NCLEX-RN | QB2 | Practice Exam #13 (50 questions)
All 50 questions are randomized each time you take the test, and do not appear in the same order.
1. A patient with chronic liver disease secondary to hepatitis C has been admitted with malnutrition. With a nursing diagnosis of alteration in nutrition, less than body requirements, the BEST long-term goal is the patient will:
- Gain at I east 10% of body weight
- Attain and maintain ideal weight
- Verbalize understanding nutritional needs
- Include high quality protein in diet
2. Health is defined as:
- State of complete physical, social, mental, and spiritual wellbeing and not merely absence of disease.{/spoiler}
- Felling of wellbeing.
- Absence of disease.
- State of complete physical and mental wellbeing only.
3. Situation: Carlo, 16 years old, comes to the ER with acute asthmatic attack. RR is 46/min and he appears to be in acute respiratory distress.Q. As a nurse you are always alerted to monitor status asthmaticus who will likely and initially manifest symptoms of:
- metabolic alkalosis
- respiratory acidosis
- respiratory alkalosis
- metabolic acidosis
4. While caring for the client during the first hour after delivery, the nurse determines that the uterus is boggy and there is vaginal bleeding. What should be the nurse's first action?
- Check vital signs
- Massage the fundus
- Offer a bedpan
- Check for perineal lacerations
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5. After teaching a group of parents about accident prevention for schoolagers, which of the following statements by the group would indicate the need for more teaching?
- "Schoolagers are more active and adventurous than are younger children."
- "Schoolagers are more susceptible to home hazards than are younger children."
- "Schoolagers are unable to understand potential dangers around them."
- "Schoolargers are less subject to parental control than are younger children."
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6. You are working in the triage area of an ED, and four patients approach the triage desk at the same time. List the order in which you will assess these patients. A.An ambulatory, dazed 25-year-old male with a bandaged head wound. B.An irritable infant with a fever, petechiae, and nuchal rigidity. C.A 35-year-old jogger with a twisted ankle, having pedal pulse and no deformity. D.A 50-year-old female with moderate abdominal pain and occasional vomiting
- A, B, C, D
- B, A, C, D
- B, A, D, C
- C, D, A, B
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7. Nurse Ron is taking a health history of an 84 year old client. Which information will be most useful to the nurse for planning care?
- General health for the last 10 years.
- Current health promotion activities.
- Family history of diseases.
- Marital status.
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8. While a client is on intravenous magnesium sulfate therapy for preeclampsia, it is essential for nurse Amy to monitor the client's deep tendon reflexes to:
- Determine her level of consciousness
- Evaluate the mobility of the extremities
- Determine her response to painful stimuli
- Prevent development of respiratory distress
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9. A stillborn baby was delivered in the birthing suite a few hours ago. After the delivery, the family remained together, holding and touching the baby. Which statement by the nurse would assist the family in their period of grief?
- What can I do for you?
- Now you have an angel in heaven.
- "Don't worry there is nothing you could have done to prevent this from happening”
- "We will see to it that you have an early discharge so that you don't have to be reminded of this experience”
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10. A client with an inguinal hernia asks the nurse why he should have surgery when he has had hernia for years. The nurse understands that surgery is recommended to:
- Abdominal pain and anorexia
- Fatigue and bruising
- Bleeding and pallor
- Petechiae and mucosal ulcers
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11. What action should the nurse consider when counseling a client of the Amish tradition?
- Speak only to the husband.
- Use complex medical terminology.
- Avoid using scientific or medical jargon.
- Stand close to the client and speak loudly.
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12. The nurse is caring for a client who has had spinal fusion,with insertion of hardware.The nurse would be most concerned with which assessment finding?
- Temperature of 101.6T (38.7’C) orally
- Complaints of discomfort during repositioning
- Old bloody drainage outlined on the surgical dressing
- Discomfort during coughing and deep breathing exercises.
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13. When bandaging the burned clients hand, the nurse should make certain that:
- The bandage is free of elastic
- The hand and finger surfaces do not touch
- The hand and fingers are not elevated above heart level
- The bandage material is moistened with sterile normal saline solution
14. The nurse is teaching the mother of a child with cystic fibrosis how to do chest percussion. The nurse should tell the mother to:
- Use the heel of her hand during percussion.
- Change the childs position every 20 minutes during percussion sessions.
- Do percussion after the child eats and at bedtime.
- Use cupped hands during percussion.
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15. The nurse is caring for a client who had an above knee amputation 2 days ago. The residual limb was wrapped with an elastic compression bandage, which has come off. Which immediate action should the nurse take?
- Apply ice to the site.
- Call the health care provider (HCP).
- Rewrap the residual limb with an elastic compression bandage.
- Apply a dry sterile dressing and elevate the residual limb on 1 pillow.
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16. 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. Whereas acute non lymphoid leukaemia has survival rate of:
- 25%
- 40%
- 75%
- 95%
17. Situation: Camila, 25 years old, was reported to be gradually withdrawing and isolating herself from friends and family members. She became neglectful of her personal hygiene. She was observed to be talking irrelevantly and incoherently. She was diagnosed as schizophrenia. Q. Which of the following disturbances in interpersonal relationships MOST often predispose, to the development of schizophrenia?
- Lack of participation in peer groups
- Faulty family atmosphere and interaction
- Extreme rebellion towards authority figures
- Solo parenting
18. The nurse is caring for a postoperative client who is receiving demand-dose hydromorphone via a patient-controlled analgesia (PCA) pump for pain control. The nurse enters the client's room and finds the client drowsy and records the following vital signs: temperature 97.2 °F (36.2 °C) orally, pulse 52 beats per minute, blood pressure 101/58 mm Hg, respiratory rate 11 breaths per minute, and SpO2 of 93% on 3 liters of oxygen via nasal cannula. Which action should the nurse take next?
- Document the findings.
- Attempt to arouse the client.
- Contact the health care provider (HCP) immediately.
- Check the medication administration history on the PCApump.
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19. The nurse is planning care for a newborn of a mother with diabetes mellitus. What is the priority nursing consideration for this newborn?
- Developmental delays because of excessive size
- Maintaining safety because of low blood glucose levels
- Choking because of impaired suck and swallow reflexes
- Elevated body temperature because of excess fat and glycogen
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20. The BSN curriculum prepares the graduates to become?
- Nurse generalist
- Nurse specialist
- Primary health nurse
- Clinical instructor
21. An infant receives a diphtheria, tetanus, and acellular pertussis (DTaP) immunization well-baby clinic. The parent returns home and calls the clinic to report that the infant has developed swelling and redness at the site of injection. Which intervention should thenurse suggest to the parent?
- Monitor the infant for a fever.
- Bring the infant back to the clinic.
- Apply a hot pack to the injection site.
- Apply a cold pack to the injection site.
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22. Situation: The following questions refer to common clinical encounters experienced by an entry level nurse.The major components of the communication process are?
- Verbal, written, and nonverbal
- Speaker, Listener and reply
- Facial expression, tone of voice and gestures
- Message, sender, channel, Receiver and Feedback
23. A nurse is caring for an 8-year-old male with cystic fibrosis. Based on the nurses understanding of the disease. What nursing intervention should the nurse expect to perform?
- Restrict sodium and fluid intake
- Give antidiarrheal medications
- Discourage coughing after postural drainage
- Administer pancreatic enzymes with each meal
24. The nurse is caring for an infant with bronchiolitis, and diagnostic tests have confirmed respiratory syncytial virus (RSV). On the basis of this finding, which is the most appropriate nursing action?
- Initiate strict enteric precautions.
- Move the infant to a room with another child with RSV.
- Leave the infant in the present room because RSV is not contagious.
- Inform the staff that they must wear a mask, gloves, and a gown when caring for the child.
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25. Question: about Kubler theory...e.g. As identified by Dr. Elizabeth Kubler-Ross, which stage of dying is characterized by the transition from, "NO, not me" to "Yes, me, but..."
- Anger
- Depression
- Acceptance
- Bargaining
26. Micronutrients are those nutrients needed by the body in a very minute amount Which of the following vitamin is considered as a MICRONUTRIENT
- Phosphorous
- Iron
- Calcium
- Sodium
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28. Nurse Jessie is assessing a client suffering from stress and anxiety. A common physiological response to stress and anxiety is:
- Urticaria
- Vertigo
- Sedation
- Diarrhea
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29. A child is treated for superficial (first-degree) thermal burns to the thigh. The child is in great discomfort and does not eat Which of the following diagnoses should receive PRIORITY?
- Altered nutrition
- Impaired skin integrity
- Risk for infection
- Acute pain
30. Situation: Nursing informatics is a way of using information technology computers and the internet in the improvement of nursing care. The first nursing informatics conference was held during 1977.Q. You are to research the different types of oxygen delivery system. From the nasal cannula up to the venturi mask. Using nursing informatics, you found out different sources of information. One of the question that needs to be answered in your research is "What type of oxygen delivery system is the most comfortable?" you will answer:
- Nasal cannula, according to the American journal of nursing and medicine
- Face masks, according to a nursing blog site
- Venturi mask, according to Wikipedia
- Oxygen tents, according to a personal website from yahoo search engine
31. 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. The episodes Mr. Liberatore has been experiencing are probably:
- small cerebral hemorrhages
- TIA's or transient ischemic attacks
- Secondary to hypoglycemia
- Secondary to hyperglycemia
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32. She decides to have a decentralized staffing system. Which of the following is an advantage of this system of staffing?
- greater control of activities
- Conserves time
- Compatible with computerization
- Promotes better interpersonal relationship
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33. A long term goal for a paranoid male client who has unjustifiably accused his wife of having many extramarital affairs would be to help the client develop:
- Insight into his behavior
- Better self control
- Feeling of self worth
- Faith in his wife
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34. Orthopnea is defined as:
- Breathing facilitated by sitting or standing up.
- Absence of breathing.
- Rapid breathing.
- Difficult breathing.
35. A mother brought her daughter, 4 years old, to the RHU because of cough and colds. Following the IMCI assessment guide, which of the following is a danger sign that indicates the need for urgent referral to a hospital?
- Inability to drink
- High grade fever
- Signs of severe dehydration
- Cough for more than 30 days
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36. In the conduct of a census, the method of population assignment based on the actual physical location of the people is termed;
- De jure
- De locus
- De facto
- De novo
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37. The physician has prescribed nitroglycerin sublingual tablets as needed for a client with angina. The nurse should tell the client to take the medication:
- After engaging in strenuous activity
- Every four hours to prevent chest pain
- As soon as he notices signs of chest pain
- At bedtime to prevent nocturnal angina
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38. The nurse is monitoring a client who is in the active stage of labor. The nurse documents that the client is experiencing labor dystocia. The nurse determines that which risk factors in the client's history placed her at risk for this complication? Select all that apply. 1.Age 54. 2.Body mass index of 28. 3.Previous difficulty with fertility. 4.Administration of oxytocin for induction. 5.Potassium level of 3.6 mEq/L (3.6 mmol/L)
- 1,2,3
- 3,4,5
- 1,2,3,4
- 2,3,5
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39. A male client with type 1 diabetes is scheduled to receive 30 U of 70/30 insulin. There is no 70/30 insulin available. As a substitution, the nurse may give the client:
- 9 II regular insulin and 21 U neutral protamine Hagedorn (NPH).
- 21 U regular insulin and 9 U NPH.
- 10 U regular insulin and 20 U NPH.
- 20 U regular insulin and 10 U NPH.
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40. The nurse is monitoring a client in preterm labor who is receiving intravenous magnesium sulfate. The nurse should monitor for which adverse effects of this medication? Select all that apply. 1.Flushing. 2.Hypertension. 3.Increased urine output. 4.Depressed respirations. 5.Extreme muscle weakness. 6.Hyperactive deep tendon reflexes
- 1,2,3,4,5
- 2,3,4
- 1,3,5,6
- 1,4,5
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41. Which of the following is an advantage of a home visit?
- It allows the nurse to provide nursing care to a greater number of people
- It provides an opportunity to do first hand appraisal of the home situation
- It allows sharing of experience among people with similar health problems
- It develops the family's initiative in providing for health needs of its members
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42. When teaching parents of a neonate the proper position for the neonates sleep, the nurse Patricia stresses the importance of placing the neonate on his back to reduce the risk of which of the following?
- Aspiration
- Sudden infant death syndrome (SIDS)
- Suffocation
- Gastro Esophageal Reflux (GER)
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43. During morning assessments the nurse finds that a clients nephrostomy tube has been clamped. The nurses first action should be to:
- Assess the drainage bag.
- Check for bladder distention.
- Unclamp the tubing.
- Irrigate the tubing.
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44. Situation: Cancer of the prostate is the leading cancer in Men other than skin cancer. The following questions will assess your knowledge and theoretical foundation in dealing with clients with prostate cancer.Q. In any biopsy, the specimen is sent to the:
- Radiologist
- Nearest of Kin (seriously?)
- Pathologist
- Medical Technologist
45. A community health nurse visits a patient who has suffered a stroke. The patients spouse explains to the nurse that the patient chokes while eating some times. Which of the following referral orders would the nurse anticipate needing for this patient?
- Speech therapist
- Dietician
- Physical therapist
- Neurologist
46. The nurse provides an educational session on client rights. Which statement by a member of the session demonstrates the best understanding of the nurse's role regarding ensuring that each client's rights are respected?
- "Autonomy is the fundamental right of each and every client."
- "A client's rights are guaranteed by both state and federal laws."
- "Being respectful and concerned will ensure that I m attentive to my clients rights."
- "Regardless of the client's condition, all nurses have the duty to value client rights."
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47. The primary purpose of a platelet count is to evaluate the:
- Potential for clot formation
- Potential for bleeding
- Presence of an antigen-antibody response
- Presence of cardiac enzymes
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48. While you are mating your routine rounds you were told that there is a client in the 10il who is in respirator and who lip-reads. To establish relationship with him, communication is best accomplished by:
- Speaking slowly but aloud
- Writing messages
- Gesturing while speaking
- Using simple "charade" approach or strategy
49. The pediatric nurse in the neonatal unit was informed that the baby that is brought to the mother in the hospital room is wrong. The nurse determines that two babies were placed in the wrong cribs. The most appropriate nursing action would be to:
- Determine who is responsible for the mistake and terminate his or her employment.
- Record the event in an incident/variance report and notify the nursing supervisor.
- Reassure both mothers, report to the charge nurse, and do not record.
- Record detailed notes of the event on the mother's medical record.
50. A woman in a child bearing age receives a rubella vaccination. Nurse Joy would give her which of the following instructions?
- Refrain from eating eggs or egg products for 24 hours
- Avoid having sexual intercourse
- Don't get pregnant at least 3 months
- Avoid exposure to sun