QB2 | Practice Exam #44 -> answers with explanation - Free NCLEX Exam Practice

NCLEX-RN | QB2 | Practice Exam #44 (50 questions)

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

 

1. During a late stage of acquired immunodeficiency syndrome (AIDS), a client demonstrates signs of AIDS-related dementia. The nurse should give the highest priority to which nursing diagnosis?

• Bathing or hygiene self-care deficit
• Ineffective cerebral tissue perfusion
• Dysfunctional grieving
• Risk for injury

2. The nurse is evaluating nutritional outcomes for an elderly client with anorexia nervosa. Which data best indicates that the plan of care is effective?

• The client selects a balanced diet from the menu.
• The clients hematocrit improves.
• The clients tissue turgor improves.
• The client gains weight.

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3. While performing a cardiac assessment on a client with an incompetent heart valve, the nurse auscultates a murmur The nurse documents the finding and describes the sound as which?

• Lub-dub sounds
• Scratchy, leathery heart noise
• A blowing or swooshing noise
• Abrupt, high-pitched snapping noise

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4. Situation: You are assigned to take care of a group of patients across the lifespan. According to the social-international perspective of child abuse and neglect, four factors place the family members at risk for abuse, these risk factors are the family members at risk for abuse. These risk factors are the family itself, the caregiver, the child and:

• The presence of a family crisis
• Genetics
• The national emphasis on sex
• Chronic poverty

5. Monica is aware that there are times when only manipulation of study variables is possible and the elements of control or randomization are not attendant Which type of research is referred to this?

• Field study
• Quasi-experiment
• Solomon-Four group design
• Post test only design

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6. Community/Public health bag is defined as:

• An essential and indispensable equipment of the community health nurse during home visit
• It contains drugs and equipment used by the community health nurse
• Is a requirement in the health center and for home visit
• It is a tool used by the community health nurse in rendering effective procedures during home visit

7. Situation: Developing countries such as the Philippines suffer from high infant and child mortality rates. Thus, as a management to the existing problem, the WHO and UNICEF launched the 1MCL If the child has severe classification because of ear problem, what would be the best thing that you should do as a nurse?

• Dry the ear by wicking
• Give an antibiotic for 5 days
• Refer urgently
• Instruct mother when to return immediately

8. Situation: One of the realities that we are confronted with is mortality. It is important for us nurses to be aware of how we view suffering, pain, illness, and even our death as well as its meaning. That way we can help our patients cope with death and dying. Q. Maria, 90 years old has planned ahead for her-death-philosophically, socially, financially and emotionally. This is recognized as:

• Acceptance that death is inevitable
• Avoidance of the true sedation
• Denial with planning for continued life
• Awareness that death will soon occur

9. Which of the following common emotional reactions to pregnancy would the nurse expect to occur during the first trimester?

• Introversion, egocentrism, narcissism
• Awkwardness, clumsiness, and unattractiveness
• Anxiety, passivity, extroversion
• Ambivalence, fear, fantasies

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10. Which of the following is considered a normal age-related change?

• Dementia
• Contractures
• Bladder holding less urine
• Wheezing when breathing

11. What would the nurse expect the admitting assessment to reveal in a client with glomerulonephritis?

• Hypertension
• Lassitude
• Fatigue
• Vomiting and diarrhea

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12. Situation: Cancer of the prostate is the leading cancer in Men other than skin cancer. The following questions will assess your knowledge and theoretical foundation in dealing with clients with prostate cancer. Q. To diagnose the presence of prostate cancer, the physician will perform:

• Transrectal needle biopsy of the prostate
• Test to identify the PSA levels
• Transrectal ultrasound
• Radiolabeled monoclonal antibody capromab pendetide with indium-111

13. Situation: Records contain those, comprehensive descriptions of patients health conditions and needs and at the same serve as evidences of every nurse's accountability in the, caregiving process. Nursing records normally differ from institution to, institution nonetheless they follow similar patterns of meeting needs for specifics, types of information. The following pertains to documentation/records management Most nurses regard this as conventional recording of the date, time and mode by which the patient leaves a healthcare unit but this record includes importantly, directs of planning for discharge that starts soon after the' person is admitted to a healthcare institution, it is accepted that collaboration or multidisciplinary involvement (of all members of the health team) in discharge results in comprehensive care. What do you call this?

• Discharge Summary
• Nursing Kardex
• Medicine and Treatment Record
• Nursing Health History and Assessment Worksheet

14. A nurse is caring for a client with the diagnosis of bulimia nervosa. The nurse understands that individuals with bulimia use food to:

• gain attention.
• control others.
• avoid growing up.
• meet emotional needs.

15. Situation NURSES are involved in maintaining a safe and healthy environment. This is part of quality care management. Q. The first step in decontamination is:

• to immediately apply a chemical decontamination foam to the area of contamination
• thorough soap and water wash and rinse of the patient
• to immediately apply personal protective equipment
• removal of the patients clothing and jewelry and then rinsing the patient with water

16. A client is in a state of uncompensated acidosis. What approximate arterial blood pH does the nurse expect the client to have?

• 7.20
• 7.35
• 7.45
• 7.48

17. All of the following laboratory data indicating infection EXCEPT:

• Increased specific type of leukocyte.
• Increased in body temp.
• Decreased WBC.
• Positive culture in blood, urine or sputum.

18. A client was admitted to the psychiatric unit after complaining to her friends and family that neighbors have bugged her home in order to hear all of her business. She remains aloof from other clients, paces the floor and believes that the hospital is a house of torture. Nursing interventions for the client should appropriately focus on efforts to:

• Convince the client that the hospital staff is trying to help
• Help the client to enter into group recreational activities
• Provide interactions to help the client learn to trust staff
• Arrange the environment to limit the client's contact with other clients

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19. Harry knows that he has to protect the rights of human research subjects. Which of the following actions of Harry ensures anonymity?

• Keep the identities of the subject secret
• Obtain informed consent
• Provide equal treatment to all the subjects of the study.
• Release findings only to the participants of the study

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20. The first exercise that should be performed by the client who had a mastectomy one day earlier is:

• Walking the hand up the wall
• Sweeping the floor
• Combing her hair
• Squeezing a ball

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21. If a patient develops a complication during a blood transfusion, the nurses first action should do to:

• Stop the transfusion
• Notify the practitioner
• Administer anantihistamine
• Administer an anti-inflammatory medication

22. A nurse is assigned to do a home visit for an 81-year-old patient The patient lives at home with an adult caretaker and is completely bed-bound following a Cerebrovascular accident (CVA) 2 weeks ago. In planning caregiver education, The nurse should be prepared to instruct the caretaker in:

• How to select a nursing home for the patient
• Performing passive range of motion exercises
• The importance of avoiding viscous drinks
• Forming a local chapter of a care giver support group

23. You educate group of people about the prevention of Cerebro-Vascular Accident (CVA), this education about CVA prevention consider as:

• Primary
• Secondary
• Thread
• None of the above

24. A pregnant client states that she waddles when she walks. The nurse s explanation is based on which of the following as the cause?

• The large size of the newborn
• Pressure on the pelvic muscles
• Relaxation of the pelvic joints
• Excessive weight gain

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25. The nurse is preparing to walk the postpartum client for the first time since delivery. Before walking the client the nurse should:

• Give the client pain medication.
• Assist the client in dangling her legs.
• Have the client breathe deeply.
• Provide the client additional fluids.

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26. Nurse Maureen is developing a plan of care for a female client with anorexia nervosa. Which action should the nurse include in the plan?

• Provide privacy during meals
• Set-up a strict eating plan for the client
• Encourage client to exercise to reduce anxiety
• Restrict visits with the family

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27. Which clients health problem motivates the nurse to question a prescription for a beta blocker?

• Heart failure
• Hypertension
• Sinus tachycardia
• Coronary artery disease

28. It includes internal and external factors that leads the individual to seek help:

• Demographic
• Sociopsychologic
• Structural
• Cues to action

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29. The American Nurses Association formulated an innovation of the Nursing process. Today, how many distinct steps are there in the nursing process?

• APIE - 4
• ADPIE - 5
• ADOPIE - 6
• ADOPIER - 7

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30. The nurse is caring for a client with an above-the knee amputation (AKA). To prevent hip flexion contractures the nurse should:

• Place the client in a prone position 15-30 minutes twice a day.
• Keep the foot of the bed elevated on shock blocks.
• Place trochanter rolls on either side of the affected leg.
• Keep the clients leg elevated on two pillows.

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31. The most important purpose of cleansing bed bath is:

• To cleanse, refresh and give comfort to the client who must remain in bed
• To expose the necessary parts of the body
• To develop skills in bed bath
• To check the body temperature of the client in bed

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32. What is important nursing care for children with leukemia on chemotherapeutic protocols?

• Preventing physical activity
• Checking their vital signs every two hours
• Having them avoid contact with infected persons
• Reducing unnecessary stimuli in their environment

33. When discharging a client after treatment for a dystonic reaction, the emergency department nurse must ensure that the client understands which of the following?

• Results of treatment are rapid and dramatic but may not last.
• Although uncomfortable, this reaction isn't serious.
• The client shouldn't buy drugs on the street.
• The client must take benztropine (Cogentin) as prescribed to prevent a return of symptoms.

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34. State in which a persons physical, emotional, intellectual and social development or spiritual functioning is diminished or impaired compared with a previous experience.

• Illness
• Disease
• Health
• Wellness

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35. A patient with bowlegs due to abnormal bone formations and deformities has a calcium level of 7.5mg/100ml. Which of the following foods would the nurse MOST likely instruct the patients to add to a diet?

• Organ meats
• Whole grains
• Egg yolks
• Lean means

36. Which nursing assessment indicates that involutional changes have occurred in a client who is three days postpartum?

• The fundus is firm and three finger widths below the umbilicus.
• The client has a moderate amount of lochia serosa.
• The fundus is firm and even with the umbilicus.
• The uterus is approximately the size of a small grapefruit.

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37. When using personal protective equipment (PPE) the nurse aide correctly follows Standard Precautions when wearing:

• double gloves when providing perineal care to a resident.
• a mask and gown while feeding a resident that coughs.
• gloves to remove a residents bedpan.
• gloves while ambulating a resident.

38. You are encouraging your patient for major cancer operation to verbalize her fears. She remarked."I am afraid to do". Your appropriate response is:

• I know how you feel about your condition
• Don't worry, you are in good hands.
• Let me call a chaplain to see you.
• Let us asks your doctor about your operation.

39. Situation Team efforts is best demonstrated in the OR Q. In the OR, the nursing tandem for every surgery is:

• Instrument technician and circulating nurse
• Nurse anesthetist, nurse assistant, and instrument technician
• Scrub nurse and nurse anesthetist
• Scrub and circulating nurses

40. Situation: Mary has been diagnosed with Bipolar I disorder. The client demonstrates extreme psychomotor agitation, flight of ideas, loud talking and elated mood. Q. The nurse has a standing order of Lithium for Mary. If the lithium level is 1.5 mEq/L, the nurse knows that she should:

• Administer the next dose and continue monitoring the client
• Report this to the physician
• Recheck the lithium level and validate first before doing any action
• Withhold the next dose and notify the physician

41. The health care provider (HOP) prescribes exenatide for a client with type 1 diabetes mellitus who takes insulin. The nurse should plan to take which most appropriate intervention?

• Withhold the medication and call the HCP 578. questioning the prescription for the client.
• Administer the medication within 60 minutes before the morning and evening meal.
• Monitor the client for gastrointestinal side effects after administering the medication.
• Withdraw the insulin from the prefilled pen into an insulin syringe to prepare for administration.

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42. The nursing applicant has given the chance to ask questions during a job interview at a local hospital. What should be the most important question to ask that can increase chances of securing a job offer?

• Begin with questions about client care assignments, advancement opportunities, and continuing education.
• Decline to ask questions, because that is the responsibility of the interviewer.
• Ask as many questions about the facility as possible.
• Clarify information regarding salary, benefits, and working hours first, because this will help in deciding whether or not to take the job.

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43. 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. In cleaning the inner cannula or other parts of the tracheostomy tube, The best cleansing mediums are:

• Hydrogen peroxide and Sterile NSS
• Povidone Iodine and Sterile NSS
• Alcohol and Sterile NSS
• Alcohol and Hydrogen Peroxide

44. The client returns to the recovery room following repair of an abdominal aneurysm. Which finding would require further investigation?

• Pedal pulses regular
• Urinary output 20mL in the past hour
• Blood pressure 108/50
• Oxygen saturation 97%

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45. When taking a health history from a female client who has a moderate level of cognitive impairment due to dementia, the nurse would expect to note the presence of:

• Accentuated premorbid traits
• Enhance intelligence
• Increased inhibitions
• Hyper vigilance

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46. A nurse is caring for a child with a diagnosis of cystic fibrosis and pneumonia. The plan of care includes nebulizer treatment and chest physiotherapy. The nurse should perform chest physiotherapy:

• Continuously during the nebulizer treatment
• Prior to the nebulizer treatment
• After the nebulizer treatment
• Intermittently during the nebulizer treatment

47. Which car safety device should be used for a child who is 8 years old and 4 feet tall?

• Seatbelt
• Booster seat
• Rear-facing convertible seat
• Front-facing convertible seat

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48. A nurse is caring for a child with a very low platelet count related to chemotherapy. The nurse should monitor this child’s urine for the presence of which constituent?

• Protein
• Glucose
• Erythrocytes
• Lymphocytes

49. Refers to the extra air that can be inhaled beyond the normal tidal volume

• Inspiratory reserve volume
• Expiratory reserve volume
• Functional residual capacity
• Residual volume

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50. A client experiences post partum hemorrhage eight hours after the birth of twins. Following administration of IV fluids and 500 ml of whole blood, her hemoglobin and hematocrit are within normal limits. She asks the nurse whether she should continue to breast feed the infants. Which of the following is based on sound rationale?

• "Nursing will help contract the uterus and reduce your risk of bleeding."
• "Breastfeeding twins will take too much energy after the hemorrhage."
• "The blood transfusion may increase the risks to you and the babies."
• "Lactation should be delayed until the "real milk" is secreted"

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NCLEX-RN | QB2 | Practice Exam #44 (50 questions)