NCLEX-RN | QB2 | Practice Exam #52 (50 questions)
All 50 questions are randomized each time you take the test, and do not appear in the same order.
1. A health care provider's prescription reads 1000 mL of normal saline (NS) to infuse over 12 hours. The drop factor is 15 drops (gtt)/1 mL. The nurse prepares to set the flow rate at how many drops per minute?
- 21 drops per minute
- 20 drops per minute
- 18 drops per minute
- 25 drops per minute
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2. Situation: You are now working as a staff nurse in a general hospital. You have to be prepared to handle situations with ethico-legal and moral implications. Q. You are admitting Jorge to the ward and you found out that he is positive for HIV. Which among the following will you do first?
- Take note of it and plan to endorse this to next shift
- Keep this matter to your self
- Write an incident report
- Report the matter to your head nurse
3. Tony with infection is receiving antibiotic therapy. Later the client complaints of ringing in the ears. This ototoxicity is damage to:
- 4th CN
- 8th CN
- 7th CN
- 9th CN
4. Which of the following best describes the technique of palpation:
- The use of the sense of hearing to listen for sounds.
- The use of tapping on a particular part of the body to produce sounds.
- The use of the senses to evaluate general appearance of the patient.
- The sense of touch to feel the body by slight or deep pressure.
5. You are the charge nurse in an emergency department (ED) and must assign two staff members to cover the triage area. Which team is the most appropriate for this assignment?
- An advanced practice nurse and an experienced LPN/LVN
- An experienced LPN/LVN and an inexperienced RN
- An experienced RN and an inexperienced RN
- An experienced RN and a nursing assistant
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6. The proper technique to monitor the intensity of a uterine contraction is:
- Place the palm of the hands on the abdomen and time the contraction
- Place the finger tips lightly on the suprapubic area and time the contraction
- Put the tip of the fingers lightly on the fundal area and try to indent the abdominal wall at the height of the contraction
- Put the palm of the hands on the fundal area and feel the contraction at the fundal area
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7. Which of the following is the most important purpose of handwashing
- To promote hand circulation
- To prevent the transfer of microorganism
- To avoid touching the client with a dirty hand
- To provide comfort
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8. Which immunization produces a permanent scar?
- DPT
- BCG
- Measles vaccination
- Hepatitis B vaccination
9. The nurse is caring for a client with myasthenia gravis who is having trouble breathing. The nurse would encourage which of the following positions for maximal lung expansion?
- Supine with no pillow to maintain patent airway
- Side-lying with back support
- Prone with head turned to one side
- Sitting or in high Fowlers
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10. The nurse has provided discharge instructions to a client who delivered a healthy newborn by cesarean delivery. Which statement made by the client indicates a need for further instruction?
- "I will begin abdominal exercises immediately."
- "I will notify the health care provider if I develop a fever."
- "I will turn on my side and push up with my arms to get out of bed"
- "I will lift nothing heavier than my newborn baby for at least 2 weeks."
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11. The physician prescribes regular insulin five units subcutaneous. Regular insulin begins to exert an effect:
- In 5-10 minutes
- In 10-20 minutes
- In 30-60 minutes
- In 60-120 minutes
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12. Proposed the GRAND THEORY OF NURSING AS CARING
- Erickson, Tomlin, Swain
- Peterson, Zderad
- Benner, Wrubel
- Boykin, Schoenhofer
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13. A patient schedule for a major surgery in one hour is very nervous and upset. Which of the following order medications would the nurse administer to relax this patient?
- Meperidine Hydrochloride(Demerol)
- Scopolamine (Transderm-Scop)
- Pentobarbital sodium(Nembutal sodium)
- Trazodone hydrochloride(Trazadone)
14. He proposed the theory of morality that is based on MUTUAL TRUST
- Freud
- Erikson
- Kohlberg
- Peters
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15. The nurse is assisting in the care of a client with diverticulosis. Which of the following assessment findings must necessitate an immediate report to the doctor?
- Bowel sounds are present
- Intermittent left lower-quadrant pain
- Constipation alternating with diarrhea
- Hemoglobin 26% and hematocrit 32
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16. The following are social data about the client except:
- Patient's lifestyle
- Religious practices
- Family home situation
- Usual health status
17. Situation: Milo, a 16-year-old male, has been diagnosed to have AIDS. He worked as entertainer in a cruise ship. Exercise precaution must be taken to protect health worker dealing with the AIDS patients. Which among these must be done as priority:
- Boil used syringe and needles
- Use gloves when handling specimen
- Label personal belonging
- Avoid accidental wound
18. Fetal distress is occurring with a laboring client. As the nurse prepares the client for a cesarean birth, what is the most important nursing action?
- Slow the intravenous flow rate.
- Continue the oxytocin drip if infusing.
- Place the client in a high Fowler's position.
- Administer oxygen, 8 to 10 L/minute, via face mask.
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19. When discussing dietary choice with a patient who is receiving heparin therapy the nurse should state that which of the following foods affect the clotting time?
- High protein foods
- Soy-based foods
- Foods high in vitamin K
- Foods containing goats milk
20. A client is returned to the nursing unit after thoracic surgery with chest tubes in place. During the first few hours postoperatively, what type of drainage should the nurse expect?
- Serous
- Bloody
- Serosanguineous
- Bloody with frequent small clots
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21. In the work setting, what is your primary responsibility in preparing for disaster management that includes natural disasters or bioterrorism incidents?
- Knowledge of the agencys emergency response plan
- Awareness of the signs and symptoms for potential agents of bioterrorism
- Knowledge of how and what to report to the CDC
- Ethical decision-making about exposing self to potentially lethal substances
22. Influence from peers and social pressure is included in what variable of HBM?
- Demographic
- Sociopsychologic
- Structural
- Cues to action
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23. The following are signs that the placenta has detached EXCEPT:
- Lengthening of the cord
- Uterus becomes more globular
- Sudden gush of blood
- Mother feels like bearing down
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24. A patient recently started on phenytoin (Dilantin) to control simple complex seizures is seen in the outpatient clinic. Which information obtained during his chart review and assessment will be of greatest concern?
- The gums appear enlarged and inflamed.
- The white blood cell count is 2300/mm3.
- Patient occasionally forgets to take the phenytoin until after lunch.
- Patient wants to renew his driver's license in the next month.
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25. During acute gout attack, the nurse administer which of the following drug:
- Prednisone (Deltasone)
- Colchicines
- Aspirin
- Allopurinol (Zyloprim)
26. A patient with acute Crohn's disease has been prescribed an elemental diet The MOST likely rationale for this is to:
- Reset the bowel
- Improve nutrition
- Improve medication absorption
- Prepare for surgery
27. A client is brought to the emergency department with partial-thickness burns to his face, neck, arms, and chest after trying to put out a car fire. The nurse should implement which nursing actions for this client? Select all that apply. 1. Restrict fluids. 2. Assess for airway patency. 3. Administer oxygen as prescribed. 4. Place a cooling blanket on the client 5. Elevate extremities if no fractures are present 6. Prepare to give oral pain medication as prescribed.
- 1,2,3,4
- 2,3,5
- 3,4,5,6
- 2,3,4
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28. When is the best time to collect urine specimen for routine urinalysis and C/S?
- Early morning
- Later afternoon
- Midnight
- Before breakfast
29. The nurse is caring for a client who has just had a modified radical mastectomy with immediate reconstruction. She's in her 30s and has two children. Although she's worried about her future, she seems to be adjusting well to her diagnosis. What should the nurse do to support her coping?
- Tell the client's spouse or partner to be supportive while she recovers.
- Encourage the client to proceed with the next phase of treatment.
- Recommend that the client remain cheerful for the sake of her children.
- Refer the client to the American Cancer Society's Reach for Recovery program or another support program.
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30. The nurse has started intravenous fluid therapy on a child. Which of the following action is appropriate?
- Using a padded arm board only if the child is active
- Checking the site at least once every two hours
- Determining the total volume infused every four hours
- Using an infusion pump to provide controlled rate of infusion
31. The nurse is assigned to care for an infant with physiologic jaundice. Which action by the nurse would facilitate elimination of the bilirubin?
- Increasing the infants fluid intake
- Maintaining the infants body temperature at 98.6F
- Minimizing tactile stimulation
- Decreasing caloric intake
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32. A child with laryngotracheobronchitis (croup) is placed in a cool mist tent The mother becomes concerned because the child is frightened, consistently crying and trying to climb out of the tent Which is the most appropriate nursing action?
- Tell the mother that the child must stay in the tent.
- Place a toy in the tent to make the child feel more comfortable.
- Call the health care provider and obtain a prescription for a mild sedative.
- Let the mother hold the child and direct the cool mist over the child's face.
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33. The nurse should tell the client, who is taking levothyroxine, to notify the health care provider (HCP) if which problem occurs?
- Fatigue
- Tremors
- Cold intolerance
- Excessively dry skin
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34. A pregnant client is receiving magnesium sulfate for severe pregnancy induced hypertension (PI H). The clinical findings that would warrant use of the antidote , calcium gluconate is:
- Urinary output 90 cc in 2 hours.
- Absent patellar reflexes.
- Rapid respiratory rate above 40/min.
- Rapid rise in blood pressure.
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35. To reduce the possibility of having a baby with a neural tube defect the client should be told to increase her intake of folic acid. Dietary sources of folic acid include:
- Meat liver eggs
- Pork fish chicken
- Spinach beets cantaloupe
- Dried beans sweet potatoes Brussels sprouts
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36. While planning care for a 2 year-old hospitalized child, which situation would the nurse expect to most likely affect the behavior?
- Strange bed and surroundings
- Separation from parents
- Presence of other toddlers
- Unfamiliar toys and games
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37. The nurse is caring for a client who experiences false sensory perceptions with no basis in reality. These perceptions are known as:
- delusions
- hallucinations
- loose associations.
- neologisms
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38. A client brought to the emergency department states that he has accidentally been taking 2 times his prescribed dose of warfarin for the past week. After noting that the client has no evidence of obvious bleeding, the nurse plans to take which action?
- Prepare to administer an antidote.
- Draw a sample for type and crossmatch and transfuse the client.
- Draw a sample for an activated partial thromboplastin time (aPTT) level
- Draw a sample for prothrombin time (PT) and international normalized ratio (INR).
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39. A plan of care for a child with cerebral palsy should include all the following except:
- Physical therapy
- Play
- Feeding
- Bowel and bladder training
40. In which of the following conditions can the causative agent pass through the placenta and affect the fetus in utero?
- Gonorrhea
- Rubella
- Candidiasis
- moniliasis
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41. 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
42. Positive symptoms of schizophrenia include which of the following?
- Hallucinations, delusions, and disorganized thinking
- Somatic delusions, echolalia, and a flat affect
- Waxy flexibility, alogia, and apathy
- Flat affect, avolition, and anhedonia
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43. The nurse is documenting her care for a client with iron deficiency anemia. Which of the following nursing diagnoses is most appropriate?
- Impaired gas exchange
- Deficient fluid volume
- Ineffective airway clearance
- Ineffective breathing pattern
44. Which of the following conditions would an irrigation of the ear canal be appropriate intervention?
- Foreign body in the ear canal
- Serous otitis
- Impacted cerumen
- Tympanic membrane perforation
45. A client is admitted with the diagnosis of pulmonary embolism. While taking a history, the client tells the nurse he was admitted for the same thing twice before, the last time just 3 months ago. The nurse would anticipate the health care provider ordering:
- Pulmonary embolectomy
- Vena caval interruption
- Increasing the coumadin therapy to an INR of 3-4
- Thrombolytic therapy
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46. Which of the following is a right that is included in the Residents Bill of Rights?
- To have staff available that speak different languages on each shift
- To have payment plan options that are based on financial need
- To have religious services offered at the facility daily
- To make decisions and participate in own care
47. 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. You also explain common eye changes associated with aging. One of these is presbyopia, which is:
- Refractive error that prevents light rays from coming to a single focus on the retina.
- Poor distant vision
- Poor near vision
- A gradual lessening of the power of accommodation
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48. Situation: Ms. J., a 34-year old white female, is admitted via the emergency room complaining of abdominal pain, fatigue, anorexia, muscle cramping, and nausea. She is a diabetic who been managed at 30 II NPH insulin every AM and a 1200-calorie ADA diet Her glucose in ER 700 mg/dL. Regular insulin 30 II was given and a repeat glucose were drawn. Results were not available upon transfer to the unit Q. Later that evening, Ms. J's abdominal pain increased in intensity. A diagnosis of appendicitis is made and Ms. J is scheduled for surgery in the morning. The physician has written the following orders: - NPO after midnight - At 6 AM starting IVF of D5W to be infused at 250 ml/hr • 15 II NPH insulin at 6AM. Draw FBS prior to initiating IV fluids The statement that best describe the rationale for these orders is:
- To provide calories to offset the patient being NPO
- To prevent a hypoglycemic reaction
- To prevent a fluid volume deficit
- To assist with the body's response to stress
49. If the school-age child is not given the opportunity to engage in tasks and activities he can carry through to completion he is likely to develop feelings of:
- Guilt
- Shame
- Stagnation
- Inferiority
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50. To examine the ear canal of the child, this is done by:
- Pull the ear down and back
- Pull the ear up and back
- Pull the ear only back
- Do not pull the ear, direct examine the ear by otoscope