NCLEX-RN | QB2 | Practice Exam #39 (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 perineal wound in a client who has returned from the operating room following an abdominal perineal resection and notes serosanguineous drainage from the wound. Which nursing intervention is most appropriate?
- Clamp the surgical drain.
- Change the dressing as prescribed.
- Notify the health care provider (HCP).
- Remove and replace the perineal packing.
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2. The nurse caring for a client with chest tubes notes that the Pleuravacs collection chambers are full. The nurse should:
- Add more water to the suction-control chamber.
- Remove the drainage using a 60mL syringe.
- Milk the tubing to facilitate drainage.
- Prepare a new unit for continuing collection.
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3. The nurse is aware that antipsychotic medications may cause which of the following adverse effects?
- Increased production of insulin
- Lower seizure threshold
- Increased coagulation time
- increased risk of heart failure
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4. Nurse May attends an educational conference on leadership styles. The nurse is sitting with a nurse employed at a large trauma center who states that the leadership style at the trauma center is task-oriented and directive. The nurse determines that the leadership style used at the trauma center is:
- Autocratic.
- Laissez-faire.
- Democratic.
- Situational.
5. A patient presents to the emergency room due to an overdose of morphine sulfate. Which of the following should the nurse has readily available?
- Glucagon
- Antibiotic
- Acetyl cysteine (Mucomyst)
- Naloxone (Narcan)
6. A couple is seeking advice regarding actions that they can take to increase their potential of becoming pregnant Which of the following recommendations should the nurse give to the couple?
- The couple should use vaginal lubricants during intercourse.
- The couple should delay having intercourse until the day of ovulation.
- The woman should refrain from douching.
- The man should be on top during intercourse.
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7. A patient is being prepared for a right breast biopsy under general anesthesia. The patient asks the nurse about the surgical scar and possible postoperative complications. Which of the following actions would be appropriate for the nurse to take?
- Review the postoperative risks with the patient
- Notify the surgeon about the patient's questions
- Compete the patient's preoperative check list
- Show the patient photos of breast surgical scar
8. A client is diagnosed with an ST segment elevation myocardial infarction (STEM!) and is receiving a tissue plasminogen activator, alteplase. Which action is a priority nursing intervention?
- Monitor for kidney failure.
- Monitor psychosocial status.
- Monitor for signs of bleeding.
- Have heparin sodium available.
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9. The nurse assesses the vital signs of a 12-month-old infant with a respiratory infection and notes that the respiratory rate is 35 breaths/minute. On the basis of this finding, which action is most appropriate?
- Administer oxygen.
- Document the findings.
- Notify the health care provider.
- Reassess the respiratory rate in 15 minutes.
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10. Situation: J.E, is an 18-year old freshman admitted to the ICU following a motor vehicle accident in which he sustained multiple trauma including a ruptured spleen, myocardial contusion, fractured pelvis, and fractured right femur. He had a mild contusion, but is alert and oriented. His vital signs BP 120/80, pulse 84, respirations 12, and temperature 99 F orally.Q. The nurse will monitor J.E. for the following signs and symptoms:
- Change in the level of consciousness, tachypnea, tachycardia, petechiae
- Onset of chest pain, tachycardia, diaphoresis, nausea and vomiting
- Loss of consciousness, bradycardia, petechiae, and severe leg pain
- Change in level of consciousness, bradycardia, chest pain and oliguria
11. A 25-year old woman comes to the clime complaining of dizziness, weakness and palpitations. What will be important for the nurse to initially evaluate when obtaining the health history?
- Activity and exercise patterns
- Nutritional patterns
- Family health status
- Coping and stress tolerance
12. Situation: Mr. Anthony is a 54-year old truck driver. He is admitted for possible gastric ulcer, He is a heavy smoker.Q. When discussing his smoking habits with Mr. Anthony, the nurse should advise him to:
- Smoke low-tar, filter cigarettes
- Smoke cigars instead
- Smoke only right after meals
- Chew gum instead
13. Situation: After an abdominal surgery, the circulating and scrub nurses have critical responsibility about sponge and Instrument count.Q. What major supportive layer of the abdominal wall must be sutured with long tensile strength such as cotton or nylon or silk suture?
- Fascia
- Muscle
- Peritoneum
- Skin
14. Situation Colostomy is a surgically created anus- It can be temporary or permanent, depending on the disease condition.Q. What health instruction will enhance regulation of colostomy (defecation) of clients?
- Irrigate after lunch everyday
- Eat fruits and vegetables in all three meals
- Eat balanced meals at regular intervals
- Restrict exercise to walking only
15. After a mastectomy or hysterectomy, clients may feel incomplete as women. The statement that should alert nurse Gina to this feeling would be:
- "I cant wait to see all my friends again"
- "I feel washed out; there isn't much left"
- "I cant wait to get home to see my grandchild"
- "My husband plans for me to recuperate at our daughter's home"
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16. SITUATION: a 20 year old college student was rushed to the ER of PGH after he fainted during their ROTO 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. Stat appendectomy was indicated. Pre-op care would include all of the following except?
- Consent signed by the father
- Enema STAT
- Skin prep of the area including the pubis
- Remove the jewelries
17. A patient with malignant cancer has decided to stop chemotherapy and receive hospice care. What is the PRIORITY nursing diagnosis?
- Alteration in comfort
- Hopelessness
- Powerlessness
- Non-compliance
18. Vitamin E plus this mineral works as one of the best antioxidant in the body according to the latest research. They are combined with 5 Alpha reductase inhibitor to reduce the risk of acquiring prostate cancer:
- Zinc
- Iron
- Selenium
- Vanadium
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19. 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
- 2,3,5
- 3,4
- 2,5
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20. A community health nurse visits a patient who had right foot amputation. Which of the following would suggest that the patient is meeting expected outcome for this type surgery?
- Stays in bed
- Verbalize constant pain
- Avoids social gathering
- Accepts altered body image
21. Which of the following item is considered the single most important factor in assisting the health professional in arriving at a diagnosis or determining the person's needs?
- Diagnostic test results
- Biographical date
- History of present illness
- Physical examination
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22. Situation: As a nurse, you should be aware and prepared of the different roles you play.Q. As a nurse, your primary focus in the workplace is the client's safety. However, personal safety is also a concern. You can communicate hazards to your co-workers through the use of the following EXCEPT:
- Formal training
- Posters
- Posting IR in the bulletin board
- Use of labels and signs
23. When selecting activities to help develop a child s fine motor skills, which of the following would BEST meet this goal?
- Sorting cardboard objects that are in different shapes
- Singing while turning the pages of a book that plays music
- Jumping rope
- Riding a three-wheeled cycle
24. Situation: You are the nurse in the Out-Patient-Department and during your shift you encountered multiple children's condition. The following questions apply.Q. Which of the following conditions is NOT true about contraindication to immunization?
- do not give DPT2 or DPT3 to a child who has convulsions within 3 days of DPT1
- do not give BOG if the child has known hepatitis.
- do not give OPT to a child who has recurrent convulsion or active neurological disease
- do not give BCG if the child has known AIDS
25. For several years, a client with chronic schizophrenia has received 10 mg of fluphenazine hydrochloride (Prolixin) by mouth four times per day. Now the client has a temperature of 102° F (38.9" C), a heart rate of 120 beats/minute, a respiratory rate of 20 breaths/ minute, and a blood pressure of 210/140 mm Hg. Because the client also is confused and incontinent, the nurse suspects malignant neuroleptic syndrome. What steps should the nurse take?
- Give the next dose of flu phenazine, call the physician, and monitor vital signs.
- Withhold the next dose of fluphenazine, call the physician, and monitor vital signs.
- Give the next dose of fluphenazine and restrict the client to the room to decrease stimulation.
- Withhold the next dose of fluphenazine, administer an antipyretic agent, and increase the client's fluid intake.
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26. During an evaluation at a community clinic, the patient completes the medical history. Which of the follow is NOT a risk factor for an acute myocardial infarction?
- Coronary artery disease
- Smoking
- Hemophilia
- Hyperlipidemia
27. The nurse asks the client with an epidural anesthesia to void every hour during labor. The rationale for this intervention is:
- The bladder fills more rapidly because of the medication used for the epidural
- Her level of consciousness is altered.
- The sensation of the bladder fining is diminished or lost.
- She is embarrassed to ask for the bedpan that frequently.
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28. Situation: Mrs. Pichay is admitted to your ward. The MD ordered Prepared for thoracentesis this pm to remove excess air from the pleural cavity. Q.To prevent leakage of fluid in the thoracic cavity how wilt you position the client after thoracentesis?
- Place flat in bed
- Turn on the unaffected side
- Turn on the affected side
- On bed rest
29. Marijuana is an example of a drug classified as schedule:
- C-I
- C-II
- C-III
- C-IV
30. A nurse plans to teach a group of 20 to 25 year-old women about oral contraceptives. The nurse should instruct that side effects of intrauterine device may include contraceptive may cause:
- Increase risk of pelvic inflammatory disease
- Cause acne to worsen
- Decrease the risk of breast and cervical cancer
- Decrease the risk of endometriosis
31. A boy has done tonsillectomy surgery 2 hours later, the child complain of pain 7 from 10, what is the appropriate diagnosis.
- Acute pain
- Swallowing difficulty
32. Situation: Infection can cause debilitating consequences when host resistance is compromised and virulence of microorganisms and environmental factors are favorable. Infection control is one important responsibility of the nurse to ensure quality of care.Q. Which of the following is the most reliable in diagnosing a wound infection?
- Culture and sensitivity
- Purulent drainage from a wound
- WBC count of 20,000/μL
- Gram stain testing
33. The nurse assesses the clients understanding of the relationship between body position and gastroesophageal reflux. Which response would indicate that the client understands measures to avoid problems with reflux while sleeping?
- I can elevate the foot of the bed 4 to 6 inches
- I can sleep on my stomach with my head turned to the left
- I can sleep on my back without a pillow under my head
- I can elevate the head of the bed 4 to 6 inches
34. A client is admitted with a diagnosis of polycythemia vera. The nurse should closely monitor the client for:
- Increased blood pressure
- Decreased respirations
- increased urinary output
- Decreased oxygen saturation
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35. Founded the second order of St Francis of Assisi
- St. Catherine
- St. Anne
- St. Clare
- St. Elizabeth
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36. Prior to providing care for a hospitalized infant, the nurse who focuses on preventive measures must.
- Introduce self to parent
- Perform hand hygiene
- Have a witness present
- Assess the child’s developmental level
37. The nurse is developing a plan for bowel and bladder retraining for a client with paraplegia. The primary goal of a bowel and bladder retraining program is:
- Optimal restoration of the clients elimination pattern
- Restoration of the clients neurosensory function
- Prevention of complications from impaired elimination
- Promotion of a positive body image
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38. An infant with a ventricular septal defect is discharged with a prescription for Lanoxin (digoxin) elixir 0.01 mg PO q 12hrs. The nurse should:
- Administer the medication using a nipple.
- Administer the medication using the calibrated dropper in the bottle.
- Administer the medication using a plastic baby spoon.
- Administer the medication in a baby bottle with 1oz. of water.
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39. The nurse is assessing a client on admission to the chemical dependency unit for alcohol detoxification. When the nurse asks about alcohol use, this client is most likely to:
- accurately describe the amount consumed.
- underestimate the amount consumed.
- overestimate the amount consumed.
- deny any consumption of alcohol.
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40. Situation: Mr. Roberto was long diagnosed with chronic renal failure. You are his nurse and the following question assesses your knowledge in the different fluid and electrolyte imbalances that are associated with chronic renal failure.Q. Mr. Roberto misses 2 sessions of hemodialysis. Blood was drawn and is sent for analysis. Which electrolyte disturbance is expected in a client with chronic renal failure?
- Hypernatremia
- Hyperkalemia
- Hypokalemia
- Alkalemia
41. 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. The alimentary canal is a continuous, coiled, hollow muscular tube that winds through the ventral cavity and is open at both ends. Its solid organs include all of the following except:
- liver
- gall bladder
- stomach
- pancreas
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42. The nurse is caring for a client whose arterial blood gases indicate metabolic acidosis. The nurse knows that of the following, the least likely to cause metabolic acidosis is:
- cardiac arrest
- Diabetic ketoacidosis
- decreased serum potassium level
- renal failure
43. The nurse employed in an emergency department is assigned to triage clients coming to the emergency department for treatment on the evening shift The nurse should assign priority to which client?
- A client complaining of muscle aches, a headache, and history of seizures
- A client who twisted her ankle when rollerblading and is requesting medication for pain
- A client with a minor laceration on the index finger sustained while cutting an eggplant
- A client with chest pain who states that he just ate pizza that was made with a very spicy sauce
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44. The nurse is providing postpartum teaching for a mother planning to breastfeed her infant Which of the clients statements indicates the need for additional teaching?
- I am wearing a support bra.
- I am expressing milk from my breast.
- I am drinking four glasses of fluid during a 24-hour period.
- While I am in the shower I will allow the water to run over my breasts.
45. A client is admitted with a diagnosis of schizotypal personality disorder Which signs would this client exhibit during social situations?
- Aggressive behavior
- Paranoia thoughts
- Emotional affect
- Independence needs
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46. Which of the following demonstrates inter-sectoral linkages?
- Two-way referral system
- Team approach
- Endorsement done by a midwife to another midwife
- Cooperation between PHN and public school teacher
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47. The nurse is caring for a client with bulimia nervosa. The nurse recognizes that the major difference in the client with anorexia nervosa and the client with bulimia nervosa is the client with bulimia:
- Is usually grossly overweight.
- Has a distorted body image.
- Recognizes that she has an eating disorder
- Struggles with issues of dependence versus independence.
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48. A nurse is evaluating the home of patient with left-sided paralysis. Which of the following observations would indicate that the patient is complying with home-based safety?
- The telephone is on a bed side table with is next to the head of the bed
- The bedside commode is on the left-side of the bed with the back of the commode facing the foot of the bed
- The walker has wheels on its back legs and has tennis balls on the front legs
- The stairs leading from the bedroom to the living area a hand rail on the right-side o fthe stairway
49. Situation: Basic knowledge on Intravenous solutions is necessary for care of clients with problems with fluids and electrolytes. Q. The physician orders the nurse to prepare an isotonic solution. Which of the following IV solution would the nurse expect the intern to prescribe?
- 5 % dextrose in water
- 10 % dextrose in water
- 0.45 % sodium chloride
- 0.5 % dextrose in 0.9% sodium chloride
50. Situation: Milo 16 y/o has been diagnosed to have AIDS, he worked as entertainer in a cruise shipiCausative organism in AIDS is one of the following:
- Fungus
- Bacteria
- Retrovirus
- Parasites