NCLEX-RN | QB2 | Practice Exam #14 (50 questions)
All 50 questions are randomized each time you take the test, and do not appear in the same order.
1. Situation: Mr. Gerald Liu, 19 y/o, is being admitted to a hospital unit complaining of severe pain in the lower abdomen. Admission vital signs reveal an oral temperature of 101.2 OF.Q. Which of the following would confirm a diagnosis of appendicitis?
- The pain is localized at a position halfway between the umbilicus and the right iliac crest.
- Mr Liu describes the pain as occurring 2 hours after eating
- The pain subsides after eating
- The pain is in the left lower quadrant
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2. The use of larvivorous fish in malaria control is the basis for which strategy of malaria control?
- Stream seeding
- Stream clearing
- Destruction of breeding places
- Zooprophylaxis
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3. When preparing a woman who is 2 days postpartum for discharge, recommendations for which of the following contraceptive methods would be avoided?
- Diaphragm
- Female condom
- Oral contraceptives
- Rhythm method
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4. Linda, A 30 year old post hysterectomy client has visited the health center. She inquired about BSE and asked the nurse when BSE should be performed. You answered that the BSE is best performed:
- 7 days after menstruation
- At the same day each month
- During menstruation
- Before menstruation
5. Situation: Mrs. Pichay is admitted to your ward. The MD ordered Prepare for thoracentesis this pm to remove excess air from the pieural cavity." Q. Which of the following nursing responsibilities is essential in Mrs. Pichay who will undergo thoracentesis?
- Support and reassure client during the procedure
- Ensure that informed consent has been signed
- Determine if client has allergic reaction to local anesthesia
- Ascertain if chest x-rays and other tests have been prescribed and completed
6. Nurse Karina knows that the following drugs have been known to be effective in treating obsessive-compulsive disorder (OCD):
- benztropine (Cogentin) and diphenhydramine (Benadryl).
- chlordiazepoxide (Librium) and diazepam (Valium)
- fluvoxamine (Luvox) and clomipramine (Anafranil)
- divalproex (Depakote) and lithium (Lithobid)
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7. 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. When preparing to examine the left breast in a reclining position, the purpose of placing a small folded towel under the client's left shoulder is to:
- bring the breast closer to the examiner's right hand
- tense the pectoral muscle
- balance the breast tissue more evenly on the chest wall
- facilitate lateral positioning of the breast
8. Mr. Bond is receiving 10 mg of Diazepam (Valium) orally t.i.d. Besides diminishing anxiety, the nurse explains that this medication is also used to:
- Reduce emotional depression
- Relax skeletal muscles
- Promote restful sleep
- Relieve inflammation
9. Cristina undergoes a biopsy of a suspicious lesion. The biopsy report classifies the lesion according to the TNM staging system as follows: TIS, NO, MO. What does this classification mean?
- No evidence of primary tumor, no abnormal regional lymph nodes, and no evidence of distant metastasis
- Carcinoma in situ, no abnormal regional lymph nodes, and no evidence of distant metastasis
- Cant assess tumor or regional lymph nodes and no evidence of metastasis
- Carcinoma in situ, no demonstrable metastasis of the regional lymph nodes, and ascending degrees of distant metastasis
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10. When planning care for a male client using paranoid ideation, nurse Jasmin should realize the importance of:
- Giving the client difficult tasks to provide stimulation
- Providing the client with activities in which success can be achieved
- Removing stress so that the client can relax
- Not placing any demands on the client
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11. Mr. Dorn has vasectomy. He asks the nurse why he just use a method of birth control because today he, had a sterilization procedure. The most correct answer is:
- The sperm count will not be negative until his testosterone level decrease
- Some minor surgery usually is necessary to ensure sterilization
- Some live sperm will be present in the ejaculatory fluid for a period of time
- Even though a vasectomy is performed, a condom is still recommended for 1 to 2 years
12. The nurse is teaching a client with Parkinsons disease ways to prevent curvatures of the spine associated with the disease. To prevent spinal flexion the nurse should tell the client to:
- Periodically lie prone without a neck pillow.
- Sleep only in dorsal recumbent position.
- Rest in supine position with his head elevated.
- Sleep on either side but keep his back straight.
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13. The physician has prescribed a cleansing enema to a client scheduled for colon surgery. The nurse would place the client:
- Prone
- Supine
- Left sim’s (left lateral)
- Dorsal recumbent
14. The nurse has an order for medication to be administered intrathecally. The nurse is aware that medications will be administered by which method?
- Intravenously
- Rectally
- Intramuscularly
- Into the cerebrospinal fluid
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15. Which client(s) would be appropriate to assign to a newly graduated RN, who has recently completed orientation? (Choose all that apply.)
- An anxious, chronic pain Client who frequently uses the call button
- A client second day post-op who needs pain medication prior to dressing changes
- A client with HIV who reports headache and abdominal and pleuritic chest pain
- A client who is being discharged with a surgically implanted catheter
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16. The nurse provides a list of instructions to a client being discharged to home with peripherally inserted central catheter (PICC). The nurse determines that the client further instructions if the client made which statement?
- "I need to wear a MedicAlert tag or bracelet."
- "I need to restrict my activity while this catheter is in place"
- "I need to keep the insertion site protected when in the shower or bath."
- "I need to check the markings on the catheter each time the dressing is changed.”
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17. The client is admitted for an open reduction internal fixation of a fractured hip. Immediately following surgery the nurse should give priority to assessing the:
- Serum collection (Davol) drain
- Clients pain
- Nutritional status
- immobilizer
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18. Situation: There are other important basic knowledge in the performance of our task as Community Health Nurse in relation to IMMUNIZATION these include:Which of the following vaccines is not done by intramuscular (IM) injection?
- Measles vaccine
- DPT
- Hepatitis B vaccines
- none of the above
19. The nurse is caring for an acutely ill 10 year-old client. Which of the following assessment findings would require the nurses immediate attention?
- Rapid bounding pulse
- Temperature of 101.3 degrees Fahrenheit (38.5 degrees Celsius)
- Profuse diaphoresis
- Slow, irregular respirations
20. A male client has a reduced serum high-density lipoprotein (HDL) level and an elevated low-density lipoprotein (LDL) level. Which of the following dietary modifications is not appropriate for this client?
- Fiber intake of 25 to 30 g daily
- Less than 30% of calories from fat
- Cholesterol intake of less than 300 mg daily
- Less than 10% of calories from saturated fat
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21. The physician ordered, Maalox, 2 hours p.c, what does p.c means?
- As desired
- Before meals
- After meals
- Before bedtime
p.c. means After meals.
22. Mr. Duffy is admitted to the CCU with a diagnosis of R/O MI. 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. You decide to discuss glaucoma prevention. Which of the following diagnostic tests should these clients request from their care provider?
- fluorescein stain
- snellen's test
- tonometry
- slit lamp
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23. A 1 year old child presents at the clinic one week after hospitalization for surgical repair of a fractured right femur. The patient is receiving pain medications every morning and evening. The best way to evaluate the effectiveness of the pain management plan is;
- To ask the child in simple terms about the comfort level of the past week
- By direct observation of the child's non-verbal behaviors during the visit
- To teach the child how to use wong/baker faces pain rating scale
- To interview the parent about behavior, moods, and sleep patterns over the past week
24. What is the priority nursing diagnosis for a client in the rehabilitative phase of recovery from a burn injury?
- Acute Pain
- Impaired Adjustment
- Deficient Diversional Activity
- Imbalanced Nutrition: Less than Body Requirements
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25. Which observation would the nurse expect to make after an amniotomy?
- Dark yellow amniotic fluid
- Clear amniotic fluid
- Greenish amniotic fluid
- Red amniotic fluid
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26. The nurse has just received a prescription to transfuse a unit of packed red blood cells for an assigned client What action should the nurse take next?
- Check a set of vital signs.
- Order the blood from the blood bank.
- Obtain Y-site blood administration tubing.
- Check to be sure that consent for the transfusion has been signed.
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27. Victims of domestic violence should be assessed for what important information?
- Reasons they stay in the abusive relationship (for example, lack of financial autonomy and isolation)
- Readiness to leave the perpetrator and knowledge of resources
- Use of drugs or alcohol
- History of previous victimization
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28. The nurse is entering the room of a patient who is blind. The nurse should:
- Speak before touching the patient
- Talk to the patient using aloud tone
- Ask then patient questions that can be answered yes or no
- Stand directly in front of the patient while talking
29. Nurse Marco is developing a plan of care for a client with anorexia nervosa. Which action should the nurse include in the plan?
- Restricts visits with the family and friends until the client begins to eat.
- Provide privacy during meals.
- Set up a strict eating plan for the client.
- Encourage the client to exercise, which will reduce her anxiety.
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30. A patient who develops hives after receiving an antibiotic is exhibiting drug:
- Tolerance
- Idiosyncrasy
- Synergism
- Allergy
31. On assessment of a postpartum client, the nurse notes that the uterus feels soft and boggy. The nurse should take which initial action?
- Document the findings.
- Elevate the client's legs.
- Massage the fundus until it is firm.
- Push on the uterus to assist in expressing clots.
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32. Situation: Nanette was rushed to the hospital due to burns. Witnesses told the emergency team that Nanette fell asleep while she is holding her cigarette thus, burning the bed sheets and herself. 2nd and 3rd degree burns are on the face, neck, anterior and posterior trunk as well as the anterior of the left leg and the whole right arm was burned. First degree burns are located on the anterior portion of the right leg and the anterior portion of the right and left arm. Nanette is a 110 lbs female clientQ. The priority nursing intervention for Nanette is to:
- Assess airway, breathing and circulation
- Check Nanette's Vital Signs
- Apply ointment over the burned surface
- Administer oxygen inhalation
33. A 23 year old female client was in an automobile accident and is now a paraplegic. She is on an intermittent urinary catheterization program and diet as tolerated. The nurse's priority assessment should be to observe for:
- Urinary retention
- Bladder distention
- Weight gain
- Bower evacuation
34. A community is experiencing an outbreak of staphylococcal infections. The nurse instructs residents that the MOST common mode of transmission is by:
- Respiratory droplets
- Contaminated foods
- Hands
- Soil
35. The home health nurse is planning for the days visits. Which client should be seen first?
- The 78-year-old who had a gastrectomy three weeks ago and has a PEG tube
- The five-month-old discharged one week ago with pneumonia who is being treated with amoxicillin liquid suspension
- The 50-year-old with MRSA being treated with Vancomycin via a PICC line
- The 30-year-old with an exacerbation of multiple sclerosis being treated with cortisone via a centrally placed venous catheter
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36. A 10 year old girl is admitted to the pediatric unit for recurrent pain and swelling of her joints, particularly her knees and ankles. Her diagnosis is juvenile rheumatoid arthritis. Nurse Janah recognizes that besides joint inflammation, a unique manifestation of the rheumatoid process involves the:
- Ears
- Eyes
- Liver
- Brain
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37. One method of assessing for sign of circulatory impairment in a client with a fractured femur is to ask the client to:
- Cough and deep breathe
- Turn himself in bed
- Perform biceps exercise
- Wiggle his toes
38. A 15-year-old girl with anorexia has been admitted to a mental health unit. She refuses to eat Which of the following statements is the best response from the nurse?
- You don't have to eat. Its your choice.
- I hope you II eat your food by mouth. Tube feedings and I.V. lines can be uncomfortable.
- Why do you think you re fat? You re underweight. Here — look in the mirror.
- "You really look terrible at this weight. I hope you'll eat."
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39. At 16 weeks gestation, no fetal heart rate was detected during assessment of a pregnant patient An ultrasound confirmed a hydatidiform molar pregnancy. Which of the following actions should the nurse tell the patient to expect during her one-year follow-up?
- Multiple serum chorionic gonadotropin levels will be drawn
- An Intrauterine device will be used to decrease vaginal bleeding
- Pregnancy will be restricted for another year
- Oral contraceptives will not be prescribed because they will increase the risk of cancer
40. Nurse Greta is aware that the following is classified as an Axis I disorder by the Diagnosis and Statistical Manual of Mental Disorders, Text Revision (DSM-IV-TR) is:
- Obesity
- Borderline personality disorder
- Major depression
- Hypertension
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41. Which action is contraindicated in the client with epiglottis?
- Ambulation
- Oral airway assessment using a tongue blade
- Placing a blood pressure cuff on the arm
- Checking the deep tendon reflexes.
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42. Which of the following techniques during labor and delivery can lead to uterine inversion?
- Fundal pressure applied to assist the mother in bearing down during delivery of the fetal head
- Strongly tugging on the umbilical cord to deliver the placenta and hasten placental separation
- Massaging the fundus to encourage the uterus to contract
- Applying light traction when delivering the placenta that has already detached from the uterine wall
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43. While caring for a patient with potassium deficiency, the nurse should expect that the patient may exhibit:
- Dysrhythmias
- Oliguria
- Diminished deep-tendonreflexes
- Hypertension
44. Situation: Johnny, sought consultation to the hospital before. Q. Her physician ordered Lugol's solution in order to:
- Rate of respiration under different condition of activities and rest
- Decrease the size of the thyroid gland only
- increase the vascularity and size of the thyroid gland
- increase the size of the thyroid gland only
45. Situation: Francis, age 46 is admitted to the hospital with diagnosis of Chronic Lymphocytic Leukemia.Q. Diagnostic assessment of Francis would probably not reveal:
- Predominance of lymhoblasts
- Leukocytosis
- Abnormal blast cells in the bone marrow
- Elevated thrombocyte counts
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46. A decision is made to not hospitalize a client with obsessive-compulsive disorder. Of the following abilities the client has demonstrated, the one that probably most influenced the decision not to hospitalize him is his ability to:
- Hold a job.
- Relate to his peers.
- Perform activities of daily living.
- Behave in an outwardly normal
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47. A patient visiting the clinic 10 days after sinus surgery for checkup complains of having a bad taste in the mouth. When the nurse smells a foul odor while examining the patients mouth, the nurse suspects the patient have an:
- Pulmonary decompensation
- Hemorrhage
- Aspiration
- Infection
48. Situation : Mr. Gerald Liu, 19 y/o, is being admitted to a hospital unit complaining of severe pain in the lower abdomen. Admission vital signs reveal an oral temperature of 101.2 OF.Q. Which of the following complications is thought to be the most common cause of appendicitis?
- A fecalith
- Internal bowel occlusion
- Bowel kinking
- Abdominal wall swelling
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49. Which of the following nursing interventions would the nurse perform during the third stage of labor?
- Obtain a urine specimen and other laboratory tests.
- Assess uterine contractions every 30 minutes.
- Coach for effective client pushing.
- Promote parent-newborn interaction.
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50. The preferred manner of delivering the baby in a gravido-cardiac is vaginal delivery assisted by forceps under epidural anesthesiA. The main rationale for this is:
- To allow a traumatic delivery of the baby
- To allow a gradual shifting of the blood into the maternal circulation
- To make the delivery effort free and the mother does not need to push with contractions
- To prevent perineal laceration with the expulsion of the fetal head
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