NCLEX-RN | QB2 | Practice Exam #29 (50 questions)
All 50 questions are randomized each time you take the test, and do not appear in the same order.
1. The mother of a 6-year-old child arrives at a clinic because the child has been experiencing itchy, red, and swollen eyes. The nurse notes a discharge from the eyes and sends a culture to the laboratory for analysis. Chlamydial conjunctivitis is diagnosed. On the basis of this diagnosis, the nurse determines that which requires further investigation?
- Possible trauma
- Possible sexual abuse
- Presence of an allergy
- Presence of a respiratory infection
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2. The nurse is assessing a client 24 hours following a cholecystectomy. The nurse notes that the T-tube has drained 750 mLof green-brown drainage since the surgery. Which nursing intervention is most appropriate?
- Clamp the T-tube.
- Irrigate the T-tube.
- Document the findings.
- Notify the health care provider.
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3. This is a process of removing pathogens but not their spores
- Sterilization
- Auto claving
- Disinfection
- Medical asepsis
4. After myocardial infarction, serum glucose levels and free fatty acids are both increase. What type of physiologic changes are these?
- Electrophysiologic
- Hematologic
- Mechanical
- Metabolic
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5. Situation: Mr. Reynaldo Layag executive officer, was brought to the hospital because of chest pain. Diagnosis of angina was established.Q. The nurse realizes that the pain associated with coronary occlusion is caused primarily by:
- Arterial Spasm
- Ischemia of the heart muscle
- Blocking of the coronary
- Irritation of the nerve endings in the cardiac plexus
6. A mother arrives at a clinic with her toddler and tells the nurse that she has a difficult time getting the child to go to bed at night. What measure is most appropriate for the nurse to suggest to the mother?
- Allow the child to set bedtime limits.
- Allow the child to have temper tantrums.
- Avoid letting the child nap during the day.
- Inform the child of bedtime a few minutes before it is time for bed.
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7. A preschooler is admitted to the hospital with a diagnosis of acute glomerulonephritis. The child's history reveals a 5-pound weight gain in one week and peritoneal edema. For the most accurate information on the status of the child's edema, nursing intervention should include:
- Obtaining the child's daily weight
- Doing a visual inspection of the child
- Measuring the child's intake and output
- Monitoring the child's electrolyte values
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8. How long should the Rectal Thermometer be inserted to the clients anus?
- 1 to 2 inches
- 5 to 1.5 inches
- 3 to 5 inches
- 2 to 3 inches
9. Nurse Len is administering sublingual nitroglycerin (Nitrostat) to the newly admitted client Immediately afterward, the client may experience:
- Throbbing headache or dizziness
- Nervousness or paresthesia.
- Drowsiness or blurred vision.
- Tinnitus or diplopia.
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10. Clinitest is used in testing the urine of a client for glucose. Which of the following, if committed by a nurse, indicates error?
- Specimen is collected after meals
- The nurse puts 1 clinitest tablet into a test tube
- She added 5 drops of urine and 10 drops of water
- If the color becomes orange or red, It is considered postitive
11. Which of these patients in the neurologic ICU will be best to assign to an RN who has floated from the medical unit?
- A 26-year-old patient with a basilar skull structure who has clear drainage coming out of the nose
- A 42-year-old patient admitted several hours ago with a headache and diagnosed with ruptured berry aneurysm.
- A 46-year-old patient who was admitted 48 hours ago with bacterial meningitis and has an antibiotic dose due
- A 65-year-old patient with a astrocytoma who has just returned to the unit after having craniotomy
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12. Situation: Nurse Joanna works as an OB-Gyn Nurse and attends to several HIGH- RISK PREGNANCIES: Particularly women with preexisting or newly acquired illness. The following conditions applyBernadette develops a deep-vein thrombosis following an auto accident and is prescribed heparin sub-Q. What should Joanna educate her about in regard to this?
- Some infants will be born with allergic symptoms to heparin
- Her infant will be born with scattered petechiae on his trunk
- Heparin can cause darkened skin in newborns
- Heparin does not cross the placenta and so does not affect a fetus
13. A client gives the home health nurse a bottle of clomipramine. The nurse notes that the medication has not been taken by the client in 2 months. Which behavior observed in the client would validate noncompliance with this medication?
- Complaints of insomnia
- Complaints of hunger and fatigue
- A pulse rate less than 60 beats/minute
- Frequent hand washing with hot, soapy water
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14. Capillary glucose monitoring is being performed every 4 hours for a client diagnosed with diabetic ketoacidosis. Insulin is administered using a scale of regular insulin according to glucose results. At 2 p.m., the client has a capillary glucose level of 250 mg/dl for which he receives 8 U of regular insulin. Nurse Mariner should expect the dose's:
- onset to be at 2 p.m. and its peak to be at 3 p.m.
- onset to be at 2:15 p.m. and its peak to be at 3 p.m.
- onset to be at 2:30 p.m. and its peak to be at 4 p.m.
- onset to be at 4 p.m. and its peak to be at 6 p.m.
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15. The last expected process in the stages of inflammation is characterized by
- There will be sudden redness of the affected part
- Heat will increase on the affected part
- The affected part will lose its normal function
- Exudates will flow from the injured site
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16. The nurse is providing care to a Puerto Rican-American client who is terminally ill. Numerous family members are present most of the time, and many of the family members are very emotional. What Is the most appropriate nursing action for this client?
- Restrict the number of family members visiting at one time.
- Inform the family that emotional outbursts are to be avoided.
- Make the necessary arrangements so that family members can visit.
- Contact the health care provider to speak to the family regarding their behaviors.
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17. An 18-month-old is being discharged following hypospadias repair. Which instruction should be included in the nurses discharge teaching?
- The child should not play on his rocking horse.
- Applying warm compresses will decrease pain.
- Diapering should be avoided for 1-2 weeks.
- The child will need a special diet to promote healing.
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18. A client with metastatic breast cancer is receiving tamoxifen. The nurse specifically monitors which laboratory value while the client is taking this medication?
- Glucose level
- Calcium level
- Potassium level
- Prothrombin time
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19. An 18-year-oid male client admitted with heat stroke begins to show signs of disseminated intravascular coagulation (DIC). Which of the following laboratory findings is most consistent with DIC?
- Low platelet count
- Elevated fibrinogen levels
- Low levels of fibrin degradation products
- Reduced prothrombin time
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20. A patient presents to the doctor s office 2-weeks status post-right-sided mastectomy. The nurse needs to measure the blood pressure. Which would be the BEST site?
- Above the left brachial artery
- Right popliteal artery
- Above the right brachial artery
- Left popliteal artery
21. A walk-in client enters into the clinic with a chief complaint of abdominal pain and diarrhea. The nurse takes the client's vital sign hereafter. What phrase of nursing process is being implemented here by the nurse?
- Assessment
- Diagnosis
- Planning
- Implementation
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22. The one filing the criminal care against an accused party is said to be the?
- Guilty
- Accused
- Plaintiff
- Witness
23. A 30 year-old diabetic woman complains of blood in the urine and dull pain over the left lower abdomen, middle back and above the pubic bone. She feels the urge to urinate frequently and urgently. For the past two days, she has had nausea and vomiting. Abdominal assessment reveals tenderness over the pubic bone; no guarding and bowel sounds are active in all quadrants.Which home intervention would be most effective?
- Oral antibiotics
- Increased fluid intake
- Increased dietary protein
- Cold application to left hand
24. A client is admitted for detoxification after a cocaine overdose. The client tells the nurse that he frequently uses cocaine but he can control his use if he chooses. Which coping mechanism is he using?
- Withdrawal
- Logical thinking
- Repression
- Denial
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25. Lochia normally disappears after how many days postpartum?
- 5 days
- 7-10 days
- 18-21 days
- 28-30 days
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26. Which of the following actions would be appropriate for the nurse to take when Caring for patient on contact precautions?
- Serve the patients meals on the disposable with plastic eating utensils
- Instruct visitors to talk to the nurse before entering the patients room
- Rinse both hands with water after removing gloves
- Place a surgical mask on the patient during transport
27. The nurse is caring for the client with a mastectomy. Which action would be contraindicated?
- Taking the blood pressure in the side of the mastectomy
- Elevating the arm on the side of the mastectomy
- Positioning the client on the unaffected side
- Performing a dextrostix on the unaffected side
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28. When the nurse determines whether resources were maximized in implementing Ligtas Tigdas, she is evaluating:
- Effectiveness
- Efficiency
- Adequacy
- Appropriateness
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29. 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.Celeste has had diarrhea for 8 days. There is no blood in the stool, he is irritable, his eyes are sunken, the nurse offers fluid to Celeste and he drinks eagerly. When the nurse pinched the abdomen it goes back slowly. How will you classify Celeste's Illness?
- Moderate dehydration
- Some dehydration
- Severe dehydration
- No dehydration
30. Which playroom activities should the nurse organize for a small group of 7 year-old hospitalized children?
- Sports and games with rules
- Finger paints and water play
- "Dress-up" clothes and props
- Chess and television programs
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31. Nurse Marta plans to administer dexamethasone cream to a female client who has dermatitis over the anterior chest. How should the nurse apply this topical agent?
- With a circular motion, to enhance absorption.
- With an upward motion, to increase blood supply to the affected area
- In long, even, outward, and downward strokes in the direction of hair growth
- In long, even, outward, and upward strokes in the direction opposite hair growth
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32. A patient comes to the emergency department complaining of severe crushing substernal pain that radiates to the left arm and jaw. The patient is diaphoretic and pale with cool clammy skin. The patient is diagnosed with acute myocardial infarction. The nursing diagnosis would be decreases cardiac output related to:
- Structural factors (incompetent valves)
- Impaired ventricular expansion
- Impaired contractility
- Fluid volume deficit
33. It is the summer season, and patients with signs and symptoms of heat-related illness present in the ED. Which patient needs attention first?
- An elderly person complains of dizziness and syncope after standing in the sun for several hours to view a parade
- A marathon runner complains of severe leg cramps and nausea. Tachycardia, diaphoresis, pallor, and weakness are observed.
- A previously healthy homemaker reports broken air conditioner for days. Tachypnea, hypotension, fatigue, and profuse diaphoresis are observed.
- A homeless person, poor historian, presents with altered mental status, poor muscle coordination, and hot, dry, ashen skin. Duration of exposure is unknown.
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34. Nurse Hazel is preparing to ambulate a female client The best and the safest position for the nurse in assisting the client is to stand:
- On the unaffected side of the client.
- On the affected side of the client.
- In front of the client.
- Behind the client.
35. Which food group should you emphasize giving on a pregnant mother in first trimester to prevent neural tube defects?
- Broccoli, Guava, Citrus fruits, Tomatoes
- Butter, Sardines, Tuna, Salmon, Egg yolk
- Wheat germ, Vegetable Oil, soybeans, corn, peanuts
- Organ meats, Green leafy vegetables, Liver, Eggs
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36. Freud states that temper tantrums is observed tn which of the following:
- Oral
- Anal
- Phallic
- Latency
37. The nurse is caring for a 10 year-old on admission to the burn unit. One assessment parameter that will indicate that the child has adequate fluid replacement is
- Urinary output of 30 ml per hour
- No complaints of thirst
- increased hematocrit
- Good skin turgor around burn
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38. 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.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
39. The etiology of schizophrenia is best described by:
- genetics due to a faulty dopamine receptor.
- environmental factors and poor parenting.
- structural and neurobiological factors.
- a combination of biological psychological, and environmental factors.
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40. The physician has ordered Pentam (pentamidine) IV for a client with pneumocystis carinii. While receiving the medication the nurse should carefully monitor the clients:
- Take aspirin for discomfort
- Avoid bending over to put on his shoes
- Remove the eye shield before going to sleep
- Continue showering as usual
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41. Situation: Sterilization is the process of removing ALL living microorganism. To be free of ALL living microorganism is sterility.Q. There are 3 general types of sterilization use in the hospital which one is not included?
- Steam sterilization
- Chemical sterilization
- Autoclaving
- Sterilization by boiling
42. A patient is 24 hours post-operative after having a right total hip arthroplasty, the patient complains of pain in the right calf rated 6 on a scale of 0 no pain l0 severe pain. The nurse observes that the right calf is warm and tender to touch, while the right foot is pale and cool.There is edema from the toes up the knee. The nurse recognizes that these are the classic signs of:
- Ineffective tissue perfusion
- Fluid overload
- Arterial occlusion
- Deep vein thrombosis
43. A client seen in the doctors office for complaints of nausea and vomiting is sent home with directions to follow a clear-liquid diet for the next 24 to 48 hours. Which of the following is not permitted on a clear-liquid diet?
- Sweetened tea
- Chicken broth
- Ice cream
- Orange gelatin
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44. Which of the following women should be considered as special targets for family planning?
- Those who have two children or more
- Those with medical conditions such as anemia
- Those younger than 20 years and older than 35 years
- Those who just had a delivery within the past 15 months
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45. In this stage of illness, the person learns to accept the illness.
- Symptom Experience
- Assumption of sick role
- Medical care contact
- Dependent patient role
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46. Packed red blood cells have been prescribed for a female client with a hemoglobin level of 7.6 g/dL (76mmol/L) and a hematocrit level of 30% (0.30). The nurse takes the client's temperature before hanging the blood transfusion and records 100.6 T (38.1 °C) orally. Which action should the nurse take?
- Begin the transfusion as prescribed.
- Administer an antihistamine and begin the transfusion.
- Delay hanging the blood and notify the health care provider (HCP).
- Administer 2 tablets of acetaminophen and begin the transfusion.
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47. A client who has been taking buspirone for 1 month returns to the clinic for a follow-up assessment The nurse determines that the medication is effective if the absence of which manifestation has occurred?
- Paranoia thought process
- Rapid heartbeat or anxiety
- Alcohol withdrawal symptoms
- Thought broadcasting or delusions
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48. The nurse is administering risperi done to a client who is scheduled to be discharged. Before discharge, which instruction should the nurse provide to the client?
- Get adequate sunlight.
- Continue driving as usual.
- Avoid foods rich in potassium.
- Get up slowly when changing positions.
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49. The nurse assesses a client with urticaria. The nurse understands that urticaria is another name for:
- hives
- a toxin
- a tubercle
- a virus
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50. Urine that remains in pt's bladder after he voids is called:
- Reflux urine
- Over flow urine
- Retention urine
- Residual urine