NCLEX-RN | QB2 | Practice Exam #36 (50 questions)
All 50 questions are randomized each time you take the test, and do not appear in the same order.
1. Nurse Meredith is in the process of giving a client a bed bath. In the middle of the procedure, the unit secretary calls the nurse on the intercom to tell the nurse that there is an emergency phone call. The appropriate nursing action is to:
- Immediately walk out of the clients room and answer the phone call.
- Cover the client place the call light within reach, and answer the phone call.
- Finish the bed bath before answering the phone call.
- Leave the client's door open so the client can be monitored and the nurse can answer the phone call.
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2. Alexandra is tasked to organize the new wing of the hospital. She was given the authority to do as she deems fit. She is aware that the director of nursing has substantial trust and confidence in her capabilities, communicates through downward and upward channels and usually uses the ideas and opinions of her staff. Which of the following is her style of management?
- Benevolent-authoritative
- Consultative
- Exploitive-authoritative
- Participative
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3. A client diagnosed with schizoaffective disorder is suffering from schizophrenia with elements of which of the following disorders?
- Personality disorder
- Mood disorder
- Thought disorder
- Amnestic disorder
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4. A daily dose of prednisone is prescribed for a client The nurse provides instructions to the client regarding administration of the medication and should instruct the client that which time is best to take this medication?
- At noon
- At bed time
- Early morning
- Any time, at the same time, each day
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5. Situation: Mr. Gerald Liu, 19 y/o, is being admitted to a hospital unit complaining of severe pain in the lower abdomen. Admission vital signs reveal an oral temperature of 101.2 OF.Q. Signs and symptoms include pain in the RLQ of the abdomen that may be localize at McBurney's point. To relieve pain, Mr. Liu should assume which position?
- Prone
- Supine, stretched out
- Sitting
- Lying with legs drawn up
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6. Situation: Leo lives in the squatter area. He goes to nearby school. He helps his mother gather molasses after school. One day, he was absent because of fever, malaise, anorexia and abdominal discomfort.Q. Which of the following is concurrent disinfection in the case of Leo?
- Investigation of contact
- Sanitary disposal of feces, urine and blood
- Quarantine of the sick individual
- Remove all detachable objects in the room.
7. Situation: You are actively practicing nurse who just finished your Graduate Studies. You earned the value of Research and would like to utilize the knowledge and skills gained in the application of research to 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 for that research study because the doctor was so insistent and I want: him to continue taking care of me." Which client right is being violated?
- Right of self determination
- Right to privacy and confidentiality
- Right to full disclosure
- Right not to be harmed
8. While administering a chemotherapeutic vesicant the nurse notes that there is a lack of blood return from the IV catheter The nurse should:
- Stop the medication from infusing
- Flush the IV catheter with normal saline
- Apply a tourniquet and call the doctor
- Continue the IV and assess the site for edema
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9. The nurse is to insert an NG Tube when suddenly she accidentally dip the end of the tube in the client's glass containing distilled drinking water which is definitely not sterile. As a nurse, what should you do?
- Don't mind the incident, continue to insert the NG Tube
- Obtain a new NG Tube for the client
- Disinfect the NG Tube before reinserting it again
- Ask your senior nurse what to do
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10. A high school student returns to school following a three-week absence due to mononucleosis. The school nurse knows it will be important for the client:
- To drink additional fluids throughout the day
- To avoid contact sports for 1-2 months
- To have a snack twice a day to prevent hypoglycemia
- To continue antibiotic therapy for six months
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11. The nurse is assessing a client's peripheral intravenous (IV) site after completion of a vancomycin infusion and notes that the area is reddened, warm, painful, and slightly edematous proximal to the insertion point of the IV catheter. At this time, which action by the nurse is best?
- Check for the presence of blood return.
- Remove the IVsite and restart at another site.
- Document the findings and continue to monitor the IV site.
- Call the health care provider (HCP) and request that the vancomycin be given orally
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12. A client with a chest injury has suffered flail chest. The nurse assesses the client for which most distinctive sign of flail chest?
- Cyanosis
- Hypotension
- Paradoxica chest movement
- Dyspnea, especially on exhalation
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13. A client is being weaned from parenteral nutrition (PN) and is expected to begin taking solid food today. The ongoing solution rate has been 100 mL/hour. The nurse anticipates that which prescription regarding the PN solution will accompany the diet prescription?
- Discontinue the PN.
- Decrease PN rate to 50 mL/hour.
- Start 0.9% normal saline at 25 mL/hour.
- Continue current infusion rate prescriptions for PN.
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14. Situation Carlo, 16 years old, comes to the ER with acute asthmatic attack. RR is 46/min and he appears to be in acute respiratory distress.Q. The asthmatic client asked you what breathing technique he can best practice when asthmatic attack starts. What will be the best position?
- Sit in high-Fowler's position with extended legs
- Push on abdomen during exhalation
- Sit-up with shoulders back
- Lean forward 30-40 degrees with each exhalation
15. A client with a clot in the right atrium is receiving a heparin sodium infusion at 1000 units/ hour and warfarin sodium 7.5 mg at 5:00 p.m. daily. The morning laboratory results are as follows: activated partial thromboplastin time (aPTT), 32 seconds; international normalized ratio (INR), 1.3. The nurse should take which action based on the client's laboratory results?
- Collaborate with the health care provider (HCP) to discontinue the heparin infusion and administer the warfarin sodium as prescribed.
- Collaborate with the HCP to obtain a prescription to increase the heparin infusion and administer the warfarin sodium as prescribed.
- Collaborate with the HCP to withhold the warfarin sodium since the client is receiving a heparin infusion and the aPTT is within the therapeutic range.
- Collaborate with the HCP to continue the heparin infusion at the same rate and to discuss use of dabigatran etexilate in place of warfarin sodium.
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16. A home health nurse is visiting a patient following a cerebrovascular accident (CVA). The patient is having trouble sleeping and is feeling sad. The patient's spouse tells the nurse that the patient is not eating much and often cries when no one is watching. Which of the following would be the nurse's MOST likely intervention?
- Assess for changes in cognitive abilities
- Complete a depression index
- Strengthen family coping methods
- Screen for pain
17. In home made oresol what is the ratio of salt and sugar if you want to prepare with 1 liter of water?
- 1 tbsp, salt and 8 tbsp, sugar
- 1 tbsp, salt and 8 tsp. sugar
- 1 tsp. salt and 8 tsp. sugar
- 8 tsp. salt and 8 tsp. sugar
18. A patient complains of in coordination, weakness and fatigue, double vision, and slurred speech laboratory test results are normal except for magnetic resonance imaging (MRI) scan which shows small plaques scattered throughout the white matter. The nurse would anticipate the diagnosis of:
- Multiple sclerosis
- Brain metastasis
- Amyotrophic lateral sclerosis (Lou Gehrig disease)
- Polyradiculoneuritis( Guillain-Barre syndrome)
19. The nurse is caring for a 40-year-old client. Which behavior by the client indicates adult cognitive development?
- Has perceptions based on reality
- Assumes responsibility for actions
- Generates new eve s of awareness
- Has maximum ability to solve problems and learn new skills
20. Which of the following procedures always requires surgical asepsis?
- Vaginal instillation of conjugated estrogen
- Urinary catheterization
- Nasogastric tube insertion
- Colostomy irrigation
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21. What is the best way to schedule medication for a client with constant pain?
- PRN at the client's request
- Prior to painful procedures
- IV bolus after pain assessment
- Around-the-clock
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22. A client with an acute exacerbation of rheumatoid arthritis is admitted to the hospital for treatment. Which drug, used to treat clients with rheumatoid arthritis, has both an anti inflammatory and immunosuppressive effect?
- Gold sodium thiomalate (Myochrysine)
- Azathioprine (Imuran)
- Prednisone (Deltasone)
- Naproxen (Naprosyn)
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23. Situation: Blood transfusion was ordered for Andre after an episode of severe bleeding.Q. Which of the following is an appropriate needle for Blood transfusion?
- A butterfly needle
- An 18 gauge angiocatheter
- A 25 gauge angiocatheter
- A 21 gauge angiocatheter
24. The nurse has just completed teaching about postoperative activity to a client who is going to have a cataract surgery. The nurse knows the teaching has been effective if the client:
- coughs and deep breathes postoperatively
- ties his own shoes
- asks his wife to pick up his shirt from the floor after he drops it.
- States that he doesn't need to wear an eyepatch or guard to bed
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25. Which of the following should the nurse expect to note as a frequent complication for child with congenital heart disease?
- Susceptibility to respiratory infection
- Bleeding tendencies
- Frequent vomiting and diarrhea
- Seizure disorder
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26. A client is scheduled for an intravenous pyelogram (IVP). Which of the following data from the client’s history indicate a potential hazard for this test?
- Reflex incontinence
- Allergy to shellfish
- Claustrophobia
- Hypertension
27. A nurse is explaining to a client about monthly hormonal changes. Starting with Day 1 of the menstrual cycle, please place the following four hormones in the chronological order in which they elevate during the menstrual cycle. 1.Follicle-stimulating hormone. 2.Gonadotropin-releasing hormone. 3.Luteinizing hormone. 4.Progesterone.
- 1.2,3,4
- 2,1,3,4
- 1,3,4,2
- 3,1,2,4
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28. Nurse Mickey is caring for a client diagnosed with bulimia. The most appropriate initial goal for a client diagnosed with bulimia is to:
- Avoid shopping for large amounts of food.
- Control eating impulses.
- Identify anxiety-causing situations
- Eat only three meals per day.
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29. Which of the following is TRUE about latent stage of labor?
- self-focused
- effacement 100%
- dilatation for 2 hours
- 3 cm cervical dilatation
30. A home health care nurse visits a patient diagnosed with rheumatoid arthritis. The nurse gathers information about the pain level after the use of prescribed pain medication to check on the effectiveness of the intervention. This phase of nursing process is called:
- Assessment
- Diagnosis
- Implementation
- Evaluation
31. A client with chronic obstructive pulmonary disease (COPD) tells the nurse, "I no longer have enough energy to make love to my husband" Which of the following nursing interventions would be most appropriate?
- Refer the couple to a sex therapist.
- Advise the woman to seek a gynecologic consult
- Suggest methods and measures that facilitate sexual activity.
- Tell the client, "if you talk this over with your husband, he will understand.
32. The nurse is performing an admission history for a client recovering from a stroke. Medication history reveals the drug clopidogrel (Plavix). Which clinical manifestation alerts the nurse to an adverse effect of this drug?
- Epistaxis
- Hypothermia
- Nausea
- Hyperactivity
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33. A three year-old has returned to the clinic 4 days after being diagnosed with gastroenteritis and dehydration. A parent reports that the vomiting has stopped, and the child is tolerating liquids, rice, applesauce, and bananas. The diarrhea persists, but seems to be decreasing in volume. When evaluating for signs of dehydration, the nurse will assess the patient's skin turgor by:
- Grasping the skin over the abdomen with two fingers and raising the skin with two fingers
- Grasping the skin over the forehead with two fingers and raising the skin with two fingers
- Holding the patient's mouth open and assessing the tongue for deep creases or furrows
- Drawing two tubes of blood and running a blood urea nitrogen (BUN) and creatinine (Cr)
34. Situation: You are assigned to take care of a group of patients across the lifespan.The painful phenomenon known as back labor occurs in a client whose fetus in what position?
- Brow position
- Right occipito-Anterior Position
- Breech position
- Left occipito-Posterior Position
35. A nurse is caring for a postoperative patient who is on subcutaneous, low-dose heparin. When administering an injection on the abdomen, the nurse avoids the umbilicus area because of the possibility of.
- Entering a larger blood vessel
- Causing increased pain
- Precipitating hyperventilation
- Umbilical infection
36. Situation: Breast cancer is the 2nd most common type of cancer after lung cancer and 99% of which, occurs in women. Survival rate is 98% if this is detected early and treated promptly. Carmen is a 53 year old patient in the high risk group for breast cancer was recently diagnosed with Breast Cancer.Q. A patient diagnosed with breast cancer has been offered the treatment choices of breast conservation surgery with radiation or a modified radical mastectomy. When questioned by the patient about these options, the nurse informs the patients that the lumpectomy with radiation.
- Reduces the fear and anxiety that accompany the diagnosis and treatment of cancer
- Has about the same 10 years survival rate as the modified radical mastectomy
- Provides shorter treatment period with a fewer long term complications
- Preserves the normal appearance and sensitivity of the breast
37. 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.Which hormone stimulates the development of the ovum?
- Follicle stimulating hormone (FSH)
- Human Chorionic Gonadotropin (HCG)
- Luteinizing Hormone (LH)
- Gonadotropin Releasing Hormone (GnRH)
38. Situation: Mr. Reynaldo Layag executive officer, was brought to the hospital because of chest pain. Diagnosis of angina was established.Q. Mr. Layag state that his anginal pain increases after activity. The nurse should realize that the angina pectoris is a sign of:
- Mitral insufficiency
- Myocardial infraction
- Myocardial ischemia
- Coronary thrombosis
39. 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
40. Myrna a 52 year old client with a fractured left tibia has a long leg cast and she is using crutches to ambulate. Nurse Joy assesses for which sign and symptom that indicates complication associated with crutch walking?
- Left leg discomfort
- Weak biceps brachii
- Triceps muscle spasm
- Forearm weakness
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41. Ketoconazole is prescribed for a client with a diagnosis of candidiasis. Which interventions should the nurse include when administering this medication? Select all that apply. 1.Restrict fluid intake. 2.Monitor liver function studies. 3.Instruct the client to avoid alcohol. 4.Administer the medication with an antacid. 5.Instruct the client to avoid exposure to the sun. 6.Administer the medication on an empty stomach.
- 1,2,3
- 2,3,5
- 1,3,5,6
- 1,2,3,4,5
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42. 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
43. The client with a recent liver transplant asks the nurse how long he will have to take an immunosuppressant Which response would be correct?
- One year
- Five years
- 10 years
- The rest of his life
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44. A patient exhibits clinical manifestation of a pulmonary embolism. Arterial blood gas (ABG) levels and a chest x-ray are ordered. Which of the following test is used to diagnose this condition?
- Computer tomography scan(CT scan)
- Magnetic resonanceimaging (MRI)
- Pulmonary angiography
- Pulmonary function test
45. Situation: Mrs. Lim has had confirmation of her pregnancy. She presents the emergency room with abdominal pain not yet diagnosed.Q. A few hours after being admitted with a diagnosis of inevitable abortion, a client begins to experience bearing down sensations and suddenly expels the products of conception in bed. To give safe nursing care, the nurse should first:
- Check the fundus for firmness
- Give her the sedation
- Immediately notify the physician
- take her immediately to the delivery home
46. A client has undergone laryngectomy. The immediate nursing priority would be:
- Keep trachea free of secretions
- Monitor for signs of infection
- Provide emotional support
- Promote means of communication
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47. A patient is being followed in the clinic for hypertension, adult onset diabetes, and obesity. The patient is apathetic about learning nutritional guide lines to reach the goals of weight loss and consumption of a healthy diet. The patient admitted to eating "what ever is put in front of me". Which of the following actions would the nurse take?
- Collaborate with the patient to set goals
- Add a nursing diagnosis of non-compliance
- Refer for Psychiatric screening for depression
- Discuss nutritional interventions with the spouse
48. A pre-operative check list form that should be completed before surgery it should be including which of the following?
- The surgical consent form
- All laboratory test
- Vital Signs
- All of above
49. Situation: The nurse is performing health education activities for Jane Segovia, a 30 years old Dentist with Insulin dependent diabetes Mellitus.Q. Jane eventually developed DKA and is being treated in the emergency room. Which finding would the nurse expect to note as confirming this diagnosis?
- Comatose state
- Decreased urine output
- Increased respiration and increase in pH
- Elevated blood glucose level and plasma bicarbonate level
50. The nurse is discussing the human immunodeficiency virus (HIV) with a group of high-risk patients. The nurse should state that this virus is found MOST commonly in which of the following body fluids?
- Blood
- Saliva
- Breast milk
- Vaginal secretions