NCLEX-RN | QB2 | Practice Exam #22 (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 measuring the chest tube drainage of a patient who had open heart surgery 4 hours ago. Which of the following is the MAXIMUM hourly amount of chest tube drainage that is expected in this time frame?
- 100ml
- 200ml
- 300ml
- 400ml
2. A patient is admitted to the hospital with klebsieilapneumoniae. During the initial intravenous dose of Amikin (amikacin sulfate), the patient develops severe respiratory distress. This is most likely:
- A side effect
- An indication of drug tolerance
- A drug allergy
- A toxic effect
3. In cleaning the thermometer after use, The direction of the cleaning to follow Medical Asepsis is:
- From bulb to stem
- From stem to bulb
- From stem to stem
- From bulb to bulb
4. The nurse is aware that the patients who are allergic to intravenous contrast media are usually also allergic to which of the following products?
- Eggs
- Shellfish
- Soy
- acidic fruits
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5. The physician has ordered Vancocin (vancomycin) 500mg IV every six hours for a client with MRSA. The medication should be administered:
- IV push
- Over 15 minutes
- Over 30 minutes
- Over 60 minutes
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6. The parents are anxious after the doctor tells that their child needs surgery. The assess parents' ability to cope with this anxiety, which of the following questions should the nurse ask
- "Did you know that feeling anxious about your child's surgery is normal?"
- "Can you wait until after surgery to begin to cope with being anxious?"
- "How do you think feeling of anxiety will affect your child?"
- "What has helped you when you felt anxious in the past?"
7. Nurses working in a midwifery office have attended a conference to learn about factors that increase a woman's risk of becoming infertile. To evaluate the nurses' learning, the conference coordinator tested the nurses' knowledge at the conclusion of the seminar. Which of the following problems should the nurses state increase a client's risk of developing infertility problems? Select all that apply. 1.Women who have menstrual cycles that are up to 30 days long. 2.Women who experience pain during intercourse. 3.Women who have had pelvic inflammatory disease. 4.Women who have excess facial hair. 5.Women who have menstrual periods that are over 5 days long.
- 2,3,4
- 1,3,5
- 1,2,4,5
- 1,2,3,4,5
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8. Marijuana is an example of a drug classified as schedule:
- C-I
- C-II
- C-III
- C-IV
9. A patient had a retinal detachment surgically repaired. The nurse identified that the detachment would MOST likely be correct and unlikely to reoccur if the retina remains attached at LEAST:
- 3 days
- 2 weeks
- 2 months
- 3 months
10. Situation: Baby Philip, a full term male child, is delivered by his mother who is RH negative.Q. If RhoGAm is given to Baby Philip's mother after delivering Baby Philip, the condition that must be present rbr the globulin to be effective is that:
- Philip's mother is Rh positive
- Baby Philip is Rh negative
- Philip's mother has no titer in her blood
- Philips mother has some titer in her blood
11. A client with autoimmune thrombocytopenia and a platelet count of 800/uL develops epistaxis and melena. Treatment with corticosteroids and immunoglobulins has been unsuccessful, and the physician recommends a splenectomy. The client states, "I don't need surgery—this will go away on its own." In considering her response to the client, the nurse must depend on the ethical principle of:
- beneficence
- autonomy
- advocacy
- justice
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12. The nurse is caring for a client diagnosed with paranoid personality disorder who is experiencing disturbed thought processes. In formulating a nursing plan of care, which best intervention should the nurse include?
- Increase socialization of the client with peers.
- Avoid using a whisper voice in front of the client.
- Begin to educate the client about social supports in the community.
- Have the client sign a release of information to appropriate parties for assessment purposes.
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13. The client with diabetes is preparing for discharge. During discharge teaching the nurse assesses the clients ability to care for himself. Which statement made by the client would indicate a need for follow-up after discharge?
- I live by myself.
- I have trouble seeing.
- I usually drive myself to the doctor.
- I have a cat in the house with me
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14. A client has 15% blood loss. Which of the following nursing assessment findings indicates hypovolemic shock?
- Systolic blood pressure less than 90mm Hg
- Pupils unequally dilated
- Respiratory rate of 4 breath/min
- Pulse rate less than 60 bpm
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15. A 16 year old child is hospitalized, according to Erik Erikson, what is an appropriate intervention?
- tell the friends to visit the child
- encourage patient to help child learn lessons missed
- call the priest to intervene
- tell the child's girlfriend to visit the child.
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16. The nurse is the first responder after a tornado has destroyed many homes in the community. Which victim should the nurse attend to first?
- A pregnant woman who exclaims, "My baby is not moving."
- A child who is complaining, "My leg is bleeding so bad, I am afraid it is going to fall off!"
- A young child standing next to an adult family member who is screaming, "I want my mommy!"
- An older victim who is sitting next to her husband sobbing, "My husband is dead. My husband is dead."
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17. The nurse is providing discharge teaching for the client with leukemia. The client should be told to avoid:
- Using oil- or cream-based soaps
- Flossing between the teeth
- The intake of salt
- Using an electric razor
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18. Situation: As a nurse researcher you must have a very good understanding of the common terms of concept used in research.Q. The recipients of experimental treatment is an experimental design or the individuals to be observed in a non experimental design are called:
- Setting
- Subjects
- Treatment
- Sample
19. The nurse is assessing a newborn after circumcision and notes that the circumcised area is red with a small amount of bloody drainage. Which nursing action is most appropriate?
- Apply gentle pressure.
- Reinforce the dressing.
- Document the findings.
- Contact the health care provider (HCP).
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20. Which one of the following symptoms is common in the client with duodenal ulcers?
- Vomiting shortly after eating
- Epigastric pain following meals
- Frequent bouts of diarrhea
- Presence of blood in the stools
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21. 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.A female client asks the nurse about the use of a cervical cap. Which statement is correct regarding the use of the cervical cap?
- It may affect Pap smear results.
- It does not need to be fitted by the physician.
- It does not require the use of spermicide.
- It must be removed within 24 hours.
22. A nonstress test is performed on a client who is pregnant, and the results of the test indicate non-reactive findings. The health care provider prescribes a contraction stress test, and the results are documented as negative. How should the nurse document this finding?
- A normal test result
- An abnormal test result
- A high risk for fetal demise
- The need for a cesarean section
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23. A client being measured for crutches asks the nurse why the crutches cannot rest up underneath the arm for extra support The nurse responds knowing that which would most likely result from this improper crutch measurement?
- A fall and further injury
- Injury to the brachial plexus nerves
- Skin breakdown in the area of the axilla
- Impaired range of motion while the client ambulates
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24. An elderly client is hospitalized for a transurethral prostatectomy. Which finding should be reported to the doctor immediately?
- Hourly urinary output of 40-50mL
- Bright red urine with many clots
- Dark red urine with few clots
- Requests for pain med every four hours
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25. A characteristic of the nursing process that is essential to promote client satisfaction and progress. The care should also be relevant with the client's needs.
- Organized and Systematic
- Humanistic
- Efficient
- Effective
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26. Situation: One of the realities that we are confronted with is mortality. It is important for us nurses to be aware of how we view suffering, pain, illness, and even our death as well as its meaning. That way we can help our patients cope with death and dying.Q. Ruby who has been told she has terminal cancer turns away aha refuses to respond to you. You can best help her by:
- Coming back periodically and indicating your availability if she would like you to sit with her
- Insisting that Ruby should talk with you because it is not good to Keep everything inside
- Leaving her alone because she is uncooperative and unpleasant to be with
- Encouraging her to be physically active as possible
27. Which of the following response is not expected to a person whose GAS is activated and the FIGHT OR FLIGHT response sets in?
- The client will not urinate due to relaxation of the detrusor muscle
- The client will be restless and alert
- Clients BP will increase, there will be vasodilation
- There will be increase glycogenolysis, Pancrease will decrease insulin secretion
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28. A 62-year-old male client was in a motor vehicle accident as an unrestrained driver. Hes now in the emergency department complaining of difficulty of breathing and chest pain. On auscultation of his lung field, no breath sounds are present in the upper lobe. This client may have which of the following conditions?
- Bronchitis
- Pneumonia
- Pneumothorax
- Tuberculosis (TB)
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29. During a prenatal class, the nurse explains the rationale for breathing techniques during preparation for labor based on the understanding that breathing techniques are most important in achieving which of the following?
- Eliminate pain and give the expectant parents something to do
- Reduce the risk of fetal distress by increasing uteroplacental perfusion
- Facilitate relaxation, possibly reducing the perception of pain
- Eliminate pain so that less analgesia and anesthesia are needed
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30. Nurse Benjie is communicating with a male client with substance-induced persisting dementia; the client cannot remember facts and fills in the gaps with imaginary information. Nurse Benjie is aware that this is typical of?
- Flight of ideas
- Associative looseness
- Confabulation
- Concretism
31. Situation: Joanna Marie, a 40 year old client was diagnosed with breast cancer.Q. Joanna was brought to the hospice. During your visit, Joanna expresses that "If I can just live a little longer to see my 3 sons finish college, J will be ready to die." Which phase of the grieving process Is Joanna experiencing?
- Denial
- Bargaining
- Depression
- Anger
32. The maternity nurse is providing instructions to a new mother regarding the psychosocial development of the newborn infant. Using Erikson's psychosocial development theory the nurse instructs the mother to take which measure?
- Allow the newborn infant to signal a need.
- Anticipate all needs of the newborn infant.
- Attend to the newborn infant immediately when crying.
- Avoid the newborn infant during the first 10 minutes of crying.
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33. The nurse is preparing to care for a child after a tonsillectomy. The nurse documents on the plan of care to place the child in which position?
- Supine
- Side-lying
- High Fowlers
- Trendelenburg
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34. During the initial interview the client reports that she has a lesion on the perineum. Further investigation reveals a small blister on the vulva that is painful to touch. The nurse is aware that the most likely source of the lesion is:
- Syphilis
- Herpes
- Gonorrhea
- Condylomata
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35. 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. A client with muscle contraction headache will exhibit a pattern different for Julie's. Which of the following is more compatible with tension headache?
- severe aching pain behind both eyes
- headache worse when bending over
- bandlike burning around the neck
- feeling of tightness bitemporally, occipitally, or in the neck
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36. The nurse is assigned to care to a 17-year-old male client with a history of substance abuse. The client asks the nurse, "Have you ever tried or used drugs?" The most correct response of the nurse would be:
- "Yes, once I tried grass"
- "No, I don't think so"
- "Why do you want to know that?"
- "How will my answer help you?"
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37. 1800 ml is equal to how many liters?
- 1.8
- 18
- 180
- 1800
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38. A patient is experiencing intermittent claudication in the legs while at rest. Which of the following should the nurse take?
- Vigorously massage the extremity
- Place ice on the ankles every 20 mnts
- Elevate the legs to heart level
- Position the legs in dependent position
39. When preparing to listen to the fetal heart rate at 12 weeks gestation, the nurse would use which of the following?
- Stethoscope placed midline at the umbilicus
- Doppler placed midline at the suprapubic region
- Fetoscope placed midway between the umbilicus and the xiphoid process
- External electronic fetal monitor placed at the umbilicus
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40. Nurse Trish is working in a mental health facility; the nurse priority nursing intervention for a newly admitted client with bulimia nervosa would be to?
- Teach client to measure I & O
- Involve client in planning daily meal
- Observe client during meals
- Monitor client continuously
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41. At a senior citizens meeting a nurse talks with a client who has diabetes mellitus Type 1. Which statement by the client during the conversation is most predictive of a potential for impaired skin integrity?
- "I give my insulin to myself in my thighs."
- "Sometimes when I put my shoes on I don't know where my toes are"
- "Here are my up and down glucose readings that I wrote on my calendar."
- "If I bathe more than once a week my skin feels too dry."
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42. Situation: Margie has been diagnosed with Bipolar I disorder. The client demonstrates extreme psychomotor agitation, flight of ideas, loud talking and elated mood.Q. Which of the following is a side effect of lithium toxicity?
- Anuria
- Oliguria
- Sudden burst of muscle strength
- Polyuria
43. A mother brings her 26 month-old to the well-child clinic. She expresses frustration and anger due to her child's constantly saying "no” and his refusal to follow her directions. The nurse explains this is normal for his age, as negativism is attempting to meet which developmental need?
- Trust
- Initiative
- Independence
- Self-esteem
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44. Situation: Maintenance of sterility is an important function a nurse should perform in any OR setting.Q. When you say sterile, it means:
- The material is clean.
- The material as well as the equipments are sterilized and had undergone a rigorous sterilization process
- There is a black stripe on the paper indicator
- The material has no microorganism nor spores present that might cause an infection
45. An ambulatory client reports edema during the day in his feet and an ankle that disappears while sleeping at night. What is the most appropriate follow-up question for the nurse to ask?
- "Have you had a recent heart attack?"
- "Do you become short of breath during your normal daily activities?"
- "How many pillows do you use at night to sleep comfortably?"
- "Do you smoke?"
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46. After discussing the possible effects of the low patient satisfaction rate, the staff started to list down possible strategies to solve the problems head-on. Should they decide to vote on the best change strategy, which of the following strategies is referred to this?
- Collaboration
- Majority rule
- Dominance
- Compromise
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47. Tertiary prevention is needed in which stage of the natural history of disease?
- Pre-pathogenesis
- Pathogenesis
- Predromal
- Terminal
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48. A client weighing 150 pounds has received burns over 50% of his body at 1200 hours. Using the Parkland formula calculate the expected amount of fluid that the client should receive by 2000 hours.
- "3400"
- "6800"
- "10200"
- "13600"
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49. The nurse is caring for a client following a Whipple procedure. The nurse notes that the drainage from the nasogastric tube is bile tinged in appearance and has increased in the past hour. The nurse should:
- Check the lab work.
- Administer an antiemetic.
- Obtain the blood pressure.
- Administer a sedative.
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50. A nursing graduate is attending an agency orientation regarding the nursing model of practice implemented in the health care facility. The nurse is told that the nursing model is a team nursing approach. The nurse determines that which scenario is characteristic of the team-based model of nursing practice?
- Each staff member is assigned a specific task for a group of clients.
- A staff member is assigned to determine the client's needs at home and begin discharge planning.
- A single registered nurse (RN) is responsible for providing care to a group of 6 clients with the aid of an unlicensed assistive personnel (UAP).
- An RN leads 2 licensed practical nurses(LPNs) and 3 LIAPs in providing care to a group of 12 clients.
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