NCLEX-RN | QB2 | Practice Exam #33 (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 assessing the arterial blood gases (ABG) of a chest trauma client with the results of pH 7.35 PO2 85 PCO2 55 and HCO3 27. What do these values indicate?

• Uncompensated respiratory acidosis
• Uncompensated metabolic acidosis
• Compensated respiratory acidosis
• Compensated metabolic acidosis

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2. Situation: Salome, 80 year old widow, has been observed to be irritable, demanding and speaking louder than usual. She would prefer to be alone and take her meals by herself, minimized receiving visitors al home and no longer bothers to answer telephone calls because of deterioration of her hearing. 'She was brought by her daughter to, the Geriatic clinic for assessment and treatmentQ. Salome was fitted a hearing aid. She understood the proper .use and wear of this device when she ways that the battery should be functional, the device is turned on and adjusted to a:

• therapeutic level
• comfortable level
• prescribed level
• audible level

3. Clarina, a college student who frequently visited the health center during the past year with multiple vague complaints of Gl symptoms before course examinations. Although physical causes have been eliminated, the student continues to express her belief that she has a serious illness. These symptoms are typically of which of the following disorders?

• Conversion disorder
• Depersonalization
• Hypochondriasis
• Somatization disorder

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4. A client is admitted with the diagnosis of pulmonary embolism. While taking a history, the client tells the nurse he was admitted for the same thing twice before, the last time just 3 months ago. The nurse would anticipate the health care provider ordering

• Pulmonary embolectomy
• Vena caval interruption
• Increasing the coumadin therapy to an INR of 3-4
• Thrombolytic therapy

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5. Katherine tells one of the staff, I don t have time to discuss the matter with you now. See me in my office later" when the latter asks if they can talk about an issue. Which of the following conflict resolution strategies did she use?

• Smoothing
• Compromise
• Avoidance
• Restriction

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6. Which of the following types of cardiomyopathy can be associated with childbirth?

• Dilated
• Hypertrophic
• Myocarditis
• Restrictive

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7. In caring for clients with pain and discomfort, which task is most appropriate to delegate to the nursing assistant?

• Assist the client with preparation of a sitz bath.
• Monitor the client for signs of discomfort while ambulating
• Coach the client to deep breathe during painful procedures
• Evaluate relief after applying a cold application.

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8. In caring for a victim of sexual assault, which task is most appropriate for an LPN/LVN?

• Assess immediate emotional state and physical injuries
• Collect hair samples, saliva swabs, and scrapings beneath fingernails.
• Provide emotional support and supportive communication.
• Ensure that the chain of custody is maintained.

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9. A client is preparing to attend a Gamblers Anonymous meeting for the first time. The nurse should tell the client that which is the first step in this 12-step program?

• Admitting to having a problem
• Substituting other activities for gambling
• Stating that the gambling will be stopped
• Discontinuing relationships with people who gamble

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10. Situation: Michelle is a 6 year old preschooler. She was reported by her sister to have measles but she is at home because of fever, upper respiratory problem and white sports in her mouth.Method of prevention is to avoid exposure to an infected person. Nursing responsibility for rehabilitation of patient includes the provision of:

• Terminal disinfection
• Injection of gamma globulin
• Immunization
• Comfort measures

11. A mastectomy patient has developed lymphedema of the left arm. The nurse should teach the patient that the BEST position for the arm is:

• Immobilized across the chest
• Dependent
• Elevated
• In traction

12. Situation: Radiation therapy is another modality of cancer management With emphasis on multidisciplinary management you have important responsibilities as a nurseQ. Albert is receiving external radiation therapy and he complains of fatigue and malaise. Which of the following nursing interventions would be most helpful for Albert?

• Tell him that sometimes these feelings can be psychogenic
• Refer him to the physician
• Reassures him that these feelings are normal
• Help him plan his activities

13. The emergency department (ED) nurse receives a telephone call and tornado has hit a local residential area and that numerous casualties is informed that have occurred. The victims will be brought to the ED. The nurse should take which initial action?

• Prepare the triage rooms.
• Activate the emergency response plan.
• Obtain additional supplies from the central supply department.
• Obtain additional nursing staff to assist in treating the casualties.

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14. The most common dose-limiting toxicity of chemotherapy is:

• Nausea and vomiting.
• Bloody stools.
• Myelosuppression.
• Inability to ingest food orahy due to stomatitis and mucositis.

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15. Which of the following point scores on the post anesthesia chart, indicates that the client has fulfilled minimal criteria for discharge from the PACU?

• One point In each of the five areas for a total score of 5.
• One point in at least three areas" respiratory, circulatory and consciousness - for a total of 3
• A total score for the five areas of 7 or above.
• Two points each in each of the five areas for a total score of 10.

16. The following are all nursing diagnoses appropriate for a gravida 1 para 0 in labor. Which one would be most appropriate for the primagravida as she completes the early phase of labor?

• Impaired gas exchange related to hyperventilation
• Alteration in placental perfusion related to maternal position
• Impaired physical mobility related to fetal-monitoring equipment
• Potential fluid volume deficit related to decreased fluid intake

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17. Smoking cessation is critical strategy for the client with Burgher s disease, Nurse Jasmin anticipates that the male client will go home with a prescription for which medication?

• Paracetamol
• Ibuprofen
• Nitroglycerin
• Nicotine (Nicotrol)

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18. The nurse is assessing the deep tendon reflexes of a client with preeclampsia. Which method is used to elicit the biceps reflex?

• The nurse places her thumb on the muscle inset in the antecubital space and taps the thumb briskly with the reflex hammer.
• The nurse loosely suspends the clients arm in an open hand while tapping the back of the clients elbow.
• The nurse instructs the client to dangle her legs as the nurse strikes the area below the patella with the blunt side of the reflex hammer.
• The nurse instructs the client to place her arms loosely at her side as the nurse strikes the muscle insert just above the wrist.

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19. A nurse is caring for a hospitalized diabetic patient with advanced peripheral recovery. Which of the following nursing action is MOST important?

• Moisturizing the skin with lotion each day
• Ensuring that foods are not too hot
• Facing the patient when speaking
• Assessing the heels for breakdown

20. Situation: A group of nursing students were discussing the normal growth and development concepts when assigned to observe the school children.Q. Resolution of the oedipal complex takes place when the child overcomes the castration complex and:

• Rejects the parent of the same sex
• Introjects behavior of both parents
• Identities with me parent of the same sex
• Identifies with the parent of the opposite sex

21. Tony has diagnosed with hepatitis A. The information from the health history that is most likely linked to hepatitis A is:

• Exposed with arsenic compounds at work
• Working as local plumber
• Working at hemodialysis clinic
• Dish washer in restaurants

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22. Situation: Still in your self-managed Child Health Nursing Clinic, your encounter these cases pertaining to the CARE OF CHILDREN WITH PULMONARY AFFECTIONS .In responding to the care concerns of children with severe disease, referral to the hospital of the essence especially if the child manifests which of the following?

• Wheezing
• Stopped bleeding
• Fast breathing
• Difficulty to awaken

23. A 40 year-old woman presents with right hip pain palpation of the pelvic girdle is normal. An X-ray shows bone deformities, with osteolytic lesions and bone enlargement The patient has not suffered trauma and has been generally health. Which serum laboratory analysis would be most useful?

• Prothrombin time
• Alkaline phosphatase
• Acid phosphatase
• Parathyroid hormone

24. Hyperthermia is:

• Body temperature between 36.4 - 37.4
• Body temperature between 39 - 41
• Body temperature below 36.
• Body temperature between 38 - 40.

25. Situation: Jimmy developed this goal for hospitalization. To get a handle on my nervousness." The nurse is going to collaborate with him to reach his goal. Jimmy was admitted to the hospital because he called his therapist that he planned to asphyxiate himself with exhaust from his car but frightened instead. He realized he needed help.Q. The nurse notes effectiveness of Interventions in using subjective and objective data in the:

• initial plans or order
• database
• problem list
• progress notes

26. Which of the following conditions may require fluid restriction?

• Fever
• Chronic Obstructive Pulmonary Disease
• Renal Failure
• Dehydration

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27. The most common causes of megaloblastic, macrocytic anemias are:

• Folate or vitamin B deficiency
• Chronic disease
• Iron deficiency
• Infection

28. During surgery requiring general anesthesia, the patients heart stops, Ventilations using the end tracheal tube (ETT) are started with an ambubag. Which of the following compression to ventilation rates is correct?

• 10 to 2
• 15 to 2
• 30 to 2
• 50 to 2

29. The nurse is preparing to discharge a client following a laparoscopic cholecystectomy. The nurse should:

• Tell the client to avoid a tub bath for 48 hours.
• Tell the client to expect clay-colored stools.
• Tell the client that she can expect lower abdominal pain for the next week.
• Tell the client to report pain in the back or shoulders.

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30. Situation: NURSES are involved in maintaining a safe and healthy environment. This is part of quality care managementQ. For a patient experiencing pruritus, you recommend which type of bath:

• Water
• colloidal (oatmeal)
• saline
• sodium bicarbonate

31. Situation: Ella Caidic Is pregnant with her first baby. She went to the clinic for check-up. Q. She complained of leg cramps, winch usually occurs at night To provide relief, the nurse must tell Mrs. Caidic to:

• dorsiflex the foot white extending the knee when the cramps occur
• dorsiflex the foot while flexing the knee when the cramps occur.
• Plantar flex the foot while flexing the knee when cramps occur
• plantar flex the foot while extending the knee when the cramps occur.

32. Which of the following conditions is most closely associated with weight gain, nausea, and a decrease in urine output?

• Angina pectoris
• Cardiomyopathy
• Left-sided heart failure
• Right-sided heart failure

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33. 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. Common anesthesia for appendectomy is:

• Spinal
• General
• Caudal
• Hypnosis

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34. Which of the following white blood cell (WBC) counts clearly indicates leukocytosis?

• 4,500/mm3
• 7,000/mm3
• 10,000/mm3
• 25,000/mm3

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35. The nurse is caring for a client with schizophrenia who experiences auditory hallucinations. The client appears to be listening to someone who isn't visible. He gestures, shouts angrily and stops shouting in mid-sentence. Which nursing intervention is the most appropriate?

• Approach the client and touch him to get his attention.
• Encourage the client to go to his room where he'll experience fewer distractions.
• Acknowledge that the client is hearing voices but make it clear that the nurse doesn't hear these voices.
• Ask the client to describe what the voices are saying

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36. While caring for a child with aventriculoperitoneal shunt revision, the nurse find the patient lying with the head and feet flexed back. The nurse should call for help and prepare for a(n):

• Spinal tap
• Shunt culture
• Electrocardiogram
• Ventricular tap

37. A client with histoplasmosis has an order for ketoconazole (Nizoral). The nurse teaches the client to do which of the following while taking this medication?

• take the medication on an empty stomach
• take the medication with an antacid
• avoid exposure to sunlght
• limit alcohol to 2 ounces per day

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38. During a routine checkup, Nurse Marianne assesses a male client with acquired immunodeficiency syndrome (AIDS) for signs and symptoms of cancer. What is the most common AIDS-related cancer?

• Squamous cell carcinoma
• Multiple myeloma
• Leukemia
• Kaposi's sarcoma

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39. Situation: Nanette was rushed to the hospital due to burns. Witnesses told the emergency team that Nanette fell asleep while she is holding her cigarette thus, burning the bed sheets and herself. 2nd and 3rd degree burns are on the face, neck, anterior and posterior trunk as well as the anterior of the left leg and the whole right arm was burned. First degree burns are located on the anterior portion of the right leg and the anterior portion of the right and left arm. Nanette is a 110 lbs female clientQ. During the emergent phase of burn, which of the following is an expected finding on Nanette?

• Decreased heart rate
• Elevated hematocrit levels
• Increased blood pressure
• Increased urinary output

40. A client has been diagnosed with RUBELLA. What precaution is used for this patient?

• Standard precaution
• Airborne precaution
• Droplet precaution
• Contact precaution

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41. In the client with terminal lung cancer, the focus of nursing care is on which of the following nursing interventions?

• Provide emotional support
• Provide nutritional support
• Provide pain control
• Prepare the clients will

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42. When performing a pelvic examination, the nurse observes a red swollen area on the right side of the vaginal orifice. The nurse would document this as enlargement of which of the following?

• Clitoris
• Parotid gland
• Skene's gland
• Bartholins gland

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43. When administering an enema to adult patient, how far should the nurse insert the tubing into the rectum?

• 2.2 to 4.4cm (1 to 2 inches)
• 4.4 to 6.6cm (1 to 3 inches)
• 6.6 to 8.8cm (3 to 4 inches)
• 8.8 to 11 cm (4 to 5 inches)

44. Refers to diseases that produced no anatomic changes but as a result from abnormal response to a stimuli.

• Functional
• Occupational
• Inorganic
• Organic

45. Which of the following would the nurse do first for a 3-year-old boy who arrives in the emergency room with a temperature of 105 degrees, inspiratory stridor, and restlessness, who is learning forward and drooling?

• Auscultate his lungs and place him in a mist tent.
• Have him lie down and rest after encouraging fluids.
• Examine his throat and perform a throat culture
• Notify the physician immediately and prepare for intubation.

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46. A home health nurse visits a patient with chronic obstructive pulmonary disease (COPD) using home oxygen at 2 liters per minute. The patient reports periods of shortness of breath and inquires about increasing the oxygen to 4 liters/minute. The nurse explains that increasing the supplemental oxygen will:

• Increased activity tolerance
• Suppress the hypoxic drive
• Alleviate the shortness of breath
• Prevent lung infection

47. The mother asks the nurse when will the soft bone at the head be closed? The nurse response would be:

• 12-18 wks.
• 2-3 mos.
• 12-18 mos.
• 14-18 wks.

48. In the emergency department, a client with facial lacerations states that her husband beat her with a shoe. After the health care team repairs her lacerations, she waits to be seen by the crisis intake nurse, who will evaluate the continued threat of violence. Suddenly the client's husband arrives, shouting that he wants to "finish the job." What is the first priority of the health care worker who witnesses this scene?

• Remaining with the client and staying calm
• Calling a security guard and another staff member for assistance
• Telling the clients husband that he must leave at once
• Determining why the husband feels so angry

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49. A nurse is providing care to a patient with a new skin graft on left leg. The patient is upset and the nurse notes copious red drainage oozing around the dressing. The nurse should immediately:

• Lift the dressing to assess the area
• Ask if the patient is having any pain
• Apply firm pressure for 10 to 15 minutes
• Assess the apical pulse

50. Situation: After abdominal surgery, the circulating and scrub nurses have critical responsibility about sponge and instrument countQ. Counting is performed thrice: during the preincision phase, the operative phase and closing phase. Who counts the sponges, needles and instruments?

• The scrub nurse only
• The circulating nurse only
• The surgeon and the assistant surgeon
• The scrub nurse and circulating nurse.

 

NCLEX-RN | QB2 | Practice Exam #33 (50 questions)