NCLEX-RN | QB2 | Practice Exam #26 (50 questions)
All 50 questions are randomized each time you take the test, and do not appear in the same order.
1. Which gloves should you remove first?
- The glove of the non dominant hand
- The glove of the dominant hand
- The glove of the left hand
- Order in removing the gloves is unnecessary
2. A client has suffered from fail and sustained a leg injury. Which appropriate question would the nurse ask the client to help determine if the injury caused fracture?
- "Is the pain sharp and continuous?"
- "Is the pain dull ache?"
- "Does the discomfort feel like a cramp?"
- "Does the pain feel like the muscle was stretched?"
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3. What is the priority nursing diagnosis during the first 24 hours for a client with full-thickness chemical burns on the anterior neck, chest, and all surfaces of the left arm?
- Risk for Ineffective Breathing Pattern
- Decreased Tissue Perfusion
- Risk for Disuse Syndrome
- Disturbed Body Image
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4. A client in the first trimester of pregnancy arrives at a health care clinic and reports that she has been experiencing vaginal bleeding. A threatened abortion is suspected, and the nurse instructs the client regarding management of care. Which statement made by the client indicates a need for further instruction?
- "I will watch for the evidence of the passage of tissue."
- "I will maintain strict bed rest throughout the remainder of the pregnancy"
- "I will count the number of perineal pads used on a daily basis and note the amount and color of blood on the pad"
- "I will avoid sexual intercourse until the bleeding has stopped, and for 2 weeks following the last evidence of bleeding"
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5. After receiving a change-of-shift report at 7:00 AM, which of these patients will you assess first?
- A 23-year-old with a migraine headache who is complaining of severe nausea associated with retching
- A 45-year-old who is scheduled for a craniotomy in 30 minutes and needs preoperative teaching
- A 59-year-old with Parkinson's disease who will need a swallowing assessment before breakfast
- A 63-year-old with multiple sclerosis who has an oral temperature of 101.80 F and flank pain
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6. The heat regulating center is found in the:
- Medulla oblongata
- Thalamus
- Hypothalamus
- Pons
7. She conducts a 6-month performance review session with a staff member. Which of the following actions is appropriate?
- She asks another nurse to attest the session as a witness.
- She informs the staff that she may ask another nurse to read the appraisal before the session is over.
- She tells the staff that the session is manager-centered.
- The session is private between the two members.
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8. Crisis is a sudden event in ones life that disturbs a persons homeostasis. Which of the following is NOT TRUE in crisis?
- The person experiences heightened feeling of stress
- Inability to function in the usual organized manner
- Lasts for 4 months
- Indicates unpleasant emotional feelings
9. A male client has a standing DNR order He then suddenly stopped breathing and you are at his bedside. You would:
- Cali the physician
- Stay with the client and do nothing
- Cali another nurse
- Call the family
10. A resident often carries a doll with her, treating it like her baby. One day she is wandering around crying that she can't find her baby. The nurse aide should:
- ask the resident where she East had the doll.
- ask the activity department if they have any other dolls.
- offer comfort to the resident and help her look for her baby.
- let the other staff know the resident is very confused and should be watched closely.
11. Situation: Anesthesia is used even during the Ancient times. In its evolution, modern marvels in the use of anesthesia enables the nurses to develop a more competitive approach in patient care.Q. Another way to prevent spinal headache is by the use of the correct needle gauge. If the client is an adult client, the anesthesiologist might order a pink spinal set. The nurse knows that the pink spinal set has a gauge of:
- 12
- 16
- 22
- 26
12. The following are lipid abnormalities. Which of the following is a risk factor for the development of atherosclerosis and PVD?
- High levels of low density lipid (LDL) cholesterol
- High levels of high density lipid (HDL) cholesterol
- Low concentration triglycerides
- Low levels of LDL cholesterol.
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13. A client is admitted to a medical nursing unit with a diagnosis of acute blindness after being involved in a hit-and-run accident. When diagnostic testing cannot identify any organic reason why this client cannot see, a mental health consult is prescribed. The nurse plans care based on which condition that should be the focus of this consult?
- Psychosis
- Repression
- Conversion disorder
- Dissociative disorder
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14. A nurse giving post operative discharge instructs a patient who had abdominal surgery, when teaching the patient about wound healing all of the following are the true EXCEPT:
- Wound may feel tightly or itchy as healing occurs
- Scabs promote infection of the new skin underneath them
- Numbness or a slight pulling sensation is normal
- Wound should not have any drainage
15. Considered as the most accurate expression of persons thought and feelings
- Verbal communication
- Non verbal communication
- Written communication
- Oral communication
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16. The nurse is performing an assessment on a client who is at 38 weeks gestation and notes that the fetal heart rate (FHR) is 174 beats/minute. On the basis of this finding, what is the priority nursing action?
- Document the finding.
- Check the mother's heart rate.
- Notify the health care provider (HCP).
- Te the client that the feta heart rate is normal.
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17. Situation: Cancer of the prostate is the leading cancer in Men other than skin cancer. The following questions will assess your knowledge and theoretical foundation in dealing with clients with prostate cancer.Q. Mr. Juan Jose Rodrigo has been diagnosed with prostate cancer just a few hours ago. Which of the following sign would alert the nurse that the cancer is already advanced?
- "I have difficulty starting my urination"
- "My backs and hips are painful and my right leg is slightly larger than the other"
- "My urine is bloody"
- "My urine is bouncing"
18. The nurse is preparing a discharge plane for a 65 year-old man with a new diagnosis of congestive heart failure. The discharge orders include furosemide 40 milligrams by mouth twice per day. The nurse recommends foods to reduce unwanted medication side effects.Which of the following foods would be most appropriate to include in the teaching plan?
- Green and leafy vegetables
- Bananas and oranges
- Chicken and Fish
- None of the above
19. Situation: The infant and child mortality rate in the low to middle income countries is ten times higher than industrialized countries. In response to this the WHO and UNICEF launched protocol Integrated Management of Childhood Illness to reduce the morbidity and mortality against childhood illnesses.If a child with diarrhea registers two signs in the yellow row in the 1MCI chart, we can classify the patient as:
- Moderate dehydration
- Some dehydration
- Severe dehydration
- No dehydration
20. The nurse is suctioning a client via an endotracheal tube. During the suctioning procedure, the nurse notes on the monitor that the heart rate is decreasing. Which nursing intervention is appropriate?
- Notify the health care provider immediately.
- Stop the procedure and reoxygenate the client.
- Ensure that the suction is limited to 15 seconds.
- Continue to suction.
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21. The nurse is instructing a client with diabetes meilitus about peritoneal dialysis. The nurse tells the client that it is important to maintain the prescribed dwell time for the dialysis because of the risk of which complication?
- Peritonitis
- Hyperglycemia
- Hyperphosphatemia
- Disequilibrium syndrome
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22. Norma has started a new drug for hypertension. Thirty minutes after she takes the drug, she develops chest tightness and becomes short of breath and tachypneic. She has a decreased level of consciousness. These signs indicate which of the following conditions?
- Asthma attack
- Pulmonary embolism
- Respiratory failure
- Rheumatoid arthritis
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23. Which step in community organizing involves training of potential leaders in the community?
- Integration
- Community organization
- Community study
- Core group formation
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24. A 10 year old who has sustained a head injury is brought to the emergency department by his mother. A diagnosis of a mild concussion is made. At the time of discharge, nurse Ron should instruct the mother to:
- Withhold food and fluids for 24 hours.
- Allow him to play outdoors with his friends.
- Arrange for a follow up visit with the child's primary care provider in one week.
- Check for any change in responsiveness every two hours until the follow-up visit.
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25. Nurse Gail places a client in a four-point restraint following orders from the physician. The client care plan should include:
- Assess temperature frequently.
- Provide diversional activities.
- Check circulation every 15-30 minutes.
- Socialize with other patients once a shift.
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26. Vic asks the nurse what PSA is. The nurse should reply that it stands for:
- prostate-specific antigen, which is used to screen for prostate cancer.
- protein serum antigen, which is used to determine protein levels.
- pneumococcal strep antigen, which is a bacteria that causes pneumonia.
- Papanicolaou-specific antigen, which is used to screen for cervical cancer.
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27. An adult arrived at the outpatient facility due to the onset of chest pain. The patient suddenly falls to the floor and is unresponsive. What action should the nurse take NEXT?
- Activate emergency call system
- Open the patient's airway
- Check for a carotid pulse
- Administer 2 rescue breaths
28. Situation : Baby Philip, a full term male child, is delivered by his mother who is RH negative.Q. When the nurse brings Philip to his mother, she comments about the milia on the baby's face. The nurse should:
- Tell her that all babies have them and they clear up in 2 to 3 days
- Explain that these are birthmarks that will disappear within a few months
- Instruct her about proper hand washing since the milia can be infectious
- Instruct her to avoid squeezing them or attempting to wash them off
29. While giving a bed bath, the nurse aide hears the alarm from a nearby door suddenly go off. The nurse aide should:
- wait a few minutes to see if the alarm stops.
- report the alarm to the charge nurse immediately.
- make the resident being bathed safe and go check the door right away.
- giving the resident a lot of quiet time and privacy.
30. Situation: Stacy is diagnosed with acute lymphoid leukemia (ALL) and beginning chemotherapy.Q. Stacy has beginning stomatitis. To promote oral hygiene and comfort, the nurse in-charge should:
- Provide frequent mouthwash with normal saline.
- Apply viscous Lidocaine to oral ulcers as needed.
- Use lemon glycerine swabs every 2 hours.
- Rinse mouth with Hydrogen Peroxide.
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31. Immunization is an example of:
- Health promotion.
- Prevent illness.
- Restoring health.
- Care of the dying.
32. Which statement about fluid replacement is accurate for a client with hyperosmolar hyperglycemic nonketotic syndrome (HHNS)?
- administer 2 to 3 L of IV fluid rapidly
- administer 6 L of IV fluid over the first 24 hours
- administer a dextrose solution containing normal saline solution
- administer IV fluid slowly to prevent circulatory overload and collapse
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33. The nurse is caring for a client who she believes has been abusing opiates. Assessment findings in a client abusing opiates such as morphine include:
- dilated pupils and slurred speech.
- rapid speech and agitation.
- dilated pupils and agitation.
- euphoria and constricted pupils.
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34. A client with COPD is in respiratory failure. Which of the following results would be the most sensitive indicator that the client requires a mechanical ventilator?
- PCO2 58
- SaO2 90
- PH 7.23
- HCO3 30
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35. Situation: Mr. Reyes suffered head injuries in a motor vehicle accidentQ. Mr. Reyes has expressive aphasia. As a part of a long range planning. The nurse should:
- Provide positive feedback when he uses the word correctly
- Wait for him to verbally state needs regardless of how long it may take
- Suggest that he get help at home because the disability is permanent
- Help the family to accept the fact that Mr, Reyes cannot participate in verbal
36. The doctor has ordered the removal of a Davol drain. Which of the following instructions should the nurse give to the client before removing the drain?
- The client should be told to breathe normally.
- The client should be told to take two or three deep breaths as the drain is being removed.
- The client should be told to hold his breath as the drain is being removed.
- The client should breathe slowly as the drain is being removed.
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37. According to them, Morality is measured of how people treat human being and that a moral child strives to be kind and just:
- Zderad and Peterson
- Benner and Wrubel
- Fowler and Westerhoff
- Schulman and Mekler
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38. Which is the primary characteristic lesion of syphilis?
- Sore eyes
- Sore throat
- Chancroid
- Chancre
39. A client is taking the prescribed dose of phenytoin to control seizures. Results of a phenytoin blood level study reveal a level of 35 mcg/mL (140 mcmol/L). Which finding would be expected as a result of this laboratory result?
- Hypotension
- Tachycardia
- Slurred speech
- No abnormal finding
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40. Situation: Mrs. Andres brought his son, Juaruto, age 3 to the Pediatric clinic. She noticed that her son is not speaking and tend to repeat everything she says. The mother also told the nurse that Juanito prefers to be alone, will cry when someone will come near him and tend to rock himself from morning till he will fell asleep.Q. If a child with autism develops destructive behavior, The drug of choice that the nurse will expect that the physician will give to control self injury is:
- Chlorpromazine [Thorazine]
- Methylphenidate [Ritalin]
- Time-out
- Valium, Librium or other Anxiolytic
41. A client with trigeminal neuralgia is being treated with carbamazepine, 400 mg orally daily. Which value indicates that the client is experiencing an adverse effect to the medication?
- Sodium level, 140 mEq/L(140 mmol/L)
- Uric acid level, 4.0 mg/dL (0.24 mmol/L)
- White blood cell count,3000mm3(3.0X10^9/L)
- Blood urea nitrogen level, 10 mg/dL (3.6 mmol/L)
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42. Which is an example of the school nurses health care provider function?
- Requesting for BCG from the RHU for school entrance immunization
- Conducting random classroom inspection during measles epidemic
- Taking remedial action on an accident hazard in the school playground
- Observing places in the school where pupils spend their free times
43. A 65 year old female is experiencing flare up of pruritus. Which of the clients action could aggravate the cause of flare ups?
- Sleeping in cool and humidified environment
- Daily baths with fragrant soap
- Using clothes made from 100% cotton
- Increasing fluid intake
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44. A client in ventricular fibrillation is about to be defibrillated. To convert this rhythm effectively the monophasic defibrillator machine should be set at which energy level (in joules, J) for the first delivery?
- 50J
- 120J
- 200J
- 360J
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45. The nurse provides instructions to a client newly diagnosed with type 1 diabetes mellitus. The nurse recognizes accurate understanding of measures to prevent diabetic ketoacidosis when the client makes which statement?
- "I will stop taking my insulin if I'm too sick to eat."
- "I will decrease my insulin dose during times of illness."
- "I will adjust my insulin dose according to the level of glucose in my urine"
- "I will notify my health care provider (HCP) if my blood glucose level is higher than 250 mg/dL (14.2 mmol/L)"
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46. Nurse Nina is assigned to care for a client diagnosed with Catatonic Stupor. When Nurse Nina enters the client's room, the client is found lying on the bed with a body pulled into a fetal position. Nurse Nina should?
- Ask the client direct questions to encourage talking
- Rake the client into the day room to be with other clients
- Sit beside the client in silence and occasionally ask open-ended question
- Leave the client alone and continue with providing care to the other clients
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47. Situation: Amanda is suffering from chronic arteriosclerosis Brain syndrome she fell while getting out of the bed one morning and was brought to the hospital, and she was diagnosed to have cerebrovascular thrombosis thus transferred to a nursing home.Q. The main difference between chronic and organic brain syndrome is that, the former:
- Occurs suddenly and reversible
- Is progressive and reversible
- tends to be progressive and irreversible
- Occurs suddenly and irreversible
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48. A nurse is assigned to a patient who is scheduled for an above the knee amputation of the left leg. During the preoperative procedure the nurse should ask the patient to:
- Write YES on the leg
- Write OTHER ONE on the right leg
- Draw an arrow on the left knee pointing upward
- Draw an arrow on the left knee pointing downward
49. A client is diagnosed with viral hepatitis, complaining of no appetite and losing my taste for food." What instruction should the nurse give the client to provide adequate nutrition?
- Select foods high in fat.
- Increase intake of fluids, including juices.
- Eat a good supper when anorexia is not as severe.
- Eat less often, preferably only 3 large meals daily.
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50. A nurse is assessing a child with suspected lead poisoning. For which of the following should the nurse assess?
- Developmental delay, constipation, anorexia, clumsiness, and pallor
- Confusion, delirium, seizures, lethargy, stupor, and coma
- Respiratory depression, obstruction, pulmonary edema,and tachypnea
- Peripheral circulatory collapse and heart failure