NCLEX-RN | QB2 | Practice Exam #25 (50 questions)

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

 

1. Situation: Mastery of Psychotropic medications is necessary for the therapeutic improvement in the health of the psychiatric clients.Q. The nurse knows that the relationship between sodium and lithium is that:

• When lithium increases, sodium also increases
• When sodium increases, lithium also increases
• They are inversely proportional
• They are directly proportional

2. A nursing student is teaching a patient and family about epilepsy prior to the patients discharge. For which statement should you intervene?

• "You should avoid consumption of all forms of alcohol?"
• "Wear you medical alert bracelet at all times"
• "Protect your loved one's airway during a seizure."
• "Its OK to take over-the-counter medications."

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3. After total knee replacement a patient is being discharged to home after which he will ambulate with a four-prong cane. When providing patient teaching regarding going up and down stairs with the cane, the first step in gong up stairs is to

• Place the unaffected extremity up on the step
• Place the cane up on the step
• Step-up on the affected extremity
• Step-up on the unaffected extremity

4. Situation: Care of clients with tracheotosmy is often a challenge to a beginning nurse. The following questions will test your knowledge on Tracheostomy and its related care.Q. The size of the Tracheostomy tube is denoted in terms of:

• French
• Gauge
• Units
• Size / mmID

5. A 22 year old client suffered from his first tonic-clonic seizure. Upon awakening the client asks the nurse, "What caused me to have a seizure? Which of the following would the nurse include in the primary cause of tonic clonic seizures in adults more the 20 years?

• Electrolyte imbalance
• Head trauma
• Epilepsy
• Congenital defect

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6. The nurse monitors the client receiving parenteral nutrition (PN) for complications of the therapy and should assess the client for which manifestations of hyperglycemia?

• Fever, weak pulse, and thirst
• Nausea, vomiting, and oliguria
• Sweating, chills, and abdominal pain
• Weakness, thirst, and increased urine output

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7. Which of the following is true about therapeutic relationship?

• Directed towards helping an individual both physically and emotionally
• Bases on friendship and mutual trust
• Goals are set by the solely nurse
• Maintained even after the client doesn't need anymore of the Nurse's help

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8. Nurse Hazel is caring for a male client who experience false sensory perceptions with no basis in reality. This perception is known as:

• Halucinations
• Delusions
• Loose associations
• Neologisms

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9. In planning for the care of a patient with Crohn's disease, the nurse and patient discuss the interventions. Which of the following treatment modalities would MOST likely be considered a primary intervention for this disease?

• Surgery
• Medications
• High-residue diet
• Blood replacement

10. A pregnant woman who is at term is admitted to the birthing unit in active labor. The client has only progressed from 2cm to 3 cm in 8 hours. She is diagnosed with hypotonic dystocia and the physician ordered Oxytocin (Pitocin) to augment her contractions. Which of the following is the most important aspect of nursing intervention at this time?

• Timing and recording length of contractions.
• Monitoring.
• Preparing for an emergency cesarean birth.
• Checking the perineum for bulging.

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11. A newly admitted client is diagnosed with Hodgkins disease undergoes an excisional cervical lymph node biopsy under local anesthesia. What does the nurse assess first after the procedure?

• Vital signs
• Incision site
• Airway
• Level of consciousness

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12. The nurse is teaching the mother regarding treatment for pedicalosis capitis. Which instruction should be given regarding the medication?

• Treatment is not recommended for children less than 10 years of age.
• Bed linens should be washed in hot water.
• Medication therapy will continue for one year
• Intravenous antibiotic therapy will be ordered.

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13. For which of the following conditions is a client with multiple myeloma (MM) monitored?

• Hypercalcemia
• Hyperkalemia
• Hypernatremia
• Hypermagnesemia

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14. To ensure safety while administering a nitroglycerine patch the nurse should:

• Wear gloves while applying the patch.
• Shave the area where the patch will be applied.
• Wash the area thoroughly with soap and rinse with hot water.
• Apply the patch to the buttocks.

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15. While reviewing stress management techniques with a patient diagnosed with multiple sclerosis, what would the nurse identify as most appropriate?

• Relaxing in a warm bubble bath
• Yoga in a cool room
• Sunbathing
• Cross-country running

16. The nurse is assigned to care for a client with complete right-sided hemiparesis from stroke (brain attack). Which characteristics are associated with this condition? Select all that apply. 1.The client is aphasic. 2.The client has weakness on the right side of the body. 3.The client has complete bilateral paralysis of the arms and legs. 4.The client has weakness on the right side of the face and tongue. 5.The client has lost the ability to move the right arm but is able to walk independently. 6.The client has lost the ability to ambulate independently but is able to feed and bathe himself or herself without assistance.

• 1,2,3
• 1,2,4
• 2,3,5,6
• 1,3,5

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17. During the acute phase, the nurse applied gentamicin sulfate (topical antibiotic) to the burn before dressing the wound. The client has all the following manifestations. Which manifestation indicates that the client is having an adverse reaction to this topical agent?

• Increased wound pain 30 to 40 minutes after drug application
• Presence of small, pale pink bumps in the wound beds
• Decreased white blood cell count
• Increased serum creatinine level

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18. Which of the following is the best indicator of the diagnosis of HIV?

• White blood cell count
• ELISA
• Western Blot
• Complete blood count

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19. A 16 month-old child has just been admitted to the hospital. As the nurse assigned to this child enters the hospital room for the first time, the toddler runs to the mother, clings to her and begins to cry. What would be the initial action by the nurse?

• Arrange to change client care assignments
• Explain that this behavior is expected
• Discuss the appropriate use of time-out
• Explain that the child needs extra attention

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20. 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

21. SITUATION: Alfred, a 40 year old construction worker developed cough, night sweats and fever. He was brought to the nursing unit for diagnostic studies. He told the nurse he did not receive a BCG vaccine during childhoodQ. How long is the duration of the maintenance phase of his treatment?

• 2 months
• 3 months
• 4 months
• 5 months

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22. Situation: Burn is cause by transfer of heat source to the body. It can be thermal, electrical radiation or chemical.Q. When a client will rush towards you and he has burning clothes on, it is your priority to do which of the following first?

• log roll on the grass/ground
• slap the flames with his hands
• Try to remove the burning clothes
• Splash the client with 1 bucket of cool water

23. The nurse is caring for a client with a radium implant for the treatment of cervical cancer. While caring for the client with a radioactive implant the nurse should:

• Provide emotional support by spending additional time with the client.
• Stand at the foot of the bed when talking to the client.
• Avoid handling items used by the client.
• Wear a badge to monitor the amount of time spent in the clients room.

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24. Situation: Radiation therapy is another modality of cancer management With emphasis on multidisciplinary management you have important responsibilities as a nurseQ. What nursing diagnosis should be the highest priority?

• Knowledge deficit regarding thrombocytopenia precautions
• Activity intolerance
• Impaired tissue integrity
• ineffective tissue perfusion, peripheral, cerebral, cardiovascular, gastrointestinal, renal

25. During which of the following stages of labor would the nurse assess crowning?

• First stage
• Second stage
• Third stage
• Fourth stage

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26. 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.At 6-week postpartum visit what should this postpartum mother's fundic height be?

• Inverted and palpable at the cervix
• Six fingerbreadths below the umbilicus
• No longer palpable on her abdomen
• One centimeter above the symphysis pubis

27. Which of the following is TRUE about Expiration?

• A passive process
• The length of which is half of the length of Inspiration
• Stridor is commonly heard during expiration
• Requires energy to be carried out

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28. A client is being evaluated for carpel tunnel syndrome. The nurse is observed tapping over the median nerve in the wrist and asking the client if there is pain or tingling. Which assessment is the nurse performing?

• Phalen maneuver
• Tinels sign
• Kernig sign
• Brudzinski sign

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29. Situation: The mental health - psychiatric nurse functions in a variety of setting with different types of clients.Q. Poverty as reflected in prevalence of communicable diseases, malnutrition and social ills such as street children, homeless and prostitution is a predisposing factor to mental illness. A community approach to cope with this problem is for the nurse to support:

• aggressive family planning methods
• provision of social welfare benefits for the poor
• social action
• free clinics and more hospitals

30. A client asks the nurse about including her 2 and 12 year-old sons in the care of their newborn sister. Which of the following is an appropriate initial statement by the nurse?

• "Focus on your sons needs during the first days at home."
• "Tell each child what he can do to help with the baby."
• "Suggest that your husband spend more time with the boys"
• "Ask the children what they would like to do for the newborn"

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31. The suggested time per hand on handwashing using the time method is:

• 5 to 10 seconds each hand
• 10 to 15 seconds each hand
• 15 to 30 seconds each hand
• 30 to 60 seconds each hand

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32. A client with ruptured appendix had surgery an hour ago and is transferred to the nursing care unit. The nurse placed the client in a semi-Fowler's position primarily to:

• Facilitate movement and reduce complications from immobility.
• Fully aerate the lungs.
• Splint the wound.
• Promote drainage and prevent subdiaphragmatic abscesses.

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33. Which of the following refers to the single cell that reproduces itself after conception?

• Chromosome
• Blastocyst
• Zygote
• Trophoblast

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34. The nurse is caring for a woman 2 hours after a vaginal delivery. Documentation indicates that the membranes were ruptured for 36 hours prior to delivery. What are the priority nursing diagnoses at this time?

• Altered tissue perfusion
• Risk for fluid volume deficit
• High risk for hemorrhage
• Risk for infection

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35. A 35-year-old client with vaginal cancer asks the nurse, What is the usual treatment for this type of cancer?" Which treatment should the nurse name?

• Surgery
• Chemotherapy
• Radiation
• Immunotherapy

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36. When a resident refuses a bedbath, the nurse aide should:

• offer the resident a bribe.
• wait awhile and then ask the resident again.
• remind the resident that people who smell don't have friends.
• tell the resident that nursing home policy requires daily bathing.

37. Mario has burn injury. After 48 hours, the physician orders for Mario 2 liters of IV fluid to be administered q12 h. The drop factor of the tubing is 10 gtt/ml. The nurse should set the flow to provide:

• 18 gtt/min
• 28 gtt/min
• 32 gtt/min
• 36 gtt/min

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38. A home health nurse is visiting a patient following a cerebrovascular accident(CVA). The patient is having trouble sleeping and is feeling sad. The patient's spouse tells the nurse that the patient is not eating much and often cries when no one is watching. Which of the following would be the nurse's MOST likely intervention?

• Assess for changes in cognitive abilities
• Complete a depression index
• Strengthen family coping methods
• Screen for pain

39. After administering inhaled corticosteroids to hospitalized child with asthama, the nurse plans to have the child rinse the mouth and gargle with water. The nurse knows the rationale for this action is prevention of:

• Tooth decay
• Oral candidiasis
• Dehydration
• Hypertrophy of the gums

40. Mr. Duffy is admitted to the CCU 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. Some of the diabetic clients are interested in understanding what is visualized during funduscopic examination. During your discussion you describe the macular area as:

• Head of the optic nerve, seen on the nasal side of the field, lighter in color than the retina.
• The area of central vision, seen on the temporal side of the optic disc, which is quite avascular.
• Area where the central retinal artery and vein appear on the retina.
• Reddish orange in color, sometimes stippled.

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41. Situation: You were on duty at the medical ward when Zeny came in for admission for tiredness, cold intolerance, constipation, and weight gain. Upon examination, the doctor's diagnosis was hypothyroidism.Q. As the nurse, you should anticipate to administer which of the following medications to Zeny who is diagnosed to be suffering from hypothyroidism?

• Levothyroxine
• Lidocaine
• Lipitor
• Levophed

42. A child suspected of having cystic fibrosis is scheduled for a quantitative sweat test. The nurse knows that the quantitative sweat test will be analyzed using:

• Pilocarpine iontophoresis
• Choloride iontophoresis
• Sodium iontophoresis
• Potassium iontophoresis

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43. Which statement is true regarding balanced skeletal traction? Balanced skeletal traction:

• Uses a Steinman pin
• Requires that both legs be secured
• Utilizes Kirschner wires
• Is used primarily to heal the fractured hips

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44. Miss Imelda asked you, What is WET TO DRY Dressing method? Your best response is:

• It is a type of mechanical debridement using Wet dressing that is applied and left to dry to remove dead tissues
• It is a type of surgical debridement with the use of Wet dressing to remove the necrotic tissues
• It is a type of dressing where in, The wound is covered with Wet or Dry dressing to prevent contamination
• It is a type of dressing where in, A cellophane or plastic is placed on the wound over a wet dressing to stimulate healing of the wound in a wet medium

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45. A Patient complains of severe menstrual cramping. Bleeding is not unusually heavy and the patient has no uterine disorders. Which of the following interventions should the nurse anticipate the doctor will order promote comfort?

• Acetaminophen (Tylenol)
• Strict bed rest
• Heating pad to the back of neck
• Ibuprofen (Motrin)

46. Mrs. Olivia is kept informed of the, progress of her delivery, the nurse anticipates the placenta to be delivered within what period of time following delivery

• 10-15 minutes
• 3-10 minutes
• 15-20 minutes
• 1-3 minutes

47. The nurse is inserting a nasogastric (NG) tube into a patient as prescribed. The nurse has advanced the tube into patient's posterior pharynx. The nurse should ask the patient to:

• Hold the breath
• Stare upwards with eyes towards the ceiling
• Perform the valsalvas maneuver
• Lower the chin towards the chest

48. A nurse is assessing an infant for possible deafness. Which of the following automatic reflexes would the nurse MOST likely check to best determine whether the child has a serious hearing problem?

• Blinking
• Vertical suspension
• Moro
• Perez

49. The nurse is caring for a patient who sustained a traumatic brain injury 4 days ago. The patient remains in a pharmacologic induced coma while receiving mechanical ventilation. The patient is on NPO status and the vital signs are within the normal range. The patients bowel sounds are absent and nasogastric tube is connected to low, intermittent suction. The nurse should prepare to begin:

• NG feeding
• Rapid weaning from the ventilator
• Total parenteral nutrition
• Chest physiotherapy

50. Which element in the circular chain of infection can be eliminated by preserving skin integrity?

• Host
• Reservoir
• Mode of transmission
• Portal of entry

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NCLEX-RN | QB2 | Practice Exam #25 (50 questions)