QB2 | Practice Exam #35 -> answers with explanation - Free NCLEX Exam Practice

NCLEX-RN | QB2 | Practice Exam #35 (50 questions)

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

 

1. Nurses are aware that diagnosis of leprosy is highly dependent on recognition of symptoms. Which of the following is an early sign of leprosy?

• Macular lesions
• Inability to close eyelids
• Thickened painful nerves
• Sinking of the nosebridge

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2. When performing a newborn assessment, the nurse should measure the vital signs in the following sequence:

• Pulse, respirations, temperature
• Temperature, pulse, respirations
• Respirations, temperature, pulse
• Respirations, pulse, temperature

3. Jomari is diagnosed with hyperosmolar hyperglycemic nonketotic syndrome (HHNS) is stabilized and prepared for discharge. When preparing the client for discharge and home management, which of the following statements indicates that the client understands her condition and how to control it?

• "I can avoid getting sick by not becoming dehydrated and by paying attention to my need to urinate, drink, or eat more than usual.”
• "If I experience trembling, weakness, and headache, I should drink a glass of soda that contains sugar."
• "I will have to monitor my blood glucose level closely and notify the physician if it's constantly elevated."
• "If I begin to feel especially hungry and thirsty, I'll eat a snack high in carbohydrates."

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4. Situation: A 19 year old nursing student has lost 36 lbs for 4 weeks. Her parents brought her to the hospital for medical evaluation. The diagnosis was ANOREXIA NERVOSA. The Primary gain of a client with anorexia nervosa is:

• Weight loss
• Weight gain
• Reduce anxiety
• Attractive appearance

5. Situation: Human development is one of the important concepts that a nurse should learn to be able to deal appropriately with their clients of different developmental stages.A pregnant client asks you about fetal development. At approximately what gestational age does the fetus's single chambered heart begin to pump its own blood cells through main blood vessels?

• 10 weeks
• 8 weeks
• 5 weeks
• 3 weeks

6. A 23 year old client has been admitted with a diagnosis of schizophrenia says to the nurse "Yes, its march, March is little woman". That's literal you know". These statement illustrate:

• Neologisms
• Echolalia
• Flight of ideas
• Loosening of association

7. The primary purpose of conducting an epidemiologic investigation is to:

• Delineate the etiology of the epidemic
• Encourage cooperation and support of the community
• Identify groups who are at risk of contracting the disease
• Identify geographical location of cases of the disease in the community

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8. SITUATION: Alfred, a 40 year old construction worker developed cough, night sweats and fever. He was brought to the nursing unit for diagnostic studies. He told the nurse he did not receive a BCG vaccine during childhood. Q. Why is Mantoux test not routinely done in the Philippines?

• It requires a highly skilled nurse to perform a Mantoux test
• The sputum culture is the gold standard of PTB Diagnosis and it will definitively determine the extent of the cavitary lesions
• Chest X Ray Can diagnose the specific microorganism responsible for the lesions
• Almost all Filipinos will test positive for Mantoux Test

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9. Situation: The mental health - psychiatric nurse functions in a variety of setting with different types of clients.Q. The MOST cost effective way to meet the mental health needs of the public is through programs with a priority goal of:

• treatment
• prevention
• rehabilitation
• research

10. The nurse is providing care to a client with a catatonic type of schizophrenia who exhibits extreme negativism. To help the client meet his basic needs, the nurse should:

• ask the client which activity he would prefer to do first
• negotiate a time when the client will perform activities.
• tell the client specifically and concisely what needs to be done.
• prepare the client ahead of time for the activity.

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11. Erik John Senna, told Nurse Blake I don t want to that, I don t want that thing.. that's too painfull" Which of the following response is NON THERAPEUTIC?

• "This must be difficult for you, but I need to inject you this for your own good"
• "You sound afraid"
• "Are you telling me you don't want this injection?"
• "Why are you so anxious? Please tell me more about your feelings Erik"

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12. What is the first intervention for a client experiencing myocardial infarction?

• Administer morphine
• Administer oxygen
• Administer sublingual nitroglycerin
• Obtain an electrocardiogram

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13. The nurse is aware that ataractics or psychic energizers are also known as:

• Anti manic
• Anti depressants
• Antipsychotics
• Anti anxiety

14. A TB patient was discharged in the hospital. A UV Lamp was placed in the room where he stayed for a week. What type of disinfection is this?

• Terminal disinfection
• Regular disinfection
• Concurrent disinfection
• Routine disinfection

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15. A client is being monitored using a central venous pressure monitor. If the pressure is .5cm of water the nurse should:

• Cali the doctor immediately
• Slow the intravenous infusion
• Listen to the lungs for rales
• Administer a diuretic

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16. 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. What pancreatic enzyme aids in the digestion of carbohydrates?

• Lipase
• Trypsin
• Amylase
• Chymotrypsin

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17. Situation: Two children were brought to you. One with chest indrawing and the other had diarrhea. The following questions apply:The child with no dehydration needs home treatment Which of the following is NOT included in the care for home management at this case?

• give drugs every 4 hours
• continue feeding the child
• give the child more fluids
• inform when to return to the health center

18. A primigravida with diabetes is admitted to the labor and delivery unit at 34 weeks gestation. Which doctors order should the nurse question?

• Magnesium sulfate 4gm (25%) IV
• Brethine lOmcg IV
• Stadol 1 mg IV push every 4 hours as needed prn for pain
• Ancef 2gm IVPB every 6 hours

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19. A client with retinal detachment is admitted to the nursing unit in preparation for a repair procedure. Which prescription should the nurse anticipate?

• Allowing bathroom privileges only
• Elevating the head of the bed to 45 degrees
• Wearing dark glasses to read or watch television
• Placing an eye patch over the clients affected eye

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20. One of the goals for a client with anorexia nervosa is that the client will demonstrate increased individual coping by responding to stress in constructive ways. Which of the following actions is the best indicator that the client is working toward meeting the goal?

• The client drinks 4 L of fluid per day.
• The client paces around the unit most of the day.
• The client keeps a journal and discusses it with the nurse.
• The client talks almost constantly with friends by telephone.

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21. The nurse provides a teaching session to the nursing staff regarding osteosarcoma. Which statement by a member of the nursing staff indicates a need for information?

• "The femur is the most common site of this sarcoma."
• "The child does not experience pain at the primary tumor site."
• "Limping, if a weight-bearing limb is affected, is a clinical manifestation."
• "The symptoms of the disease in the early stage are almost always attributed to normal growing pains"

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22. The nurse in the nursing care unit checks the fluctuation in the water-seal compartment closed chest drainage system. The fluctuation has stopped, the nurse would:

• Vigorously strip the tube to dislodge a clot.
• Raise the apparatus above the chest to move fluid.
• Increase wall suction above 20 cm H2O pressure.
• Ask the client to cough and take a deep breath.

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23. A first day postoperative client on a PCA pump reports that the pain control is inadequate. What is the first action you should take?

• Deliver the bolus dose per standing order.
• Contact the physician to increase the dose.
• Try non-pharmacological comfort measures.
• Assess the pain for location, quality, and intensity.

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24. The nurse is planning to teach a client with malaborption syndrome about the necessity of following a low-fat diet The nurse develops a list of high-fat foods to avoid and should include which food items on the list? Select all that apply. 1.Oranges. 2.Broccoli. 3.Margarine. 4.Cream cheese. 5.Luncheon meats. 6.Broiled haddock

• 3,4,5
• 1,2,3
• 2,3,4,5
• 4,5,6

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25. When preparing the mother who is on her 4th month of pregnancy for abdominal ultrasound, the nurse should instruct her to:

• Observe NPO from midnight to avoid vomiting
• Do perineal flushing properly before the procedure
• Drink at least 2 liters of fluid 2 hours before the procedure and not void until the procedure is done
• Void immediately before the procedure for better visualization

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26. Situation: Care of clients with tracheotosmy is often a challenge to a beginning nurse. The following questions will test your knowledge on Tracheostomy and its related care.Q. Which of the following is NOT true with regards to securing the Tracheostomy?

• The cuff provides sufficient securing
• The Tracheostomy can be sutured in place
• The Tracheostomy can be stapled in place
• Tie or Velcro tie are used to generally secure the Tracheostomy around the client

27. Situation: Because of the serious consequences of severe burns management requires a multidisciplinary approach. You have important responsibilities as a nurse.Q. While Sergio was lighting a barbecue grill with a lighter fluid, his shirt burst into flames. The most effective way to extinguish the flames with as little further damage as possible is to:

• log roll on the grass/ground
• slap the flames with his hands
• remove the burning clothes
• pour cold liquid over the flames

28. Nurse Carla is aware that one of the following vaccines is done by intramuscular (IM) injection?

• Measles
• OPV
• BCG
• Tetanus toxoid

29. An infertility specialist is evaluating whether a womans cervical mucus contains enough estrogen to support sperm motility. Which of the following tests is the physician conducting?

• Ferning capacity.
• Basal body temperature.
• Culposcopy.
• Hysterotomy.

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30. The nurse is assigned a patient who had surgery under GA. The patient respiratory rate is 4/ mnt and the O2 saturation on 3mL/mnt of O2 via nasal canula is 84%. The nurse is awaiting the result of an ABG and anticipate that which of the following elevated?

• Arteriai O2 saturation (SaO2)
• HYDROGEN ion concentration (PH)
• Partial pressure of arterial CO2 (PaCO2)
• None of the above

31. Immediately following the birth of a full term newborn, which of the following nursing diagnoses should take PRIORITY?

• Ineffective airway clearance related to nasal and oral secretions
• Ineffective thermoregulation related to environmental factors
• Risk for imbalanced fluid volume related to weak sucking reflex
• Risk for injury related to immature defense mechanisms

32. Mr. Liberatore, age 76, is admitted to your unit. He has a past medical history of hypertension, DM, hyperlipidemia. Recently he has had several episodes where he stops talking mid sentence and stares into space. Today the episode lasted for 15 minutes. The admission diagnosis is impending CVA.Q. During your assessment of Julie she tells you all visual symptoms are gone but that she now has a severe pounding headache over her left eye. You suspect Julie may have:

• a tension headache
• the aura and headache of migraine
• a brain tumor
• a conversion reaction

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33. How can central venous access devices (CVADs) be of value in a patient receiving chemotherapy who has stomatitis and severe diarrhea?

• The chemotherapy can be rapidly completed allowing the stomatitis and diarrhea to resolve.
• Crystalloid can be administered to prevent dehydration.
• Concentrated hyperalimentation fluid can be administered through the CVAD.
• The chemotherapy dose can be reduced.

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34. When transferring a patient from a bed to a chair, the nurse should use which muscles to avoid back injury?

• Abdominal muscles
• Back muscles
• Leg muscles
• Upper arm muscles

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35. A 5 years old patient who under went abdominal surgery suffers from deficient fluid volume related to nothing by mouth (NPO) status; intravenous fluid therapy is given for hydration. Which of the following indicates that the treatment is effective?

• Urinary output of 15ml/hr
• Respiration rate, 35
• Heart rate 100
• Good skin turgor

36. Situation: You are actively practicing nurse who has just finished your graduate studies. You learned the value of research and would like to utilize the knowledge and skills gained in the application of research to the nursing service. The following questions apply to research.Q. An 85 year old client in a nursing home tells a nurse, " I signed the papers of that research study because the doctor was so insistent and I want him to continue taking care for me. "Which client right is being violated?

• Right of self determination
• Right to privacy and confidentiality
• Right to self disclosure
• Right not to be harmed

37. An infant born with an imperforate anus returns from surgery after requiring a colostomy. The nurse assesses the stoma and notes that it is red and edematous. Based on this finding, which action should the nurse take?

• Elevate the buttocks.
• Document the findings.
• Apply ice immediately.
• Call the health care provider.

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38. The nurse has given instructions on pursed-lip breathing to a client with COPD. Which statement by the client would indicate effective teaching?

• I should inhale through my mouth very deeply.
• I should tighten my abdominal muscles with inhalation.
• I should contract my abdominal muscles with exhalation.
• I should make inhalation twice as long as exhalation.

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39. A client with emphysema is receiving intravenous aminophymne. Which aminophylline level is associated with signs of toxicity?

• 5 micrograms/mL
• 10 micrograms/mL
• 20 micrograms/mL
• 25 micrograms/mL

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40. A client complains of difficulty of swallowing, when the nurse try to administer capsule medication. Which of the following measures the nurse should do?

• Dissolve the capsule in a glass of water
• Break the capsule and give the content with an applesauce
• Check the availability of a liquid preparation
• Crash the capsule and place it under the tongue

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41. The clinic nurse is reviewing the health care provider s prescription for a child who has been diagnosed with scabies. Lindane has been prescribed for the child. The nurse questions the prescription if which is noted in the child's record?

• The child is 18 months old.
• The child is being bottle-fed.
• A sibling is using lindane for the treatment of scabies.
• The child has a history of frequent respiratory infections.

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42. A client with AIDS is taking Zovirax (acyclovir). Which nursing intervention is most critical during the administration of acyclovir?

• Limit the clients activity
• Encourage a high-carbohydrate diet.
• Use an incentive spirometer to improve respiratory function.
• Encourage fluids.

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43. The nurse is preparing for the discharge of a client who has been hospitalized for paranoid schizophrenia. The client's husband expresses concern over whether his wife will continue to take her daily prescribed medication. The nurse should inform him that:

• his concern is valid but his wife is an adult and has the right to make her own decisions.
• he can easily mix the medication in his wife's food if she stops taking it.
• his wife can be given a long-acting medication that is administered every 1 to 4 weeks.
• his wife knows she must take her medication as prescribed to avoid future hospitalizations.

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44. Which type of medication order might read Vitamin K 10 mg I.M. daily x 3 days?

• Single order
• Standard written order
• Standing order
• Stat order

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45. Which of the following is TRUE with regards to Client Goals?

• They are specific, measurable, attainable and time bounded
• They are general and broadly stated
• They should answer for WHO, WHAT ACTIONS, WHAT CIRCUMSTANCES, HOW WELL and WHEN.
• Example is: After discharge planning, Client demonstrated the proper psychomotor skills for insulin injection.

46. An infant weighed 7 pounds 8 ounces at birth. If growth occurs at a normal rate, what would be the expected weight at 6 months of age?

• Double the birth weight
• Triple the birth weight
• Gain 6 ounces each week
• Add 2 pounds each month

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47. The home care nurse is visiting an older client whose spouse died 6 months ago. Which behaviors by the client indicates effective coping? Select all that apply. 1.Neglecting personal grooming. 2.Looking at old snapshots of family. 3.Participating in a senior citizens program. 4.Visiting the spouse's grave once a month. 5.Decorating a wall with the spouse's pictures and awards received

• 1,2,3,4
• 1,3,4
• 2,3,4,5
• 1,2,4,5

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48. In teaching a female client who is HIV-positive about pregnancy, the nurse would know more teaching is necessary when the client says:

• "The baby can get the virus from my placenta."
• "I'm planning on starting on birth control pills."
• "Not everyone who has the virus gives birth to a baby who has the virus”
• "I'll need to have a C-section if I become pregnant and have a baby."

49. Situation: As a perioperative nurse, you are aware of the correct processing methods for preparing instruments and other devices for patient use to prevent infection.Q. You have a critical heat labile instrument to sterilize and are considering to use high level of disinfectant What should you do?

• Cover the soaking vessel to contain the vapour
• Double the amount of high level of disinfectant
• Test the potency of the high level of disinfectant
• Prolong the exposure time according to manufacturer's direction

50. 60 year old post CVA patient is taking TPA for his disease, the nurse understands that this is an example of what level of prevention?

• primary
• secondary
• tertiary
• nota

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NCLEX-RN | QB2 | Practice Exam #35 (50 questions)