NCLEX-RN | QB2 | Practice Exam #23 (50 questions)

All 50 questions are randomized each time you take the test, and do not appear in the same order.

 

1. A patient has an elevated prothrombin (PT) time. Which medication should the Nurse consider as a possible cause of the elevated PT Time?

• Rifampi
• Vitamin K
• Birth control pills
• Phenytoin (Dilantin)

2. A 70-year-old male who is recovering from a stroke exhibits signs of unilateral neglect. Which behavior is suggestive of unilateral neglect?

• The client is observed shaving only one side of his face.
• The client is unable to distinguish between two tactile stimuli presented simultaneously.
• The client is unable to complete a range without turning his head side to side.
• The client is unable to carry out cognitive and motor activity at the same time.

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3. Situation Team efforts is best demonstrated in the ORQ. The breakdown in teamwork is often times a failure in:

• Electricity
• inadequate supply
• Leg work
• Communication

4. A client with asthma has low pitched wheezes present on the final half of exhalation. One hour later the client has high pitched wheezes extending throughout exhalation. This change in assessment indicates to the nurse that the client

• Has increased airway obstruction
• Has improved airway obstruction
• Needs to be suctioned
• Exhibits hyperventilation

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5. A 6-year-old child with leukemia is hospitalized and is receiving combination chemotherapy. Laboratory results indicate that the child is neutropenic, and protective isolation procedures are initiated. The grandmother of the child visits and brings a fresh bouquet of flowers picked from her garden, and asks the nurse for a vase for the flowers. Which response should the nurse provide to the grandmother?

• "I have a vase in the utility room,and I will get it for you."
• "I will get the vase and wash it well before you put the flowers in it."
• "The flowers from your garden are beautiful, but should not be placed in the child's room at this time."
• "When you bring the flowers into the room, place them on the bedside stand as far away from the child as possible"

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6. The physician has prescribed Cyclogel (cyclopentolate hydrochloride) drops for a client following a scleral buckling. The nurse knows that the purpose of the medication is to:

• Rest the muse es of accommodation
• Prevent post-operative infection
• Constrict the pupils
• Reduce the production of aqueous humor

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7. A community health nurse is instructing a neighborhood class about botulism. The nurse teaches the group that the most likely mode of infection would be by:

• Direct contact with contaminated soil
• Direct contact with respiratory secretions
• Sexual intercourse
• Ingestion of contaminated food

8. A client is admitted to a psychiatric facility with a diagnosis of chronic schizophrenia. The history indicates that the client has been taking neuroleptic medication for many years. Assessment reveals unusual movements of the tongue, neck, and arms. Which condition should the nurse suspect?

• Tardive dyskinesia
• Dystonia
• Neuroleptic malignant syndrome
• Akathisia

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9. The nurse determines the client needs further instruction on cimetidine if which statements were made? Select all that apply. 1."I will take the cimetidine with my meals." 2."I'll know the medication is working if my diarrhea stops." 3."My episodes of heartburn will decrease if the medication is effective." 4."Taking the cimetidine with an antacid will increase its effectiveness " 5."I will notify my health care provider if I become depressed or anxious." 6."Some of my blood levels will need to be monitored closely since 1 also take warfarin for atrial fibrillation"

• 1,2,3
• 1,2,4
• 2,3,4
• 1,3,5

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Luer lok fitting IV tubing

Surgical hat cover

Disposable long-sleeve gown

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11. After taking an overdose of phenobarbital (Barbita), Mario is admitted to the emergency department. Dr. Trinidad prescribes activated charcoal (Charcocaps) to be administered by mouth immediately. Before administering the dose, the nurse verifies the dosage ordered. What is the usual minimum dose of activated charcoal?

• 5 g mixed in 250 ml of water
• 15 g mixed in 500 ml of water
• 30 g mixed in 250 ml of water
• 60 a mixed in 500 ml of water

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12. The chart of a client hospitalized for a total hip repair reveals that the client is colonized with MRSA. The nurse understands that the client:

• Will not display symptoms of infection
• Is less likely to have an infection
• Can be placed in the room with others
• Cannot colonize others with MRSA

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13. A nurse assessing a 16-month-old child observes bruises scattered over the body that are at different stage of healing. The child also has poor and diaper rash. The goal of treatment for this child is to:

• Ensure the physical and emotional safety of the child
• Remove the child from the parents
• Admonish the parents of the child
• Ensure that the child stays with the biological parents

14. The physician orders dextrose 5 % in water, 1,000 ml to be infused over 8 hours. The LV. tubing delivers 15 drops/ml. Nurse John should run the I.V. infusion at a rate of:

• 30 drops/minute
• 32 drops/minute
• 20 drops/minute
• 18 drops/minute

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15. Among the following clients, which among them is high risk for potential hazards from the surgical experience?

• 67-year-old client
• 49-year-old client
• 33-year-old client
• 15-year-old client

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16. The client is in stress because he was told by the physician he needs to undergo surgery for removal of tumor in his bladder. Which of the following are effects of sympatho-adreno- medullary response by the client? 1.Constipation. 2.Urinary frequency. 3.Hyperglycemia. 4.Increased blood pressure

• 1,2,4
• 1,4
• 3,4
• 1,3,4

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17. The nurse is caring for a client admitted with multiple trauma. Fractures include the pelvis femur and ulna. Which finding should be reported to the physician immediately?

• Hematuria
• Muscle spasms
• Dizziness
• Nausea

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18. A marathon runner experiences a sudden onset of sharp pain in calf immediately after workout The nurse in the clinic notes mild swelling of the calf and tenderness to touch. Which of the following would the nurse suspect the patient is experiencing?

• Bursitis
• Tendonitis
• Plantar fasciitis
• Joint dislocation

19. The nurse is caring for a client with stage III Alzheimers disease. A characteristic of this stage is:

• Memory loss
• Failing to recognize familiar objects
• Wandering at night
• Failing to communicate

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20. A patient in a one-car rollover presents with multiple injuries. Prioritize the interventions that must be initiated for this patient. A.Secure/start two large-bore IVs with normal saline. B.Use the chin lift or jaw thrust method to open the airway. C.Assess for spontaneous respirations. D.Give supplemental oxygen per mask. E.Obtain a full set of vital signs. F.Remove patient's clothing. G.Insert a Foley catheter if not contraindicated.

• C, B, D, A, E, F, G
• E, A, F, G, B, C, D
• D, A, F, E, B, C, G
• B, C, D, E, F, G, A

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21. Situation: One important toot a community health nurse uses in the conduct of his/her activities is the CHN Bag. Which of the following BEST DESCRIBES the use of this vital facility for our practice?ln consideration of the steps in applying the bag technique, which side of the paper lining of the CHN bag is considered clean to make a non-contaminated work area?

• The lower lip
• The outer surface
• The upper lip
• The inside surface

22. A patient returning from a3-hour shoulder repair with general anesthesia is being transported from the operating room (OR) to the post-anesthesia care unit (PACU). The nurse knows that the patient is at high risk for injury related to residual anesthesia. During this time period the patient is at LOWEST risk for

• Airway Obstruction
• Vomiting
• Impaired Circulation
• Fluid volume deficit

23. The nurse is preparing to give a bed bath to an immobilized client with tuberculosis. The nurse should wear which items when performing this care?

• Surgical mask and gloves
• Particulate respirator, gown, and gloves
• Particulate respirator and protective eyewear
• Surgical mask, gown, and protective eyewear

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24. A child has been diagnosed with acute otitis media of the right ear. Which interventions should the nurse include in the plan of care? Select all that apply. 1.Provide a soft diet 2.Position the child on the left side. 3.Administer an antihistamine twice daily. 4.Irrigate the right ear with normal saline every 8 hours. 5.Administer ibuprofen for fever every 4 hours as prescribed and as needed. 6.Instruct the parents about the need to administer the prescribed antibiotics for the full course of therapy.

• 2,3,5
• 1,4,5
• 1,5,6
• 1,2,3,4

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25. A client receiving haloperidol (Haldol) complains of a stiff jaw and difficulty swallowing. The nurse's first action is to:

• reassure the client and administer as needed lorazepam (Ativan) I.M.
• administer as needed dose of benztropine (Cogentin) I.M. as ordered.
• administer as needed dose of benztropine (Cogentin) by mouth as ordered.
• administer as needed dose of haloperidol (Haldol) by mouth.

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26. The client with right sided weakness needs to learn how to use a cane. The nurse plans to teach the client to position the cane by holding it with the:

• Left hand and placing the cane in front of the left foot
• Right hand and placing the cane in front of the right foot
• Left hand and 6 inches lateral to the left foot
• Right hand and 6 inches lateral to the left foot

27. SITUATION: a 20 year old college student was rushed to the ER of PGH after he fainted during their ROTC drill. Complained of severe right iliac pain. Upon palpation of his abdomen, Ernie jerks even on slight pressure. Blood test was ordered. Diagnosis is acute appendicitis.Q. NGT was connected to suction. In caring for the patient with NGT, the nurse must

• Irrigate the tube with saline as ordered
• Use sterile technique in irrigating the tube
• advance the tube every hour to avoid kinks
• Offer some ice chips to wet lips

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28. A client is found to be comatose and hypoglycemic with a blood sugar level 50 mg/dl. What nursing action is implemented first?

• Infuse 1000 ml of D5W over a 12-hour period
• Administer 50% glucose IV
• Check the clients urine for the presence of sugar and acetone
• Encourage the client to drink orange juice with added sugar

29. Situation: Burn is cause by transfer of heat source to the body. It can be thermal, electrical radiation or chemical.Q. The IV fluid of choice for burn as well as dehydration is:

• 0.45% NaCl
• NSS
• Sterile water
• D5LR

30. Situation: You are the nurse in the Out-Patient-Department and during your shift you encountered multiple children's condition. The following questions apply.Which of the following conditions is NOT true about contraindication to immunization?

• do not give DPT2 or DPT3 to a child who has convulsions within 3 days of DPT1
• do not give BOG if the child has known hepatitis .
• do not give OPT to a child who has recurrent convulsion or active neurologic disease
• do not give BCG if the child has known AIDS

31. A2-years-old child in the emergency department exhibits symptoms of bacterial meningitis. Which of the following tests confirm or rule out this diagnosed?

• Magnetic resonanceimaging (MRI)
• Magneto encephalogram
• Computed tomography scan(CT)
• Lumbar puncture (LP)

32. The nurse is conducting preoperative teaching with a client about the use of an incentive spirometer. The nurse should include which piece of information in discussions with the client?

• Inhale as rapidly as possible.
• Keep a loose seal between the lips and the mouthpiece.
• After maximum inspiration, hold the breath for 15 seconds and exhale.
• The best results are achieved when sitting up or with the head of the bed elevated 45 to 90 degrees.

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33. Assessment of a newborn male reveals that the infant has hypospadias. The nurse knows that:

• The infant should not be circumcised.
• Surgical correction will be done by six months of age.
• Surgical correction is delayed until six years of age.
• The infant should be circumcised to facilitate voiding.

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34. Dr. Marquez tells a client that an increase intake of foods that are rich in Vitamin E and beta-carotene are important for healthier skin. The nurse teaches the client that excellent food sources of both of these substances are:

• Fish and fruit jam
• Oranges and grapefruit
• Carrots and potatoes
• Spinach and mangoes

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35. The nurse is preparing to discharge a patient with chronic low back pain. Which statement by the patient indicates that additional teaching is necessary?

• "I will avoid exercise because the pain gets worse."
• "I will use heat or ice to help control the pain."
• "I will not wear high-heeled shoes at home or work."
• "I will purchase a firm mattress to replace my old one."

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36. Gina a postpartum client is diagnosed with endometritis. Which position would you expect to place her based on this diagnosis?

• Supine
• Left side lying
• Trendelinburg
• Semi-fowlers

37. A client has just had surgery to create an ileostomy. The nurse assesses the client in the immediate postoperative period for which most frequent complication of this type of surgery?

• Folate deficiency
• Malabsorption of fat
• Intestinal obstruction
• Fluid and electrolyte imbalance

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38. A patient who is 18-hour postoperative after an above-the knee amputation complaints of feeling like something is crawling under the dressing as well as increased pressure of the dressing. The nurse suspects hemorrhage. The patient's vital signs remain within the normal range. What should the nurse do FIRST?

• Call the physician
• Place ice around the dressing
• Encourage patient to discuss fears
• Lower the temperature of the room

39. A nurse is implementing nursing interventions to monitor a patient following kidney surgery. Which of the following complications would be the MOST likely post-operative risk after renal surgery?

• Deep vein thrombosis
• Hemorrhage
• Nausea
• Hemiparesis

40. A five month-old boy has been vomiting green colored vomit for ten hours. He has intermittent abdominal pain during which he draws his legs up to his chest, turns pale and cries forcefully. On observation, there is bleeding in the stool which has a jelly-like consistency. Abdominal palpation reveals a long tube-like mass. There is no fever, rash nor diarrhea. Bowel sounds are hyperactive in all quadrants.Which is the most likely form of initial treatment?

• Manual manipulation
• Surgical resection
• Barium enema
• Endoscopy

41. The community health nurse makes a home visit to a family. During the visit, the nurse observes that the mother is beating her child. What is the priority nursing intervention in this situation?

• Assess the child's injuries.
• Report the incident to protective agencies.
• Refer the family to appropriate support group.
• Assist the family to identify stressors and use of other coping mechanisms to prevent further incidents.

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42. In assessing the clients potential for an inhalation injury as a result of a flame burn, what is the most important question to ask the client on admission?

• "When was your last chest x-ray?"
• "Have you ever had asthma or any other lung problem?"
• "In what exact place or space were you when you were burned?"
• "Are you a smoker?"

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43. A pediatric client with ventricular septal defect repair is placed on a maintenance dosage of digoxin. The dosage is 8 mcg/kg/day and the client's weight is 7.2 kg. The health care provider (HOP) prescribes the digoxin to be given twice daily. The nurse prepares how many mcg of digoxin to administer to the client at each dose?

• 12.6 mcg
• 21.4mcg
• 28.8mcg
• 32.2mcg

44. Dr. House is about to conduct an ophthalmoscope examination. Which of the following, if done by a nurse, is a correct preparation before the procedure?

• Provide the necessary draping to ensure privacy
• Open the windows, curtains and Eight to allow better illumination
• Pour warm water over the ophthalmoscope to ensure comfort
• Darken the room to provide better illumination

45. Situation: Celina age 25, a ramp model, suddenly became blind after her boyfriend broke off with her. A thorough workup did not reveal any pathological findings.Q. Initially the relevant nursing diagnosis the nurse includes in her care plan is:

• Self-esteem disturbance
• impaired adjustment
• Ineffective individual coping
• Ineffective denial

46. Situation: You are now working as a staff nurse in a general hospital. You have to be prepared to handle situations with ethico-legaml and moral implications.Q. You are on night duty in the surgical ward. One of our patients Martin is prisoner who sustained an abdominal gunshot wound. He is being guarded by policemen from the local police unit. During your rounds you heard a commotion. You saw the policeman trying to hit Martin. You asked why he was trying to hurt Martin. He denied the matter. Which among the following activities will you do first?

• Write an incident report
• Call security officer and report the incident
• Call your nurse supervisor and report the incident
• Call the physician on duty

47. The nurse is caring for clients on a respiratory unit. Upon receiving the following client reports which client should be seen first?

• Client with emphysema expecting discharge
• Bronchitis client receiving IV antibiotics
• Bronchitis client with edema and neck vein distention
• COPD client with abnormal PO2

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48. For a normal person the urine specific gravity is ranged between:

• 1.000 and 1.010
• 1.015 and 1.025
• 1.025 and 1.050
• 1.050 and 1.070

49. The postterm neonate with meconium-stained amniotic fluid needs care designed to especially monitor for which of the following?

• Respiratory problems
• Gastrointestinal problems
• Integumentary problems
• Elimination problems

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50. A nurse is assigned to instruct a client in the method of testicular self-examination. The instruction should include mention that the best time to perform this task is:

• Immediately after getting out of bed in the morning
• Immediately before going to bed
• In the morning after breakfast
• After a warm bath or shower

 

NCLEX-RN | QB2 | Practice Exam #23 (50 questions)