QB2 | Practice Exam #19 -> answers with explanation
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NCLEX-RN | QB2 | Practice Exam #19 (50 questions)
All 50 questions are randomized each time you take the test, and do not appear in the same order.
1. Situation: The question with regards to the OPERATING ROOM.Q. When the client is discharged from the hospital and is not capable of doing the needed care services, the following can assume the role, EXCEPT:
- family members
- chaplain
- significant others
- responsible caregiver
2. SITUATION: Alfred, a 40 year old construction worker developed cough, night sweats and fever. He was brought to the nursing unit for diagnostic studies. He told the nurse he did not receive a BCG vaccine during childhoodQ. Mang Alfred is now a new TB patient with an active disease. What is his category according to the DOH?
- II
- III
- IV
- I
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3. A Community nurse interviews an 87-year-old patient diagnosed with early Alzheimer s disease. Because the patient provides conflicts information, the nurse compares subjective and objectives data to find a possible reason for the conflicting data. This process of assessment is called:
- Data verification
- Analytical interpretation
- Mental assessment
- Subjective observation
4. Which of the following statement is incorrect about a patient with dysphagia?
- The patient will find pureed or soft foods, such as custards, easier to swallow than water
- Fowler's or semi Fowler's position reduces the risk of aspiration during swallowing
- The patient should always feed himself
- The nurse should perform oral hygiene before assisting with feeding.
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5. The nurse is preparing to hang fat emulsion (lipids) and notes that fat globules are visible at the top of the solution. The nurse should take which action?
- Roll the bottle of solution gently.
- Obtain a different bottle of solution.
- Shake the bottle of solution vigorously.
- Run the bottle of solution under warm water.
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6. During a private conversation, a client with borderline personality disorder asks the nurse to keep his secret and then displays multiple, self-inflicted, superficial lacerations on the forearms. What is the nurse's best response?
- "That's it! You're on suicide precautions"
- "I'm going to tell your physician. Do you want to tell me why you did that?"
- "Tell me what type of instrument you used. I'm concerned about infection"
- "The team needs to know when something important occurs in treatment. I need to tell the others, but let's talk about it first."
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7. One of the most important criteria for the diagnosis of physical abuse is inconsistency between the appearance of the injury and the history of how the injury occurred. Which one of the following situations should alert the nurse to the possibility of abuse?
- An 18-month-old with sock and mitten burns from a fall into the bathtub
- A six-year-old with a fractured clavicle following a fall from her bike
- An eight-year-old with a concussion from a skateboarding accident
- A two-year-old with burns to the scalp and face from a grease spill
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8. A home care nurse visits a patient with diabetes. The patient cast three well balanced meals sweet dessert and exercises 30 minutes a day twice a week. Also, the patient is complaint with taking hypoglycemia medications Blood glucose level ranges from 150-200 mg/ dl The nurse sets a goal of eliminating sweet desserts and increasing the frequency of exercises to 3 times a week. This week, the patient exercised 3 times for 30 minutes and ate dessert only after dinner. The glucose ranges from 100-150 mg/dL The nurse evaluate that:
- The goal will not be met
- Progression is being made towards the goal
- The goal is met
- The goal is inappropriate
9. What numerator is used in computing general fertility rate?
- Estimated midyear population
- Number of registered live births
- Number of pregnancies in the year
- Number of females of reproductive age
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10. A client with AIDS has impaired nutrition due to diarrhea. The nurse teaches the client about the need to avoid certain foods. Which diet selection by the client would indicate a need for further teaching?
- Tossed salad
- Baked chicken
- Broiled fish
- Steamed rice
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11. If a central venous catheter becomes disconnected accidentally, what should the nurse in- charge do immediately?
- Clamp the catheter
- Call another nurse
- Call the physician
- Apply a dry sterile dressing to the site.
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12. An eight year-old boy has a new diagnosis of Attention Deficit Hyperactive Disorder (ADHD) and begins pharmacological and psychological therapies. His medication regimen includes short-acting methylphenidate 5 mg orally every 12 hours.Which side effect is most likely?
- Insomnia
- Initial increased hyperactivity
- Lethargy
- Hypertension
13. The client with urinary tract infection is given a prescription for trimethoprim (Bactrim-DS) for her infection. Which of the following statements would indicate that she understands the principles of antibiotic therapy?
- I'll take the pills until I feel better and keep the rest for recurrences
- I'll take all the pills then return to my doctor
- I'll take the pills until the symptoms go away then reduce the dose to one pill a day
- I'll take all the pills then have the prescription renewed once
14. A client is admitted to the emergency room with complaints of substernal chest pain radiating to the left jaw. Which ECG finding is suggestive of acute myocardial infarction?
- Peaked P wave
- Changes in ST segment
- Minimal QRS wave
- Prominent U wave
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15. When antibiotics are not producing the desired outcome for a client with osteomyelitis, the nurse interprets this as suggesting the occurrence of which of the following as most likely?
- Formation of scar tissue interfering with absorption
- Development of pus leading to ischemia
- Production of bacterial growth by avascular tissue
- Antibiotics not being instilled directly into the bone
16. The nurse is reviewing a clients record and notes that the health care provider has documented that the client has chronic renal disease. On review of the laboratory results, the nurse most likely would expect to note which finding?
- Elevated creatinine level
- Decreased hemoglobin level
- Decreased red blood cell count
- Increased number of white blood cells in the urine
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17. The psychiatrist orders lithium carbonate 600 mg p.o t.i.d for a female client. Nurse Katrina would be aware that the teaching about the side effects of this drug were understood when the client state, "I will call my doctor immediately if I notice any:
- Sensitivity to bright light or sun
- Fine hand tremors or slurred speech
- Sexual dysfunction or breast enlargement
- Inability to urinate or difficulty when urinating
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18. Situation: It is common that client ask the nurse personal questions.Q. When the client asks about the family of the nurse the MOST appropriate response is:
- Avoid the situation and redirect the clients attention
- Give a brief and simple response and focus on the client
- Why don't we talk about your family instead?
- Introduce another topic like the client's interests
19. The nurse who works on the night shift enters the medication room and finds a co-worker with a tourniquet wrapped around the upper arm. The co-worker is about to insert a needle, attached to a syringe containing a clear liquid, into the antecubital area. Which is the most appropriate action by the nurse?
- Call security.
- Call the police.
- Call the nursing supervisor.
- Lock the co-worker in the medication room until help is obtained.
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20. In lMCI, severe conditions generally require urgent referral to a hospital. Which of the following severe conditions Does not always require urgent referral to hospital?
- Mastoiditis
- Severe dehydration
- Severe pneumonia
- Severe febrile disease
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21. Which of the following client statements about clozapine (Clozaril) indicates that the client needs additional teaching?
- "I need to have my blood checked once every several months while I'm taking this drug."
- "I need to sit on the side of the bed for a while when I wake up in the morning."
- "The sleepiness I feel will decrease as my body adjusts to clozapine"
- "I need to call my doctor whenever I notice that I have a fever or sore throat."
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22. A newly delivered infant has a pink trunk and blue hands and feet, pulse rate of 60 and does not respond to your attempts to stimulate her. She also appears to be limp and taking slow, gasping breaths. What is her Apgar score
- 3
- 6
- 7
- 9
23. Situation: Ensuring safety is one of your most important responsibilities. You will need to provide instructions and information to your clients to prevent complications.Q. Herbert has a laryngectomy and he is now for discharge. Re verbalized his concern regarding his laryngectomy tube being dislodged. What should you teach him first?
- Recognize that prompt closure of the tracheal opening may occur
- Keep calm because there is no immediate emergency
- Reinsert another tubing immediately
- Notify the physician at once
24. You are the PHN in the city health center. A client underwent screening for AIDS using ELISA. His result was positive. What is the best course of action that you may take?
- Get a thorough history of the client focusing on the practice of high risk behavior
- Ask the client to be accompanied by a significant person before revealing the result.
- Refer the client to the physician since he is the best person to reveal the result to the client
- Refer the client for a supplementary test, such as Western blot, since the ELISA result maybe false
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25. A client has been taking omeprazole for 4 weeks. The ambulatory care nurse evaluates that the client is receiving the optimal intended effect of the medication if the client reports the absence of which symptom?
- Diarrhea
- Heartburn
- Flatulence
- Constipation
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26. The nurse is caring for an adolescent with a five-year history of bulimia. A common clinical finding in the client with bulimia is:
- Extreme weight loss
- Dental caries
- Hair loss
- Decreased temperature
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27. If a couple would like to enhance their fertility, the following means can be done: 1.Monitor the basal body temperature of the woman everyday to determine peak period of fertility; 2.Have adequate rest and nutrition; 3.Have sexual contact only during the dry period of the woman; 4.Undergo a complete medical check-up to rule out any debilitating disease
- 1 only
- 1&4
- 1,2,4
- 1,2,3,4
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28. A client has undergone for an ileal conduit, the nurse in charge should closely monitor the client for occurrence of which of the following complications related to pelvic surgery?
- Ascites
- Thrombophlebitis
- Inguinal hernia
- Peritonitis
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29. What country did Florence Nightingale train in nursing?
- Belgium
- US
- Germany
- England
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30. The nurse reviews the record of a child who is sus- pected to have glomerulonephritis. Which statement by the child's parent should the nurse expect that is associated with this diagnosis?
- "I'm so glad they didn't find any protein in his urine."
- "I noticed his urine was the color of coca-cola lately."
- "His health care provider said his kidneys are working well."
- "The nurse who admitted my child said his blood pressure was low"
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31. The physician has ordered injections of Neumega (oprelvekin) for a client receiving chemotherapy for prostate cancer. Which finding suggests that the medication is having its desired effect?
- Hct 12.8g
- Platelets 250 000mm3
- Neutrophils 4 000mm3
- RBC 4.7 million
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32. 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 was given a drug at birth to reverse the effects of a narcotic given to his mother in labor What drug is commonly used for this?
- Naloxone (Narcan)
- Morphine Sulfate
- Sodium Chloride
- Penicillin G
33. Situation: Nurse Macarena is a Family Planning and Infertility Nurse Specialist and currently attends to FAMILY PLANNING CLIENTS AND INFERTILE COUPLES. The following conditions pertain to meeting the nursing needs of this particular population group.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
34. Nurse Joan is providing information to a community group about violence in the family. Which statement by a group member would indicate a need to provide additional information?
- "Abuse occurs more in low-income families"
- "Abuser Are often jealous or self-centered"
- "Abuser use fear and intimidation"
- "Abuser usually have poor self-esteem"
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35. When a person has a fever or diaphoresis, the urine output will be which of the following:
- Increased and diluted
- Increased and concentrated
- Decreased and highly diluted
- Decreased and highly concentrated
36. Situation: Mental Retardation is an increasingly common childhood disorder that impairs learning.Q. The possible nursing diagnosis for a mentally retarded child who is hyperactive is:
- Impaired physical mobility
- Potential for injury
- Impaired social adjustment
- Ineffective coping
37. A 25 year old male is admitted to a mental health facility because of inappropriate behavior. The client has been hearing voices, responding to imaginary companions and withdrawing to his room for several days at a time. Nurse Monette understands that the withdrawal is a defense against the client's fear of:
- Phobia
- Powerlessness
- Punishment
- Rejection
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38. Situation: As a perioperative nurse, you are aware of the correct processing methods for preparing instruments and other devices for patient use to prevent infection.Q. As an OR nurse, what are your foremost considerations for selecting chemical agents for disinfection?
- Material compatibility and efficiency
- Odor and availability
- Cost and duration of disinfection process
- Duration of disinfection and efficiency
39. Situation: Jerome, a 37 years old man, was admitted to the hospital with periodic episode of manic behavior alternating with me depression. Diagnosis: Bipolar 1 disorder.Q. A priority nursing diagnosis would be
- Ineffective individual coping
- Altered family process
- Potential for violence, self directed
- Sensory perceptual disturbance
40. (TB) has a productive cough and hemoptysis. Which of the following types of isolation room would be the BEST choice for the patient?
- Negative-pressure
- Positive-pressure
- Reverse isolation
- D Standard isolation
41. Situation: Joanna Marie, a 40 year old client was diagnosed with breast cancer.Q. The nurse is instruction Joanna about breast self examination. The nurse instructs Joanna to perform Breast Self Examination:
- At the onset of menstruatio
- 1 week after menstruation begins
- Every month during ovulation
- Weekly at the same time each day
42. SITUATION: Marvin, A male patient diagnosed with colon cancer was newly put in colostomy.Q. The next day, the nurse will assess Marvin's stoma. The nurse noticed that a prolapsed stoma is evident if she sees which of the following?
- A sunken and hidden stoma
- A dusky and bluish stoma
- A narrow and flattened stoma
- Protruding stoma with swollen appearance
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43. A two-year-old is admitted for repair of a fractured femur and is placed in Bryants traction. Which finding by the nurse indicates that the traction is working properly?
- The infant no longer complains of pain.
- The buttocks are 15° off the bed.
- The legs are suspended in the traction.
- The pins are secured within the pulley.
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44. Anew parent expresses concern to the nurse regarding sudden infant death syndrome (SIDS). She asks the nurse how to position her new infant for sleep. In which position should the nurse tell the parent to place the infant?
- Side or prone
- Back or prone
- Stomach with the face turned
- Back rather than on the stomach
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45. A mother calls a neighbor who is a nurse and tells the nurse that her 3-year-old child has just ingested liquid furniture polish. The nurse would direct the mother to take which immediate action?
- Induce vomiting.
- Cali an ambulance.
- Call the Poison Control Center.
- Bring the child to the emergency department.
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46. The nurse is providing dietary teaching for a client with elevated cholesterol levels. Which cooking oil is not suggested for the client on a low-cholesterol diet?
- Safflower oil
- Sunflower oil
- Coconut oil
- Canola oil
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47. A client is admitted to a psychiatric facility by court order for evaluation for antisocial personality disorder. This client has a long history of initiating fights and abusing animals and recently was arrested for setting a neighbor's dog on fire. When evaluating this client for the potential for violence, the nurse should assess for which behavioral clues?
- A rigid posture, restlessness, and glaring
- Depression and physical withdrawal
- Silence and noncompliance
- Hypervigilance and talk of past violent acts
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48. She dies of yellow fever in her search for truth to prove that yellow fever is carried by mosquitoes.
- Clara Louise Maass
- Pearl Tucker
- Isabel Hampton Robb
- Caroline Hampton Robb
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49. The outcome that is unrelated to a crisis state is:
- Learning more constructive coping skills
- Decompensation to a lower level of functioning.
- Adaptation and a return to a prior level of functioning.
- A higher level of anxiety continuing for more than 3 months.
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50. The nurse is giving discharge instructions to a client with pulmonary sarcoidosis. The nurse concludes that the client understands the information if the client indicates to report which early sign of exacerbation?
- Fever
- Fatigue
- Weight loss
- Shortness of breath
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