NCLEX-RN | QB2 | Practice Exam #37 (50 questions)
All 50 questions are randomized each time you take the test, and do not appear in the same order.
1. Which of the following are the functions of amniotic fluid? 1.Cushions the fetus from abdominal trauma. 2.Serves as the fluid for the fetus. 3.Maintains the internal temperature. 4.Facilitates fetal movement
- 1 and 3
- 1, 3 and 4
- 1, 2 and 3
- All of the above.
2. SITUATION: John Smith was diagnosed with Acute Close Angle Glaucoma. He is being seen by Nurse JetQ. What specific manifestation would nurse Jet see in Acute close angle glaucoma that she would not see in an open angle glaucoma?
- Loss of peripheral
- Irreversible vision loss
- There is an increase in IOP
- Pain
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3. The nurse is assigned to teach health-seeking behaviors to young women. One topic the nurse plans to includes is the importance of the Pap test, which is used mainly to detect:
- Ovarian cyst
- Patency of the fallopian tube
- Cervical cancer
- Uterine infections
4. A patient with a spinal cord injury at level C3-4 is being cared for in the ED. What is the priority assessment?
- Determine the level at which the patient has intact sensation.
- Assess the level at which the patient has retained mobility.
- Check blood pressure and pulse for signs of spinal shock.
- Monitor respiratory effort and oxygen saturation level.
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5. An adult is supine. Which of the ff. can the nurse to to prevent external rotation of the legs?
- put a pillow under the clients lower legs
- place a pillow directly under the client knee
- use a trochanter roll alongside the client's upper thighs
- lower the client's legs so that they are below hips.
6. A client with frequent urinary tract infections asks the nurse how she can prevent the reoccurrence. The nurse should teach the client to:
- Douche after intercourse
- Void every three hours
- Obtain a urinalysis monthly
- Wipe from back to front after voiding
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7. Which patient should you, as charge nurse, assign to a new graduate RN who is orienting to the neurologic unit?
- A 28-year-old newly admitted patient with spinal cord injury
- A 67-year-old patient with stroke 3 days ago and left-sided weakness
- An 85-year-old dementia patient to be transferred to long-term care today
- A 54-year-old patient with Parkinson's who needs assistance with bathing
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8. Nurse Joan is assigned to come for client who has just undergone eye surgery. Nurse Joan plans to teach the client activities that are permitted during the post operative period. Which of the following is best recommended for the client?
- Watching circus
- Bending over
- Watching TV
- Lifting objects
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9. Mrs. Hogan, a 43-year-old woman, is admitted to your unit for cholecystectomy.Q. On the morning of Mrs. Hogan's planned cholecystectomy she awakens with a pain in her right scapular area and thinks she slept in poor position. While doing the pre-op checklist you note that on her routine CB report her WBC is 15,000. Your responsibility at this point is:
- to notify the surgeon at once; this is an elevated WBC indicating an inflammatory reaction
- to record this finding in a prominent place on the pre op checklist and in your preop notes
- to call the laboratory for a STAT repeat WBC
- none. This is not an unusual finding
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10. The nurse prepares a client for ear irrigation as prescribed by the health care provider. Which action should the nurse take when performing the procedure?
- Warm the irrigating solution to 98.6°F(37.0°C).
- Position the client with the affected side up following the irrigation.
- Direct a slow, steady stream of irrigation solution toward the eardrum.
- Assist the client to turn his or her head so that the ear to be irrigated is facing upward.
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11. Situation: Mr. Gonzales was admitted to the hospital with ascites and jaundice. To rule out cirrhosis of the liver:Q. Mr. Gonzales develops hepatic encephalopathy. Which clinical manifestation is most common with this condition?
- Increased urine output
- Altered level of consciousness
- Decreased tendon reflex
- Hypotension
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12. The nurse provided discharge instructions to the parents of a 2-year-old child who had an orchiopexy to correct cryptorchidism. Which statement by the parents indicates the need for further instruction?
- "I'll check his temperature"
- "I'll give him medication so he'll be comfortable"
- "I'll check his voiding to be sure there's no problem"
- "I'll let him decide when to return to his play activities."
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13. Considered as the most accessible and convenient method for temperature taking
- Oral
- Rectal
- Tympanic
- Axillary
14. Situation: Mang Jose, 39 year old farmer, unmarried, had been confined in the National Center for Mental Health for three years with a diagnosis of schizophrenia.Q. The most common defense mechanism used by a paranoid client is:
- Displacement
- Suppression
- Rationalization
- Projection
15. Situation: Maintenance of sterility is an important function a nurse should perform in any OR setting.Q. Two (2) organizations endorsed that sterility are affected by factors other that the time itself, these are:
- The PNA and the PRC
- AORN and JCAHO
- ORNAP and MCNAP
- MMDA and DILG
16. A client has stress incontinence has been given a pamphlet that describes Kegel exercises. Which of the following statements indicates to the nurse that the client has understood the instructions contained in the pamphlet?
- "I should perform these exercises every evening.”
- "It will probably take a year before the exercises are effective”
- "I can do these exercises sitting up, lying down or standing.”
- ”1 need to tighten my abdominal muscles to do these exercises correctly”
17. A vaginal exam reveals a breech presentation in a newly admitted client. The nurse should take which of the following actions at this time?
- Prepare the client for a caesarean section
- Apply the fetal heart monitor
- Place the client in the Trendelenburg position
- Perform an ultrasound exam
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18. All of the following are clinical manifestations of fluid volume excess except:
- Edema
- Oliguria
- Distended neck veins
- Increased CVP
19. Situation: The question with regards to the OPERATING ROOM.Q. Who is responsible in daily monitoring the standards of safe, nursing practice in the operating suite?
- surgeon
- perioperative nurse
- OR nurse supervisor
- chief nurse
20. Situation: Mastery of research design determination is essential in passing the Nurse Licensure Examination.Q. Community A was selected randomly as well as community nurse Edna conducted teaching to Community A and assess if community A will have better status than community B. This is an example of:
- Comparative
- Correlational
- Experimental
- Qualitative
21. A client appears upset and tearful, but denies pain and refuses pain medication, because "my sibling is a drug addict and has ruined out lives." What is the priority intervention for this client?
- Encourage expression of fears on past experiences.
- Provide accurate information about use of pain medication.
- Explain that addiction is unlikely among acute care clients.
- Seek family assistance in resolving this problem.
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22. Total parenteral nutrition is ordered for an adult. Which nutrient is not likely to be in the solution?
- Dextrose 10%
- Trace minerals
- Amino acids
- None of the above
23. A nurse is assessing the peripheral circulation of patients extremities. The chart indicates the patient has edema in both lower extremities. Which of the following assessment techniques would the nurse MOST likely use to assess for this?
- Inspection and auscultation
- Inspection and palpation
- Palpation and percussion
- Percussion and auscultation
24. Situation: Organ donation is a new form of treatment that provides multiple complication such as rejection.Q. You would expect that in cases of organ donation, you would expect that the immunosuppressant medications such as Cyclosporine, Prednisone and Imuran are taken:
- For 2 years
- When the suture heals
- When rejection is not anymore viable
- For the rest of the client's life
25. Prior to administering an enema, the nurse will assist the patient to assume what position:
- Prone with pillow under knees
- Left-side with right knee flexed
- Right-side with left knee flexed
- On back with head of bed flat
26. A patient with diabetic retinopathy is experiencing an episode of unresolved hemorrhage in the eye. The nurse identifies the MOST likely procedure to benefit this patient would be:
- Enucleation
- Radial keratotomy
- Vitrectomy
- Peripheral Iridectomy
27. A client has undergone with penile implant. After 24 hrs of surgery, the clients scrotum was edematous and painful. The nurse should:
- Assist the client with sitz bath
- Apply war soaks in the scrotum
- Elevate the scrotum using a soft support
- Prepare for a possible incision and drainage.
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28. Situation: Mr. Reynaldo Layag executive officer, was brought to the hospital because of chest pain. Diagnosis of angina was established.Q. When cardiovascular disease is concern, reduction of the saturated fat in the diet may be desired and substance made of polyunsaturated fat When teaching about this diet the nurse should instruct Mr. Layag to avoid:
- Fish
- Corn Oil
- Whole milk
- soft margarine
29. A client is admitted with a diagnosis of delusions of grandeur. This diagnosis reflects belief that one is:
- highly important or famous.
- being persecuted.
- connected to events unrelated to oneself.
- responsible for the evil in the world.
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30. The nurse is caring for a client with irritable bowel syndrome, irritable bowel syndrome is characterized by:
- Development of pouches in the wall of the intestine
- Alternating bouts of constipation and diarrhea
- Swelling thickening and abscess formation
- Hypocalcemia and iron-deficiency anemia
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31. Situation: Mr. Sean is admitted to the hospital with a bowel obstruction. He complained of colicky pain and inability to pass stool.Q. Which of these findings by Nurse Leonard, would indicate that the obstruction is in the early stages?
- high pitched tinkling or rumbling bowel sounds
- hypoactive bowel sounds
- no bowel sounds auscultated
- normal bowel sounds heard in all four quadrants
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32. 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
33. Situation: A client is brought into the emergency department with brain stem contusionQ. Which of the following combinations of adverse effects must be carefully monitored when administering LV. insulin to a client diagnosed with diabetic ketoacidosis?
- Hypokalemia and hypoglycemia
- Hypocalcemia and Hyperkalemia
- Hyperkalemia and hyperglycemia
- Hypernatremia and hypercalcemia
34. The nurse is preparing to care for a child with a diagnosis of intussusception. The nurse reviews the child's record and expects to note which sign of this disorder documented?
- Watery diarrhea
- Ribbon-like stools
- Profuse projectile vomiting
- Bright red blood and mucus in the stools
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35. Which of the following is used to determine the activity of the brain:
- Electrocardiography
- Electromyography
- Electroencephalography
- Echocardiography
36. Situation: Rudy was diagnosed to have chronic renal failure. Hemodialysis is ordered that an A-V shunt was surgically created.Q. Diet therapy for Rudy, who has acute renal failure, is tow-protein, low potassium and sodium. The nutrition instruction should include:
- Recommend protein of high biologic value like eggs, poultry and lean meat
- Encourage client to include raw cucumbers, carrot, cabbage, and tomatoes
- Allowing the client cheese, canned foods, and other processed food
- Bananas, cantaloupe, orange and other fresh fruits can be included in the diet
37. An elderly client has a stage 11 pressure ulcer on her sacrum. During assessment of the clients skin the nurse would expect to find:
- A deep crater with a nonpainful wound base
- A craterous area with a nonpainful wound base
- Cracks and b sters with redness and induration
- Nonblanchable redness with tenderness and pain
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38. A home care patient with chronic obstructive pulmonary disease (COPD) reports an upset stomach. The patient is taking theophylline (Theo-Dur) and triamcinolone acetonide (Azmacort), the nurse should instruct the patient to take
- Theo-Dur on an empty stomach
- Theo- Dur and Azmacort at the same time
- Theo- Dur and Azmacort 12 hours apart
- Theo-Dur with milk or crackers
39. Important teaching for clients receiving antipsychotic medication such as haloperidol (Haldol) includes which of the following instructions?
- Use sunscreen because of photosensitivity.
- Take the antipsychotic medication with food.
- Have routine blood tests to determine levels of the medication.
- Abstain from eating aged cheese.
40. A child is seen in the pediatricians office for complaints of bone and joint pain. Which of the following other assessment findings may suggest leukemia?
- Abdominal pain
- Increased activity level
- Increased appetite
- Petechiae
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41. Situation: Mr. Gonzales was admitted to the hospital with ascites and jaundice. To rule out cirrhosis of the liver:Q. The biopsy of Mr. Gonzales confirms the diagnosis of cirrhosis. Mr. Gonzales is at increased risk for excessive bleeding primarily because of:
- Impaired clotting mechanism
- Varix formation
- Inadequate nutrition
- Trauma of invasive procedure
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42. A patient with end-stage cardiomyopathy and angina pectoris to the office complaining of frequent chest pain and severe dyspnea. With a nursing diagnosed of alteration in comfort, what is the BEST long term goal for this patients?
- Perform all activities of daily living without complaints of chest pain or shortness of breath
- Verbalize and employ strategies to decrease pain and increase coronary blood flow
- Take pain medications around the check and use supplement oxygen at all times
- Understand the disease process and accept the limitation that it places on his lifestyle
43. Situation: Prevention of Dengue is an important nursing responsibility and controlling its spread is priority once outbreak has been observed. Which of these signs may NOT be REGARDED as a truly positive signs indicative of Dengue H-fever?
- Prolonged Bleeding Time
- Appearance of at least 20 petechiae within 1 cm square
- Steadily increasing hematocrit count
- Fall in the platelet count
44. Which of the following provides that nurses must be a member of a national nurse organization?
- R.A 877
- 1981 Code of ethics approved by the house of delegates and the PNA
- Board resolution No. 1955 Promulgated by the BON
- RA 7164
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45. Situation: A client is brought into the emergency department with brain stem contusionQ. Two days after the admission, the client has a large amount of urine and a serum sodium level of 155 mEq/dl. Which, of the following conditions may be developing?
- Myxedema coma
- Diabetes insipidus
- Type 1 diabetes mellitus
- Syndrome of inappropriate antidiuretic hormone secretion (SIADH)
46. One month after starting new medications for hypertension, a patient returns to the clinic with blood pressure in the range. The patient admits to taking the medications only when "feeling bad" Which of the following actions would the nurse take?
- Assess further determine the reason the reason for the patient's Actions
- Add a new diagnosis of non-compliance
- Re-educate the patient about the importance of following his medication plan
- Reevaluate the need for daily medication since the blood pressure is acceptable
47. The nurse is reviewing the history and physical examination of a client who will be receiving asparaginase, an antineoplastic agent The nurse contacts the health care provider before administering the medication if which disorder is documented in the client's history?
- Pancreatitis
- Diabetes mellitus
- Myocardial infarction
- Chronic obstructive pulmonary disease
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48. To prevent preterm labor from progressing, drugs are usually prescribed to halt the labor. The drugs commonly given are:
- Magnesium sulfate and terbutaline
- Prostaglandin and oxytocin
- Progesterone and estrogen
- Dexamethasone and prostaglandin
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49. In the year 1980, the World Health Organization declared the Philippines, together with some other countries in the Western Pacific Region, "free" of which disease?
- Pneumonic plaque
- Poliomyelitis
- Small pox
- Anthrax
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50. A husband and wife seek emergency crisis intervention because he slapped her repeatedly the night before. The husband indicates that his childhood was marred by an abusive relationship with his father. When intervening with this couple, the nurse knows they are at risk for repeated violence because the husband:
- has only moderate impulse control.
- denies feelings of jealousy or possessiveness.
- has learned violence as an acceptable behavior.
- feels secure in his relationship with his wife.
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