NCLEX-RN | QB2 | Practice Exam #20 (50 questions)
All 50 questions are randomized each time you take the test, and do not appear in the same order.
1. The nurse is teaching the mother of a child with attention deficit disorder regarding the use of Ritalin (methylphenidate). The nurse recognizes that the mother understands her teaching when she states the importance of:
- Offering high-calorie snacks
- Watching for signs of infection
- Observing for signs of oversedation
- Using a sunscreen with an SPF of 30
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2. A young man was running along an ocean pier, tripped on an elevated area of the decking, and struck his head on the pier railing. According to his friends, "He was unconscious briefly and then became alert and behaved as though nothing had happened/ Shortly afterward, he began complaining of a headache and asked to be taken to the emergency department If the client's intracranial pressure (ICP) is increasing, the nurse would expect to observe which of the following signs first?
- pupillary asymmetry
- irregular breathing pattern
- involuntary posturing
- declining level of consciousness
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3. The nurse is describing the medication side and adverse effects to a client who is taking oxazepam. Which information should the nurse incorporate in the discussion?
- Consume a low-fiber diet.
- Increase fluids and bu k in the diet.
- Rest if the heart begins to beat rapidly.
- Take antidiarrheal agents if diarrhea occurs.
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4. Dr. Marquez orders a continuous intravenous nitroglycerin infusion for the client suffering from myocardial infarction. Which of the following is the most essential nursing action?
- Monitoring urine output frequently
- Monitoring blood pressure every 4 hours
- Obtaining serum potassium levels daily
- Obtaining infusion pump for the medication
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5. The nurse is providing instructions to the client newly diagnosed with diabetes mellitus who has been prescribed pramlintide. Which instruction should the nurse include in the discharge teaching?
- "Inject the pramlintide at the same time you take your other medications."
- "Take your prescribed pills 1 hour before or 2 hours after the injection."
- "Be sure to take the pramlintide with food so you dont upset your stomach."
- "Make sure you take your pramlintide immediately after you eat so you don't experience a low blood sugar."
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6. The nurse has just assisted a client back to bed after a fall. The nurse and health care provider have assessed the client and have determined that the client is not injured. After completing the incident report, the nurse should implement which action next?
- Reassess the client.
- Conduct a staff meeting to describe the fall.
- Document in the nurse's notes that an incident report was completed.
- Contact the nursing supervisor to update information regarding the fall.
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7. A woman, whose menstrual cycle is 35 days long, states that she often has a slight pain on one side of her lower abdomen on day 21 of her cycle. She wonders whether or not she has ovarian cancer. What is the nurse's best response?
- "Women often feel a slight twinge when ovulation occurs."
- "Ovarian cancer is a possibility and you should seek medical attention as soon as possible."
- "Ovarian cancer is unlikely because the pain is not a constant pain"
- "It is more likely that such pain indicates an ovarian cyst because pain is more common with that problem."
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8. A client develops a temperature of 102F following coronary artery bypass surgery. The nurse should notify the physician immediately because elevations in temperature:
- Increase cardiac output
- Indicate cardiac tamponade
- Decrease cardiac output
- Indicate graft rejection
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9. An infant with a diagnosis of hydrocephalus is scheduled for surgery. Which is the priority nursing intervention in the preoperative period?
- Test the urine for protein.
- Reposition the infant frequently.
- Provide a stimulating environment.
- Assess blood pressure every 15 minutes.
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10. The nurse is caring for a patient two hours after a pacemaker placement The patient suddenly starts complaining of chest pain. The nurse observes dyspnoea, cyanosis and absent breath sounds on the right side. The nurse should anticipate what complications?
- Hemothorax
- Perforation of the heart
- Pneumothorax
- Hemorrhage
11. The nurse is preparing to discharge a client who is taking an MAOIL The nurse should instruct the client to:
- Wear protective clothing and sunglasses when outside.
- Avoid over-the-counter cold and hay fever preparations.
- Drink at least eight glasses of water a day.
- Increase his intake of high-quality protein.
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12. A child undergoes surgical removal of a brain tumor. During the postoperative period, the nurse notes that the child is restless, the pulse rate is elevated, and the blood pressure has decreased significantly from the baseline value. The nurse suspects that the child is in shock. Which is the most appropriate nursing action?
- Place the child in a supine position.
- Notify the health care provider (HCP).
- Place the child in Trendelenburg position.
- Increase the flow rate of the intravenous fluids.
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13. The client with severe sensory alteration is transferred to the intensive care unit. Moments later, the client became restless and agitated with complaints of hallucinations. The nurse noted the change in the level of consciousness as:
- Delirium
- Dementia
- Stupor
- Confusion
14. Amanda, accidentally aspirate a large piece of nut and it passes the carina. Probabilty wise, Where will the nut go?
- Right main stem bronchus
- Left main stem bronchus
- Be dislodged in between the carina
- Be blocked by the closed epiglottis
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15. Mario is complaining to other clients about not being allowed by staff to keep food in his room. Which of the following interventions would be most appropriate?
- Allowing a snack to be kept in his room
- Reprimanding the client
- Ignoring the clients behavior
- Setting limits on the behavior
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16. A female patient admitted for abdominal pain complains of generalized pain, nausea vomiting and constipation. Nursing assessment finds: temperature,38.60C (101.50F), heart rate-92; respiration rate-18; blood pressure level, 130/68mmHg. The patient has rebound tenderness and abdominal rigidity. In the past hour, her pain has localized on the right side. The nurse suspects:
- Intestinal obstruction
- Influenza
- Appendicitis
- Pyloric Stenosis
17. A four-year-old is admitted to the hospital for treatment of Kawasakis disease. The medication commonly prescribed for the treatment of Kawasakis disease is:
- Aspirin (acetylsalicylic acid)
- Benadryl (diphenhydramine)
- Polycillin (ampicillin)
- Betaseron (interferon beta)
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18. The primary physiological alteration in the development of asthma is:
- Bronchiolar inflammation and dyspnea
- Hypersecretion of abnormally viscous mucus
- Infectious processes causing mucosal edema
- Spasm of bronchiolar smooth muscle
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19. A client was admitted to the psychiatric unit after complaining to her friends and family that neighbors have bugged her home in order to hear all of her business. She remains aloof from other clients, paces the floor and believes that the hospital is a house of torture. Nursing interventions for the client should appropriately focus on efforts to
- Convince the client that the hospital staff is trying to help
- Help the client to enter into group recreational activities
- Provide interactions to help the client learn to trust staff
- Arrange the environment to limit the clients contact with other clients
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20. The nurse is caring for a client who Is a retired nurse. A 24-hour urine collection for Creatinine clearance is to be done. The client tells the nurse, "I can't remember what this test is for." The best response by the nurse is:
- "It provides a way to see if you are passing any protein in your urine."
- "It tells how well the kidneys filter wastes from the blood"
- "It tells if your renal insufficiency has affected your heart."
- "The test measures the number of particles the kidney filters."
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21. The adrenal cortex is responsible for producing which substances?
- Glucocorticoids and androgens
- Catecholamines and epinephrine
- Mineralocorticoids and catecholamines
- Norepinephrine and epinephrine
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22. A healthy patient is in doctor s office for a pre operative visit before a total replacement The nurse interviewing the patient charts the following medications: aspirin 81 mg once a day, vitamin E 260 international units once a day, and unknown amount of a herbal supplement once a day, based on the patient's medication list which of the following labs would be important pre-operatively?
- Prostate specific antigen(PSA)
- Blood glucose
- Creatine phospho kinaseiso enzymes (CPK enzymes)
- Prothrombin time
23. An 18-month-old is admitted to the hospital with acute laryngotracheobronchitis. When assessing the respiratory status the nurse should expect to find:
- Inspiratory stridor and harsh cough
- Strident cough and drooling
- Wheezing and intercostal retractions
- Expiratory wheezing and nonproductive cough
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24. The burned client is ordered to receive intravenous cimetidine, an H2 histamine blocking agent, during the emergent phase. When the client's family asks why this drug is being given, what is the nurse's best response?
- "To increase the urine output and prevent kidney damage."
- "To stimulate intestinal movement and prevent abdominal bloating"
- "To decrease hydrochloric acid production in the stomach and prevent ulcers"
- "To inhibit loss of fluid from the circulatory system and prevent hypovolemic shock."
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25. After receiving a dose of penicillin, a client develops dyspnea and hypotension. Nurse Celestina suspects the client is experiencing anaphylactic shock. What should the nurse do first?
- Page an anesthesiologist immediately and prepare to intubate the client.
- Administer epinephrine, as prescribed, and prepare to intubate the client if necessary.
- Administer the antidote for penicillin, as prescribed, and continue to monitor the clients vital signs.
- Insert an indwelling urinary catheter and begin to infuse I.V. fluids as ordered.
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26. Situation: Mrs. Andreas brought his son, Johnny, age 3 to the Pediatric clinic. She noticed that her son is not speaking and tend to repeat everything she says. The mother also told the nurse that Johnny prefers to be alone, will cry when someone will come near him and tend to rock himself from morning till he will fell asleep.Q. The best treatment approach for autistic children is encouraging their desired behavior through positive reinforcement This is:
- Milieu Therapy
- Psychoanalysis
- Behavior Therapy
- Play Therapy
27. The nurse teaches a client about the effects of diphenhydramine, which has been prescribed as a cough suppressant The nurse determines that the client needs further instruction if the client makes which statement?
- "I will take the medication on an empty stomach”
- "I wont drink alcohol while taking this medication."
- "I won't do activities that require mental alertness while taking this medication”
- ”1 will use sugarless gum, candy or oral rinses to decrease dryness in my mouth”
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28. A pregnant client tells the clinic nurse that she wants to know the sex of her baby as soon as it can be determined. The nurse informs the client that she should be able to find out the sex at 12 weeks' gestation because of which factor?
- The appearance of the fetal external genitalia
- The beginning of differentiation in the fetal groin
- The fetal testes are descended into the scrotal sac
- The internal differences in males and females become apparent
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29. SITUATION : Wide knowledge about the human ear, its parts and its functions will help a nurse assess and analyze changes in the adult client's health.Q. Nurse Anna is doing a caloric testing to his patient, Aida, a 55 year old university professor who recently went into coma after being mauled by her disgruntled 3rd year nursing students whom she gave a failing mark. After instilling a warm water in the ear, Anna noticed a rotary nystagmus towards the irrigated ear. What does this means?
- Indicates a CN VIII Dysfunction
- Abnormal
- Normal
- Inconclusive
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30. Situation: If a child with diarrhea registers one sign in the pink row and one in the yellow; row in the IMCI Chart.If the child has sunken eyes, drinking eagerly thirsty and skin pinch goes back slowly the classification would be:
- no dehydration
- moderate dehydration
- some dehydration
- severe dehydration
31. Mr Bates is admitted to the surgical ICU following a left adrenalectomy. He is sleepy but easily aroused. An IV containing hydrocortisone is running. The nurse planning care for Mr. Bates knows it is essential to include which of the following nursing interventions at this time?
- Monitor blood glucose levels every shift to detect development of hypo- or hyperglycemia.
- Keep flat on back with minimal movement to reduce risk of hemorrhage following surgery.
- Administer hydrocortisone until vital signs stabilize, then discontinue the IV.
- Teach Mr. Bates how to care for his wound since he is at high risk for developing postoperative infection.
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32. In an individual with Sjogren s syndrome, nursing care should focus on:
- moisture replacement.
- electrolyte balance.
- nutritional supplementation.
- arrhythmia management.
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33. Caring is the essence and central unifying, a dominant domain that distinguishes nursing from other health disciplines. Care is an essential human need.
- Benner
- Watson
- Leininger
- Swanson
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34. SITUATION: Mr. Francisco, 70 years old, suddenly could not lift his spoons nor speak at breakfast He was rushed to the hospital unconscious. His diagnosis was CVA.Q. Considering Mr. Francisco's conditions, which of the following is most important to include in preparing Francisco's bedside equipment?
- Hand bell and extra bed linen
- Sandbag and trochanter rolls
- Footboard and splint
- Suction machine and gloves
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35. During a home visit, the client tells the nurse shes not taking prescribed doses of haloperidol (Haldol) because she's tired of bothering with it and doesn't need it. The nurse's best action is to:
- Explain the negative effects of skipping the medication.
- Consult with the physician about changing the medication to haloperidol decanoate (Haldol Decanoate) injections.
- Have the client's family begin commitment procedures so that her medication regimen can be supervised more closely.
- Refer the client to a partial hospitalization program so that she can participate regularly in group therapy sessions.
36. Nurse Lou considers shifting to transformational leadership. Which of the following statements best describes this type of leadership?
- Uses visioning as the essence of leadership
- Serves the followers rather than being served
- Maintains full trust and confidence in the subordinates
- Possesses innate charisma that makes others feel good in his presence.
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37. A client who is found unresponsive has arterial blood gases drawn and the results indicate the following: pH is 7.12, PaCO2 is 90 mm Hg (90 mm Hg), and HCO3A is 22 mEq/L (22 mmol/L). The nurse interprets the results as indicating which condition?
- Metabolic acidosis with compensation
- Respiratory acidosis with compensation
- Metabolic acidosis without compensation
- Respiratory acidosis without compensation
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38. Which of the following compilations should the nurse carefully monitors a client with acute pancreatitis.
- Myocardial Infarction
- Cirrhosis
- Peptic ulcer
- Pneumonia
39. A client is about to be discharged with a prescription for the antipsychotic agent haloperidol (Haldol), 10 mg by mouth twice per day. During a discharge teaching session, the nurse should provide which instruction to the client?
- Take the medication 1 hour before a meal.
- Decrease the dosage if signs of illness decrease.
- Apply a sunscreen before being exposed to the sun.
- Increase the dosage up to 50 mg twice per day if signs of illness don't decrease.
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40. The nurse is preparing a client with a new diagnosis of hypothyroidism for discharge. The nurse determines that the client understands discharge instructions if the client states that which signs and symptoms are associated with this diagnosis? Select all that apply. 1.Tremors. 2.Weight loss. 3.Feeling cold. 4.Loss of body hair. 5.Persistent lethargy. 6.Puffiness of the face
- 3,4,5,6
- 1,2,3,4
- 2,4,6
- 1,3,5
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41. Situation: The abuse of dangerous drug is a serious public health concern that nurses need to address,Q. The nurse should recognize that the unit primarily responsible for education and awareness of the members of the family on the ill effects of dangerous drugs is the:
- law enforcement agencies
- school
- church
- family
42. Situation: Nette, a nurse palpates the abdomen of Mrs. Medina, a primigravida. She is unsure of the date of her last menstrual period. Leopold's Maneuver is done. The obstetrician told mat she appears to be 20 weeks pregnantJn doing Leopold's maneuver palpation which among the following is NOT considered a good preparation?
- The woman should lie in a supine position with her knees flexed slightly
- The hands of the nurse should be cold so that abdominal muscles would contract and tighten
- Be certain that your hands are warm (by washing them in warm water first if necessary)
- The woman empties her bladder before palpation
43. A client is diagnosed with stage II Hodgkins lymphoma. The nurse recognizes that the client has involvement
- In a single lymph node or single site
- In more than one node or single organ on the same side of the diaphragm
- In lymph nodes on both sides of the diaphragm
- In disseminated organs and tissues
44. A home care patient with chronic obstructive pulmonary disease (COPD) reports an upset stomach. The patient is taking theophylline(Theo-Dur) and triamcinolone acetonide (Azmacort) The nurse should instruct the patient to take:
- Theo-dur an empty stomach
- Theo-dur and Azmacort at the same time
- Theo-dur and azmacort 12 hours apart
- Theo-dur milk or crackers
45. Which of the following is the best guarantee that the patients priority needs are met?
- Checking with the relative of the patient
- Preparing a nursing care plan in collaboration with the patient
- Consulting with the physician
- Coordinating with other members of the team
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46. SITUATION: Knowledge of the drug prophantheline bromide [Probanthine] Is necessary in treatment of various disorders.Q. What should the nurse caution the client when using this medication
- Avoid hazardous activities like driving, operating machineries etc.
- Take the drug on empty stomach
- Take with a full glass of water in treatment of ulcerative colitis
- I must take double dose if I missed the previous dose
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47. The nurse in a neonatal intensive care unit (NICU) receives a telephone call to prepare for the admission of a 43-week gestation newborn with Apgar scores of 1 and 4. In planning for admission of this newborn, what is the nurse's highest priority?
- Turn on the apnea and cardiorespiratory monitors.
- Connect the resuscitation bag to the oxygen outlet.
- Set up the intravenous line with 5% dextrose in water.
- Set the radiant warmer control temperature at 36.5 °C (97.6 F).
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48. Which client is at greatest risk for a Caesarean section due to cephalopeivic disproportion (CPD)?
- A 25-year-old gravida 2 para 1
- A 30-year-old gravida 3 para 2
- A 17-year-old gravida 1 para 0
- A 32-year-old gravida 1 para 0
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49. Contact transmission of infectious organism in the hospital is usually cause by
- Urinary catheterization
- Spread from patient to patient
- Spread by cross contamination via hands of caregiver
- Cause by unclean instruments used by doctors and nurses
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50. A home health nurse is visiting a patient who recently suffered a Cerebrovascular accident (CVA). The nurse would MOST likely implement which of the following interventions to prevent muscle and ligament deformities?
- Daily moist heat and isometric exercises
- Daily balance training and routine medications for pain
- Instruct patient to use non-affected side to perform activities of daily living
- Daily range of motion exercises.