NCLEX-RN | QB2 | Practice Exam #9 (50 questions)

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

 1. Rectal examination is done with a client in what position?

• Dorsa recumbent
• Sims position
• Supine
• Lithotomy

2. A client is admitted with suspected pernicious anemia. Which findings support the diagnosis of pernicious anemia?

• The client complains of feeling tired and list less.
• The client has waxy pale skin.
• The client exhibits loss of coordination and position sense.
• The client has a rapid pulse rate and a detectable heart murmur.

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3. A client in the prenatal clinic is assessed to have a blood pressure of 180/96. The nurse should give priority to:

• Providing a calm environment
• Obtaining a diet history
• Administering an analgesic
• Assessing fetal heart tones

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4. A client is admitted to the hospital. Twelve hours later the nurse observes hand tremors, hyperexicitability, tachycardia, diaphoresis and hypertension. The nurse suspects alcohol withdrawal. The nurse should ask the client:

• at what time was your last drink taken?
• Why didst you tell us you're a drinker?
• Do you drink beer or hard liquor?
• How long have you been drinking?

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5. Situation: Rosanna 20 y/0 unmarried patient believes that the toilet for the female patient in contaminated with AIDS virus and refuses to use it unless she flushes it three times and wipes the toilet seat the same number of times with antiseptic solution.Q. Assessment data upon admission help the nurse to identify this appropriate nursing diagnosis

• Ineffective denial
• Impaired adjustment
• Ineffective individual coping
• Impaired social interaction

6. The physician has prescribed ranitidine (Zantac) for a client with erosive gastritis. The nurse should administer the medication:

• 30 minutes before meals
• With each meal
• In a single dose at bedtime
• 60 minutes after meals

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7. Andy made an error and his senior nurse issued a written warning. Andy arrived in his house mad and kicked the door hard to shut it off. What adaptation mode is this?

• Biologic/Physiologic adaptive mode
• Psychologic adaptive mode
• Sociocultural adaptive mode
• Technological adaptive mode

8. The cervical dilatation taken at 8:00 AM in a G1P0 patient was 6 centimeters. A repeat LE. done at 10 A. M. showed that cervical dilation was 7 cm. The correct interpretation of this result is:

• Labor is progressing as expected
• The latent phase of Stage 1 is prolonged
• The active phase of Stage 1 is protracted
• The duration of labor is normal

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9. During surgery requiring general anesthesia, the patients heart stops, Ventilations using the end tracheal tube (ETT) are started with an ambu bag. Which of the following compression to ventilation rates is correct?

• 10 to 2
• 15 to 2
• 30 to 2
• 50 to 2

10. Which of the following criteria allows Nurse Kris to perform home deliveries?

• Normal findings during assessment
• Previous CS
• Diabetes history
• Hypertensive history

11. A nurse is assessing a 4-month-old formula-fed infant The parent reports the infant has been irritable, crying excessively, not sleeping well, and vomiting. Gastro-esophageal reflux is expected. What nursing intervention should the nurse expect to teach the parent?

• Place the infant in an infant seat after eating
• Give large frequent feedings
• Position the child in a swing
• Thin formula with water

12. A patient is admitted for pain management due to lung cancer with metastasis of the bone. With a nursing diagnosis of alteration in comfort t the nurse would anticipate the best shot­ term goal for this patient would be to:

• Not complain of pain
• Appear comfortable and sleep well
• Verbalize that pain is relived
• Verbalize that pain is tolerated

13. The nurse is caring for a client who underwent a subtotal gastrectomy 24 hours earlier. The client has a nasogastric (NG) tube. The nurse should:

• Apply suction to the NG tube every hour.
• Clamp the NG tube if the client complains of nausea.
• Irrigate the NG tube gently with normal saline solution.
• Reposition the NG tube if pulled out.

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14. 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 patientconsent for the surgicalprocedure
• Educate the patient on therisk factors and side-effects of the surgery
• Ensure that the patient hasa post-surgery physicaltherapy order

15. The nurse is to open a sterile package from central supply. Which is the correct direction to open the first lap?

• Toward the nurse
• Away from the nurse
• To the nurses left or right hand
• It does not matter as long as the nurse touches only the outside edge

16. The nurse is assigned to care for a group of clients. On review of the clients medical records, the nurse determines that which client is most likely at risk for a fluid volume deficit?

• client with an ileostomy
• A client with heart failure
• A client on long-term corticosteroid therapy
• A client receiving frequent wound irrigations

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17. The nurse has given instructions to a client returning home after knee arthroscopy. Which statement by the client indicates that the instructions are understood?

• "I can resume regular exercise tomorrow."
• "I can't eat food for the remainder of the day"
• "I need to stay off the leg entirely for the rest of the day."
• "I need to report a fever or swelling to my health care provider."

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18. Situation: Among common conditions found in children especially among poor communities are ear infection/problems. The following questions apply.Q. A child with ear problem should be assessed for the following EXCEPT:

• is there any fever?
• ear discharge
• if discharge is present for how long?
• ear pain

19. Developed the CLINICAL NURSING - A HELPING ART MODEL

• Swanson
• Hall
• Weidenbach
• Zderad

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20. Situation: Infection can cause debilitating consequences when host resistance is compromised and virulence of microorganisms and environmental factors are favorable. Infection control is one important responsibility of the nurse to ensure quality of care.Q. As a nurse you know that one of the complications that you have to watch out for when caring for Omar who is receiving total parenteral nutrition is:

• stomatitis
• hepatitis
• dysrhythmia
• infection

21. Situation: Sexually Transmitted Diseases are important to identify during pregnancy because of their potential effect on the pregnancy, fetus, or newborn. The following questions pertain to STD's.Cryocautery may also be used to remove large lesions. The healing period after cryocautery may be completed in 4-6 weeks but may cause some discomforts to the woman. What measures can alleviate these discomforts?

• Kegel's Exercise
• Cool air
• Topical steroids
• Sitz baths and lidocaine cream

22. Situation: Johnny, sought consultation to the hospital beforeQ. He has to take drugs to treat hyperthyroidism, which of the following will you not expect that the doctor will prescribe?

• Anorexia
• Cytomel (Liothyronine)
• Tapazole
• Levothyroxine

23. A patient has pacemaker implanted. Which of the following interventions is appropriate for the nursing diagnosis of risk for injury?

• Have patient avoid exposure to magnetic resonance imaging(MRI)
• Observe incision site for redness, purulent drainage
• Offer back rubs to promote relaxation
• Instruct patient in dorsiflexion exercises of ankles

24. Which phase of the employment process includes getting on the payroll and completing documentary requirements?

• Orientation
• Induction
• Selection
• Recruitment

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25. A patient has an acute inflammation of the gallbladder. The physician orders the nurse to schedule the patient for surgery .Which of the following surgical procedures will the physician MOST likely perform?

• Pancreatectomy.
• Cholecystectomy.
• Hepatectomy.
• Cricothoracotom.

26. Situation: You are now working as a staff nurse in a general hospital. You have to be prepared to handle situations with ethico-legal and moral implications.Q. You are on duty in the medical ward. You were asked to check the narcotics cabinet. You found out that what is on record does not tally with the drugs used. Which among the following will you do first?

• Write an incident report and refer the matter to the nursing director
• Keep your findings to yourself
• Report the matter to your supervisor
• Find out from the endorsement any patient who might have been given narcotics

27. A nurse is caring for a patient who is 6 hours post left lobectomy.On assessment the nurse observes that the patient has become very restless and the nail beds are blue, the vital signs reveal tachycardia, tachypnea and blood pressure is rising.Which of the following complication is MOST likely?

• Pneumonia
• Hypoxia
• Postoperative bleeding
• Broncho pleural fistula

28. Following mitral valve replacement surgery a client develops PVC s. The health care provider orders a bolus of Lidocaine followed by a continuous Lidocaine infusion at a rate of 2 mgm/minute. The TV solution contains 2 grams of Lidocaine in 500 cc's of D5W. The infusion pump delivers 60 microdrops/cc. What rate would deliver 4 mgm of Lidocaine/ minute?

• 60 microdrops/minute
• 20 microdrops/minute
• 30 microdrops/minute
• 40 microdrops/minute

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29. Medical asepsis includes:

• Hand washing.
• Personal protective equipment (uniform, gown, gloves, facemask).
• Cleaning, Disinfecting, Sterilizing.
• All of the above.

30. The two blood vessels most commonly used for TPN infusion are the:

• Subclavian and jugular veins
• Brachial and subclavian veins
• Femoral and subclavian veins
• Brachial and femoral veins

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31. Situation: You are working as a Pediatric Nurse in your own Child Health Nursing Clinic, the following cases pertain to ASSESSMENT AND CARE OF THE NEWBORN AT RISK conditions.Q. Baby John develops hyperbilirubinemia. What is a method used to treat hype

• when a girl has a geographic tongue
• when a boy has a possible inguinal hernia
• when a child has symptoms of epiglottitis
• when children are under 5 years of age

32. Julius is admitted with complaints of severe pain in the lower right quadrant of the abdomen. To assist with pain relief the nurse should take which of the following actions?

• Encourage the client to change positions frequently in bed.
• Administer Demerol 50 mg IM q 4 hours and PRN.
• Apply warmth to the abdomen with a heating pad.
• Use comfort measures and pillows to position the client.

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33. A client is admitted with symptoms of pseudomembranous colitis. Which finding is associated with Clostridium difficile?

• Diarrhea containing blood and mucus
• Cough fever and shortness of breath
• Anorexia weight loss and fever
• Development of ulcers on the lower extremities

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34. A child with asthma is experiencing thick respiratory secretions resulting in increased work of breathing. The best nursing intervention is to:

• Encourage fluids
• Eliminate dairy products
• Decrease relative humidity of the room
• Have the child lay on the left side.

35. A client with peptic ulcer is being assessed by the nurse for gastrointestinal perforation. The nurse should monitor for:

• (+) guaiac stool test
• Slow, strong pulse
• Sudden, severe abdominal pain
• Increased bowel sounds

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36. A client had oral surgery following a motor vehicle accident The nurse assessing the client finds the skin flushed and warm. Which of the following would be the best method to take the client's body temperature?

• Oral
• Axillary
• Arterial line
• Rectal

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

• Hodgkin’s lymphoma
• Cervical cancer
• Multiple myeloma
• Ovarian cancer

38. The nurse is providing dietary instructions to the mother of an eight-year-old child diagnosed with celiac disease. Which of the following foods if selected by the mother would indicate her understanding of the dietary instructions?

• Whole-wheat bread
• Spaghetti
• Hamburger on wheat bun with ketchup
• Cheese omelet

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39. Situation: Nurses in all practice areas are likely to come in contact with clients suffering from acute or chronic drug abuse.Q. Being in contact with reality and the environment is a function of the:

• conscience
• ego
• super ego
• id

40. Yesterday a client with schizophrenia began treatment with haloperidol (Haldol). Today the nurse notices that the client is holding his head to one side and complaining of neck and jaw spasms. What should the nurse do?

• Assume that the client is posturing.
• Tell the client to lie down and relax.
• Evaluate the client for adverse reactions to haloperidol.
• Put the client on the list for the physician to see tomorrow.

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41. The nurse in the postpartum unit is caring for a client who has just delivered a newborn infant following a pregnancy with placenta previa. The nurse reviews the plan of care and prepares to monitor the client for which risk associated with placenta previa?

• Infection
• Hemorrhage
• Chronic hypertension
• Disseminated intravascular coagulation

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42. The nurse provides instructions to a client who is taking levothyroxine. The nurse should tell the client to take the medication in which way?

• With food
• At lunchtime
• On an empty stomach
• At bedtime with a snack

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43. Situation: Mariah is a 31 year old lawyer who has been married for 6 moths. She is now pregnantShe consults you for guidance.She tells the nurse that she does not take milk regularly. She claims that she does not want to gain too much weight during her pregnancy. Which of the following nursing diagnosis is a priority?

• Potential self-esteem disturbance related to physiologic changes in pregnancy
• Ineffective individual coping related to physiologic changes in pregnancy
• Fear related to the effects of pregnancy
• Knowledge deficit regarding nutritional requirements pregnancies related to lack of information sources.

44. A client is admitted with disseminated herpes zoster. According to the Centers for Disease Control Guidelines for Infection Control:

• Airborne precautions will be needed.
• No special precautions will be needed.
• Contact precautions will be needed.
• Droplet precautions will be needed.

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45. Situation: Human development is one of the important concepts that a nurse should learn to be able to deal appropriately with their clients of different developmental stages.How long is the gestational period of a full term pregnancy?

• Ranging from 245 days to 259 days
• around 5,554 hours to 5,880 hours
• More than 294 days
• Averaging of 266 to 294 days

46. The nurse is providing discharge teaching for a client with newly diagnosed Crohn s disease about dietary measures to implement during exacerbation episodes. Which statement made by the client indicates a need for further instruction?

• "I should increase the fiber in my diet”
• "I will need to avoid caffeinated beverages."
• "I'm going to learn some stress reduction techniques”
• "I can have exacerbations and remissions with Crohn's disease”

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47. A client is found sitting on the floor of the bathroom in the day treatment clinic with moderate lacerations on both wrists. Surrounded by broken glass, she sits staring blankly at her bleeding wrists while staff members call for an ambulance. How should the nurse approach her initially?

• Enter the room quietly and move beside her to assess her injuries.
• Call for staff back-up before entering the room and restraining her.
• Move as much glass away from her as possible and sit next to her quietly.
• Approach her slowly while speaking in a calm voice, calling her name, and telling her that the nurse is here to help her.

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48. Situation: Some equipment and materials in our hospital are color coded, this is to increase the safety and proficiency of rendering patients care.Q. Medical gases are used a lot in the OR. Some gases are used to operate equipment and some are used to administer general anesthesia through inhalation. What is the identifying color of the tank which contains 'laughing gas'?

• Yellow
• Green
• Black
• Blue

49. Which one of the following its major function to supply energy:

• Protein
• Carbohydrates
• Fats
• Minerals

50. Situation: Milo, a 16-year-old male, has been diagnosed to have AIDS. He worked as entertainer in a cruise ship.You are assigned in a private room of Milo. Which procedure should be of utmost importance?

• Alcohol wash
• Universal precaution
• Washing Isolation
• Gloving technique

 

NCLEX-RN | QB2 | Practice Exam #9 (50 questions)