NCLEX-RN | QB2 | Practice Exam #30 (50 questions)

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

 

1. Where should you put a wet adult diaper?

• Green trashcan
• Black trashcan
• Orange trashcan
• Yellow trashcan

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2. Nurse Joey discusses the goal of the department Which of the following statements is a goal?

• Increase the patient satisfaction rate
• Eliminate the incidence of delayed administration of medications
• Establish rapport with patients
• Reduce response time to two minutes

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3. A patient hospitalized with Crohn s disease has developed fever Increased respiratory rate, increased heart rate, chills, diaphoreses, and increased abdominal discomfort The nurse knows that patient has MOST likely developed

• Intestinal obstruction
• intestinal parasite infestation
• Intestinal perforation
• Ascites

4. In what area of the body will be affected by bed sore if the patient maintains supine position?

• heels
• ilium
• sacrum
• malleolus

5. The client with COPD is to be discharged home while receiving continuous oxygen at a rate of 2 L/min via cannula. What information does the nurse provide to the client and his wife regarding the use of oxygen at home?

• Because of his need for oxygen, the client will have to limit activity at home
• The use of oxygen will eliminate the client's shortness of breath
• Precautions are necessary because oxygen can spontaneously ignite and explode
• Use oxygen during activity to relieve the strain on the client's heart

6. A client with acute kidney injury has a serum potassium level of 7.0 mEq/L (7.0 mmol/ L). The nurse should plan which actions as a priority? Select all that apply. 1.Place the client on a cardiac monitor. 2.Notify the health care provider (HCP). 3.Put the client on NPO (nothing by mouth) status except for ice chips. 4.Review the client's medications to determine if any contain or retain potassium. 5.Allow an extra 500 mL of intravenous fluid intake to dilute the electrolyte concentration.

• 1,2,3
• 2,3,4,5
• 1,2,4
• 1,3,5

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7. A client has been receiving chlorpromazine (Thorazine), an antipsychotic, to treat his psychosis. Which finding should alert the nurse that the client is experiencing pseudoparkinsonism?

• Restlessness, difficulty sitting still, pacing
• Involuntary rolling of the eyes
• Tremors, shuffling gait, mask like face
• Extremity and neck spasms, facial grimacing, jerky movements

8. The nurse is caring to a client diagnosed with severe depression. Which of the following nursing approach is important in depression?

• Protect the client against harm to others.
• Provide the client with motor outlets for aggressive, hostile feelings.
• Reduce interpersonal contacts.
• Deemphasizing preoccupation with elimination, nourishment, and sleep.

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9. Which of the following is OBJECTIVE data:

• Dizziness
• Chest pain
• Anxiety
• Blue nails

10. The teenager with a fiberglass cast asks the nurse if it will be okay to allow his friends to autograph his cast Which response would be bes

• It will be alright for your friends to autograph the cast.
• Because the cast is made of plaster autographing can weaken the cast.
• If they don't use chalk to autograph it is okay.
• Autographing or writing on the cast in any form will harm the cast.

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11. Which of the following statements is true regarding language development of young children?

• Infants can discriminate speech from other patterns of sound.
• Boys are more advanced in language development than girls of the same age.
• Second-born children develop language earlier than first-born or only children.
• Using single words for an entire sentence suggests delayed speech development.

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12. A male client complains of abdominal discomfort and nausea while receiving tube feedings. Which intervention is most appropriate for this problem?

• Give the feedings at room temperature.
• Decrease the rate of feedings and the concentration of the formula.
• Place the client in semi-Fowlers position while feeding.
• Change the feeding container every 12 hours.

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13. A community is experiencing an outbreak of staphylococcal infections. The nurse instructs residents that the MOST common mode of transmission is by

• Respiratory droplets
• Contaminated foods
• Hands
• Soil

14. The nurse is measuring the chest tube drainage of a patient who had open heart surgery 4 hours ago. Which of the following is the MAXIMUM hourly amount of chest tube drainage that is expected in this time frame?

• 100ml
• 200ml
• 300ml
• 400ml

15. Which of the following may cause an increase in the cystitis symptoms?

• Water
• Orange juice
• Coffee
• Mango juice

16. The nurse is assigned to care for a client in traction. The nurse creates a plan of care for the client and should include which action in the plan?

• Ensure that the knots are at the pulleys.
• Check the weights to ensure that they are off of the floor.
• Ensure that the head of the bed is kept at a 45-to 90-degree angle.
• Monitor the weights to ensure that they are resting on a firm surface.

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17. Nurse Trish must verify the clients identity before administering medication. She is aware that the safest way to verify identity is to:

• Check the clients identification band.
• Ask the client to state his name.
• State the client's name out loud and wait a client to repeat it.
• Check the room number and the client's name on the bed.

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18. Situation: Developing countries such as the Philippines suffer from high infant and child mortality rates. Thus, as a management to the existing problem, the WHO and UNICEF launched the 1MCI.A 6 month old baby Len was brought to the health center because of fever and cough for 2 days. She weighs 5 kg. Her temperature is 38.5 taken axillary. Further examination revealed that she has general rashes, her eyes are red and she has mouth ulcers non deep and non extensive, There was no pus draining from her eyes. Most probably Baby Len has:

• Severe complicated measles
• Fever: No MALARIA
• Very severe febrile disease
• Measles with eye or mouth complications

19. A woman is menstruating. If hormonal studies were to be done at this time, which of the following hormonal levels would the nurse expect to see?

• Both estrogen and progesterone are high.
• Estrogen is high and progesterone is low.
• Estrogen is low and progesterone is high.
• Both estrogen and progesterone are low.

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20. Joey stresses the importance of promoting esprit d corps among the members of the unit. Which of the following remarks of the staff indicates that they understand what he pointed out?

• "Lets work together in harmony; we need to be supportive of one another"
• "In order that we achieve the same results; we must all follow the directives of Julius and not from other managers”
• "We will ensure that all the resources we need are available when needed"
• "We need to put our efforts together in order to raise the bar of excellence in the care we provide to all our patients."

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21. A 4-year-old child brought to the community health clinic for scheduled immunizations. The child should receive:

• Varicella, rotavirus, pneumococcal and hepatitis B
• Measles, mumps, rubella and varicella
• Rotavirus and inactivated polio virus
• Varicella and haemophilus influenza

22. Which of the following is not true about OXYGEN?

• Oxygen is odorless, tasteless and colorless gas.
• Oxygen can irritate mucus membrane
• Oxygen supports combustion
• Excessive oxygen administration results in respiratory acidosis

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23. Situation: Mental Retardation is an increasingly common childhood disorder that impairs learning.Q. Mental retardation is:

• delay in normal growth and development caused by an inadequate environment
• lack of development of sensory abilities
• a condition of subaverage intellectual functioning that originates during the developmental period and is associated with impairment in adaptive behavior
• a severe lag in neuromuscular development and motor abilities

24. Sputum examination is the major screening tool for pulmonary tuberculosis. Clients would sometimes get false negative results in this exam. This means that the test is not perfect in terms of which characteristic of a diagnostic examination?

• Effectiveness
• Efficacy
• Specificity
• Sensitivity

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25. The nurse is providing counseling to a group of sexually active single women. Most of the women have expressed a desire to have children in the future, but not within the next few years. Which of the following actions should the nurse suggest the women take to protect their fertility for the future? Select all that apply. 1.Use condoms during intercourse. 2.Refrain from smoking cigarettes. 3.Maintain an appropriate weight for height. 4.Exercise in moderation. 5.Refrain from drinking carbonated beverages.

• 1,2,3 and 4
• 2,3,4
• 1,2,3 and 5
• 2,5

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26. A female client is to be discharged from an acute care facility after treatment for right leg thrombophlebitis. The Nurse Betty notes that the client's leg is pain-free, without redness or edema. The nurse's actions reflect which step of the nursing process?

• Assessment
• Diagnosis
• Implementation
• Evaluation

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27. What is the responsibility of the nurse in obtaining an informed consent for surgery?

• Describing in a clear and simply stated manner what the surgery will involve
• Explaining the benefits alternatives and possible risks and complications of surgery
• Using the nurse/client relationship to persuade the client to sign the operative permit
• Providing the informed consent for surgery and witnessing the clients signature

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28. The nurse is assessing an infant with Gastroeosophageal reflux disease (GERD). To help identify any complications of GERD, what is the most important question the nurse should ask the infant's parents?

• Frequency of respiratory tract infection
• Frequency of vomiting
• Time between bowl movements
• Time between feeds

29. The nurse is monitoring a 3-year-old child for signs and symptoms of increased intracranial pressure (ICP) after a craniotomy. The nurse plans to monitor for which early sign or symptom of increased ICP?

• Vomiting
• Bulging anterior fontanet
• Increasing head circumference
• Complaints of a frontal headache

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30. A patient undergoing treatment for cancer with bone metastasis is experiencing severe pain. Which of the following treatment would the nurse MOST likely expect to improve the patient's pain control?

• Adjuvant radiation therapy
• Palliative radiation therapy
• Curative radiation therapy
• Radio surgery (stereotactic)

31. A young client is in the hospital with his left leg in Bucks traction. The team leader asks the nurse to place a footplate on the affected side at the bottom of the bed. The purpose of this action is to:

• Anchor the traction
• Prevent footdrop
• Keep the client from sliding down in bed
• Prevent pressure areas on the foot

32. Situation: Basic knowledge on Intravenous solutions is necessary for care of clients with problems with fluids and electrolytes.Q. An informed consent is required for:

• Closed reduction of a fracture
• Insertion of intravenous catheter
• Irrigation of the external ear canal
• Urethral catheterization

33. A nurse assesses a 3-month-old infant. The patient expresses anxiety and feeling over whelmed. The nurse offer information on available parenting support. This level of child abuse prevention is classified as which of the following?

• Intervention
• Primary
• Secondary
• Tertiary

34. A patient is 2-days post operative hernia repair and has an order for a dressing change patients has been diagnosed with auto immune deficiency disease syndrome(AIDS). While performing the dressing change the nurse should take which of the following actions?

• Put the patient in a private room
• Wear gloves during the dressing change
• Wear gloves gown, and mask during dressing change
• Put the patient in reverse isolation

35. A process of heat loss which involves the transfer of heat from one surface to Another without contact is:

• Radiation
• Conduction
• Convection
• Evaporation

36. As the charge nurse, you are reviewing the charts of clients who were assigned to a newly graduated RN. The RN has correctly charted dose and time of medication, but there is no documentation regarding non-pharmaceutical measures. What action should you take first?

• Make a note in the nurse's file and continue to observe clinical performance
• Refer the new nurse to the in-service education department.
• Quiz the nurse about knowledge of pain management
• Give praise for the correct dose and time and discuss the deficits in charting.

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37. Which of the following best describes the language of a 24-month-old?

• Doesn't understand yes and no
• Understands the meaning of words
• Able to verbalize needs
• Asks why? to most statements

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38. Situation: Children have a special fascination with the workings of the digestive system. To fully understand the digestive processes, Nurse Lavigna must be knowledgeable of the anatomy and physiology of the gastrointestinal system.Q. Most digestive activity occurs in the pyloric region of the stomach. What hormone stimulates the chief cells to produce pepsinogen?

• Gastrin
• Pepsin
• HCI
• Insulin

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39. Stage of GAS wherein, the Level of resistance are decreased

• Stage of Alarm
• Stage of Resistance
• Stage of Homeostasis
• Stage of Exhaustion

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40. A 1-month-old infant is seen in a clinic and is diag- nosed with developmental dysplasia of the hip. On assessment, the nurse understands that which find- ing should be noted in this condition?

• Limited range of motion in the affected hip
• An apparent lengthened femur on the affected side
• Asymmetrical adduction of the affected hip when the infant is placed supine with the knees and hips flexed
• Symmetry of the gluteal skinfolds when the infant is placed prone and the legs are extended against the examining table

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41. The nurse is performing an assessment on a pregnant client in the last trimester with a diagnosis of severe preeclampsia. The nurse reviews the assessment findings and determines that which finding is most closely associated with a complication of this diagnosis?

• Enlargement of the breasts
• Complaints of feeling hot when the room is cool
• Periods of fetal movement followed by quiet periods
• Evidence of bleeding, such as in the gums, petechiae, and purpura

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42. A client being hemodialyzed suddenly becomes short of breath and complains of chest pain. The client is tachycardic, pale, and anxious and the nurse suspects air embolism. What are the priority nursing actions? Select all that apply. 1.Administer oxygen to the client. 2.Continue dialysis at a slower rate after checking the lines for air. 3.Notify the health care provider (HCP) and Rapid Response Team. 4.Stop dialysis, and turn the client on the left side with head lower than feet. 5.Bolus the client with 500 mL of normal saline to break up the air embolus.

• 1,3,4
• 1,2,3
• 1,2,3,4
• 2,3,4,5

43. All of the following is true about digestion that occurs in the Mouth except:

• It is where the digestion process starts
• Mechanical digestion is brought about by mastication
• The action of ptyalin or the salivary trypsin breaks down starches into maltose
• Deglutition occurs after food is broken down into small pieces and well mixed with saliva

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44. Nurse Oliver measures a clients temperature at 102°F What is the equivalent Centigrade temperature?

• 40.1 °C
• 38.9 °C
• 48 C
• 38 °C

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45. Nurse Sherry is teaching male client regarding his permanent artificial pacemaker. Which information given by the nurse shows her knowledge deficit about the artificial cardiac pacemaker?

• take the pulse rate once a day in the morning upon awakening
• May be allowed to use electrical appliances
• Have regular follow up care
• May engage in contact sports

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46. Lactation Amenorrhea Method(LAM) can be an effective method of natural birth control if

• The mother breast feeds mainly at night time when ovulation could possibly occur
• The mother breastfeeds exclusively and regularly during the first 6 months without giving supplemental feedings
• The mother uses mixed feeding faithfully
• The mother breastfeeds regularly until 1 year with no supplemental feedings

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47. Nurse Amy has documented an entry regarding client care in the clients medical record. When checking the entry, the nurse realizes that incorrect information was documented. How does the nurse correct this error?

• Erases the error and writes in the correct information.
• Uses correction fluid to cover up the incorrect information and writes in the correct information.
• Draws one line to cross out the incorrect information and then initials the change.
• Covers up the incorrect information completely using a black pen and writes in the correct information

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48. Situation: One of the realities that we are confronted with is mortality. It is important for us nurses to be aware of how we view suffering, pain, illness, and even our death as well as its meaning. That way we can help our patients cope with death and dying.Q. Which of the following statements would best indicate that Ruffy; who is dying has accepted this impending death?

• "I'm ready to do.”
• "I have resigned myself to dying"
• "What's the use"?
• "I'm giving up"

49. A parent brings a 10-month-old infant into the department saying, "my baby put a button in her mouth and now she is not breathing!" After the nurse determines the infant is not breathing. What should the nurse do NEXT?

• Perform the Heimlich maneuver
• Initiate cardio pulmonary resuscitation (CPR)
• Administer 4 back blows
• Administer 4 thrusts midline on the patient back

50. Mr. Marquez with rheumatoid arthritis is about to begin aspirin therapy to reduce inflammation. When teaching the client about aspirin, the nurse discusses adverse reactions to prolonged aspirin therapy. These include:

• weight gain.
• fine motor tremors.
• respiratory acidosis.
• bilateral hearing loss.

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NCLEX-RN | QB2 | Practice Exam #30 (50 questions)