NCLEX-RN | QB2 | Practice Exam #50 (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 asked by the nurse aide Are peptic ulcers really caused by stress? The nurse would be correct in replying with the following:
- Peptic ulcers result from overeating fatty foods.
- Peptic ulcers are always caused from exposure to continual stress.
- Peptic ulcers are like all other ulcers which ah result from stress.
- Peptic ulcers are associated with H. pylori although there are other ulcers that are associated with stress.
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2. According to Erikson the developmental task of the infant is to establish trust. Parents and caregivers foster a sense of trust by:
- Holding the infant during feedings
- Speaking quietly to the infant
- Providing sensory stimulation
- Consistently responding to needs
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3. The nurse is preparing to administer medication using a clients nasogastric tube. Which actions should the nurse take before administering the medication? Select all that apply. 1.Check the residual volume. 2.Aspirate the stomach contents. 3.Turn off the suction to the nasogastric tube. 4.Remove the tube and place it in the other nostril. 5.Test the stomach contents for a pH indicating acidity.
- 1,2,3,5
- 2,3,4,5
- 1,2,5
- 1,2,3,4
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4. A client who had cardiac surgery 24 hours ago has had a urine output averaging 20mL/hour for 2 hours. The client received a single bolus of 500 mL of intravenous fluid. Urine output for the subsequent hour was 25 mL. Daily laboratory results indicate that the blood urea nitrogen level is 45 mg/dL(16 mmol/L) and the serum creatinine level is 2.2 mg/dL (194 mcmol/L). On the basis of these findings, the nurse would anticipate that the client is at risk for which problem?
- Hypovolemia
- Acute kidney injury
- Glomerulonephritis
- Urinary tract infection
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5. While caring for a neonate with a meningocele, the nurse should AVOID positioning the child on the:
- Abdomen
- Left side
- Right side
- Back
6. 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 The following are signs of severe complicated measles:
- Clouding of the cornea
- Deep or extensive mouth ulcers
- Pus draining from the eyes
- A and b only
7. Situation: After abdominal surgery, the circulating and scrub nurses have critical responsibility about sponge and instrument count Q. When is the first sponge instrument count reported?
- Before closing the subcutaneous layer
- Before peritoneum is closed
- Before closing the skin
- Before the fascia is sutured
8. Nurse Linda is preparing a client with multiple sclerosis for discharge from the hospital to home. Which of the following instruction is most appropriate?
- "Practice using the mechanical aids that you will need when future disabilities arise".
- "Follow good health habits to change the course of the disease".
- "Keep active, use stress reduction strategies, and avoid fatigue."
- "You will need to accept the necessity for a quiet and inactive lifestyle."
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9. 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. As a nurse you know that one of the complications that you have to watch out for when caring for Omar who is receiving total parenteral nutrition is:
- stomatitis
- hepatitis
- dysrhythmia
- infection
10. A patient with an unsteady gait and a history of falls has care plan interventions that include keeping the walker in reach and pathways free of obstacles. On evaluation after 1 week, the patient has had no falls, but the gait remains unsteady. The nurse should:
- Continue the plan of care as written
- Allow the patient to replace the walker with a cane
- Allow the patient to ambulate short distances without the walker
- Have the patient practice stepping over small objects
11. Situation: Mrs. Lim has had confirmation of her pregnancy. She presents the emergency room with abdominal pain not yet diagnosed. Q. Mrs. Lim has been complaining of vaginal bleeding and one sided lower quadrant pain. The nurse suspects mat she has:
- Abruptio placenta
- An incomplete abortion
- An ectopic pregnancy
- A rupture of graafian foilicle
12. In monitoring a client's response to disease-modifying antirheumatic drugs (DMARDs), which assessment findings would the nurse consider acceptable responses? Select all that apply.
- 1,2,3,4
- 2,3,4,5
- 3,4,5
- 1,2,3
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13. A home care nurse makes a follow-up visit to a patient who had shingles. A month since the onset, the patient pain level is 6 on a scale of 1 to 10 where 1 is no pain and 10 is greater pain. Two weeks ago, the pain Level decreases without any caring. The patient's condition has:
- Met the expected outcome
- Partially met the expected outcome
- Has not improved
- Has worsened
14. Nurse Gina is aware that the defense mechanism commonly used by clients who are alcoholics is:
- Displacement
- Denial
- Projection
- Compensation
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15. A 32 year old male graduate student, who has become increasingly withdrawn and neglectful of his work and personal hygiene, is brought to the psychiatric hospital by his parents. After detailed assessment, a diagnosis of schizophrenia is made. It is unlikely that the client will demonstrate:
- Low self esteem
- Concrete thinking
- Effective self boundaries
- Weak ego
16. A woman who has been discharged from hospital with a permanent colostomy in lace is performing irrigation at home for the first time. After five minutes from the start of the procedure, she begins to have stomach cramps. Which intervention would most likely decrease the symptoms?
- Increase the flow of irrigation solution
- Decrease the temperature of the water
- Clamp the catheter for 1-2 minutes
- Elevate the bag of irrigation solution
17. Situation: You are assigned to take care of a group of patients across the lifespan. The elderly patient is at higher risk for urinary incontinence because:
- Increased glomerular filtration
- Diuretic use
- Decreased bladder capacity
- Decreased glomerular filtration
18. A client LMP began July 5. Her EDO should be which of the following?
- January 2
- March 28
- April 12
- October 12
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19. A 65 years old client is in the first stage of Alzheimer s disease. Nurse Patricia should plan to focus this client's care on:
- Offering nourishing finger foods to help maintain the clients nutritional status.
- Providing emotional support and individual counseling.
- Monitoring the client to prevent minor illnesses from turning into major problems.
- Suggesting new activities for the client and family to do together.
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20. The nurse is teaching basic infant care to a group of first-time parents. The nurse should explain that a sponge bath is recommended for the first two weeks of life because:
- New parents need time to learn how to hold the baby.
- The umbilical cord needs time to separate.
- Newborn skin is easily traumatized by washing.
- The chance of chilling the baby outweighs the benefits of bathing.
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21. The first action that the nurse should take if she finds the client has an 02 saturation of 68% is:
- Elevate the head.
- Recheck the O2 saturation in 30 minutes.
- Apply oxygen by mask.
- Assess the heart rate.
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22. A child was recently diagnosed with spastic cerebral palsy. Which of the following statement by the parent would indicate to the nurse that parent understands teaching about illness?
- Full recovery is possible
- This illness should not progress
- Cerebral palsy is a hereditary disease
- Surgery can sometimes improve walking
23. A child with measles developed fever and general weakness after being exposed to another child with rubella. In what stage of infectious process does this child belongs?
- Incubation period
- Prodromal period
- Illness period
- Convalescent period
24. Situation: Celina age 25, a ramp model, suddenly became blind after her boyfriend broke off with her. A thorough workup did not reveal any pathological findings. Q. An appropriate nursing intervention which can help Celina is:
- Establishing a trusting relationship
- Encourage her to verbalize her feelings
- Reinforce reality
- Accept her limitation as a person
25. A 2 year-old child is receiving temporary total parental nutrition (TPhl) through a central venous line. This is the first day of TPN therapy. Although all of the following nursing actions must be included in the plan of care of this child, which one would be a priority at this time?
- Use aseptic technique during dressing changes
- Maintain central line catheter integrity
- Monitor serum glucose levels
- Check resit ts of liver function tests
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26. Which of the following would the nurse identify as the priority nursing diagnosis during toddler's vasoocclusive sickle cell crisis?
- Pain related to tissue anoxia
- Pain related to fear of unknown
- Pain related to sever anxiety
- Pain related to increased cardiac output
27. Situation: A research study was under taken in order to identify and analyze a disabled boy's coping reaction pattern during stress. Q. The process recording was the principal tool for data collection. Which of the following is NOT a part of a process recording?
- Non verbal narrative account
- Audio and interpretation
- Audio-visual recording
- Verbal narrative account
28. Situation: Two children were brought to you. One with chest indrawing and the other had diarrhea. The following questions apply: The 1st child who is 13 months has fast breathing using IMCI parameters he has:
- 40 breaths per minute or more
- 50 breaths per minute
- 30 breaths per minute or more
- 60 breaths per minute
29. The nurse is teaching a group of women about fertility awareness, the nurse should emphasize that basal body temperature:
- Can be done with a mercury thermometer but no a digital one.
- The average temperature taken each morning.
- Should be recorded each morning before any activity.
- Has a lower degree of accuracy in predicting ovulation than the cervical mucus test.
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30. The nurse has obtained a unit of blood from the blood bank and has checked the blood bag properly with another nurse. Just before beginning the transfusion, the nurse should assess which priority item?
- Vitalsigns
- Skin color
- Urine output
- Latest hematocrit level
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31. Situation: A patient was admitted in the Medical Floor at St Lukes Hospital. He was asymptomatic. The doctor suspects diverticulosis. Q. Upon review of Mr. Trinidad's chart, Nurse Drew noticed that he weighs 121 lbs and his height is 5 ft, 4 in. After computing for his Body Mass Index (BMI), you can categorize him as:
- obese
- normal
- underweight
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32. A client with iron-deficiency anemia is taking an oral iron supplement. The nurse should tell the client to take the medication with:
- Orange juice
- Water only
- Milk
- Apple juice
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33. A home health nurse is planning for her daily visits. Which client should the home health nurse visit first?
- A client with AIDS being treated with Foscarnet.
- A client with a fractured femur in a long leg cast.
- A client with laryngeal cancer with a laryngectomy.
- A client with diabetic ulcers to the left foot.
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34. A client with COPD has developed secondary polycythemia. Which nursing diagnosis would be included in the plan of care because of the polycythemia?
- Impaired tissue perfusion related to thrombosis
- Activity intolerance related to dyspnea
- Impaired tissue perfusion related to decrease cardiac output
- Impaired tissue perfusion related to blood loss
35. A patient who underwent hand surgery requiring general anesthesia presents to the post anesthesia care unit (PACll) after extubation, The nurse should FIRST assess:
- Circulatory status
- Wound status
- Respiratory status
- Hydration status
36. A hospitalized client cannot find his handkerchief and accuses other client in the room and the nurse of stealing them. Which is the most therapeutic approach to this client?
- Divert the clients attention.
- Listen without reinforcing the clients belief.
- Inject humor to defuse the intensity.
- Logically point out that the client is jumping to conclusions.
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37. Assessment of a 2-year old child revealed baggy pants . Using the IMCI guidelines, how will you manage this child?
- Refer the child urgently to a hospital for confinement
- Coordinate with the social worker to enroll the child in a feeding program
- Make a teaching plan for the mother, focusing on the menu planning for her child
- Assess and treat the child for health problems like infections and intestinal parasitism
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38. What is the first intervention for a client experiencing MI?
- Administer morphine
- Administer oxygen
- Administer sublingual nitroglycerin
- Obtain an ECG
39. A 3-years old child is seen at the pediatricians office. The parents the child has had vomiting and diarrhea for the past 15 hours. The child's is lethargic with the following vital signs: temperature 37.20 C (99.0 F), heart rate 145,respiration rate 25, and blood pressure level 95/55 mmHg. Which of the vital sign is abnormal?
- 37.20 C (99.00 F)
- Heart rate 145
- Respiration rate 25
- Blood pressure level 95/55
40. Pulse pressure is defined as which of the following:
- Difference between systolic and diastolic pressure.
- Expansion of the artery as blood moves through it.
- Difference between arterial and venous pressure.
- Difference between venous and systolic pressure.
41. A community is experiencing an out break of staphylococcal infections. The nurse instructs residents that the MOST common mode of transmission is by:
- Respiratory droplets
- Contaminated foods
- Hands
- Soil
42. Which nursing action is most appropriate when trying to diffuse a clients impending violent behavior?
- Place the client in seclusion
- Leaving the client alone until he can talk about his feelings
- Involving the client in a quiet activity to divert attention
- Helping the client identify and express feelings of anxiety and anger
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43. A nursing student is presenting a clinical conference to peers regarding Freud s psychosexual stages of development, specifically the anal stage. The student explains to the group that which characteristic relates to this stage of development?
- This stage is associated with toilet training.
- This stage is characterized by the gratification of self.
- This stage is characterized by a tapering off of conscious biological and sexual urges.
- This stage is associated with pleasurable and conflicting feelings about the genital organs.
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44. A patient is receiving from surgery using spinal anesthesia. The patient develops a spinal headache. Which of the following nursing actions would be MOST appropriate?
- Elevate the head of the bed 30 degrees
- Keep the patient well hydrated
- Limit intake of salty food
- Lower the temperature of the room
45. The mother of a one-year-old with sickle cell anemia wants to know why the condition didn't show up in the nursery. The nurses response is based on the knowledge that:
- There is no test to measure abnormal hemoglobin in newborns.
- Infants do not have insensible fluid loss before a year of age.
- Infants rarely have infections that would cause them to have a sickling crises.
- The presence of fetal hemoglobin protects the infant.
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46. The community nurse is conducting a health promotion program at a local school and is discussing the risk factors associated with cancer. Which of the following, if identified by the client as a risk factor, indicates a need for further instructions?
- Viral factors
- Stress
- Low-fat and high-fiber diets
- Exposure to radiation
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47. Mrs. Mitchell has been given a copy of her diet. The nurse discusses the foods allowed on a 500-mg low sodium diet. These include:
- A ham and Swiss cheese sandwich on who e wheat bread
- Mashed potatoes and broiled chicken
- A tossed salad with oil and vinegar and olives
- Chicken bouillon
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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. Ms. Reynaldita is a promiscuous woman in Manila submits herself to the clinic for certain examinations. She is experiencing vaginal irritation, redness, and a thick cream cheese vaginal discharge. As a nurse, you will suspect that Ms. Reynaldita is having what disease?
- Gardnerella Vaginalis
- Candida Albicans
- Treponema Pallidum
- Moniliasis
49. Situation: Mr. Felix, a 79 year old man who is brought to the Surgical Unit from PACU after a transurethral resection. You are assigned to receive him. You noted that he has a 3-way indwelling catheter for continuous fast dip bladder irrigation which is connected to straight drainage. Q. Immediately after surgery what would you expect his urine to be?
- Light yellow
- Amber
- Bright red
- Pinkish to red
50. Which statement by the client with rheumatoid arthritis would indicate that she needs additional teaching to safely receive the maximum benefit of her aspirin therapy?
- I always take aspirin with food to protect my stomach
- Once I learned to take aspirin with meals, I was able to start using the inexpensive generic brand
- I always watch for bleeding gums or blood in my stool
- I try to take aspirin only on days when the pain seems particularly bad