NCLEX-RN | QB2 | Practice Exam #51 (50 questions)

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

 

1. A patient with heart failure has the following vital signs: blood pressure level, 136/84 mmHg, heart rate 48, temperature 37.1 C (98.8 F); and respiration rate 20 per minute. Which of these vital signs should be reported to the physician prior to administering the next dose of digoxin?

• Blood pressure
• Pulse
• Temperature
• Respiration rate

2. A patient who had abdominal surgery 6 days ago , has been ambulating the halls without much difficulty. However, on day 7 postoperative the patient complains of increased pain at incisional site and is walking hunched over the MOST likely cause of the change is

• Over assertion the day before
• Pulmonary edema
• wound infection
• deep vein thrombosis

3. After 3 days of taking haloperidol, the client shows an inability to sit still, is restless and fidgety, and paces around the unit. Of the following extrapyramidal adverse reactions, the client is showing signs of:

• Dystonia.
• Akathisia.
• Parkinsonism.
• Tardive dyskinesia.

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4. Defined by Pender as all activities directed toward increasing the level of well being and self actualization.

• Health prevention
• Health promotion
• Health teaching
• Self actualization

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5. A nurse evaluates a patient for signs of rebleeding from ruptured intracranial aneurysm that required surgical ligation. The highest risk for aneurysm rebleed is within:

• 6 hours
• 24 hours
• 48 hours
• 72 hours

6. A nurse plans to teach a group of 20 to 25-year-old women about oral contraceptives. The nurse should instruct that oral contraceptives may:

• Increase the risk of pelvic inflammatory disease
• Cause acne to worsen
• Decrease the risk of breast and cervical cancer
• Decrease the risk of endometriosis

7. The physician has ordered Dilantin (phenytoin) l00mg intravenously for a client with generalized tonic clonic seizures. The nurse should administer the medication:

• Rapidly with an IV push
• With IV dextrose
• Slowly over 2-3 minutes
• Through a small vein

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8. The nurse is performing a routine examination for a 24 year-old man with diabetes mellitus. He takes insulin injections twice daily and monitors his blood sugar regularly. He is vegetarian with a body mass index of 17. The nurse is concerned about his weight Which additional information is most likely required to calculate his ideal daily caloric intake?

• Daily elimination pattern
• Protein and carbohydrate intake
• Activity and exercise level
• HDL and LDL cholesterol levels

9. The nurse is caring for a 4-year-old child with human immunodeficiency virus (HIV) infection. The nurse should expect which statement that is aligned with the psychosocial expectations of this age?

• "Being sick is scary."
• "I know it hurts to die."
• "I know I will be healthy soon."
• "I know I am different than other kids."

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10. In what phase of Nurse patient relationship does a nurse review the clients medical records thereby learning as much as possible about the client?

• Pre Orientation
• Orientation
• Working
• Termination

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11. Which of the following is a job task performed by the nurse aide?

• Participating in resident care planning conferences
• Taking a telephone order from a physician
• Giving medications to assigned residents
• Changing sterile wound dressings

12. The nurse is teaching parents about the treatment plan for a 2 weeks-old infant with Tetralogy of Fallot. While awaiting future surgery, the nurse instructs the parents to immediately report:

• Loss of consciousness
• Feeding problems
• Poor weight gain
• Fatigue with crying

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13. A (child / boy] in the emergency-department, oriented, crying and open his eyes spontaneously, the child move as responding to pain, based on Glasgow Coma Scale, the child scores at:

• 15
• 13
• 11
• 9

14. The nurse should avoid the use of the dorsogiuteal site for an intramuscular injection in children because of the risk of injury to which of the following nerves?

• vagus
• Sciatic
• Llioinguinal
• Lumbar plexus

15. Situation: The nurse engages the client in a. nurse-patient interaction. Q. The best time to inform the client about terminating the nurse-patient relationship is

• when the client asks, how long one relationship would be
• during the working phase
• towards the end of the relationship
• at the start of the relationship

16. A client who hallucinates is not in touch with reality. It is important for the nurse to:

• Isolate the client from other patients.
• Maintain a safe environment.
• Orient the client to time, place, and person.
• Establish a trusting relationship.

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17. Situation: Understanding different models of care is a necessary part of the nurse patient relationship. Q. A nurse is caring to client with phobia who is being treated for the condition. The client is introduced to short periods of exposure to the phobia object while in relaxed state. The nurse understands that this form of behaviour modification can be best described as:

• Systematic desensitization
• Aversion therapy
• Self-control therapy
• Operant conditioning

18. A co-worker informs that the nurse about experiencing increased level of stress associated with daily responsibilities to help cope with professional stress, the nurse should encourage the co-worker to:

• Make a list of unfinished tasks
• complete complex mental task before physical tasks
• Acknowledge daily accomplishments
• Spend time with colleague away from work

19. In caring for clients with renal calculi; which is the priority nursing intervention?

• Record vital signs
• Strain urine
• Limit fluids
• Administer analgesics as prescribed

20. In Maslow s hierarchy of physiologic needs, the human need of greatest priority is:

• Love
• Elimination
• Nutrition
• Oxygen

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21. The nurse is teaching a group of new graduates about the safety needs of the client receiving chemotherapy. Before administering chemotherapy the nurse should:

• Administer a bolus of IV fluid.
• Administer pain medication.
• Administer an antiemetic.
• Allow the patient a chance to eat.

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22. Which of the following urinary symptoms does the pregnant woman most frequently experience during the first trimester?

• Dysuria
• Frequency
• incontinence
• Burning

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23. Abnormal skin color which indicates yellowish color is called:

• Erythema
• Ecchymosis
• Jaundice
• Pallor

24. The elderly client is admitted to the emergency room. Which symptom is the client with fractured hip most likely to exhibit?

• Pain
• Disalignment
• Cool extremity
• Absence of pedal pulses

25. Nurse Linda is caring for a client with head injury and monitoring the client with decerebrate posturing. Which of the following is a characteristic of this type of posturing?

• Upper extremity flexion with lower extremity flexion
• Upper extremity flexion with lower extremity extension
• Extension of the extremities after a stimulus
• Flexion of the extremities after stimulus

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26. 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. Nurse Joseph is performing a WEBERS TEST. He placed the tuning fork in the patients forehead after tapping it onto his knee. The client states that the fork is louder in the LEFT EAR. Which of the following is a correct conclusion for nurse Joseph to make?

• He might have a sensory hearing loss in the left ear
• Conductive hearing loss is possible in the right ear
• He might have a sensory hearing loss in the right hear, and/or a conductive hearing loss in the left ear
• He might have a conductive hearing loss in the right ear, and/or a sensory hearing loss in the left ear.

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27. Situation: Mr. Santos, 50, is to undergo cystoscopy due to multiple problems like scantly urination, hematuria, and dysuria. Q. You are the nurse in charge of Mr. Santos. How should you position the patient during cystoscopy?

• Supine
• Lithotomy
• Semi-fowler
• Trendelenburg

28. The most common normal position of the fetus in utero is:

• Transverse position
• Vertical position
• Oblique position
• None of the above

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29. Situation: A group of nursing students were discussing the normal growth and development concepts when assigned to observe the school children. Q. Any surgery should be delayed, if possible, because of me effects on personality development during the

• Oral Stage.
• Anal Stage
• Oedipal Stage
• Latency Stage

30. Which interventions should the nurse include when creating a care plan for a child with hepatitis? Select all that apply. 1. Providing a low-fat, well-balanced diet 2. Teaching the child effective hand-washing techniques. 3. Scheduling playtime in the playroom with other children. 4. Notifying the health care provider (HOP) if jaundice is present 5. Instructing the parents to avoid administering medications unless prescribed. 6. Arranging for indefinite home schooling because the child will not be able to return to school.

• 1,2,3,4
• 1,2,5
• 2,3,4,5
• 1,4,5,6

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31. A patient with congestive heart failure and severe peripheral edema has a nursing diagnosis of fluid volume excess. What are the two MOST important interventions for the nurse to initiate?

• Diuretic therapy and intake and output
• Nutritional education and low-sodium diet
• Daily weights and intake output
• Low-sodium diet and elevate legs when in bed

32. What would be the long-term goal for a child with asthma?

• Quickly reverse airflow obstruction
• Correct hypoxemia
• Deliver humidified oxygen via nasal cannula
• Develop a home and school management plan

33. The nurse wanted to give a child toddler described the oral madaction. What is the right way:

• Open the baby's mouth and put medicine
• Give the medicine spoon in a special play
• Give the medicine in Bottles
• Explain to the child that the medicine delicious

34. Nurse Michelle is caring for an elderly female with osteoporosis. When teaching the client, the nurse should include information about which major complication:

• Bone fracture
• Loss of estrogen
• Negative calcium balance
• Dowager's hump

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35. High-pitched gurgles head over the right lower quadrant are:

• A sign of increased bowel motility
• A sign of decreased bowel motility
• Normal bowel sounds
• A sign of abdominal cramping

36. A client with a history of hypertension is diagnosed with primary hyperaldosteronism. This diagnosis indicates that the client's hypertension is caused by excessive hormone secretion from which organ?

• adrenal cortex
• pancreas
• adrenal medulla
• parathyroid

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37. The nurse is administering eye drops to a client with glaucoma. To achieve maximum absorption, the nurse should instill the eyedrop into the:

• conjunctival sac
• pupil
• sclera
• vitreous humor

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38. 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. The three main consequence of leukaemia that cause the most danger is:

• Neutropenia causing infection, anemia causing impaired oxygenation and thrombocytopenia leading to bleeding tendencies
• Central nervous system infiltration, anemia causing impaired oxygenation and thrombocytopenia leading to bleeding tendencies.
• Splenomegaly hepatomegaly fractures
• Invasion by the leukemic cells to the bone causing severe bone pain

39. The nurse is assessing a pregnant client with type 1 diabetes mellitus about her understanding regarding changing insulin needs during pregnancy. The nurse determines that further teaching is needed if the client makes which statement?

• "I will need to increase my insulin dosage during the first 3 months of pregnancy."
• "My insulin dose will likely need to be increased during the second and third trimesters."
• "Episodes of hypoglycemia are more likely to occur during the first 3 months of pregnancy."
• "My insulin needs should return to prepregnant levels within 7 to 10 days after birth if I am bottle-feeding”

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40. The nurse is caring for a client with a basal cell epithelioma. The primary cause of basal cell epithelioma is:

• Sun exposure
• Smoking
• Ingestion of alcohol
• Food preservatives

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41. Sally Baker, a 40-year-old woman, is admitted to the hospital with an established diagnosis of mitral stenosis. She is scheduled for surgery to repair her mitral valve. Q. You are seeing more clients with diagnoses of mitral valve prolapse. You know those mitral valve prolapse is usually a benign cardiac condition, but may be associated with atypical chest pain. This chest pain is probably caused by:

• ventricular ischemia
• dysfunction of the left ventricle
• papillary muscle ischemia and dysfunction
• cardiac arrhythmias

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42. Which of the following would the nurse assess in a client experiencing abruptio placenta?

• Bright red, painless vaginal bleeding
• Concealed or external dark red bleeding
• Palpable fetal outline
• Soft and non tender abdomen

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43. A client scheduled for disc surgery tells the nurse that she frequently uses the herbal supplement kava-kava (piper methysticum). The nurse should notify the doctor because kava-kava:

• Increases the effects of anesthesia and post-operative analgesia
• Eliminates the need for antimicrobial therapy following surgery
• Increases urinary output so a urinary catheter will be needed post-operatively
• Depresses the immune system so infection is more of a problem

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44. Situation: Nursing informatics is a way of using information technology computers and the internet in the improvement of nursing care. The first nursing informatics conference was held during 1977. Q. The challenge most associated with the utilization of an electronic record system is which of the following?

• Cost
• Accuracy
• Privacy
• Curability

45. Mr. Duffy is admitted to the CCU with a diagnosis of R/O Ml. He presented in the ER with a typical description of pain associated with an Ml, and is now cold and clammy, pale and dyspneic. He has an IV of D5W running, and is complaining of chest pain. Oxygen therapy has not been started, and he is not on the monitor. He is frightened. Q. The nurse is aware of several important tasks that should all be done immediately in order to give Mr. Duffy the care he needs. Which of the following nursing interventions will relieve his current myocardial ischemia?

• stool softeners, rest
• O2 therapy, analgesia
• Reassurance, cardiac monitoring
• Adequate fluid intake, low-fat diet

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46. David, an adolescent has a history of truancy from school, running away from home and "borrowing" other people's things without their permission. The adolescent denies stealing, rationalizing instead that as long as no one was using the items, it was all right to borrow them. It is important for the nurse to understand the psychodynamically, this behavior may be largely attributed to a developmental defect related to the:

• Superego
• Oedipal complex
• Id
• Ego

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47. The nurse is caring for a client following a mastectomy. Which nursing intervention would assist in preventing lymphedema of the affected arm?

• Placing cool compresses on the affected arm
• Elevating the affected arm on a pillow above heart level
• Avoiding arm exercises in the immediate postoperative period
• Maintaining an intravenous site below the antecubital area on the affected side

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48. Vitamin K is administered to the newborn shortly after birth for which of the following reasons?

• To stop hemorrhage
• To treat infection
• To replace electrolytes
• To facilitate clotting

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49. The nurse is assessing a female client with possible diagnosis of osteoarthritis. The most significant risk factor for osteoarthritis is:

• Obesity
• Race
• Job
• Age

50. A client who has been diagnosed of hypertension is being taught to restrict intake of sodium. The nurse would know that the teachings are effective if the client states that:

• I can eat celery sticks and carrots
• I can eat broiled scallops
• I can eat shredded wheat cereal
• I can eat spaghetti on rye bread

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NCLEX-RN | QB2 | Practice Exam #51 (50 questions)