NCLEX-RN | QB2 | Practice Exam #28 (50 questions)

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

 

1. The nurse is caring for a client hospitalized with a facial stroke. Which diet selection would be suited to the client?

• Roast beef sandwich potato chips pickle spear iced tea
• Split pea soup mashed potatoes pudding milk
• Tomato soup cheese toast Jello coffee
• Hamburger baked beans fruit cup iced tea

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2. When giving narcotic analgesics to mother in labor, the special consideration to follow is:

• The progress of labor is well established reaching the transitional stage
• Uterine contraction is progressing well and delivery of the baby is imminent
• Cervical dilatation has already reached at least 8 cm. and the station is at least (+)2
• Uterine contractions are strong and the baby will not be delivered yet within the next 3 hours.

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3. A client tells the nurse she is having her menstrual period every 2 weeks and it lasts for 1 week. Which of the following conditions is best defined by this menstrual pattern?

• Amenorrhea
• Dyspareunia
• Oligorrhagia
• menorrhagia

4. Situation: Johnny, sought consultation to the hospital beforeQ. Basal Metabolic rate is assessed on Johnny to determine his metabolic rate. In assessing the BMR using the standard procedure, you need to tell Johnny that:

• Slip your hand under the nape of her neck
• Restraining his upper and lower extremities
• Obstructing his hearing
• Obstructing his nostril with a clamp

5. Nurse Ronald should explain that the most beneficial between-meal snack for a client who is recovering from the full-thickness burns would be a:

• Cheeseburger and a malted
• Piece of blueberry pie and milk
• Bacon and tomato sandwich and tea
• Chicken salad sandwich and soft drink

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6. A woman was working in her garden. She accidentally sprayed insecticide into her right eye. She calls the emergency department, frantic and screaming for help. The nurse should instruct the woman to take which immediate action?

• Irrigate the eyes with water.
• Come to the emergency department.
• Call the health care provider (HCP).
• Irrigate the eyes with diluted hydrogen peroxide.

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7. Which of the following nursing diagnosis takes PRIORITY for a patient after gastrointestinal surgery?

• Impaired skin integrity related to surgical incision
• Constipation related to surgery
• Risk for infection related to surgical incision
• Acute pain related to surgical incision

8. An 16-year-old boy is admitted to the facility after acting out his aggressions inappropriately at school. Predisposing factors to the expression of aggression include:

• violence on television.
• passive parents.
• an internal locus of control.
• a single-parent family

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9. A community health nurse should be resourceful and meet the needs of the client A villager ask him, "Can you test my urine for glucose?" Which of the following technique allows the nurse to test a client's urine for glucose without the need for intricate instruments.

• Acetic Acid test
• Nitrazine paper test
• Benedict's test
• Litmus paper test

10. Clonidine (Catapres) can be used to treat conditions other than hypertension. For which of the following conditions might the drug be administered?

• Phencyclidine (POP) intoxication
• Alcohol withdrawal
• Opiate withdrawal
• Cocaine withdraws

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11. Situation: Mr. Reynaldo Layag executive officer, was brought to the hospital because of chest pain. Diagnosis of angina was established.Q. When teaching Mr. Layag, who has been placed on a high-unsaturated fatty acid diet, the nurse should stress the importance of increasing the intake of:

• Enriched whole milk
• Red meats, such as beef
• Vegetables and Whole Grains
• Liver and other glandular organ meals

12. Which client is most likely to have iron deficiency anemia?

• A client with cancer receiving radiation therapy twice a week
• A toddler whose primary nutritional intake is milk
• A client with peptic ulcer who had surgery 6 weeks ago
• A 15-year old client in sickle cell crisis

13. Some central venous access devices (CVAD) have more than one lumen. These multi lumen catheters:

• Have an increased risk of infiltration.
• Only work a short while because the small bore clots off.
• Are beneficial to patient care but are prohibitively expensive.
• Allow different medications or solutions to be administered simultaneously.

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14. In what position should a dyspnea patient be placed?

• Prone
• Recumbent
• Semi-fowlers
• Trendelenburg

15. The nurse is caring for a client with compound fracture of the tibia and fibula. Skeletal traction is applied. Which of these priorities should the nurse include in the care plan?

• Order a trapeze to increase the client's ambulation
• Maintain the client in a flat, supine position at all times.
• Provide pin care at least every hour
• Remove traction weights for 20 minutes every two hours.

16. The nurse is providing dietary instructions for a client with iron-deficiency anemia. Which food is a poor source of iron?

• Tomatoes
• Legumes
• Dried fruits
• Nuts

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17. A 50-year-old patient is being admitted to the hospital in a vegetative state of unknown etiology what is the PRIORITY nursing diagnosis?

• Risk for impaired skin integrity
• Impaired swallowing
• Altered cerebral tissue perfusion
• Altered thought processes

18. A client with diverticulitis is admitted with nausea vomiting and dehydration. Which finding suggests a complication of diverticulitis?

• Pain in the left lower quadrant
• Boardlike abdomen
• Low-grade fever
• Abdominal distention

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19. JP has been diagnosed with gout and wants to know why colchicine is used in the treatment of gout. Which of the following actions of colchicines explains why it's effective for gout?

• Replaces estrogen
• Decreases infection
• Decreases inflammation
• Decreases bone demineralization

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20. A 75 year old client is admitted to the hospital with the diagnosis of dementia of the Alzheimer's type and depression. The symptom that is unrelated to depression would be?

• Apathetic response to the environment
• "I don't know" answer to questions
• Shallow of labile effect
• Neglect of personal hygiene

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21. Francis with leukemia has neutropenia. Which of the following functions must frequently assessed?

• Blood pressure
• Bowel sounds
• Heart sounds
• Breath sounds

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22. It refers to the preparation of the bed with a new set of linens

• Bed bath
• Bed making
• Bed shampoo
• Bed lining

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23. The nurse is caring to a child client who has had a tonsillectomy. The child complains of having dryness of the throat Which of the following would the nurse give to the child?

• Cola with ice
• Yellow non-citrus Jello
• Cool cherry Kool-Aid
• A glass of milk

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24. To prevent deformities of the knee joints in a client with an exacerbation of rheumatoid arthritis the nurse should:

• Tell the client to remain on bed rest until swelling subsides.
• Discourage passive range of motion because it will cause further swelling.
• Encourage motion of the joint within the limits of pain.
• Tell the client she will need joint immobilization for 23 weeks.

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25. SITUATION: Wide knowledge about the human ear, its parts and its functions will help a nurse assess and analyze changes in the adult client's health.Q. Peachy was rushed by his father, Steven into the hospital admission. Peachy is complaining of something buzzing into her ears. Nurse Joemar assessed peachy and found out It was an insect What should be the first thing that Nurse Joemar should try to remove the insect out from peachy's ear?

• Use a flashlight to coax the insect out of peachys ear
• Instill an antibiotic ear drops
• Irrigate the ear
• Pick out the insect using a sterile clean forceps

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26. The nurse is assessing the newborn boy. Apgar scores are 7 and 9. The newborn becomes slightly cyanotic. What is the initial nursing action?

• Elevate his head to promote gravity drainage of secretions.
• Wrap him in another blanket, to reduce heat loss.
• Stimulate him to cry,, to increase oxygenation.
• Aspirate his mouth and nose with bulb syringe.

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27. Situation: Milo 16 y/o has been diagnosed to have AIDS, he worked as entertainer in a cruise ship:Exercise precaution must be taken to protect health worker dealing with the AIDS patients, which among these must be done as priority?

• Boil used syringes and needles
• Use gloves when handling specimen
• Label personal belonging
• Avoid accidental wound

28. When assessing a client for risk of hyperphosphatemia which piece of information is most important for the nurse to obtain?

• A history of radiation treatment in the neck region
• Any history of recent orthopedic surgery
• A history of minimal physical activity
• A history of the clients food intake

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29. The oncology nurse specialist provides an educational session to nursing staff regarding the characteristics of Hodgkin's disease. The nurse determines that further education is needed if a nursing staff member states that which of the following is characteristic of the disease?

• Presence of Reed-Sternberg cells
• Involvement of lymph nodes, spleen, and liver
• Occurs most often in the older client
• Prognosis depends on the stage of the disease

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30. A client is admitted with a possible bowel obstruction. Which question during the nursing history is least helpful in obtaining information regarding this diagnosis?

• Tell me about your pain.
• What does your vomit took like?
• Describe your usual diet.
• Have you noticed an increase in abdominal size?

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31. Following mitral valve replacement surgery a client develops PVC s. The health care provider orders a bolus of Lidocaine followed by a continuous Lidocaine infusion at a rate of 2 mgm/minute. The TV solution contains 2 grams of Lidocaine in 500 cc's of D5W. The infusion pump delivers 60 microdrops/cc. What rate would deliver 4 mgm of Lidocaine/ minute?

• 60 microdrops/minute
• 20 microdrops/minute
• 30 microdrops/minute
• 40 microdrops/minute

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32. SITUATION: Devon, A registered nurse, witnessed an old woman hit by a motorcycle while crossing a train railway. The old woman fell at the railway. Devon rushed at the scene.Q. The old woman complains of pain. Devon noticed that the knee is reddened, warm to touch and swollen. John interprets that this signs and symptoms are likely related to

• Infection
• Thrombophlebitis
• Inflammation
• Degenerative disease

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33. At what stage of labor is the mother is advised to bear down?

• When the mother feels the pressure at the rectal area
• During a uterine contraction
• In between uterine contraction to prevent uterine rupture
• Anytime the mother feels like bearing down

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34. A nurse who is assigned to care for a client with dementia and agitated behaviors knows that the client worked as a housekeeper prior to becoming ill,Which of the following activities is MOST likely to help the client if agitation develops?

• Watching a movie about a house keeper
• Reading a sheet of paper that contains stains removing tips
• Dusting furniture in the assigned room with a cloth
• Singing songs about cleaning

35. When teaching parents about the child s readiness for toilet training, which of the following signs should the nurse instruct them to watch for in the toddler?

• Demonstrates dryness for 4 hours
• Demonstrates ability to sit and walk
• Has a new sibling for stimulation
• Verbalizes desire to go to the bathroom

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36. When a client has cervical halter traction to immobilize the cervical spine counteraction is provided by:

• Elevating the foot of the bed
• Elevating the head of the bed
• Application of the pelvic girdle
• Lowering the head of the bed

37. Situation: An entry level nurse should be able to apply theoretical knowledge in the performance of the basic nursing skills.Q. When suctioning the endotracheal tube, the nurse should:

• Explain procedure to patient: Insert catheter gently applying suction. Withdrawn using twisting motion.
• Insert catheter until resistance is met; then withdraw slightly applying suction intermittently as catheter is withdrawn.
• Hyperoxygenate client insert catheter using back and forth motion
• Insert suction, catheter four inches into the tube, suction 30 seconds using twirling motion as catheter is withdrawn.

38. While preparing post operative paper work for a patient scheduled for neurosurgery, the nurse asks about the patient's use of medications, the patient reports taking an aspirin tablet every day, but has not taken it today. The patient has had nothing by mouth since midnight of the day before, the nurse should:

• Inform the anesthesiologist immediately
• Tell the patient the surgery must be rescheduled
• Record the information on the form in red ink
• Obtain blood sample and notify the attending physician

39. Nurse Patricia is aware that the major health complication associated with intractable anorexia nervosa would be?

• Cardiac dysrhythmias resulting to cardiac arrest
• Glucose intolerance resulting in protracted hypoglycemia
• Endocrine imbalance causing cold amenorrhea
• Decreased metabolism causing cold intolerance

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40. Which of the following factors are affecting body temperature:

• Food intake.
• Age and Gender
• Climate.
• All of the above

41. Situation: Rosanna 20 y/0 unmarried patient believes that the toilet for the female patient in contaminated with AIDS virus and refuses to use it unless she flushes it three times and wipes the toilet seat the same number of times with antiseptic solution.Q. An effective nursing intervention to help Rosana is:

• Convincing her to use the toilet after the nurse has used it first.
• Explaining to her that AIDS cannot be transmitted by using the toilet
• Allowing her to flush and clear the toilet seat until she can manage her anxiety
• Explaining to her how AIDS is transmitted.

42. 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

43. A client who has been receiving urokinase has a large bloody bowel movement Which action would be best for the nurse to take immediately?

• Administer vitamin K IM.
• Stop the urokinase.
• Reduce the urokinase and administer heparin.
• Stop the urokinase and call the doctor.

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44. Situation: Mr. Anthony Martinelli is a 54-year old truck driver. He is admitted for possible gastric ulcer, He is a heavy smoker.Q. When you report on duty your team leader tells you that Mr. Martinelli accidentally received 1000 ml of fluids in 2 hours and that you are to be alert for signs of circulatory overload. Which of the following signs would not be likely to occur?

• moist gurgling respirations
• Weak, slow pulse
• Distended neck veins
• Dyspnea and coughing

45. A preoperative client expresses anxiety to the nurse about upcoming surgery. Which response by the nurse is most likely to stimulate further discussion between the client and the nurse?

• "If it's any help, everyone is nervous before surgery"
• "I will be happy to explain the entire surgical procedure to you"
• "Can you share with me what you've been told about your surgery?"
• "Let me tell you about the care you 11 receive after surgery and the amount of pain you can anticipate."

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46. A patient finds their 2-weeks-old infant unresponsive. The infant is limp, cyanotic and pale. There is no respiration, while the skin is cold to the touch. The parent begins resuscitation, and the infant is transferred to the hospital where the infant expires. The MOST likely diagnosis is:

• Sudden infant death syndrome
• Apparent life-threatening event
• Apnea of infancy
• Apnea of unknown origin

47. SITUATION: A 65 year old woman was admitted for Parkinsons Disease. The charge nurse is going to make an initial assessment.Q. The patient was prescribed with levodopa. What is the action of this drug?

• Increase dopamine availability
• Activates dopaminergic receptors in the basal ganglia
• Decrease acetylcholine availability
• Release dopamine and other catecholamine from neurological storage sites

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48. Situation: Blood transfusion was ordered for Andre after an episode of severe bleeding.Q. During blood administration, the nurse should carefully monitor adverse reaction. To monitor this, it is essential for the nurse to:

• Stay with the client for the first 15 minutes of blood administration
• Stay with the client for the entire period of blood administration
• Run the infusion at a faster rate during the first 15 minutes
• Tell the client to notify the staff immediately for any adverse reaction

49. A client with acute myelocytic leukemia is being treated with busulfan. Which laboratory value would the nurse specifically monitor during treatment with this medication?

• Clotting time
• Uric acid eve
• Potassium level
• Blood glucose level

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50. The placenta has been delivered and the nurse now adds the medication ordered to the Lv. solution which is:

• Methergin
• Oxytocin
• Penicillin
• Atropine

 

NCLEX-RN | QB2 | Practice Exam #28 (50 questions)