NCLEX-RN | QB2 | Practice Exam #32 (50 questions)
All 50 questions are randomized each time you take the test, and do not appear in the same order.
1. The doctor orders hourly urine output measurement for a postoperative male client The nurse Trish records the following amounts of output for 2 consecutive hours: 8 a.m.: 50 ml; 9 a.m.: 60 ml. Based on these amounts, which action should the nurse take?
- Increase the I.V. fluid infusion rate
- Irrigate the indwelling urinary catheter
- Notify the physician
- Continue to monitor and record hourly urine output
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2. The physician has ordered Dilantin (phenytoin) for a client with generalized seizures. When planning the clients care the nurse should:
- Maintain strict intake and output.
- Check the pulse before giving the medication.
- Administer the medication 30 minutes before meals.
- Provide oral hygiene and gum care every shirt.
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3. Situation: With the improvement in life expectancies and the emphasis in the quality of life it is important to provide quality care to our older patients. There are frequently encountered situations and issues relevant to the older, patients.Q. Cardiac ischemia in an older patient usually produces:
- ST-T wave changes
- Very high creatinine kinase level
- chest pain radiating to the left arm
- acute confusion
4. The physician is preparing to remove a central line. The nurse should tell the client to:
- Breathe normally
- Take slow deep breaths
- Take a deep breath and hold it
- Breathe as quickly as possible
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5. Situation: Consider the following hypothesis: The Job turnover rate and job dissatisfaction levels of graduate nurses who have worked less than 2 years is higher than for those graduate nurses who have worked for more than 2 years". Q.The major reason for conducting nursing research is to:
- Improve nursing care for clients
- Promote the growth of the nursing profession
- Document to cost effectiveness of nursing care
- Ensure accountability of nursing practice
6. The emergency room is flooded with clients injured in a tornado. Which clients can be assigned to share a room in the emergency department during the disaster?
- A client having auditory hallucinations and the client with ulcerative colitis
- The client who is pregnant and the client with a broken arm
- A child who is cyanotic with severe dypsnea and a client with a frontal head injury
- The client who arrives with a large puncture wound to the abdomen and the client with chest pain
7. A garment factory does not have an occupational nurse. Who shall provide the occupational health needs of the factory workers?
- Occupational health nurse at the Provincial Health Office
- Physician employed by the factory
- Public Health nurse of the RHU of their municipality
- Rural Sanitary inspector of the RHU in their municipality
8. The nurse is monitoring a patients urine to determine hydration status what urine color would indicate the BEST hydration?
- Clear
- Amber
- Tea
- Pale gold
9. The nursing instructor asks the student to describe fetal circulation, specifically the ductus venosus. Which statement by the student indicates an understanding of the ductus venosus?
- "It connects the pulmonary artery to the aorta."
- "It is an opening between the right and left atria."
- "It connects the umbilical vein to the inferior vena cava”
- "It connects the umbilical artery to the inferior vena cava."
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10. Which of the following immunizations should not be given to a 4-month-old sibling client with leukemia?
- Diphtheria and tetanus and pertussis (DPT) vaccine.
- Hepatitis B vaccine
- Haemophilus influenzae type b vaccines (Hib)
- Oral poliovirus vaccine (OPV)
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11. A nurse visits a patient who is 37-weeks pregnant and asking for information about breast feeding versus feeding prepared infant formula. A beneficial reason to breast feed includes:
- Readily available and economical
- Keeps a baby full longer
- Larger curds than cow's milk and therefore is easier to digest
- Encourage greater deposits of subcutaneous fat in an infant
12. Nurse Bea notices a female client sitting alone in the corner smiling and talking to herself. Realizing that the client is hallucinating. Nurse Bea should:
- Invite the client to help decorate the dayroom
- Leave the client alone until he stops talking
- Ask the client why he is smiling and talking
- Tell the client it is not good for him to talk to himself
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13. For a patient with a colostomy, which of the following-intervention is appropriate for preventing the risk of the impaired skin related to exposure excretions?
- Empty pouch when it is completely full
- Remove the skin barrier inspect the skin monthly
- Recaps Skin barrier opening to size of stoma with each change
- Cut an opening in the skin barrier then the circumference of the stoma
14. A child is receiving a series of the hepatitis B vaccine and arrives at the clinic with his parent for the second dose. Before administering the vaccine, the nurse should ask the child and parent about a history of a severe allergy to which substance?
- Eggs
- Penicillin
- Sulfonamides
- A previous dose of hepatitis B vaccine or component
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15. While receiving radiation therapy for the treatment of breast cancer, a client complains of dysphagia and skin texture changes, at the radiation site. Which of the following instructions would be most appropriate to suggest to minimize the risk of complications, and promote healing?
- Wash the radiation site vigorously with soap and water to remove dead cells.
- Eat a diet high in protein and calories to optimize tissue repair.
- Apply cool compresses to the radiation site to reduce edema,
- Drink warm fluids throughout the day to relieve discomfort in swallowing.
16. Situation: Margie has been diagnosed with Bipolar I disorder. The client demonstrates extreme psychomotor agitation, flight of ideas, loud talking and elated mood.Q. The doctor ordered lithium. You know that this is indicated in patients with:
- Depression
- Mania
- Schizophrenia
- Anxiety disorders
17. Situation: Margie has been diagnosed with Bipolar I disorder. The client demonstrates extreme psychomotor agitation, flight of ideas, loud talking and elated mood.Q. Which of the following is NOT a drug use to augment lithium toxicity?
- Urea
- Mannitol
- Aminophylline
- Acetylcysteine
18. Which of the following measures would be appropriate for the nurse to teach the parent of a nine month-old infant about diaper dermatitis?
- Use only cloth diapers that are rinsed in bleach
- Do not use occlusive ointments on the rash
- Use commercial baby wipes with each diaper change
- Discontinue a new food that was added to the infants diet just prior to the rash
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19. The mother of an 8-year-old child being treated for right lower lobe pneumonia at home calls the clinic nurse. The mother tells the nurse that the child complains of discomfort on the right side and that ibuprofen is not effective. Which instruction should the nurse provide to the mother?
- Increase the dose of ibuprofen.
- Increase the frequency of ibuprofen.
- Encourage the child to lie on the left side.
- Encourage the child to lie on the right side.
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20. When assessing a male client for suicidal risk, which of the following methods of suicide would the nurse identify as most lethal?
- Wrist cutting
- Head banging
- Use of gun
- Aspirin overdose
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21. The nurse is providing care for a client who has a sacral pressure ulcer with wet-to-dry dressing. Which guideline is appropriate for a wet-to-dry dressing?
- The wound should remain moist form the dressing.
- The wet-to-dry dressing should be tightly packed into the wound.
- The dressing should be allowed to dry out before removal.
- A plastic sheet-type dressing should cover the wet dressing.
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22. The home care nurse is monitoring a pregnant client with gestational hypertension who is at risk for preeclampsia. At each home care visit, the nurse assesses the client for which classic signs of preeclampsia? Select all that apply. 1.Proteinuria. 2.Hypertension. 3.Low-grade fever. 4.Generalized edema. 5.Increased pulse rate. 6.Increased respiratory rate
- 1,2
- 3,4
- 2,3,5
- 2,5
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23. A 2-month-old child in the emergency department has projectile vomiting after feeding. The vomitus is nonbilious containing milk and gastric juices. Immediately after vomiting the child tries to feed again. The nurse palpates the child's abdomen during feeding and notes a firm area to the right of the umbilicus at the upper right quadrant Which of the following is consistent with this history?
- Hirschsprungs disease
- Hypertrophic pyloric stenosis
- Gastro esophageal reflux
- Tracheoesophagel fistula
24. Situation: Basic knowledge on Intravenous solutions is necessary for care of clients with problems with fluids and electrolytes. Q. A nurse is assigned to care for a group of clients. On review of the client's medical records the nurse determines that which client is at risk for excess fluid volume?
- The client taking diuretics
- The client with renal failure
- The client with an ileostomy
- The client who requires gastrointestinal suctioning
25. Laboratory studies are performed for a child suspected to have iron deficiency anemia. The nurse reviews the laboratory results, knowing that which result indicates this type of anemia?
- Elevated hemoglobin level
- Decreased reticulocyte count
- Elevated red blood cell count
- Red blood cells that are microcytic and hypochromic
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26. Sulfisoxazole, 1 g orally twice daily, is prescribed for an adolescent with a urinary tract infection. The medication label reads "500-mg tablets." The nurse has determined that the dosage prescribed is safe. The nurse administers how many tablets per dose to the adolescent?
- 1/2 tablet
- 1 tablet
- 2 tablets
- 3 tablets
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27. Which of the following situations cannot be delegated by the registered nurse to the nursing assistant?
- A postoperative client who is stable needs to ambulate.
- Client in soft restraint who is very agitated and crying.
- A confused elderly woman who needs assistance with eating.
- Routine temperature check that must be done for a client at end of shift.
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28. The nurse is caring for an infant receiving intravenous fluid. Signs of fluid overload in an infant include:
- Swelling of the hands and increased temperature
- Increased heart rate and increased blood pressure
- Swelling of the feet and increased temperature
- Decreased heart rate and decreased blood pressure
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29. The nurse understands that the fetal head is in which of the following positions with a face presentation?
- Completely flexed
- Completely extended
- Partially extended
- Partially flexed
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30. A client with bladder cancer is being treated with iridium seed implants. The nurses discharge teaching should include telling the client to:
- Strain his urine
- increase his fluid intake
- Report urinary frequency
- Avoid prolonged sitting
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31. A four-year-old with cystic fibrosis has a prescription for Viokase pancreatic enzymes to prevent malabsorption. The correct time to give pancreatic enzyme is:
- One hour before meals
- Two hours after meals
- With each meal and snack
- On an empty stomach
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32. A patient complains of left eye redness and itching, the doctor told you to putatropine eye drops for the patient to examine his eye. The nurse should instill the eye drops into:
- The left eye.
- The right eye.
- Both right and left eyes.
- Neither of the eyes.
33. Maylene had just received her 4th dose of tetanus toxoid. She is aware that her baby will have protection against tetanus for:
- 10 year
- 5 years
- 3 years
- Lifetime
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34. The nurse is caring for a patient with suspected diverticulitis. The nurse would be most prudent in questioning which of the following diagnostic tests?
- Abdominal ultrasound
- Barium enema
- Complete blood count
- Computed tomography (CT) scan
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35. The client who experienced an inhalation injury 6 hours ago has been wheezing. When the client is assessed, wheezes are no longer heard. What is the nurse's best action?
- Raise the head of the bed.
- Notify the emergency team.
- Loosen the dressings on the chest.
- Document the findings as the only action.
36. Situation: Arnold, age 67, has had successfully treated depressive disease for more than 10 years. Lately he has been developing a plan of action. Arnold is admitted to hospital for reassessment.Q. Arnold is placed on suicide precautions. Which would be the most therapeutic way to provide his safety measures?
- Not allow him to leave his room
- Remove all sharp and cutting objects
- Give him the opportunity to ventilate feelings
- Assign staff member to be with him at all times
37. A 27 year-old woman presents with stomach cramping with alternating constipation and diarrhea. She had been diagnosed with irritable bowel syndrome two years before and has so far managed the illness with lifestyle changes, including diet and exercise. What is the most appropriate advice?
- Increase dairy intake
- Use antacids to relive pain
- Increase dietary fiber
- Avoid emotional stress triggers
38. The nurse formulates a nursing diagnosis of Impaired social interaction related to disorganized thinking for a client with schizotypal personality disorder Based on this nursing diagnosis, which nursing intervention takes highest priority?
- Helping the client to participate in social interactions
- Establishing a one-on-one relationship with the client
- Exploring the effects of the clients behavior on social interactions
- Developing a schedule for the client's participation in social interactions
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39. The chief complain should be record using:
- Nurse words.
- Patient words.
- Physician words.
- None of the above.
40. Cataracts result in opacity of the crystalline lens. Which of the following best explains the functions of the lens?
- The lens controls stimulation of the retina.
- The lens orchestrates eye movement.
- The lens focuses light rays on the retina.
- The lens magnifies small objects.
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41. A client with trigeminal neuralgia tells the nurse that acetaminophen is taken daily for the relief of generalized discomfort Which laboratory value would indicate toxicity associated with the medication?
- Sodium level of 140 mEq/L (140 mmol/L)
- Platelet count of 400,000 mm3 (400x10^9/L)
- Prothrombin time of 12 seconds (12 seconds)
- Direct bilirubin level of 2 mg/dL (34 mcmol/L)
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42. Tourette syndrome is characterized by the presence of multiple motor and vocal tics. A vocal tic that involves repeating one's own sounds or words is known as:
- echolalia
- palilalia
- apraxia
- aphonia
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43. Situation: Survey and Statistics are important part of research that is necessary to explain the characteristics of the population.Q. Which of the following is not true about a Pure Experimental Research?
- There is a control group
- There is an experimental group
- Selection of subjects in the control group is randomized
- There is a careful selection of subjects in the experimental group
44. Which of the following is a characteristic of a reassuring fetal heart rate pattern?
- A fetal heart rate of 180bpm
- A baseline variability of 35bpm
- A fetal heart rate of 90 at the baseline
- Acceleration of FHR with fetal movements
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45. In which of the following disorders would the nurse expect to assess sacral edema in bedridden client?
- DM
- Pulmonary emboli
- Renal failure
- Right-sided heart failure
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46. Situation: There are other important basic knowledge in the performance of our task as Community Health Nurse in relation to IMMUNIZATION these include:Q. This is the vaccine needed before a child reaches one (1) year in order for him/her to qualify as a "fully immunized child".
- DPT
- Measles
- Hepatitis B
- BCG
47. A child is admitted to the pediatric ward with fever, lethargy, joint pain and abdominal pain for several weeks. The patient has a history of recurrent respiratory and ear infections. Physical findings include wide spread ecchymosis, generalized lymph adenopathy, hepato splenomegaly, and pallor. Lab work show a low hemoglobin level, low RBC count, low hematocrit, and low platelets. The nurse should expect the bone marrow stain to show a:
- Large number of lymphoblasts and lymphocytes
- Low number of lymphoblasts and large number of lymphocytes
- Low number of lymphoblasts and lymphocytes
- Large number of lymphoblasts and low number of lymphocytes
48. The nurse is monitoring an infant with congenital heart disease closely for signs of heart failure (HF). The nurse should assess the infant for which early sign of HF?
- Pallor
- Cough
- Tachycardia
- Slow and shallow breathing
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49. A child has a right femur fracture caused by a motor vehicle crash and is placed in skin traction temporarily until surgery can be performed. During assessment, the nurse notes that the dorsalis pedis pulse is absent on the right foot Which action should the nurse take?
- Administer an analgesic.
- Release the skin traction.
- Apply ice to the extremity.
- Notify the health care provider (HCP).
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50. The nurse is caring for a patient with magnesium toxicity. Which of the following clinical manifestation should the nurse anticipate?
- Paresthesia
- Decreased deep-tendon reflexes
- Cardiac palpitations
- Decreased cardiac output