NCLEX-RN | QB2 | Practice Exam #24 (50 questions)
All 50 questions are randomized each time you take the test, and do not appear in the same order.
1. The primary reason for rapid continuous rewarming of the area affected by frostbite is to:
- Lessen the amount of cellular damage
- Prevent the formation of blisters
- Promote movement
- Prevent pain and discomfort
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2. Nurse Donna is aware that the shift of body fluids associated with Intravenous administration of albumin occurs in the process of:
- Osmosis
- Diffusion
- Active transport
- Filtration
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3. The clinic nurse is assessing jaundice in a child with hepatitis. Which anatomical area would provide the best data regarding the presence of jaundice?
- The nail beds
- The skin in the sacral area
- The skin in the abdominal area
- The membranes in the ear canal
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4. Situation: ENTEROSTOMAL THERAPY is now considered especially in nursing. You are participating in the OSTOMY CARE CLASS.Q. You would know after teaching. Fermin that dietary instruction for him is effective when he states, "ft is important that I eat:
- Soft foods that are easily digested and absorbed by my large intestine"
- Bland food so that my intestines do not become irritate"
- Food low in fiber so that there is less stool."
- Everything that I ate before the operation, while avoiding foods that cause gas.
5. Which of the following is NOT a contraindication in taking ORAL temperature?
- Quadriplegic
- Presence of NGT
- Dyspnea
- Nausea and Vomitting
6. The examination that indicates physical inspection of the vagina and cervix with palpation of uterus and ovaries is called:
- A Pap test.
- Electrocardiography.
- Pelvic examination.
- Paracentesis.
7. A male patient needs to receive a unit of whole blood. What type of intravenous (IV) device should the nurse consider starting?
- A small catheter to decrease patient discomfort
- The type of IV device the patient has had in the past which worked well
- A large bore catheter
- The type of device the physician prefers
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8. Situation: There are other important basic knowledge in the performance of our task as Community Health Nurse in relation to IMMUNIZATION these include:The correct temperature to store vaccines in a refrigerator is:
- between -4 deg C and +8 deg C
- between 2 deg C and +8 deg C
- between -8 deg C and 0 deg C
- between -8 deg C and +8 deg C
9. 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 pregnant.In her pregnancy, she experienced fatigue and drowsiness. This probably occurs because:
- of high blood pressure
- she is expressing pressure
- the fetus utilizes her glucose stores and leaves her with a Sow blood glucose
- of the rapid growth of the fetus
10. Situation: Mrs. Cruz was admitted in the Medical Floor due to pyrosis, dyspepsia and difficulty of swallowing.Q. Based from the symptoms presented, Nurse Yoshi might suspect:
- Esophagitis
- Hiatal hernia
- GERD
- Gastric Ulcer
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11. A patient has been hospitalized with a new diagnosis of crohn's disease. The nurse best determine the patients hydration level by monitoring the:
- Color of urine
- Brightness of eyes
- Capillary refill in nail beds
- Temperature of lower extremities
12. A child with asthma is experiencing thick respiratory secretions resulting in increased work of breathing. The best nursing intervention is to:
- Encourage fluids
- Eliminate dairy products
- Decrease relative humidity of the room
- Have the child lay on the left side.
13. The nurse is monitoring the laboratory results of a client receiving an antineoplastic medication by the intravenous route. The nurse plans to initiate bleeding precautions if which laboratory result is noted?
- A clotting time of 10 minutes
- An ammonia level of 10 mcg/dL (6 mcmol/L).
- A platelet count of 50,000 mm3 (50X10^9/L)
- A white blood cell count of 5000 mm3 (5.0X10^9/L)
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14. The clinic nurse is performing an admission assessment on a client and notes that the client is taking azelaic acid. The nurse determines that which client complaint may be associated with use of this medication?
- Itching
- Euphoria
- Drowsiness
- Frequent urination
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15. A client has just been admitted with portal hypertension. Which nursing diagnosis would be a priority in planning care?
- Fluid volume excess
- Potential complication hemorrhage
- Ineffective individual coping
16. A client in labor has been given epidural anesthesia with Marcaine (bupivacaine). To reverse the hypotension associated with epidural anesthesia the nurse should have which medication available?
- Narcan (naloxone)
- Dobutrex (dobutamine)
- Romazicon (flumazenil)
- Adrenalin (epinephrine)
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17. The nurse is aware that the primary nursing diagnosis for the client is:
- Altered nutrition: less than body requirement
- Altered nutrition: more than body requirement
- Impaired tissue integrity
- Risk for malnutrition
18. The nurse is assisting a patient to ambulate in hall. The patient has a history of coronary artery disease (CAD) and had coronary artery bypass graft surgery (CABG) 3 days ago. The patient reports chest pain rated 3 on a scale of 0 (no pain) to 10 (severe pain). The nurse should first:
- Determine how long it has been since the patient's last dose of aspirin
- Obtain a chair for the patient to sit down
- Assess the patient's radial pulse
- Ask the patient to take several slow, deep breaths.
19. Reyes syndrome, a potentially fatal illness associated with liver failure and encephalopathy is associated with the administration of which over-the-counter (OTC) medication?
- acetaminophen (Tylenol)
- ibuprofen (Motrin)
- aspirin
- brompheniramine/pseudoephedrine (Dimetapp)
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20. A 65 years old male client requests his medication at 9 p.m. instead of 10 p.m. so that he can go to sleep earlier. Which type of nursing intervention is required?
- Independent
- Dependent
- Interdependent
- Intradependent
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21. Clay colored stools indicate:
- Upper GI bleeding
- Impending constipation
- An effect of medication
- Bile obstruction
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22. Situation: Nurse Minette is an independent nurse practitioner following-up referred clients in their respective homes. Here she handles a case of POSTPARTUM MOTHER AND FAMILY focusing on HOME CARE.Q. Nurse Minette needs to schedule a first home visit to OB client Leah. When is a first home-care visit typically made?
- Within 4 days after discharge
- Within 24 hours after discharge
- Within 1 hour after discharge
- Within 1 week of discharge
23. Situation: Basic knowledge on Intravenous solutions is necessary for care of clients with problems with fluids and electrolytes. Q. The nurse is making initial rounds on the nursing unit to assess the condition or assigned clients. The nurse notes that the client's IV site is cool, pale and swollen and the solution is not infusing. The nurse concludes that which of the following complications has been experienced by the client?
- Infection
- Phlebitis
- Infiltration
- Thrombophlebitis
24. A patient with exacerbation of congestive heart failure has a nursing diagnosis of excess fluid volume. The nurse monitors fluids intake and output and administers furosemide, as ordered. Which of the following indicates the efficacy of the intervention?
- The patient has pitting edema
- The patient has shortness of breath
- The patient has a decrease in weight
- The patient has jugular vein distention
25. Which of the following laboratory values is expected for a client just diagnosed with chronic lymphocytic leukemia?
- Elevated sedimentation rate
- Uncontrolled proliferation of granulocytes
- Thrombocytopenia and increased lymphocytes
- Elevated aspartate aminotransferase and alanine aminotransferase levels.
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26. Diagnosis of leprosy is highly dependent on recognition of symptoms. Which of the following is an early sign of leprosy?
- Macular lesions
- Inability to close eyelids
- Thickened painful nerves
- Sinking of the nose bridge
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27. She knows that performance appraisal consists of all the following activities EXCEPT:
- Setting specific standards and activities for individual performance.
- Using agency standards as a guide.
- Determine areas of strength and weaknesses
- Focusing activity on the correction of identified behavior.
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28. What is true of primary facilities?
- They are usually government-run
- Their services are provided on an out-patient basis
- They are training facilities for health professionals
- A community hospital is an example of this level of health facilities
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29. Situation: Mrs. Pichay is admitted to your ward. The MD ordered Prepared for thoracentesis this pm to remove excess air from the pleural cavity.Q. During thoracentesis, which of the following nursing intervention will be most crucial?
- Place patient in a quiet and cool room
- Maintain strict aseptic technique
- Advise patient to sit perfectly still during needle insertion until it has been withdrawn from the chest
- Apply pressure over the puncture site as soon as the needle is withdrawn
30. The nurse assists with a lumbar puncture on a child with suspect bacterial meningitis. If the diagnosis is correct, the cerebrospinal fluid, should have which of the following qualities?
- High glucose level
- Low protein level
- Cloudy or turbid appearance
- Pink or blood-tinged appearance
31. When the license of nurse Krina is revoked, it means that she:
- Is no longer allowed to practice the profession for the rest of her life
- Will never have her/his license re-issued since it has been revoked
- May apply for re-issuance of his/her license based on certain conditions stipulated in RA 9173
- Will remain unable to practice professional nursing
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32. This patient care model works best when there are plenty of patient but few nurses
- Functional nursing
- Team nursing
- Primary nursing
- Total patient care
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33. Several clients is newly admitted and diagnosed with leprosy. Which of the following clients should be classified as a case of multibacillary leprosy?
- 3 skin lesions, negative slit skin smear
- 3 skin lesions, positive slit skin smear
- 5 skin lesions, negative slit skin smear
- 5 skin lesions, positive slit skin smear
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34. A client with paranoid schizophrenia repeatedly uses profanity during an activity therapy session. Which response by the nurse would be most appropriate?
- "Your behavior wont be tolerated. Go to your room immediately."
- "You re just doing this to get back at me for making you come to therapy."
- "Your cursing is interrupting the activity. Take time out in your room for 10 minutes."
- "I'm disappointed in you. You can't control yourself even for a few minutes."
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35. Mr. Duffy is admitted to the CCll with a diagnosis of R/O Ml. He presented in the ER with a typical description of pain associated with an Ml, and is now cold and clammy, pale and dyspneic. He has an IV of D5W running, and is complaining of chest pain. Oxygen therapy has not been started, and he is not on the monitor. He is frightened.Q. On his second day in CCll Mr. Duffy suffers a life-threatening cardiac arrhythmia. Considering his diagnosis, which is the most probable arrhythmia?
- atrial tachycardia
- ventricular fibrillation
- atrial fibrillation
- heart block
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36. Dr. Rodriguez orders 250 milliliters of packed red blood cells (RBC) for a patient This therapy is administered for treatment of:
- Thrombocytopenia.
- Anemia.
- Leukopenia.
- Hypoalbuminemia.
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37. A couple has brought in their Toddler daughter for examination. The parents tell the nurse that they are worried about all the safety risks for this age group. As the nurse plans to teach the parents about these risks, the nurse remembers that toddler are at a greater risk for injury from:
- Poisoning and child abduction
- Home accidents
- Physiological changes of aging
- Automobile accidents, suicide, and substance abuse
38. All of the following are assessment sites for body temperature except:
- Oral Site.
- Rectal Site.
- Axillary Site.
- Apical
39. Situation Nurses hold a variety of roles when providing care to a perioperative patient.Q. Which of the following role would be the responsibility of the scrub nurse?
- Assess the readiness of the client prior to surgery
- Ensure that the airway is adequate
- Account for the number of sponges, needles, supplies, Used during the surgical procedure
- Evaluate the type of anesthesia appropriate for the surgical client
40. Emergency medical technicians transport a 28 yr-old iron worker to the emergency department. They tell the nurse, "He fell from a two-story building. He has a large contusion on his left chest and a hematoma in the left parietal area. He has compound fracture of his left femur and he's comatose. We intubated him and he's maintaining an arterial oxygen saturation of 92% by pulse oximeter with a manual-resuscitation bag." Which intervention by the nurse has the highest priority?
- Assessing the left leg
- Assessing the pupils
- Placing the client in Trendelenburg's position
- Assessing the level of consciousness
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41. Which of the following blood vessel layers may be damaged in a client with an aneurysm?
- External
- Internal
- Media
- Internal and Medial
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42. Before turning Mr. Hans to wash his back, which instruction should the nurse provide to minimize his discomfort?
- Hold your breath as you are turning.
- Move your upper body first then legs.
- Curl up in a ball before you move.
- Avoid twisting your body while moving.
43. Situation: Survey and Statistics are important part of research that is necessary to explain the characteristics of the population.Q. The researcher implemented a medication regimen using a new type of combination of drugs to manic patients while another group of manic patient receives the routine drugs. The researcher however hand picked the experimental group for they are the clients with multiple episodes of bipolar disorder. The researcher utilized which research design?
- Quasi-experimental
- Pure experimental
- Phenomenological
- Longitudinal
44. Which meal tray should the nurse deliver to a client of Orthodox Judaism faith who follows a kosher diet?
- Pork roast, rice, vegetables, mixed fruit, milk
- Crab salad on a croissant, vegetables with dip, potato salad, milk
- Noodles and cream sauce with shrimp and vegetables, salad, mixed fruit, iced tea
- Sweet and sour chicken with rice and vegetables, mixed fruit juice
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45. Heberdens nodes are a common sign of osteoarthritis. Which of the following statement is correct about this deformity?
- It appears only in men
- It appears on the distal interphalangeal joint
- It appears on the proximal interphalangeai joint
- It appears on the dorsolateral aspect of the interphalangeal joint.
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46. Situation: Nurse Anna is a new BSEN graduate and has just passed her Licensure Examination for Nurses in the Philippines. She has likewise been hired as a new Community Health Nurse in one of the Rural Health Units in their City which of the following conditions may be acceptable TRUTHS applied to Community Health Nursing Practice.Which of the following is the primary focus of community health nursing practice?
- Cure of illnesses
- Prevention of illness
- Rehabilitation back to health
- Promotion of health
47. The patient with migraine headaches has a seizure. After the seizure, which action can you delegate to the nursing assistant?
- Document the seizure.
- Perform neurologic checks.
- Take the patients vital signs.
- Restrain the patient for protection.
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48. A client is to begin a 6-month course of therapy with isoniazid. The nurse should plan to teach the client to take which action?
- Use alcohol in small amounts only.
- Report yellow eyes or skin immediately.
- Increase intake of Swiss or aged cheeses.
- Avoid vitamin supplements during therapy.
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49. When should the client test his blood sugar levels for greater accuracy?
- During meals
- In between meals
- Before meals
- 2 Hours after meals
50. Situation: The mental health - psychiatric nurse functions in a variety of setting with different types of clients.Q. The parents of special children who are behaviorally disturbed need mental health education. Which of these topics would the school nurse consider as priority for their parents' class?
- Drug education
- Child abuse
- Effective parenting
- Sex education