric nurse visits a client with chronic schizophrenia who was recently discharged after a prolong stay in a state hospital The client lives in a boarding home, reports no family involvement, and has little social interaction. The nurse plan to refer the client to a day treatment program in order to help him with:

• Managing his hallucinations
• Medication teaching
• Social skills training
• Vocational training

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40. When preparing Judy with acquired immunodeficiency syndrome (AIDS) for discharge to the home, the nurse should be sure to include which instruction?

• "Put on disposable gloves before bathing."
• "Sterilize all plates and utensils in boiling water."
• Avoid sharing such articles as toothbrushes and razors.
• Avoid eating foods from serving dishes shared by other family members.

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41. Situation: Nurse Joanna works as an OB-Gyn Nurse and attends to several HIGH- RISK PREGNANCIES: Particularly women with preexisting or newly acquired illness. The following conditions apply.Q. The cousin of Bernadette with sickle-cell anemia alerted Joanna that she may need further instruction on prenatal care. Which statement signifies this fact?

• I've stopped jogging so I don't risk becoming dehydrated
• I take an iron pull every day to help grow new red blood cells
• I am careful to drink at least eight glasses of fluid everyday
• I understand why folic acid is important for red cell formation

42. Clients with fractured mandibles usually have them immobilized with wires. The life­ threatening problem that can develop postoperatively is:

• Infection
• Vomiting
• Osteomyelitis
• Bronchospasm

43. A nurse will need to change the dressing on a patients central venous catheter during the shift. The nurse should plan to:

• Limit the patients activity for an hour dressing change
• Position the patient on to the left side before removing the old dressing
• Put on sterile gloves after explaining the procedure to the patient
• Cleanse the insertion site using a circular motion

44. After a client signs the form, giving informed consent for surgery and the physician! eaves the room, the client asks the nurse, "When will this hotel bring me some food?" After confirming that the client is confused, which of the following would be the nurse's priority action?

• Reporting that the consent has been obtained from a confused client.
• Teaching preoperative moving, coughing, and deep-breathing,exercises.
• Inserting a bladder catheter to urine output.
• Administering preoperative medication immediately.

45. An obstetric client is admitted with dehydration. Which IV fluid would be most appropriate for the client?

• .45 normal saline
• Dextrose 1% in water
• Lactated Ringers
• Dextrose 5% in .45 normal saline

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46. Silver sulfadiazine is prescribed for a client with a burn injury. Which laboratory finding requires the need for follow-up by the nurse?

• Glucose level of 99 mg/dL (5.65 mmol/L)
• Magnesium level of 1.5 mEq/L (0.75 mmol/L)
• Platelet level of 300,000 mm3 (300A109/L)
• White blood cell count of 3000 mm3 (3.0 A109/L)

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47. The morning of the second postoperative day following hip surgery for a fractured right hip, the nurse will ambulate the client The first intervention is to:

• Get the client up in a chair after dangling at the bedside.
• Use a walker for balance when getting the client out of bed
• Have the client put minimal weight on the affected side when getting up
• Practice getting the client out of bed by having her slightly flex her hips

48. A couple comes to the family planning clinic and asks about sterilization procedures. Which question by the nurse should determine whether this method of family planning would be most appropriate?

• Did you ever had surgery?
• Do you plan to have any other children?
• Do either of you have diabetes mellitus?
• "Do either of you have problems with high blood pressure?"

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49. Which of the following signs and symptoms would the nurse expect to find when assessing an Asian patient for postoperative pain following abdominal surgery?

• Decreased blood pressure and heart rate and shallow respirations
• Quiet crying
• Immobility, diaphoresis, and avoidance of deep breathing or coughing
• Changing position every 2 hours

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50. Which task should be assigned to the nursing assistant?

• Placing the client in seclusion
• Emptying the Foley catheter of the preeclamptic client
• Feeding the client with dementia
• Ambulating the client with a fractured hip

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NCLEX-RN | QB2 | Practice Exam #5 (50 questions)