NCLEX-RN | QB2 | Practice Exam #21 (50 questions)
All 50 questions are randomized each time you take the test, and do not appear in the same order.
1. A 35 year old female has intense fear of riding an elevator. She claims As if I will die inside." The client is suffering from:
- Agoraphobia
- Social phobia
- Claustrophobia
- Xenophobia
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2. What volume of air can safely be infused into a patient with a central venous access device (CVAD)?
- It is dependent on the patient's weight and height.
- Air entering the patient through a CVAD will follow circulation to the lungs where it will be absorbed and cause no problems.
- It is dependent on comorbidities such as asthma or chronic obstructive lung disease.
- None.
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3. Situation: Two children were brought to you. One with chest indrawing and the other had diarrhea. The following questions apply:Nina's treatment should include the following EXCEPT:
- Reassess the child and classify him for dehydration
- For infants under 6 months old who are not breastfed, give 100-200 ml clean water as well during this period.
- Give in the health center the recommended amount of ORS for 4 hours.
- Do not give any other foods to the child for home treatment
4. Tonic contractures of muscles in the neck, mouth, and tongue. The nurse should recognize this as:
- psychotic symptoms
- parkinsonism
- akathisia
- dystonia
5. A client with human immunodeficiency syndrome has gastrointestinal symptoms including diarrhea. The nurse should teach the client to avoid:
- Calcium-rich foods
- Canned or frozen vegetables
- Processed meat
- Raw fruits and vegetables
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6. Which of the following parameters would the nurse monitor to evaluate the effectiveness of thickened feedings for an infant with gastroesophageal reflux (GER)?
- Vomiting
- Stools
- Uterine
- Weight
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7. The community health nurse is creating a poster for an educational session for a group of women and will be discussing the risk factors associated with breast cancer Which risk factors for breast cancer should the nurse list on the poster? Select all that apply. 1.Multiparity. 2.Early menarche. 3.Early menopause. 4.Family history of breast cancer. 5.High-dose radiation exposure to chest. 6.Previous cancer of the breast, uterus, or ovaries
- 1,2,4,5,6
- 2,4,5,6
- 3,4,5
- 1,2,3,4
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8. A client with a serum glucose level of 618 mg/dl is admitted to the facility. Hes awake and oriented, has hot dry skin, and has the following vital signs: temperature of 100.6° F (38.1° C), heart rate of 116 beats/minute, and blood pressure of 108/70 mm Hg. Based on these assessment findings, which nursing diagnosis takes the highest priority?
- deficient fluid volume related to osmotic diuresis
- decreased cardiac output related to elevated heart rate
- imbalanced nutrition: Less than body requirements related to insulin deficiency
- ineffective thermoregulation related to dehydration
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9. Four clients are admitted to a medical unit If only one private room is available it should be assigned to:
- The client with ulcerative colitis
- The client with neutropenia
- The client with cholecystitis
- The client with polycythemia vera
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10. The long-term care nurse is performing assessments on several of the residents. Which are normal age-related physiological changes the nurse should expect to note? Select all that apply. 1.Increased heart rate. 2.Decline in visual acuity. 3.Decreased respiratory rate. 4.Decline in long-term memory. 5.Increased susceptibility to urinary tract infections. 6.Increased incidence of awakening after sleep onset
- 1,2,5,6
- 2,3,5
- 1,3,4,5
- 2,5,6
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11. The physician has prescribed quinidine polygalacturonate (Apo-Quinidine), 8.25 mg/kg every 4 hours for a patient who weighs 50kgs. The drug is available as a 275 mg tablet. The nurse should administer how many tablets for each dose?
- 2,5
- 2
- 1,5
- 1
12. A patient comes to the medical office with complaints of some urinary incontinence. The nurse discovers the incontinence occurs because of an inability to delay voiding long enough to reach a toilet after the patient feels a sensation of bladder fullness. This type of incontinence is:
- Stress
- Functional
- Overflow
- Urge
13. The nurse is planning care for a child with hemolytic-uremic syndrome who has been anuric and will be receiving peritoneal dialysis treatment The nurse should plan to implement which measure?
- Restrict fluids as prescribed.
- Care for the arteriovenous fistula.
- Encourage foods high in potassium.
- Administer analgesics as prescribed.
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14. 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
15. Situation: Dennis 40 y/o married man, an electrical engineer was admitted with the diagnosis of paranoid disorders. He has became suspicious and distrustful 2 months before admission. Upon admission, he kept on saying, "my wife has been planning to kill me." Q. One morning, Dennis was seen tilting his head as if he was listening to someone. An appropriate nursing intervention would be:
- Tell him to socialize with other patient to diverts his attention
- Involve him in group activities
- Address him by name to ask if he is hearing voices again
- Request for an order of antipsychotic medicine
16. Six hours after birth the infant is found to have an area of swelling over the right parietal area that does not cross the suture line. The nurse should chart this finding as:
- A cephalhematoma
- Molding
- Subdural hematoma
- Caput succedaneum
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17. The primary complication of a central venous access device (CVAD) is:
- Thrombus formation in the vein.
- Pain and discomfort.
- Infection.
- Occlusion of the catheter as the result of an intra-lumen clot.
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18. The physician has prescribed a Becioforte (beciomethasone) inhaler two puffs twice a day for a client with asthma. The nurse should tell the client to report:
- Increased weight
- A sore throat
- Difficulty in sleeping
- Changes in mood
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19. Situation: The nurse is often met with the following situations when clients become angry and hostile.Q. To encourage thought Which of the following approaches is NOT therapeutic?
- "Why do you feel angry?"
- "When do you usually feel angry?"
- "How do you usually express anger?"
- "What situations provoke you to be angry?"
20. In evaluating the appropriateness of various exercises enjoyed by a patient with osteoporosis, the nurse would recommend:
- Walking
- Bowling
- Sit-ups
- GOT
21. In Leopold s maneuver step #3 you palpated a hard round movable mass at the supra pubic area. The correct interpretation is that the mass palpated is:
- The buttocks because the presentation is breech.
- The mass palpated is the head.
- The mass is the fetal back.
- The mass palpated is the fetal small part.
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22. The nurse in the emergency department is responsible for the triage of four recently admitted clients. Which client should the nurse send directly to the treatment room?
- A 23-year-old female complaining of headache and nausea
- A 76-year-old male complaining of dysuria
- A 56-year-old male complaining of exertional shortness of breath
- A 42-year-old female complaining of recent sexual assault
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23. A client admitted to the psychiatric unit claims to be the Pope and insists that he will not be kept away from his subjects. The most likely explanation for the clients delusion is:
- A reaction formation
- A stressful event
- Low self-esteem
- Overwhelming anxiety
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24. The clinic nurse instructs parents of a child with sickle cell anemia about the precipitating factors related to sickle cell crisis. Which, if identified by the parents as a precipitating factor, indicates the need for further instruction?
- Stress
- Trauma
- Infection
- Fluid overload
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25. A nurse is caring for a patient receiving total parenteral nutrition (TPN). The patient reports the sudden onset of feeling short of breath and anxious. The nurse hears crackles in bilateral lower lobes of the lungs and the patient's O2 saturation is 90% on room air. The nurse must IMMEDIATELY:
- Turn off the TPN
- Notify the physician
- Asses the patient's capillary blood glucose level
- Attempt to suction the patient's airway
26. A male clients left tibia was fractured in an automobile accident, and a cast is applied. To assess for damage to major blood vessels from the fracture tibia, the nurse in charge should monitor the client for:
- Swelling of the left thigh
- Increased skin temperature of the foot
- Prolonged reperfusion of the toes after blancing
- Increased blood pressure
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27. A patient undergoing cancer treatment has developed acute hypocalcaemia with sign of weakness, nausea and vomiting. Which of the following would the nurse anticipate to be the initial treatment?
- Thiazide diuretic
- Intravenous normal saline(0.9% NaCI)
- A potassium supplement
- Broad-spectrum antibiotic
28. Mrs. Hogan, a 43-year-old woman, is admitted to your unit for cholecystectomy. Q. Mrs. Hogan is transported to the recovery room following her cholecystectomy. As you continue to check her vital signs you note a continuing trend in Mrs. Hogan's status: her BP is gradually dropping and her pulse rate is increasing. Your most appropriate nursing action is to:
- Order whole blood for Mrs. Hogan from the lab
- Increase IV fluid rate of infusion and place in trendelenburg position
- Immediately report signs of shock to the head nurse and/or surgeon and monitor VS closely
- Place in latera sims position to facilitate breathing
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29. A nurse teaches a woman who wishes to become pregnant that if she assesses for spinnbarkeit she will be able closely to predict her time of ovulation. Which technique should the client be taught in order to assess for spinnbarkeit?
- Take her temperature each morning before rising.
- Carefully feel her breasts for glandular development.
- Monitor her nipples for signs of tingling and sensitivity.
- Assess her vaginal discharge for elasticity and slipperiness.
30. The client with enuresis is being taught regarding bladder retraining. The nurse should advise the client to refrain from drinking after:
- "700"
- "1000"
- "1200"
- "1900"
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31. A client is admitted to the emergency department following a fall from a horse and the health care provider (HCP) prescribes insertion of a urinary catheter. While preparing for the procedure, the nurse notes blood at the urinary meatus. The nurse should take which action?
- Notify the HCP before performing the catheterization.
- Use a small-sized catheter and an anesthetic gel as a lubricant.
- Administer parenteral pain medication before inserting the catheter.
- Clean the meatus with soap and water before opening the catheterization kit.
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32. Situation: Jolina is an 18 year old beginning college student Her mother observed that she is having problems relating with her friends. She is undecided about her future. She has lost insight, lost interest in anything and complained and complained of constant tiredness.Q. After one week of antidepressant medication; Jolina still manifests depression. The nurse evaluates this as:
- Unusual because action of antidepressant drug is immediate
- Unexpected because therapeutic effectiveness takes within a few days
- Expected because therapeutic effectiveness takes 2-4 weeks
- Ineffective result because perhaps the drug's dosage is inadequate
33. A nursing assistant assigned to care for a client receiving linear accelerator radium therapy for laryngeal cancer states I don't want to be assigned to that radioactive patient.0 The best response by the nurse is to:
- Tell the nursing assistant that the client is not radioactive.
- Tell the nursing assistant to wear a radiation badge to detect the amount of radiation that she is receiving.
- instruct her regarding the use of a lead-lined apron.
- Ask a co-worker to care for the client.
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34. The nurse is watching the cardiac monitor and notices that the rhythm suddenly changes. There are no P waves, the QRS complexes are wide, and the ventricular rate is regular but more than 140 beats/minute. The nurse determines that the client is experiencing which dysrhythmia?
- Sinus tachycardia
- Ventricular fibrillation
- Ventricular tachycardia
- Premature ventricular contractions
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35. Which of the following assessments would be important for the nurse to make to determine whether or not a client is recovering as expected from spinal anesthesia?
- Level of consciousness
- Rate and depth of respirations
- Rate of capillary refill in the toes
- Degree of response to pinpricks in the legs and toes
36. A patient with advanced lung cancer is exhibiting cyanosis and edema of the head and upper extremities. Which of the following intervention would MOST likely provide an immediate benefit for this patient?
- Place in Trendelenburg position
- Position on the right side
- Elevate the head of the bed
- Elevate extremities
37. A child is treated for bacterial meningitis with an intravenous antimicrobial agent Which of the following BEST indicates effectiveness of the treatment?
- Increased appetite
- Temperature 37.2 C (99 F)
- Episodes of apnoea
- increased intra cranial pressure
38. The nurse in the emergency department is caring for a young female victim of sexual assault The client's physical assessment is complete, and physical evidence has been collected. The nurse notes that the client is withdrawn, confused, and at times physically immobile. How should the nurse interpret these behaviors?
- Signs of depression
- Reactions to a devastating event
- Evidence that the client is a high suicide risk
- Indicative of the need for hospital admission
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39. Skeletal traction is applied to the right femur of a client injured in a fall. The primary purpose of the skeletal traction is to:
- Realign the tibia and fibula.
- Provide traction on the muscles.
- Provide traction on the ligaments.
- Realign femoral bone fragments.
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40. Situation: Understanding different models of care is a necessary part of the nurse patient relationship.Q. The nurse is preparing to provide reminiscence activity for a group of clients. Which of the following clients will the nurse select for this group?
- A client who experiences profound depression with moderate cognitive impairment
- A catatonic, immobile with moderate cognitive impairment
- An undifferentiated schizophrenic client with moderate cognitive impairment
- A client with mild depression who exhibits who demonstrates normal cognition
41. The nurse is providing instructions to the unlicensed assistive personnel (IIAP) regarding care of an older client with hearing loss. What should the nurse tell the LIAP about older clients with hearing loss?
- They are often distracted.
- They have middle ear changes.
- They respond to low-pitched tones.
- They develop moist cerumen production.
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42. Oxtriphylline (Choledyl SA) 0.2 g has been ordered. Available tablets are lOOmg. How many tablets should be given?
- 0.5 tablets
- 2.0 tablets
- 2.5 tablets
- 5.0 tablets
43. Prior to providing care for a hospitalized infant, the nurse MUST:
- Introduce self to parent
- Perform hand hygiene
- Have a witness present
- Assess the child's developmental level
44. A home health nurse has completed the assessment of a 72-year-old patient with & gait disturbance that will begin home physical therapy. During the interview, the patient reported significant difficulty sleeping more than 4 hours at night Which of the following responses would be appropriate for the nurse to make?
- "Try doing some type of exercise two hours before bedtime"
- "Drink a cup of warm tea before you go to bed"
- "Make sure the bedroom is dark when you get in bed"
- "A nap in the middle of the day should help"
45. Situation: If a child with diarrhea registers one sign in the pink row and one in the yellow; row in the IMCI Chart.Q. 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
46. A 59-year-old patient arrives in the emergency department diaphoretic and complains of chest pain and shortness of breath. The patient's sibling states that this has happened before and it is just anxiety. Upon evaluation the physician diagnosis unstable angina and prescribes anti-anginal medications. What is the expected results of this drug therapy
- Balanced between oxygen supply and demand
- Increase in blood flow to the heart
- Reduction in oxygen demand and consumption
- Vessel relaxation
47. The nurse is monitoring a client in labor. The nurse suspects umbilical cord compression if which is noted on the external monitor tracing during a contraction?
- Variability
- Accelerations
- Early decelerations
- Variable decelerations
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48. During conversation of Nurse John with a client, he observes that the client shift from one topic to the next on a regular basis. Which of the following terms describes this disorder?
- Flight of ideas
- Concrete thinking
- Ideas of reference
- Loose association
49. A nurse is providing education in a community setting about general measures to avoid excessive sun exposure. Which of the following recommendations is appropriate?
- Apply sunscreen only after going in the water.
- Avoid peak exposure hours from 9am to 1pm
- Wear loosely woven clothing for added ventilation
- Apply sunscreen with a sun protection factor (SPF) of 15 or more before sun exposure.
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50. The patient states My stomach hurts about two hours after I eat v Based upon this information the nurse suspects the patient likely has a:
- Gastric ulcer
- Duodena ulcer
- Peptic ulcer
- Curlings ulcer