NCLEX-RN | QB2 | Practice Exam #47 (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 is not a part of IMCI case management process:
- Counse the mother
- Identify the illness
- Assess the child
- Treat the child
2. The patient with a cervical SCI has been placed in fixed skeletal traction with a halo fixation device. When caring for this patient the nurse may delegate which action (s) to the LPN/ LVN? (Choose all that apply), A. Check the patient's skin for pressure form device, B. Assess the patient's neurologic status for changes, C. Observe the halo insertion sites for signs of infection, D. Clean the halo insertion sites with hydrogen peroxide.
- A, C & D
- A, B, C & D
- A, B, D
- B, C, D
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3. Situation: Nurse Joanna works as an OB-Gyn Nurse and attends to several HIGH- RISK PREGNANCIES: Particularly women with preexisting or newly acquired illness. The following conditions apply Bernadette received a laceration on her leg from her automotive accident Why are lacerations of lower extremities potentially more serious in pregnant women than others?
- Lacerations can provoke allergic responses because of gonadotropic hormone
- Increased bleeding can occur from uterine pressure on leg veins
- A woman is less able to keep the laceration clean because of her fatigue
- Healing is limited during pregnancy, so these will not heal until after birth
4. When administering a tuberculin skin test the nurse should insert the needle at a:
- 15° angle
- 30° angle
- 45° angle
- 90° angle
5. Which behavioral characteristic describes the domestic abuser?
- Alcoholic
- Over confident
- High tolerance for frustrations
- Low self-esteem
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6. A 6-year-old child has just been diagnosed with localized Hodgkins disease, and chemotherapy is planned to begin immediately. The mother of the child asks the nurse why radiation therapy was not prescribed as a part of the treatment. What is the nurse's best response?
- "It's very costly and chemotherapy works just as well.”
- "I'm not sure, I'll discuss it with the health care provider"
- "Sometimes age has to do with the decision for radiation therapy."
- "The health care provider would prefer that you discuss treatment options with the oncologist"
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7. Situation: Johnny, sought consultation to the hospital before Q. Which of the following is a side effect of Lugol's solution?
- Decrease the vascularity and size of the thyroid gland
- Nystagmus
- Enlargement of the Thyroid gland
- Excessive salivation
8. Situation: As a nurse, you should be aware and prepared of the different roles you play. Q. As a nurse, what is one of the best way to reconcile medications across the continuum of care?
- Endorse on a case-to-case basis
- Communication a complete list of the patient's medication to the next provider of service
- Endorse in writing
- Endorse the routine and stat medications every shift
9. Upon admission to the hospital a client reports having the worst headache ever had.v The nurse should give the highest priority to which action?
- Administering pain medication
- Starting oxygen
- Performing neuro checks
- Inserting a Foley catheter
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10. Situation: Gringo seeks psychiatric counseling for his ritualistic behavior of counting his money as many as 10 times before leaving home. Q. Person with OCD usually manifest:
- Fear
- Apathy
- Suspiciousness
- Anxiety
11. The nurse is conducting an initial assessment of a client in crisis. When assessing the client's perception of the precipitating event that led to the crisis, which is the most appropriate question?
- "With whom do you live?"
- "Who is available to help you?"
- What leads you to seek help now?
- "What do you usually do to feel better?"
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12. A client with a head injury has a fixed, dilated right pupil; responds only to painful stimuli; and exhibits decorticate posturing. Nurse Kate should recognize that these are signs of:
- Meningeal irritation
- Subdural hemorrhage
- Medullary compression
- Cerebral cortex compression
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13. The nurse notes variable decelerations on the fetal monitor strip. The most appropriate initial action would be to:
- Notify her doctor.
- Increase the rate of IV fluid.
- Reposition the client.
- Readjust the monitor.
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14. What will the nurse teach the diabetic client regarding exercise in his /her treatment program?
- During exercise the body will use carbohydrates for energy production, which in turn will decrease the need for insulin
- With an increase in activity the body will utilize more carbohydrates; therefore more insulin will be required.
- The increase in activity results in an increase in the utilization of insulin; therefore the client should decrease his/her carbohydrate intake
- Exercise will improve pancreatic circulation and stimulate the islet of Langerhans to increase the production of intrinsic insulin
15. The nurse is caring for a hearing-impaired client. Which approach will facilitate communication?
- Speak loudly.
- Speak frequently.
- Speak at a normal volume.
- Speak directly into the impaired ear.
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16. Lidocaine is a medication frequently ordered for the client experiencing:
- Atrial tachycardia
- Ventricular tachycardia
- Heart block
- Ventricular bradycardia
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17. The normal color of urine is:
- Dark amber
- Reddish brown
- Cloudy
- Light yellow
18. The nurse is creating a plan of care for a client in skin traction. The nurse should monitor for which priority finding in this client?
- Urinary incontinence
- Signs of skin breakdown
- The presence of bowel sounds
- Signs of infection around the pin sites
19. Which of the following illnesses is the leading cause of death in the US?
- Cancer
- Coronary artery disease
- Liver failure
- Renal failure
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20. What parental behavior toward a child during an admission procedure should cause Nurse Ron to suspect child abuse?
- Flat affect
- Expressing guilt
- Acting overly solicitous toward the child.
- Ignoring the child.
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21. Which of the following etiologic factors predispose a client to Tourette syndrome?
- No known etiology
- Abnormalities in brain neurotransmitters, structural changes in basal ganglia and caudate nucleus, and genetics
- Abnormalities in the structure and function of the ventricles
- Environmental factors and birth-related trauma
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22. Situation: In your professional nursing role, it is essential to establish a meaningful nurse patient relationship. Q. The objection of the nurse-patient relationship is to provide an opportunity of the patient to:
- Clarify problems
- Develop insights
- Have a corrective emotional experience
- Develop interpersonal relationship
23. John suddenly experiences a seizure, and Nurse Gina notice that John exhibits uncontrollable jerking movements. Nurse Gina documents that John experienced which type of seizure?
- Tonic seizure
- Absence seizure
- Myoclonic seizure
- Clonic seizure
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24. Effective hand washing requires the use of:
- Soap or detergent to promote emulsification
- Hot water to destroy bacteria
- A disinfectant to increase surface tension
- All of the above
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25. Situation: Nurse Minette is an independent nurse practitioner following-up referred clients in their respective homes. Here she handles a case of POSTPARTUM MOTHER AND FAMILY focusing on HOME CARE. If you were Minette, which of the following actions, would alert you that a new mother is entering a postpartum at taking-hold phase?
- She urges the baby to stay awake so that she can breastfeed him in her
- She tells you she was in a lot of pain all during labor
- She says that she has not selected a name for the baby as yet
- She sleeps as if exhausted from the effort of labor
26. The nurse is caring for a client with a cerebral injury that impaired his speech and hearing. Most likely, the client has experienced damage to the:
- frontal lobe
- parietal lobe
- occipital lobe
- temporal lobe
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27. The five-year-old is being tested for enterobiasis (pinworms). Which symptom is associated with enterobiasis?
- Rectal itching
- Nausea
- Oral ulcerations
- Scalp itching
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28. Nikki a 5-month old infant was brought by his mother to the health center because of diarrhea for 4 to 5 times a day. Her skin goes back slowly after a skin pinch and her eyes are sunken. Using the IMCI guidelines, you will classify this infant in which category?
- No signs of dehydration
- Some dehydration
- Severe dehydration
- The data is insufficient
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29. Which client is at highest risk for suicide?
- One who appears depressed, frequently thinks of dying, and gives away all personal possessions
- One who plans a violent death and has the means readily available
- One who tells others that he or she might do something if life doesn't get better soon
- One who talks about wanting to die
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30. The nurse is teaching a client about the risk factors associated with colorectal cancer. The nurse determines that further teaching is necessary related to colorectal cancer if the client identifies which item as an associated risk factor?
- Age younger than 50 years
- History of colorectal polyps
- Family history of colorectal cancer
- Chronic inflammatory bowel disease
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31. Which nursing diagnosis takes the highest priority for a client with Parkinsons crisis?
- Imbalanced nutrition: less than body requirements
- Ineffective airway clearance
- Impaired urinary elimination
- Risk for injury
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32. Situation: You are assigned at the surgical ward and clients have been complaining of post pain at varying degrees. Pain as you know is very subjective. Q. A one-day postoperative abdominal surgery client has been complaining of severe throbbing abdominal pain described as 9 in 1 - 10 pain rating. Your assessment reveals bowel sounds on all quadrants and the dressing is dry and intact. What nursing intervention would you take?
- Medicate client as prescribed
- Encourage client to do-imagery
- Encourage deep breathing exercise
- Call surgeon stat
33. Situation: Mariah is a 31 year old lawyer who has been married for 6 moths. She is now pregnant. She consults you for guidance. The nurse palpates the abdomen of Mariah. Now at 5 month gestation, what level of the abdomen can be the fundic height be palpated?
- Symphysis pubis
- Midpoint between the umbilicus and the xiphoid process
- Midpoint between the symphysis pubis the umbilicus
- Umbilicus
34. A client is admitted to the psychiatric unit with a diagnosis of borderline personality disorder. The nurse expects the assessment to reveal:
- unpredictable behavior and intense interpersonal relationships.
- inability to function as a responsible parent.
- somatic symptoms.
- coldness, detachment, and lack of tender feelings.
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35. Situation: Jolina is an 18 year old beginning college student Her mother observed that she is having problems relating with her friends. She is undecided about her future. She has lost insight, lost interest in anything and complained and complained of constant tiredness. Q. Jolina continues to verbalize feeling sad and hopeless. She is not mixing well with other clients. One of the nurse's important consideration for Jolina Initially is to:
- Formulate a structured schedule so she is able to channel her energies externally
- Let her alone until she feels like mingling with others
- Encourage her to join socialization hour so she will start to relate with others
- Encourage her to join group therapy with other patients
36. A patient receiving chemotherapy developed some raised, red edematous wheals on the skin, which of the following care plan alter natives MOST likely need to occur before the treatment?
- Rain forced relaxation techniques
- Continue chemotherapy without change
- Continue with radiation therapy only
- Pre-medicate the patient with an antihistamine
37. Situation: Mrs. Davis is admitted to your ward. The MD ordered Prepare for thoracentesis this pm to remove excess air from the pleural cavity." Q. To prevent leakage of fluid in the thoracic cavity how will you position the client after thoracentesis?
- Place flat in bed
- Turn on the unaffected side
- Turn on the affected side
- On bed rest
38. During the assessment of a laboring client the nurse notes that the FHT are loudest in the upper-right quadrant The infant is most likely in which position?
- Right breech presentation
- Right occipital anterior presentation
- Left sacral anterior presentation
- Left occipital transverse presentation
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39. A patient exhibits clinical manifestation of a pulmonary embolism. Arterial blood gas (ABG) levels and a chest x-ray are ordered. Which of the following test is used to diagnose this condition?
- Computer tomography scan(CT scan)
- Magnetic resonance imaging (MRI)
- Pulmonary angiography
- Pulmonary function test
40. The nurse is reviewing laboratory results and notes that a clients serum sodium level is 150 mEq/L (150 mmol/L). The nurse reports the serum sodium level to the health care provider (HCP) and the HOP prescribes dietary instructions based on the sodium level. Which acceptable food items does the nurse instruct the client to consume? Select all that apply. 1.Peas. 2.Nuts. 3.Cheese. 4.Cauliflower. 5.Processed oat cereals.
- 1,2,4
- 2,3,4,5
- 1,3,5
- 2,3,4
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41. 60 years age a patient weighed 73 kilograms (161 pounds). During the current clinic visit the nurse note the patient has an unintended weight loss. This weight loss over 6 months would be considered clinically significant as soon as it reaches the point of being more than a:
- 5% loss
- 8% loss
- 10% loss
- 20% loss
42. Nurse Katrina should anticipate that all of the following drugs may be used in the attempt to control the symptoms of Meniere's disease except:
- Antiemetics
- Diuretics
- Antihistamines
- Glucocorticoids
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43. When conducting discharge teaching for the parent of a child newly diagnosed with cystic fibrosis. Which of the following statement by the parent indicates the need for further teaching?
- Weekly weights help evaluate effectiveness of nutritional interventions
- Weekly weights help the doctor know if may child is absorbing nutrients
- Weekly weights reassure my child that recovery is progressing
- Weekly weights help the doctor know if my child needs additional enzymes
44. True labor contraction Is best described by this discomfort that:
- starts over the fundus, radiating downward to the cervix
- radiates upward and downward from the umbilicus
- Is localized over the fundus of the uterus
- begins In the lower back and the abdomen radiating over entire abdomen
45. A client has been taking lithium carbonate (Lithane) for hyperactivity, as prescribed by his physician. While the client is taking this drug, the nurse should ensure that he has an adequate intake of:
- Sodium.
- Iron.
- Iodine.
- Calcium.
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46. The nurse is repositioning the client who has returned to the nursing unit following internal fixation of a fractured right hip. The nurse uses a:
- Pillow to keep the right leg abducted during turning
- Pillow to keep the right leg adducted during turning
- Trochanter roll to prevent external rotation while turning
- Trochanter roll to prevent abduction while turning
47. Which of the following is a sign or symptom of a hemolytic reaction to blood transfusion?
- Hemoglobinuria
- Chest pain
- Urticaria
- Distended neck veins
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48. Grace is exhibiting withdrawn patterns of behavior Nurse Johnny is aware that this type of behavior eventually produces feeling of:
- Repression
- Loneliness
- Anger
- Paranoia
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49. A 12-month old boy weighs 9 kgs. His birth weight was 3 kgs. The mother asks if her baby's weight Is appropriate to his age. The nurse's therapeutic response is:
- He needs to take more milk for supplement
- Weight must be doubled during this time
- Weight is right because weight is tripled at this age
- He is underweight for this age.
50. A client who has been taking carisoprodol (Soma) at home for a fractured arm is admitted with a blood pressure of 80/50 mmHg, a pulse rate of 115 bpm, and respirations of 8 breaths/minute and shallow, the nurse interprets these finding as indicating which of the following?
- Expected common side effects
- Hypersensitivity reactions
- Possible habituating effects
- Hemorrhage from GI irritation