NCLEX-RN | QB2 | Practice Exam #46 (50 questions)
All 50 questions are randomized each time you take the test, and do not appear in the same order.
1. Situation: Manny, 6 years old was admitted at Cardinal Santos Hospital due to increasing frequency of bowel movements, abdominal cramps and distension. Q. Voluminous, watery stools can deplete fluids and electrolytes. The acid base imbalance that can occur is:
- metabolic alkalosis
- metabolic acidosis
- respiratory acidosis
- respiratory alkalosis
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2. The nurse is observing the respirations of a client when she notes that the respiratory cycle is marked by periods of apnea lasting from 10 seconds to one minute. The apnea is followed by respirations that gradually increase in depth and frequency. The nurse should document that the client is experiencing:
- Cheyne-Stokes respirations
- Kussmaul respirations
- Biot respirations
- Diaphragmatic respirations
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3. A client taking anticoagulant medication has developed a cardiac tamponade. Which finding is associated with cardiac tamponade?
- A toothbrush
- A soft gauze pad
- Antiseptic mouthwash
- Lemon and glycerin swabs
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4. Situation: There are other important basic knowledge in the performance of our task as Community Health Nurse in relation to IMMUNIZATION these include: Q. This vaccine content is derived from RNA recombinants:
- Measles
- Tetanus toxoids
- Hepatitis B vaccines
- DPT
5. A 62 year-old diabetes type II patient is admitted to hospital for amputation of the right foot due to gangrene and ischemia, Pre-operatively, the patient rates the pain as 9 (using the 1-10 pain scale). How can this patient's phantom (sprit) pain best be controlled?
- Post-operative elevation of limp
- Apply pressure bandage to stump
- Control pain pre-operatively
- Apply ice to the site for twenty minutes
6. When describing dizygotic twins to a couple, on which of the following would the nurse base the explanation?
- Two ova fertilized by separate sperm
- Sharing of a common placenta
- Each ova with the same genotype
- Sharing of a common chorion
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7. The home care nurse is providing wound care for a patient The nurse evaluates the wound and notes the presence of granulation tissue in the wound bed. This observation represents which phase of wound healing?
- Maturation
- Inflammation
- Proliferation
- Finalization
8. Situation: Margie has been diagnosed with Bipolar I disorder. The client demonstrates extreme psychomotor agitation, flight of ideas, loud talking and elated mood. Q. Nursing care plan for a client with Mania like Margie should give priority to:
- Discourage him from manipulating the staff
- Prevent him from assaulting other patient
- Protect him against suicidal attempts
- Provide adequate food and fluid intake
9. A 34 year old quadriplegia patient resides at home with his wife. In order to prevent contractures of all extremities, the community care nurse will instruct the patient's wife in the performance of:
- Active range of motion exercise
- Passive range of motion exercise
- Active assistive range of motion exercise
- Resistive range of motion exercise
10. What type of patient care model is the most common for student nurses and private duty nurses?
- Total patient care
- Team nursing
- Primary Nursing
- Case management
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11. A patient had a retinal detachment surgically repaired. The nurse identified that the detachment would MOST likely be correct and unlikely to reoccur if the retina remains attached at LEAST:
- 3 days
- 2 weeks
- 2 months
- 3 months
12. Health belief model was formulated in 1975 by who?
- Becker
- Smith
- Dunn
- Leavell and Clark
13. When blood sugar level is above normal range, this means that patient has:
- Hypotension
- Hypoglycemia
- Hyperglycemia
- Bradycardia
14. The nurse is caring for a client in an acute manic state. What s the most effective nursing action for this client?
- Assigning him to group activities
- Reducing his stimulation
- Assisting him with self-care
- Helping him express his feelings
15. 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. Mr. Rodrigo said that he has difficulty voiding. Which of the following is the best nursing action to encourage voiding in any clients with voiding difficulties?
- Encourage the client to drink plenty of fluids to promote urination
- Bring the client to the bathroom and stay with him when the sensation to void is felt by the client
- Catheterize the client
- Encourage the use of bathroom or commode rather than bedpans
16. Which of the following statements best describe the nutritional profile of the adolescent?
- Rapid growth, desires company with meals
- Rapid growth, eat meals alone
- Slow but steady growth, poor eating habits
- Stunted growth, voracious appetite
17. The typology of family nursing problems is used in the statement of nursing diagnosis in the care of families. The youngest child of the Reyes family has been diagnosed as mentally retarded. This is classified as:
- Health threat
- Health deficit
- Foreseeable crisis
- Stress point
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18. The common characteristic of autism child is:
- Impulsivity
- Self destructiveness
- Withdrawal
- Hostility
19. A client who uses a respiratory inhaler asks the nurse to explain how he can know when half his medication is empty so that he can refill his prescription. The nurse should tell the client to:
- Shake the inhaler and listen for the contents.
- Drop the inhaler in water to see if it floats.
- Check for a hissing sound as the inhaler is used.
- Press the inhaler and watch for the mist.
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20. A client is admitted with a tumor in the parietal lobe. Which symptoms would be expected due to this tumors location?
- Hemiplegia
- Aphasia
- Paresthesia
- Nausea
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21. A child is treated for possible acetaminophen (Tylenol) overdose. The child is currently stable with normal vital signs. Which of the following organ function system would be MOST affected?
- Liver
- Lungs
- Stomach
- Heart
22. For a rectal examination, the patient can be directed to assume which of the following positions?
- Genupectoral
- Sims
- Horizontal recumbent
- Al of the above
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23. The client presents to the clinic with a serum cholesterol of 275mg/dL and is placed on rosuvastatin (Crestor). Which instruction should be given to the client taking rosuvastatin (Crestor)?
- Report muscle weakness to the physician.
- Allow six months for the drug to take effect.
- Take the medication with fruit juice.
- Report difficulty sleeping.
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24. Situation: Leukemia is the most common type of childhood cancer. Acute Lymphoid Leukemia is the cause of almost 1/3 of all cancer that occurs in children under age 15. Q. Gold standard in the diagnosis of leukaemia is by which of the following?
- Blood culture and sensitivity
- Bone marrow biopsy
- Blood biopsy
- None
25. Situation: Consider the following hypothesis: The Job turnover rate and job dissatisfaction levels of graduate nurses who have worked less than 2 years is higher than for those graduate nurses who have worked for more than 2 years" Q. Which is you independent variable?
- Job dissatisfaction
- Job turnover rate
- Job dissatisfaction and Job turnover rate
- Length of employment
26. A nurse at the fertility clinic is counseling a couple about the tests that will be needed to determine the cause of their infertility. Which test should the nurse describe that will evaluate the woman’s organs of reproduction?
- Biopsy
- Cystogram
- Culdoscopy
- Hysterosalpingogram
27. SITUATION: Wide knowledge about the human ear, its parts and its functions will help a nurse assess and analyze changes in the adult client's health. Q. Aling myrna has Menieres disease. What typical dietary prescription would nurse Oca expect the doctor to prescribe?
- A low sodium , high fluid intake
- A high calorie, high protein dietary intake
- low fat, low sodium and high calorie intake
- low sodium and restricted fluid intake
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28. A behavior-modification program has been started for an adolescent with oppositional defiant disorder Which statement describes the use of behavior modification?
- Distractors are used to interrupt repetitive or unpleasant thoughts.
- Techniques using stressors and exercise are used to increase awareness of body defenses.
- A system of tokens and rewards is used as positive reinforcement.
- Appropriate behavior is learned through observing the action of models.
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29. A hospitalized patient has fallen from bed. The nurse notes shortening of the left leg. Pain upon movement of the left leg, and rapid, swallow respirations. What action should the nurse take FIRST?
- Call for help
- Immobilize the left leg
- Obtain blood pressure
- Evaluate lung sounds
30. The nurse is caring for a client diagnosed with metastatic cancer of the bone. The client is exhibiting mental confusion and a BP of 150/100. Which laboratory value would correlate with the clients symptoms reflecting a common complication with this diagnosis?
- Potassium 5.2mEq/L
- Calcium 13mg/dL
- Inorganic phosphorus 1.7mEq/L
- Sodium 138mEq/L
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31. Which of the following is included in a full liquid diet?
- Popsicles
- Pureed vegetable meat
- Pineapple juice with pulps
- Mashed potato
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32. Intravenous heparin therapy is prescribed for a client. While implementing this prescription, the nurse ensures that which medication is available on the nursing unit?
- Vitamin K
- Protamine sulfate
- Potassium chloride
- Aminocaproic acid
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33. A client with hypertension ask the nurse which factors can cause blood pressure to drop to normal levels?
- Kidneys' excretion to sodium only.
- Kidneys' retention of sodium and water
- Kidneys excretion of sodium and water
- Kidneys retention of sodium and excretion of water
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34. A 62 year-old man is diagnosed with localized non cell tumor of the lung without metastasis and under lobectomy. After the procedure, he is brought to Postoperative Anesthesia Care Unit for recovery with chest tube drainage system in place and administered by nasal cannula. Which nursing action is initially most important?
- Assess level of consciousness
- Attach chest tubes to the bed sheets
- Perform deep breathing and coughing
- Apply elastic stockings to the legs
35. SITUATION: Alfred, a 40 year old construction worker developed cough, night sweats and fever. He was brought to the nursing unit for diagnostic studies. He told the nurse he did not receive a BCG vaccine during childhood Q. According to the DOH, the most hazardous period for development of clinical disease is during the first
- 6-12 months after
- 3-6 months after
- 1-2 months after
- 2-4 weeks after
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36. The client with dementia is experiencing confusion late in the afternoon and before bedtime. The nurse is aware that the client is experiencing what is known as:
- Chronic fatigue syndrome
- Normal aging
- Sundowning
- Delusions
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37. A patient presents with pneumonia and dyspnea. The patient has an ineffective airway clearance related to excessive tracheobronchial secretions. Which of the following interventions would the nurse implement to enhance the patient's airway clearance? Heart rate: 80/min. Respiratory rate: 32/min. Temperature: 40°C.
- Administer oxygen as ordered
- Maintain a comfortable position
- Increase fluid intake
- Administer prescribed analgesics
38. A patient is taught how to perform a breast self-exam by a nurse. Which statement is BEST described as understanding of the proper procedure for doing a breast self-exam?
- Use of the palm of the hand to feel for lumps
- Apply three different levels of pressure to feel breast tissue
- Stand when performing breast self-exam
- Perform self-exam annually
39. The nurse knows that a 60-year-old female clients susceptibility to osteoporosis is most likely related to:
- Lack of exercise
- Hormonal disturbances
- Lack of calcium
- Genetic predisposition
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40. A perimenopausal woman with a small body frame is at high risk for a condition in which bone resorption exceeds the rate of bone formation. She drinks one-three cups of coffee per day since she was 25 years old and smokes five-ten cigarettes per day for the past 20 years. The nurse advises the patient to increase her dietary intake of milk and green leafy vegetables. Which additional foods are most appropriate to recommend?
- Egg yolk, cheese
- Peanuts, poultry
- Whole grains, cereals
- Lentils and black beans
41. The six-month-old client with a ventral septal defect is receiving Digitalis for regulation of his heart rate. Which finding should be reported to the doctor?
- Blood pressure of 126/80
- Blood glucose of 110mg/dL
- Heart rate of 60bpm
- Respiratory rate of 30 per minute
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42. The registered nurse is planning the client assignments for the day. Which is the most appropriate assignment for an unlicensed assistive personnel (UAP)?
- A client requiring a colostomy irrigation
- A client receiving continuous tube feedings
- A client who requires urine specimen collections
- A client with difficulty swallowing food and fluids
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43. A client has recently been diagnosed with open-angle glaucoma. The nurse should tell the client to avoid taking:
- Aleve (naprosyn)
- Benadryl (diphenhydramine)
- Tylenol (acetaminophen)
- Robitussin (guaifenesin)
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44. Lorraine, a 27 year old executive was brought to the ER for an unknown reason. She is starting to speak but her speech is disorganized and cannot be understood. On what level of anxiety does this features belongs?
- Mild
- Moderate
- Severe
- Panic
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45. Mandy, a patient calls the clinic today because he is taking atorvastatin (Lipitor) to treat his high cholesterol and is having pain in both of his legs. You instruct him to:
- Stop taking the drug and make an appointment to be seen next week.
- Continue taking the drug and make an appointment to be seen next week.
- Stop taking the drug and come to the clinic to be seen today.
- Walk for at least 30 minutes and call if symptoms continue.
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46. The nurse reviews the arterial blood gas results of a client and notes the following: pH 7.45, PaC02 of 30 mm Hg (30 mm Hg), and HCO3A of 20 mEq/L (20 mmol/L). The nurse analyzes these results as indicating which condition?
- Metabolic acidosis, compensated
- Respiratory alkalosis, compensated
- Metabolic alkalosis, uncompensated
- Respiratory acidosis, uncompensated
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47. A client is being admitted for problems with Meniere's disease. What is most important to the nurse to assess?
- Diet history
- Screening hearing test
- Effect on client's activities of daily living (ADLs)
- Frequency and severity
48. Nurse Joey is aware that the signs & symptoms that would be most specific for diagnosis anorexia are?
- Excessive weight loss, amenorrhea & abdominal distension
- Slow pulse, 10% weight loss & alopecia
- Compulsive behavior, excessive fears & nausea
- Excessive activity, memory lapses & an increased pulse
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49. Which is CONTRARY to the principles in planning a home visit?
- A home visit should have a purpose of objective
- The plan should revolve around the family health needs
- A home visit should be conducted in the manner prescribed by RHU
- Planning of continuing care should involve a responsible-family member
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50. Nurse Krina recognizes that the suicidal risk for depressed client is greatest
- As their depression begins to improve
- When their depression is most severe
- Before nay type of treatment is started
- As they lose interest in the environment
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