NCLEX-RN | QB2 | Practice Exam #27 (50 questions)
All 50 questions are randomized each time you take the test, and do not appear in the same order.
1. Situation: Andrea is admitted to the ER following an assault where she was hit on the face and head. She was brought to the ER by a police woman. Emergency measures were stated.Q. Andrea's respiration is described as waxing and waning. You know that this rhythm of respiration is defined as:
- Perform range and motion exercise on the head or neck
- Kussmaul's
- Cheyne Stokes
- Eupnea
2. 39 year-old male has the following vital signs the patient has received 2 unites of packed red blood cells (PRBCs) and is intubated. Which of the vital signs is considered out of normal range? Blood pressure: 126/78 mmHg. Heart rate: 62/min. O2 saturation: 89% on room air. Temperature: 37°C
- Heart rate
- O2 saturation rate
- Core temperature
- Blood pressure
3. Situation: Nurses hold a variety of roles when providing care to a perioperative patient.Q. Which of the following nursing intervention is done when examining the incision wound and changing the dressing?
- Observe the dressing and type and odor of drainage if any
- Get patient's consent
- Wash hands
- Request the client to expose the incision wound
4. Which of the following parameters should be checked when assessing respirations?
- Rate
- Rhythm
- Symmetry
- All of the above
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5. Myrna a public health nurse will conduct outreach immunization in a barangay Masay with population of about 1500. The estimated number of infants in the barangay would be:
- 45 infants
- 50 infants
- 55 infants
- 65 infants
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6. The balance of a research s benefit vs. its risks to the subject is:
- Analysis
- Risk-benefit ratio
- Percentile
- Maximum risk
7. The nurse is teaching the mother of a 5 month-old about nutrition for her baby. Which statement by the mother indicates the need for further teaching?
- "I'm going to try feeding my baby some rice cereal."
- "When he wakes at night for a bottle, I feed him?"
- "I dip his pacifier in honey so he I take it."
- "I keep formula in the refrigerator for 24 hours."
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8. Mr. Marquez reports of losing his job, not being able to sleep at night, and feeling upset with his wife. Nurse John responds to the client, "You may want to talk about your employment situation in group today." The Nurse is using which therapeutic technique?
- Observations
- Restating
- Exploring
- Focusing
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9. A client is unable to get out of bed and get dressed unless the nurse prompts every step. This is an example of which behavior?
- Word salad
- Tangential
- Perseveration
- Avolition
10. A client with Addisons disease asks the nurse what he needs to know to manage his condition. The nurse should give priority to:
- Emphasizing the need for strict adherence to his medication regimen
- Teaching the client to avoid lotions and skin preparations containing alcohol
- Explaining the need to avoid extremes of temperature
- Assisting the client to choose a diet that contains adequate protein fat and carbohydrates
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11. The nurse is caring for a client admitted to the hospital with a suspected diagnosis of acute appendicitis. Which laboratory result should the nurse expect to note if the client does have appendicitis?
- Leukopenia with a shift to the left
- Leukocytosis with a shift to the left
- Leukopenia with a shift to the right
- Leukocytosis with a shift to the right
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12. When performing a postpartum assessment on a client, the nurse notes the presence of clots in the lochia. The nurse examines the clots and notes that they are larger than 1 cm. Which nursing action is most appropriate?
- Document the findings.
- Reassess the client in 2 hours.
- Notify the health care provider (HCP).
- Encourage increased oral intake of fluids.
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13. Malou was diagnosed with severe preeclampsia is now receiving I.V. magnesium sulfate. The adverse effects associated with magnesium sulfate is:
- Anemia
- Decreased urine output
- Hyperreflexia
- Increased respiratory rate
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14. A client begins clozapine (Clozaril) therapy after several other antipsychotic agents fail to relieve her psychotic symptoms. The nurse instructs her to return for weekly white blood cell (WBC) counts to assess for which adverse reaction?
- Hepatitis
- Infection
- Granulocytopenia
- Systemic dermatitis
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15. A patient recently under went joint replacement surgery, which of the following nursing diagnosis takes PRIORITY?
- Risk for peripheral neurovascular dysfunction
- Deficient knowledge on appropriate activity precaution
- Impaired physical mobility
- Sexuai dysfunction related to pain
16. A client is admitted to the psychiatric unit with a diagnosis of alcohol intoxication and suspected alcohol dependence. Other assessment findings include an enlarged liver, jaundice, lethargy, and rambling, incoherent speech. No other information about the client is available. After the nurse completes the initial assessment, what is the first priority?
- Instituting seizure precautions, obtaining frequent vital signs, and recording fluid intake and output
- Checking the clients medical records for health history information
- Attempting to contact the client's family to obtain more information about the client
- Restricting fluids and leaving the client alone to "sleep off" the episode
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17. A client with glomerulonephritis is placed on a low-sodium diet Which of the following snacks Is suitable for the client with sodium restriction?
- Peanut butter cookies
- Grilled cheese sandwich
- Cottage cheese and fruit
- Fresh peach
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18. The nurse is planning to admit a pregnant client who is obese. In planning care for this client, which potential client needs should the nurse anticipate? Select all that apply. 1.Bed rest as a necessary preventive measure may be prescribed. 2.Routine administration of subcutaneous heparin may be prescribed. 3.An overbed lift may be necessary if the client requires a cesarean section. 4.Less frequent cleansing of a cesarean incision, if present, may be prescribed. 5.Thromboembolism stockings or sequential compression devices may be prescribed.
- 1,2,4
- 3,4,5
- 1,3,5
- 2,3,5
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19. You want to perform a pelvic examination on one of your pregnant clients. You prepare your client for the procedure by:
- Asking her to void
- Taking her vital signs and recording the readings
- Giving the client a perineal care
- Doing a vaginal prep
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20. Situation: Mental Retardation is an increasingly common childhood disorder that impairs learning.Q. A child with an IQ of 35-49 is:
- Barely trainable
- Trainable
- Educable
- Requires total care
21. A client with a femoral popliteal bypass graft is assigned to a semiprivate room. The most suitable roommate for this client is the client with:
- Hypothyroidism
- Diabetic ulcers
- Ulcerative colitis
- Pneumonia
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22. The nurse is performing an assessment on a client with dementia. Which piece of data gathered during the assessment indicates a manifestation associated with dementia?
- Use of confabulation
- Improvement in sleeping
- Absence of sundown syndrome
- Presence of personal hygienic care
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23. The nurse at a college campus is preparing to medicate several students who have been exposed to meningococcal meningitis. Which would the nurse most likely administer?
- Ampicillin (Omnipen)
- Ciprofoxacin (Cipro)
- Vancomycin (Vancocin)
- Piperacillin/Tazobactam (Zosyn)
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24. 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. Post op care for appendectomy include the following except
- Early ambulation
- Diet as tolerated after fully conscious
- Nasogastric tube connect to suction
- Deep breathing and leg exercise
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25. The nurse is caring for patient with deep vein thrombosis(DVT), The patient's heparin sodium infusion has been discontinued and the patient is receiving prescribed warfarin sodium (Coumadin). The nurse should advise the patient that which of the following needs to be continued?
- Daily complete blood count (CBC)
- Laboratory tests for partia Ithromboplastin time (PTT)
- Strict bedrest
- Wearing elasticized support stockings
26. A child comes in the clinic with several lesions to scalp. The round lesions have dandruff like scaling with hair loss, what is the most likely diagnosis:
- Impetigo
- Ringworm
- Ascariasis
- Amoebiasis
27. Situation: You are assigned in the Orthopedic Ward where clients are complaining of pain in varying degrees upon movement of body parts.Q. Troy is a one day post open reduction and internal fixation (ORIF) of the left hip and is in pain. Which of the following observation would prompt you to call the doctor?
- Dressing is intact but partially soiled
- Left foot is cold to touch and pedal pulse is absent
- Left leg in limited functional anatomic position
- BP 114/78, pulse of 82 beats/minute
28. Situation You are assigned in the Orthopedic Ward where clients are complaining of pain in varying degrees upon movement of body parts.Q. There is an order of Demerol 50 mg I.M. now and every 6 hours p r n. You injected Demerol at 5 pm. The next dose of Demerol 50 mg LM. is given:
- When the client asks for the next dose
- When the patient is in severe pain
- At 11 pm
- At 12pm
29. 20 cc is equal to how many ml?
- 20
- 200
- 2000
- 20000
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30. Considered as Safest and most non invasive method of temperature taking
- Oral
- Rectal
- Tympanic
- Axillary
31. Situation: Prevention of Dengue is an important nursing responsibility and controlling its spread is priority once outbreak has been observed.Which of the following is the most important treatment of patients with Dengue H-fever?
- Give aspirin for fever
- Replacement of body fluids
- Avoid unnecessary movement
- Ice cap over abdomen in case of melena
32. James Perez, a nurse on a geriatric floor, is administering a dose of digoxin to one of his patients. The woman asks why she takes a different pill than her niece, who also has heart trouble. James replies that as people get older, liver and kidney function decline, and if the dose is as high as her niece's, the drug will tend to:
- have a shorter half-life.
- accumulate.
- have decreased distribution.
- have increased absorption.
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33. The act of utilizing the environment of the patient to assist him in his recovery is theorized by
- Nightingale
- Benner
- Swanson
- King
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34. Situation: Marie is 5 1/2 years old and described by the mother as bedwetting at night.Q. Which of the following is the MOST common physiological cause of night bedwetting?
- deep sleep factors
- abnormal bladder development or structure problems
- infections familial and genetic factors
- None of the above.
35. The doctor has prescribed Exelon (rivastigmine) for the client with Alzheimers disease. Which side effect is most often associated with this drug?
- Urinary incontinence
- Headaches
- Confusion
- Nausea
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36. Discharge teaching for a child with celiac disease would include instructions about avoiding which of the following?
- Rice
- Milk
- Wheat
- Chicken
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37. Situation: Rico. 1 month delivered via NSVDQ. Mrs. Cadacia observed on Ricos buttocks, a gray color, What do you call this pigmentation in the skin?
- milia
- telangiectatic nevi
- erythema toxicum
- mongohan spots
38. A patient presents to the emergency department with complaints of head ache, dizziness and confusion. Clinical symptoms include tachypnea and dyspnea with the use of accessory muscles to facilitate breathing. Which of the following orders would the nurse MOST likely implement to reduce the patient's confusion and disorientation?
- Oxygen therapy
- Chest physical therapy
- Bronchodilators
- Hydration fluids
39. A patient who has Alzheimer s disease is told by the nurse to brush his teeth. He shouts angrily, "Tomato soup!" Which of the following actions by the nurse would be correct?
- Focusing on the emotional reaction
- Clarifying the meaning of his statement
- Giving him step-by-step directions
- Doing the procedure for him
40. The placenta should be delivered normally within minutes after the delivery of the baby.
- 5 minutes
- 30 minutes
- 45 minutes
- 60 minutes
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41. During preoperative preparation of a patient for amputation of the left leg. The nurse has primary responsibility for:
- Witnessing the patient signature on the consent form
- Explaining the procedure to the patient
- Explaining the risks of the surgery to the patient
- Making appropriate incision lines on the leg.
42. A client has received a transfusion of platelets. The nurse evaluates that the client is benefiting most from this therapy if the client exhibits which finding?
- Increased hematocrit level
- Increased hemoglobin level
- Decline of elevated temperature to normal
- Decreased oozing of blood from puncture sites and gums
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43. Kitty, a 9 year old child has very limited vocabulary and interaction skills. She has an I.Q. of 45. She is diagnosed to have Mental retardation of this classification:
- Profound
- Mild
- Moderate
- Severe
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44. Which woman is not a candidate for RhoGam?
- A gravida 4 para 3 that is Rh negative with an Rh-positive baby
- A gravida 1 para 1 that is Rh negative with an Rh-positive baby
- A gravida II para 0 that is Rh negative admitted after a stillbirth delivery
- A gravida 4 para 2 that is Rh negative with an Rh-negative baby
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45. A patient has pulmonary embolism. Which of the following nursing diagnoses has PRORITY?
- Anxiety related to pain, dyspnea, and concern of illness
- Risk for injury related to altered hemodynamic status
- Acute pain related to congestion and possible lung infarction
- Ineffective breathing pattern related to acute increase in alveolar dead air space
46. Situation: Mang Felix, a 79 year old man who is brought to the Surgical Unit from PACU after a transurethral resection. You are assigned to receive him. You noted that he has a 3-way indwelling catheter for continuous fast dip bladder irrigation which is connected to a straight drainage.Q. Knowing that proper documentation of assessment findings and interventions share important responsibilities of the nurse during first postoperative days, which of the following is the LEAST relevant to document in the case of Mang Felix?
- Chest pain and vital signs
- Intravenous infusion rate
- Amount color and consistency of bladder irrigation drainage
- Activities of daily living started
47. A client using an over-the counter nasal decongestant spray reports unrelieved and worsening nasal congestion. The nurse should instruct the client to do which of the following?
- Switch to a stronger dosage of the medication.
- Discontinue the medication for a few weeks
- Use the spray more frequently
- Combine the spray with an oral decongestant.
48. The physician has prescribed Novalog insulin for a client with diabetes mellitus. Which statement indicates that the client knows when the peak action of the insulin occurs?
- I will make sure I eat breakfast within 10 minutes of taking my insulin.
- I will need to carry candy or some form of sugar with me all the time
- I will eat a snack around three o clock each afternoon.
- I can save my dessert from supper for a bedtime snack.
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49. A nurse is caring for a 2 year-old child after corrective surgery for Tetralogy of Fallot The mother reports that the child has suddenly begun seizing. The nurse recognizes this problem is probably due to:
- A cerebral vascular accident
- Postoperative meningitis
- Medication reaction
- Metabolic alkalosis
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50. Nurse Monet is caring for a female client who has suicidal tendency. When accompanying the client to the restroom, Nurse Monet should:
- Give her privacy
- Allow her to urinate
- Open the window and allow her to get some fresh air
- Observe her
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