NCLEX-RN | QB2 | Practice Exam #11 (50 questions)

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

 

1. A patient is one day post-operative repair of a large umbilical hernia. The patient complains of abdominal pain and described feeling the sutures give way. Upon assessment of the abdomen the nurse observes an evisceration. The nurse's IMMEDIATE response should be to:

• Medicate the patient for pain
• Instruct the patient to cough hard
• Have the patient perform the valsalvas maneuver
• Cover the abdomen with a sterile soaked dressing

2. A newborn is diagnosed with respiratory distress syndrome (RDS). Which position is best for maintaining an open airway?

• Prone with his head turned to one side.
• Side-lying with a towel beneath his shoulders.
• Supine with his neck slightly flexed.
• Supine with his neck slightly extended.

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3. Tony will start a 6 month therapy with Isoniazid (INH). Nurse Trish plans to teach the client to:

• Use alcohol moderately
• Avoid vitamin supplements while o therapy
• Incomplete intake of dairy products
• May be discontinued if symptoms subsides

4. Which of the following is the best source of Vitamin E?

• Green leafy vegetables
• Vegetable oil
• Fortified Milk
• Fish liver oil

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5. The nurse performs vaginal exams on a laboring woman ana records this data is correctly Interpreted as:

• fetal presenting part is 1 cm. above the ischial spines
• cervical dilatation is 25% completed
• progress of effacement is 5 cm. completed
• fetal presenting part is 1 cm below the ischial spines

6. After 4 hours of active labor, the nurse notes that the contractions of a primigravida client are not strong enough to dilate the cervix. Which of the following would the nurse anticipate doing?

• Obtaining an order to begin IV oxytocin infusion
• Administering a light sedative to allow the patient to rest for several hour
• Preparing for a cesarean section for failure to progress
• Increasing the encouragement to the patient when pushing begins

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7. Situation: Mrs. Pichay is admitted to your ward. The MD ordered Prepared for thoracentesis this pm to remove excess air from the pleural cavity." Q. Chest x-ray was ordered after thoracentesis. When you client asks what is the reason for another chest x- ray you will explain:

• to rule out pneumothorax
• to rule out any possible perforation
• to decongest
• to rule out any foreign: body

8. A patient with bacterial meningitis is treated with intravenous antimicrobial agent Which of the following BEST indicates effectiveness of treatment?

• Severe headache
• Negative kernigs sign
• Nuchal rigidity
• Photophobia

9. A client is admitted to the mental health unit with a diagnosis of depression. The nurse should develop a plan of care for the client that includes which intervention?

• Encouraging quiet reading and writing for the first few days
• Identification of physical activities that will provide exercise
• No socializing activities, until the client asks to participate in milieu
• A structured program of activities in which the client can participate

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10. A client has a diagnosis of borderline personality disorder She has attached herself to one nurse and refuses to speak with other staff members. She tells the nurse that the other nurses are mean, withhold her medication, and mistreat her. The staff is discussing this problem at their weekly conference. Which intervention would be most appropriate for the nursing staff to implement?

• Provide an unstructured environment for the client.
• Rotate the nurses who are assigned to the client.
• Ignore the client's behaviors.
• Bend unit rules to meet the client's needs.

11. Situation: Clients with Bipolar disorder receives a very high nursing attention due to the increasing rate of suicide related to illness.Q. A client visits the physician's office to seek treatment for depression, feeling of hopelessness, poor appetite, insomnia, fatigue, low self-esteem, poor concentration, and difficulty making decisions. The client states that these symptoms began at least 2 years ago. Based on this report, the nurse suspects:

• cyclothymic disorder
• Major depression
• Bipolar disorder
• Dysthymic disorder

12. A two-month-old infant has just received her first Tetramune injection. The nurse should tell the mother that the immunization:

• Will need to be repeated when the child is four years of age.
• Is given to determine whether the child is susceptible to pertussis.
• Is one of a series of injections that protects against diphtheria pertussis tetanus and H.influenzae b.
• Is a one-time injection that protects against measles mumps rubella and varicella.

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13. Which of the following information cannot be seen in the PRC identification card?

• Registration Date
• License Number
• Date of Application
• Signature of PRC chairperson

14. The nurse is caring for a patient who had a total proctocolectomy 24 hours ago due to malignant neoplasm in the rectum. The patient continues to receive intravenous fluids has started a clear liquid diet. The nurse understands that the patient is at INCREASED for which of the following postoperative complications?

• Dissemination intravascular coagulopathy (DIC)
• Atelectasis
• Syndrome of inappropriate anti-diuretics hormone(SIADH)
• Hypokalemia

15. The nurse has given a client taking ethambutol information about the medication. The nurse determines that the client understands the instructions if the client states that he or she will immediately report which finding?

• Impaired sense of hearing
• Gastrointestinal side effects
• Orange-red discoloration of body secretions
• Difficulty in discriminating the color red from green

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16. Situation: Basic knowledge on Intravenous solutions is necessary for care of clients with problems with fluids and electrolytes. Q. A nurse reviews the client's electrolytes laboratory report and notes that the potassium level is 3.2 mEq/L. Which of the following would the nurse note on the electrocardiogram as a result of the laboratory value?

• U waves
• P waves
• Elevated T waves
• Elevated ST segment

17. One of the participants in a hilot training class asked you to whom she should refer patient in labor who develops a complication. You will answer, to the:

• Public health nurse
• Rural health midwife
• Municipal health officer
• Any of these health professionals

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18. Age, Sex, Race etc. is included in what variable of HBM?

• Demographic
• Sociopsychologic
• Structural
• Cues to action

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19. A couple is seeking infertility counseling. During the history it is noted that the man is a cancer survivor, drinks one beer every night with dinner, and takes a sauna every day after work. Which of the following is an appropriate response by the nurse?

• It is unlikely that any of these factors is impacting his fertility.
• Daily alcohol consumption could be causing his infertility problems.
• Sperm may be malformed when exposed to the heat of the sauna.
• Cancer survivors have the same fertility rates as healthy males.

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20. The nurse in the emergency room is caring for a client with multiple rib fractures and a pulmonary contusion. Assessment reveals a respiratory rate of 38 a heart rate of 136 and restlessness. Which associated assessment finding would require immediate intervention?

• Occasional small amounts of hemoptysis
• Midline trachea with wheezing on auscultation
• Subcutaneous air and absent breath sounds
• Pain when breathing deeply with rales in the upper lobes

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21. The nurse in a newborn nursery is monitoring a preterm newborn for respiratory distress syndrome. Which assessment findings should alert the nurse to the possibility of this syndrome? Select all that apply. 1.Cyanosis. 2.Tachypnea. 3.Hypotension. 4.Retractions. 5.Audible grunts. 6.Presence of a barrel chest

• 1,2,3,4,5
• 2,3,5,6
• 1,2,4
• 1,2,4,5

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22. 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 (OxyContln)Which 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.

23. The nurse is obtaining a history on an 80-year-old client Which statement made by the client might indicate a potential for fluid and electrolyte imbalance? My skin is always so dry.

• My skin is always so dry.
• I often use laxatives.
• I have always liked to drink a lot of ice tea.
• I sometimes have a problem with dribbling urine.

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24. Nursing is a unique profession, Concerned with all the variables affecting an individual s response to stressors, which are intra, inter and extra personal in nature.

• Neuman
• Johnson
• Watson
• Parse

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25. The school nurse has provided an instructional session about impetigo to parents of the children attending the school. Which statement, if made by a parent, indicates a need for further instruction?

• "It is extremely contagious."
• "It is most common in humid weather"
• "Lesions most often are located on the arms and chest."
• "It might show up in an area of broken skin, such as an insect bite."

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26. The most prevalent form of meningitis among children aged 2 months to 3 years is caused by which microorganism?

• Hemophilus influenzae
• Morbillivirus
• Neisseria meningitidis
• Streptococcus pneumoniae

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27. A client with cancer develops xerostomia. The nurse can help alleviate the discomfort the client is experiencing associated with xerostomia by:

• Offering hard candy
• Administering analgesic medications
• Splinting swollen joints
• Providing saliva substitute

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28. A 17 year-old is brought to the clinic by her mother She complains of episodes during which her fingers become cold, numb and white. After this subsides, the fingers turn red, swell and cause severe and throbbing pain. On examination, the fingers ail appear normal and the patient has no pain. The nurse performs a history assessment to identify potential causes.Which trigger is most likely?

• Excessive exercise
• Ingestion of tea
• Exposure to cold
• Washing up

29. An intoxicated patient presents with slurred speech, mild confusion, and uncooperative behavior. The patient is a poor historian but admits to "drinking a few on the weekend? What is the priority nursing action for this patient?

• Administer IV fluid support with supplemental thiamine as ordered.
• Obtain an order for a blood alcohol level.
• Contact the family to obtain additional history and baseline information.
• Administer naloxone (Narcan) 2 - 4 mg as ordered.

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30. Which of the following is the first sign of dehydration?

• Tachycardia
• Restlessness
• Thirst
• Poor skin turgor

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31. The initial nursing intervention for the significant-others during shock phase of a grief reaction should be focused on:

• Presenting full reality of the loss of the individuals
• Directing the individual's activities at this time
• Staying with the individuals involved
• Mobilizing the individuals support system

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32. 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. Because of these laboratory findings, the nurse is aware that her most appropriate action is to prevent which of the following?

• Infections and cross contamination
• Injury might lead to bleeding
• Over activity that might lead to exhaustion
• Hypercoagulation that might lead to thrombus formation

33. Dr. Smith orders a gram of human salt poor albumin product for a patient The product is available in a 50 milliliter vial with a concentration of 25 percent What dosage will the nurse administer?

• The nurse should use the entire 50 milliliter vial.
• The nurse should determine the volume to administer from the physician.
• This concentration of product should not be used.
• The nurse will administer 4 milliliters.

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34. Mr. Liberatore, age 76, is admitted to your unit. He has a past medical history of hypertension, DM, hyperlipidemia. Recently he has had several episodes where he stops talking mid sentence and stares into space. Today the episode lasted for 15 minutes. The admission diagnosis is impending CVA.Q. During your assessment of Julie she tells you all visual symptoms are gone but that she now has a severe pounding headache over her left eye. You suspect Julie may have:

• a tension headache
• the aura and headache of migraine
• a brain tumor
• a conversion reaction

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35. A client with variant angina is scheduled to receive an oral calcium channel blocker twice daily. Which statement by the client indicates the need for further teaching?

• "I should notify my doctor if my feet or legs start to swell"
• "My doctor told me to call his office if my pulse rate decreases below 60"
• "Avoiding grapefruit juice will definitely be a challenge for me, since I usually drink it every morning with breakfast"
• My spouse told me that since I have developed this problem, we are going to stop walking in the mall every morning."

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36. Situation: Breast cancer is the 2nd most common type of cancer after lung cancer and 99% of which, occurs in women. Survival rate is 98% if this is detected early and treated promptly. Carmen is a 53 year old patient in the high risk group for breast cancer was recently diagnosed with Breast Cancer.Q. During breast self-examination, the purpose of standing in front of the mirror it to observe the breast for:

• thickening of the tissue
• axillary
• lumps in the breast tissue
• change in size and contour

37. Situation: The national objective for maintaining the health of all Filipinos is a primary responsibility of the DOH.Which of the following is the most important responsibility of a nurse in the prevention of unnecessary deaths from pneumonia and other severe disease?

• Weighing of the child
• Provision of careful assessment
• Taking of the temperature of the sick child
• Giving of antibiotics

38. The nurse is assessing a recently admitted newborn. Which finding should be reported to the physician?

• The umbilical cord contains three vessels.
• The newborn has a temperature of 98F.
• The feet and hands are bluish in color.
• A large soft swelling crosses the suture line.

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39. 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.At 17 weeks gestation, a fetus isn't considered to be ballotable. Ballottement means that:

• The examiner feels rebound movement of the fetus.
• The examiner feels fetal movement.
• The client feels irregular, painless uterine contractions.
• The client feels fetal movement.

40. A client is to have a hysterosalpingogram. Which of the following information should the nurse provide the client prior to the procedure?

• "The test will be performed through a small incision next to your belly button.”
• "You will be on bed rest for a full day following the procedure”
• "An antibiotic fluid will be instilled through a tube in your cervix"
• "You will be asked to move from side to side so that x-ray pictures can be taken."

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41. A client is scheduled to undergo a bone marrow aspiration from the sternum. What position would the nurse assist the client into for this procedure?

• Dorsal recumbent
• Supine
• High Fowlers
• Lithotomy

42. The nurse in a maternity unit is reviewing the clients records. Which clients should the nurse identify as being at the most risk for developing disseminated intravascular coagulation (DIC)? Select all that apply. 1.A primigravida with mild preeclampsia. 2.A primigravida who delivered a 10-lb infant 3 hours ago. 3.A gravida II who has just been diagnosed with dead fetus syndrome. 4.A gravida IV who delivered 8 hours ago and has lost 500 mL of blood. 5.A primigravida at 29 weeks of gestation who was recently diagnosed with severe preeclampsia

• 1,2,3,4
• 2,3
• 3,5
• 2,4,5

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43. Which of the following if done by the nurse, is correct during NGT Insertion?

• Use an oil based lubricant
• Measure the amount of the tube to be inserted from the Tip of the nose, to the earlobe, to the xiphoid process
• Soak the NGT in a basin of ice water to facilitate easy insertion
• Check the placement of the tube by introducing 10 cc of sterile water and auscultating for bubbling sound

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44. Situation: The national objective for maintaining the health of all Filipinos is a primary responsibility of the DOH.In responding to the care concerns to children with severe disease, referral to the hospital is of the essence especially if the child manifests which of the following?

• Stopped feeding well
• Fast breathing
• Wheezing
• Difficulty to awaken

45. The nurse is caring for a client who has just had implantation of an automatic internal cardioverter-defibrillator. The nurse should assess which item based on priority?

• Anxiety level of the client and family
• Presence of a MedicAlert card for the client to carry
• Knowledge of restrictions on post discharge physical activity
• Activation status of the device, heart rate cutoff, and number of shocks it is programmed to deliver

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46. Situation: In a client with widespread colon cancer, A colectomy is the surgical procedure of choice instead of an Abdominal perineal resection.Q. An expert nurse in the field of colostomy and ileostomy is called as a/an:

• Enterostomal Therapy Nurse
• Ostomy nurse
• Nurse oncologist
• Nurse Enterostomist

47. The doctor has ordered the patient to be on 1 to 3 litters of oxygen using a nasal cannula at all times, the home care nurse notes the oxygen is currently at 2 L/minute the oxygen saturation( Sa02) reading is currently 85% and the partial pressure of CO2 is within normal limits. Based on an evaluation of this information, which of the following actions would the nurse MOST likely perform?

• Decrease the O2 to 1 L/minute and monitor O2 saturation
• continue the O2 at 2 L/minute and monitor O2 saturation
• Increase the O2 to 3 L/minute and monitor O2 saturation
• continue to monitor 02 saturation and ca the doctor for new orders

48. Jose who has been hospitalized with schizophrenia tells Nurse Ron, My heart has stopped and my veins have turned to glass'" Nurse Ron is aware that this is an example of:

• Somatic de usions
• Depersonalization
• Hypochondriasis
• Echolalia

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49. The nurse is caring for a client with leukemia who has received the drug Daunorubicin (Cerubidine). Which of the following common side effects would cause the most concern?

• Nausea
• Vomiting
• Cardiotoxicity
• Alopecia

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50. Jerry has diagnosed with appendicitis. He develops a fever, hypotension and tachycardia. The nurse suspects which of the following complications?

• Intestinal obstruction
• Peritonitis
• Bowel ischemia
• Deficient fluid volume

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NCLEX-RN | QB2 | Practice Exam #11 (50 questions)