NCLEX-RN | QB2 | Practice Exam #45 (50 questions)

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

 

1. A client with angina is experiencing migraine headaches. The physician has prescribed Sumatriptan succinate (Imitrex). Which nursing action is most appropriate?

• Call the physician to question the prescription order.
• Try to obtain samples for the client to take home.
• Perform discharge teaching regarding this drug.
• Consult social services for financial assistance with obtaining the drug.

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2. Situation: Mrs. Cruz was admitted in the Medical Floor due to pyrosis, dyspepsia and difficulty of swallowing. Q. Mrs. Cruz complained of pain and difficulty in swallowing. This term is referred as:

• Odynophagia
• Dysphagia
• Pyrosis
• Dyspepsia

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3. Situation: Pharmacological treatment was not effective for Johnny s hyperthyroidism and now he is scheduled for Thyroidectomy. Q. While critical items and should be:

• Sterilization
• Decontaminated
• Sterilized
• Disinfected

4. A home health nurse is teaching a family member about the care of a patients peripherally inserted central catheter (PICC). Which of the following would be appropriate for the nurse to make?

• "Place the used intravenous tubing in a leak proof container and then this in sealed container inside a second leak proof container".
• "You will need to put on a disposable face mask before you connect the port of the PICC"
• "The port of the PICC catheter will need to be cleansed with providence-iodine Betadine) after the insulin is completed"
• "The empty medication container can be placed in the same container as your house hold refuses"

5. You are performing abdominal exam on a 9th month pregnant woman. While lying supine, she felt breathless, had pallor, tachycardia, and cold clammy skin. The correct assessment of the woman's condition is that she is:

• Experiencing the beginning of labor
• Having supine hypotension
• Having sudden elevation of BP
• Going into shock

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6. A parent brings a 10-month-old infant into the department saying, "my baby put a button in her mouth and now she is not breathing!" After the nurse determines the infant is not breathing. What should the nurse do NEXT?

• Perform the Heimlich maneuver
• Initiate cardio pulmonary resuscitation (CPR)
• Administer 4 back blows
• Administer 4 thrusts midline on the patient back

7. The primary factor responsible for body heat production is the:

• Metabolism
• Release of thyroxin
• Muscle activity
• Stress

8. The following pain medications are ordered for a patient who had a right leg amputation. Oxycodone 5 mg every 4 hours as needed and morphine 5 mg every 4 hours as needed. The nurse administered oxycodone 2 hours ago, but the patient reports pain rated 8 on a scale of 0 (no pain) to 10 (severe pain) as the dressing change beings. After evaluating the effectiveness of the pain medication, what action should the nurse take? Blood pressure: 169/98 mmHg. Heart rate: 112/min. Respiratory rate: 22/mm. Temperature: 36.7°C.

• Administer additional oxycodone 5 mg
• Administer morphine 5 mg
• Change the dressing quickly
• Encourage deep breathing

9. What is the priority when working with a group of middleaged adult clients?

• Cessation of smoking
• Prevention of infection
• Abstinence from alcohol
• Decreasing high-density lipoproteins levels

10. A client is diagnosed with cancer of the jaw. A course of radiation therapy is to be followed by surgery. The client is concerned about the side effects related to the radiation treaments. Nurse Ria should explain that the major side effects that will experienced is:

• Fatigue
• Alopecia
• Vomiting
• Leucopenia

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11. The nurse is caring for a 20 lbs (9 kg) 6 month-old with a 3 day history of diarrhea, occasional vomiting and fever Peripheral intravenous therapy has been initiated, with 5% dextrose in 0.33% normal saline with 20 mEq of potassium per liter infusing at 35 ml/hr. Which finding should be reported to the health care provider immediately?

• 3 episodes of vomiting in 1 hour
• Periodic crying and irritability
• Vigorous sucking on a pacifier
• No measurable voiding in 4 hours

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12. The home health nurse is visiting an elderly client following a hip replacement Which finding requires further teaching?

• The client shares her apartment with a cat.
• The client has a grab bar near the commode.
• The client usually sits on a soft low sofa.
• The client wears supportive shoes with nonskid soles.

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13. The physician has prescribed Cobex (cyanocobalamin) for a client following a gastric resection. Which lab result indicates that the medication is having its intended effect?

• Neutrophil count of 4500 cu mm
• Hgb of 14.2 g/dL
• Platelet count of 250 000 cu. mm
• Eeosinophil count of 200 cu mm

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14. A client with anorexia nervosa tells a nurse, My parents never hug me or say I've done anything right." Which of the following Interventions is the best to use with this family?

• Teach the family principles of assertive behavior.
• Discuss the difficulties the family has in social situations.
• Help the family convey a positive attitude toward the client.
• Explore the family's ability to express affection appropriately

15. Which is the most appropriate nursing action in obtaining a blood pressure measurement?

• Take the proper equipment place the client in a comfortable position, and record the appropriate information in the client's chart
• Measure the clients arm, if you are not sure of the size of cuff to use.
• Have the client recline or sit comfortably in a chair with the forearm at the level of the heart.
• Document the measurement, which extremity was used, and the position that the client was in during the measurement.

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16. David, 68 year old male client is scheduled for Serum Lipid analysis. Which of the following health teaching is important to ensure accurate reading?

• Tell the patient to eat fatty meals 3 days prior to the procedure
• NPO for 12 hours pre-procedure
• Ask the client to drink 1 glass of water 1 hour prior to the procedure
• Tell the client that the normal serum lipase level is 50 to 140 U/L

17. Which nursing diagnosis is most appropriate for an elderly client with osteoarthritis?

• Risk for injury
• Impaired urinary elimination
• Ineffective breathing pattern
• Imbalanced nutrition: less than body requirements

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18. SITUATION: Devon, A registered nurse, witnessed an old woman hit by a motorcycle while crossing a train railway. The old woman fell at the railway. Devon rushed at the scene. Q. The old woman was now immobilized and brought to the emergency room. The X-ray shows a fractured femur and pelvis. The ER Nurse would carefully monitor the old woman for which of the following sign and symptoms?

• Tachycardia and Hypotension
• Fever and Bradycardia
• Bradycardia and Hypertension
• Fever and Hypertension

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19. The student nurse is aware that the pathognomonic sign of measles is Kopliks spot and you may see Koplik's spot by inspecting the:

• Nasa mucosa
• Buccal mucosa
• Skin on the abdomen
• Skin on neck

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20. Situation: Anesthesia is used even during the Ancient times. In its evolution, modern marvels in the use of anesthesia enables the nurses to develop a more competitive approach in patient care. Q. An anesthesia delivered directly to the spinal canal is known as:

• Epidural
• Intrathecal
• General
• Local

21. Which criterion in priority setting of health problems is used only in community health care?

• Modifiability of the problem
• Nature of the problem presented
• Magnitude of the health problem
• Preventive potential of the health problem

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22. Situation: The question with regards to the OPERATING ROOM. Q. The patient has a right to information regarding the operation or other invasive procedure and potential effects. This right is achieved through:

• Enlightened Consent
• preoperative visit
• charting
• doctor's rounds

23. Nurse John is aware that self mutilation among Bipolar disorder patients is a means of:

• Overcoming fear of failure
• Overcoming feeling of insecurity
• Relieving depression
• Relieving anxiety

24. As a counselor, the nurse performs which of the following task?

• encourage client to express feelings and concerns
• helps client to learn a dance or song to enable her to participate in activities
• help the client prepare in group activities
• assist the client in setting limits on her behavior

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25. Situation: Jimmy developed this goal for hospitalization. To get a handle on my nervousness/ The nurse is going to collaborate with him to reach his goal. Jimmy was admitted to the hospital because he called his therapist that he planned to asphyxiate himself with exhaust from his car but frightened instead. He realized he needed help. Q. The nurse recognized that Jimmy had conceptualized his problem and the next priority goal in the care plan is:

• help the client find meaning in his experience
• help the client to plan alternatives
• help the client cope with present problem
• help the client to communicate

26. An indicator of success in community organizing is when people are able to:

• Participate in community activities for the solution of a community problem
• Implement activities for the solution of the community problem
• Plan activities for the solution of the community problem
• Identify the health problem as a common concern

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27. A 20-year-old is admitted to the rehabilitation unit following a motorcycle accident. Which would be the appropriate method for measuring the client for crutches?

• Measure five finger breadths under the axilla.
• Measure 3 inches under the axilla.
• Measure the client with the elbows flexed 10°.
• Measure the client with the crutches 20 inches from the side of the foot.

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28. Situation: The OR is divided in three zones to control traffic flow and contamination. Q. Insulin using insulin syringe are given using how many degrees of needle insertion?

• 45
• 180
• 90
• 15

29. When a resident is expressing anger, the nurse aide should:

• correct the resident's misperceptions.
• ask the resident to speak in a kinder tone.
• listen closely to the resident's concerns.
• remind the resident that everyone gets angry.

30. Which of the following terms refer to the degree to which an instrument measures what it is supposed to be measure?

• Validity
• Reliability
• Meaningfulness
• Sensitivity

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31. One staff suggests that they review the pattern of nursing care that they are using, which is described as a:

• job description
• system used to deliver care
• manual of procedure
• rules to be followed

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32. He plans to use a Likert Scale to determine:

• degree of agreement and disagreement
• compliance to expected standards
• level of satisfaction
• degree of acceptance

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33. Which of the following is TRUE about the mechanism of action of the Aortic and Carotid bodies?

• If the BP is elevated, the RR increases
• If the BP is elevated, the RR decreases
• Elevated BP leads to Metabolic alkalosis
• Low BP leads to Metabolic acidosis

34. Time table showing planned work days and shifts of nursing personnel is:

• Staffing
• Schedule
• Scheduling
• Planning

35. The nurse is monitoring a client in preterm labor who is receiving intravenous magnesium sulfate. The nurse should monitor for which adverse effects of this medication? Select all that apply. 1. Flushing 2. Hypertension 3. Increased urine output 4. Depressed respirations 5. Extreme muscle weakness 6. Hyperactive deep tendon reflexes

• 1,2,3,4,5
• 2,3,4,6
• 1,4,5
• 1,3,5

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36. The nurse is planning care for several children who were admitted during the shift. Daily weights should be the plan of care for the child who is receiving:

• Total parenteral nutrition(TPN)
• Supplement oxygen
• Intravenous antHneffective
• Chest physiotherapy

37. The nurse is preparing to take vital sign in an alert client admitted to the hospital with dehydration secondary to vomiting and diarrhea. What is the best method used to assess the client's temperature?

• Oral
• Axillary
• Radial
• Heat sensitive tape

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38. Which medication, if prescribed for the client with glaucoma, should the nurse question?

• Betaxolol
• Pilocarpine
• Erythromycin
• Atropine sulfate

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39. The nurse is preparing to administer 100 ml potassium chloride solution. The prescriptions indicate that this should be infuse for 2 hours. The nurse should administer how many ml per hour?

• 10
• 25
• 50
• 100

40. After 14 days in the hospital, which finding indicates that her condition in improving?

• She tells the nurse that she had no idea that she is thin
• She arrives earlier than scheduled time of group therapy
• She tells the nurse that she eat 3 times or more in a day
• She gained 4 lbs in two weeks

41. Situation: Nurse Macarena is a Family Planning and Infertility Nurse Specialist and currently attends to FAMILY PLANNING CLIENTS AND INFERTILE COUPLES. The following conditions pertain to meeting the nursing needs of this particular population group. 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

42. The home care nurse observe that the asthmatic patient has a cough wheezing . The nurse administers an albuterol (Proventil) nebulizer treatment as ordered. Which type of implementation is this?

• Discharge planning
• Instruct
• Monitoring and surveillance
• Therapeutic interventions

43. The nurse is evaluating the intake and output of a client for the first 12 hours following an abdominal cholecystectomy. Which finding should be reported to the physician?

• Output of 10mL from the Jackson-Pratt drain
• Foley catheter output of 285mL
• Nasogastric tube output of 150mL
• Absence of stool

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44. 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. Before you used disinfected instrument it is essential that you:

• Rinse with tap water followed by alcohol
• Wipe the instrument with sterile water
• Dry the instrument thoroughly
• Rinse with sterile water

45. In order for Bucks traction applied to the right leg to be effective, the client should be placed in which position?

• Supine
• Prone
• Sim's
• Lithotomy

46. An adolescent client hospitalized with anorexia nervosa is described by her parents as the perfect child.When planning care for the client the nurse should:

• Allow her to choose what foods she will eat
• Provide activities to foster her self-identity
• Encourage her to participate in morning exercise
• Provide a private room near the nurses station

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47. Situation: As a nurse in the Oncology Unit you have to be prepared to provide efficient and effective care to your patients. Q. What side effects are most apt to occur to patient during radiation therapy to the pelvis?

• Urinary retention
• Abnormal vaginal or perineal discharge
• Paresthesia of the lower extremities
• Nausea and vomiting and diarrhea

48. Situation: Sexually Transmitted Diseases are important to identify during pregnancy because of their potential effect on the pregnancy, fetus, or newborn. The following questions pertain to STD's. The microorganism that causes Reynaldita's infection is a:

• Bacteria
• Protozoa
• Fungus
• Virus

49. Situation: Mr Gil age 86 years, has been diagnosed with Alzheimer s disease. Q. Which characteristics could the nurse expect when observing Mr. Gil?

• Transient ischemic attacks
• Remissions and exacerbations
• Rapid deterioration of mental functioning because of arteriosclerosis
• Slowly progressive deficits in intellect, which may be noted for a long time

50. Defined as an alteration in normal function resulting in reduction of capacities and shortening of life span.

• Illness
• Disease
• Health
• Wellness

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NCLEX-RN | QB2 | Practice Exam #45 (50 questions)