NCLEX-RN | QB2 | Practice Exam #54 (50 questions)
All 50 questions are randomized each time you take the test, and do not appear in the same order.
1. A client with chronic pain reports to you, the charge nurse, that the nurse have not been responding to requests for pain medication. What is your initial action?
- Check the MARs and nurses' notes for the past several days.
- Ask the nurse educator to give an in-service about pain management.
- Perform a complete pain assessment and history on the client
- Have a conference with the nurses responsible for the care of this client.
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2. The nurse is caring for a client with acquired immunodeficiency syndrome who has oral candidiasis. The nurse should clean the clients mouth using:
- 75mL per hour
- 100mL per hour
- 150mL per hour
- 200mL per hour
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3. The nurse should explain to the client with psoriasis that treatment usually involves:
- Avoiding exposure to the sum
- Topical application of steroids
- Potassium permanganate baths
- Debridement of necrotic plaques
4. Tacrolimus is prescribed for a client who underwent a kidney transplant. Which instruction should the nurse include when teaching the client about this medication?
- Eat at frequent intervals to avoid hypoglycemia.
- Take the medication with a full glass of grapefruit juice.
- Change positions carefully due to risk of orthostatic hypotension.
- Take the oral medication every 12 hours at the same times every day.
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5. A client recently admitted to the hospital with sharp, substernal chest pain suddenly complains of palpitations. The nurse notes a rise in the client's arterial blood pressure and a heart rate of 144 beats/minute. On further questioning, the client admits to having used cocaine recently after previously denying use of the drug. The nurse concludes that the client is at high risk for which complication of cocaine use?
- Coronary artery spasm
- Bradyarrhythmias
- Neurobehavioral deficits
- Panic disorder
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6. Mark, with a diagnosis of generalized anxiety disorder wants to stop taking his lorazepam (Ativan). Which of the following important facts should nurse Betty discuss with the client about discontinuing the medication?
- Stopping the drug may cause depression
- Stopping the drug increases cognitive abilities
- Stopping the drug decreases sleeping difficulties
- Stopping the drug can cause withdrawal symptoms
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7. A patient who has a diagnosis is metastatic cancer of the kidney is told by the physician that the kidney needs to be removed. The patient asks the nurse. "What should I do?"Which of the following responses by the nurse would be most therapeutic?
- "Let's talk about your options."
- "You need to follow the doctors advice."
- "What does your family want you to do."
- "I wouldn't have the surgery done without a second opinion."
8. A client with cystic fibrosis is taking pancreatic enzymes. The nurse should administer this medication:
- Once per day in the morning
- Three times per day with meals
- Once per day at bedtime
- Four times per day
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9. A client is scheduled for an Intravenous Pyelogram (IVP). In order to prepare the client for this test, the nurse would:
- Instruct the client to maintain a regular diet the day prior to the examination
- Restrict the client's fluid intake 4 hours prior to the examination
- Administer a laxative to the client the evening before the examination
- Inform the client that only 1 x-ray of his abdomen is necessary
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10. An attorney who throws books and furniture around the office after losing a case is referred to the psychiatric nurse in the law firm's employee assistance program. The nurse knows that the client's behavior most likely represents the use of which defense mechanism?
- Regression
- Projection
- Reaction-formation
- Intellectualization
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11. A client is discharged home with a prescription for Coumadin (sodium warfarin). The client should be instructed to:
- Have a Protime done monthly.
- Eat more fruits and vegetables.
- Drink more liquids.
- Avoid crowds.
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12. Situation: Elderly clients usually produce unusual signs when it comes to different diseases. The ageing process is a complicated process and the nurse should understand that it is an inevitable fact and she must be prepared to care for the growing elderly population. Q. Hypoxia may occur in the older patients because of which of the following physiologic changes associated with aging.
- Ineffective airway clearance
- Decreased alveolar surfaced area
- Decreased anterior-posterior chest diameter
- Hyperventilation
13. A stillborn baby was delivered in the birthing suite a few hours ago. After the delivery, the family remained together, holding and touching the baby. Which statement by the nurse would assist the family in their period of grief?
- "What can I do for you?"
- "Now you have an angel in heaven."
- "Don't worry there is nothing you could have done to prevent this from happening”
- "We will see to it that you have an early discharge so that you don't have to be reminded of this experience”
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14. During the night, shift report, the charge nurse learns that an elderly patient has become very confused and Is shouting obscenities and undressing himself. Which of the following actions is the most appropriate Initial nursing response?
- Restrain the patient with a Posey jacket
- Medicate the patient with haloperidol (Haldol) as ordered.
- Notify the physician
- Complete a nursing assessment of the patient
15. A male client is hospitalized with Guillain-Barre Syndrome. Which assessment finding is the most significant?
- Even, unlabored respirations
- Soft, non distended abdomen
- Urine output of 50 ml/hr
- Warm skin
16. 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 risk of pelvic inflammatory disease
- Cause acne to worsen
- Decrease the risk of breast and cervical cancer
- Decrease the risk of endometriosis
17. The doctor accidentally cuts the bowel during surgery. As a result of this action the client develops an infection and suffers brain damage. The doctor can be charged with:
- Negligence
- Tort
- Assault
- Malpractice
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18. Before administering Methyltrexate orally to the client with cancer the nurse should check the:
- IV site
- Electrolytes
- Blood gases
- Vital signs
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19. Shaniqua with a history of polysubstance abuse is admitted to the facility. She complains of nausea and vomiting 24 hours after admission. The nurse assesses the client and notes piloerection, pupillary dilation, and lacrimation. The nurse suspects that the client is going through which of the following withdrawals?
- Alcohol withdrawal
- Cannabis withdrawal
- Cocaine withdrawal
- Opioid withdrawal
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20. A client with nontropical sprue has an exacerbation of symptoms. Which meal selection is responsible for the recurrence of the clients symptoms?
- Tossed salad with oil and vinegar dressing
- Baked potato with sour cream and chives
- Cream of tomato soup and crackers
- Mixed fruit and yogurt
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21. A 68-year-old woman is scheduled to undergo mitral valve replacement for severe mitral stenosis and mitral regurgitation. Although the diagnosis was made during childhood, she did not have any symptoms until 4 years ago. Recently, she noticed increased symptoms, despite daily doses of digoxin and furosemide. During the initial interview with the nice lady, the nurse would most likely learn that the client's childhood health history included:
- Chicken pox
- Rheumatic fever
- Meningitis
- Poliomyelitis
22. Situation: You are a nurse working in the medical ward. Q. Ms. Rachel, has been admitted with right upper quadrant pain and has been placed on a low fat diet. Which of the following trays would be acceptable for her?
- liver, fried potatoes and avocado
- whole milk, rice and pastry
- ham, mashed potatoes, cream peas
- skim milk, lean fish, tapioca pudding
23. A 64 year old male client with a long history of cardiovascular problem including hypertension and angina is to be scheduled for cardiac catheterization. During pre cardiac catheterization teaching, Nurse Cherry should inform the client that the primary purpose of the procedure is...
- To determine the existence of CHD
- To visualize the disease process in the coronary arteries
- To obtain the heart chambers pressure
- To measure oxygen content of different heart chambers
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24. Which of the following tests measures the total quantity of prothrombin In the blood and monitors the effectiveness of warfarin sodium (Coumadin) therapy and prolonged deficiencies in the extrinsic factor?
- Thrombin time (TT)
- Prothrombin time (PT)
- Partial prothrombin time(PTT)
- Activated partial thromboplastin time (aPTT)
25. If patient asks the nurse her opinion about a particular physicians and the nurse replies that the physician is incompetent, the nurse could be held liable for:
- Slander
- Libel
- Assault
- Respondent superior
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26. Rifabutin is prescribed for a client with active Mycobacterium avium complex (MAC) disease and tuberculosis. For which side and adverse effects of the medication should the nurse monitor? Select all that apply. 1. Signs of hepatitis 2. Flu-like syndrome 3. Low neutrophil count 4. Vitamin B6 deficiency 5. Ocular pain or blurred vision 6. Tingling and numbness of the fingers
- 1,2,3,4
- 1,2,3,5
- 1,2,3
- 2,3,5,6
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27. A male client had a nephrectomy 2 days ago and is now complaining of abdominal pressure and nausea. The first nursing action should be to:
- Auscultate bowel sounds.
- Palpate the abdomen.
- Change the client's position.
- Insert a rectal tube.
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28. Nurse Monique is monitoring the effectiveness of a clients drug therapy. When should the nurse Monique obtain a blood sample to measure the trough drug level?
- 1 hour before administering the next dose.
- Immediately before administering the next dose.
- Immediately after administering the next dose.
- 30 minutes after administering the next dose.
29. A client presents to the emergency department with upper gastrointestinal bleeding and is in moderate distress. In planning care, what is the priority nursing action for this client?
- Assessment of vital signs
- Completion of abdominal examination
- Insertion of the prescribed nasogastric tube
- Thorough investigation of precipitating events
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30. Which medication will the nurse have available for the emergency treatment of tetany in the client who has had a thyroidectomy?
- Calcium chloride
- Potassium chloride
- Magnesium sulfate
- Sodium bicarbonate
31. Smallpox has the potential to spread quickly because it is transmitted via which route?
- Air-borne
- Droplets
- Contact
- Absorption
32. Which of the following is true about the NURSING CARE PLAN?
- It is nursing centered
- Rationales are supported by interventions
- Verbal
- At least 2 goals are needed for every nursing diagnosis
33. The following pain medications are ordered for a patient who had a right leg debridement.Oxycodone 5 mg every 4 hours as needed and morphine 5 mg every 4 hours as needed. The nurse administered oxycodone 2 hours ago, but the patient report pain Rated 8 on a scale of 0 (no pain) to 10 (Severe pain) as the dressing change begins. Vital signs are: blood pressure level, 169/98 mmHg; heart rate, 112; Respiration rate 22; temperature 36.7 C (98.1 F). After evaluating the effectiveness of the pain Medication, what action should the nurse take?
- Administer additional oxycodone 5 mg
- Administer morphine 5 mg
- Change the dressing quickly
- Encourage deep breathing
34. Situation: Amanda is suffering from chronic arteriosclerosis Brain syndrome she fell while getting out of the bed one morning and was brought to the hospital, and she was diagnosed to have cerebrovascular thrombosis thus transferred to a nursing home. Q. What do you call a STROKE that manifests a bizarre behavior?
- Inorganic Stroke
- Inorganic Psychoses
- Organic Stroke
- Organic Psychoses
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35. May arrives at the health care clinic and tells the nurse that her last menstrual period was 9 weeks ago. She also tells the nurse that a home pregnancy test was positive but she began to have mild cramps and is now having moderate vaginal bleeding. During the physical examination of the client, the nurse notes that May has a dilated cervix. The nurse determines that May is experiencing which type of abortion?
- Inevitable
- Incomplete
- Threatened
- Septic
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36. Situation: Understanding different models of care is a necessary part of the nurse patient relationship. Q. A biological or medical approach in treating psychiatric patient is:
- Million therapy
- Somatic therapy
- Behavioral therapy
- Psychotherapy
37. The nurse is caring for a female client who was admitted to the mental health unit recently for anorexia nervosa. The nurse enters the client's room and notes that the client is engaged in rigorous push-ups. Which nursing action is most appropriate?
- Interrupt the client and weigh her immediately.
- Interrupt the client and offer to take her for a walk.
- Allow the client to complete her exercise program.
- Tell the client that she is not allowed to exercise rigorously.
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38. Which of the following treatments is the definitive one for a ruptured aneurysm?
- Antihypertensive medication administration
- Aortogram
- Beta-adrenergic blocker administration
- Surgical intervention
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39. The nurse is caring for a client with uremic frost. The nurse is aware that uremic frost is often seen in clients with:
- Severe anemia
- Arteriosclerosis
- Liver failure
- Parathyroid disorder
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40. The nurse is assessing an adult female client for hypovolemia. Which laboratory result would help the nurse in confirming a volume deficit?
- Hematocrit 55%
- Potassium 5.0mEq/L
- Urine specific gravity 1.016
- BUN 18mg/dL
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41. A client in the cardiac step-down unit requires suctioning for excess mucous secretions. The dysrhythmia most commonly seen during suctioning is:
- Bradycardia
- Tachycardia
- Premature ventricular beats
- Heart block
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42. You continuously evaluate the clients adaptation to pain. Which of the following behaviors indicate appropriate adaptation?
- The client reports pain reduction and decreased activity
- The client denies existence of pain
- The client can distract himself during pain episodes
- The client reports independence from watchers
43. Silver sulfadiazine is prescribed for a client with a partial-thickness burn and the nurse provides teaching about the medication. Which statement made by the client indicates need for further teaching about the treatments?
- "The medication is an antibacterial."
- "The medication will help heal the burn."
- "The medication is likely to cause stinging everytime it is applied"
- "The medication should be applied directly to the wound."
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44. The nurse who is caring for a client with cancer notes a WBC of 500/mm3 on the laboratory results. Which intervention would be most appropriate to include in the clients plan of care?
- Assess temperature every four hours because of risk for hypothermia.
- Instruct the client to avoid large crowds and people who are sick.
- Instruct in the use of a soft toothbrush.
- Assess for signs of bleeding.
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45. Nurse Ronald is aware that the amniotic fluid in the third trimester weighs approximately:
- 2 kilograms
- 1 kilograms
- 100 grams
- 1.5 kilograms
46. A patient recently diagnosed with multiple sclerosis has been taking the following prescribed medications: baclofen (lioresal), diazepam (valium), Amantadine (symmetrel), and phenytoin (dilantin). When the patient presents with complaints of fatigue, the nurse should address the dosage and frequency of which medication?
- Baclofen
- Diazepam
- Amantadine
- Phenytoin
47. Situation: After an abdominal surgery, the circulating and scrub nurses have critical responsibility about sponge and Instrument count. Q. Like sutures, needles also vary in shape and uses. If you are the scrub nurse for a patient who is prone to keloid formation and has a low threshold of pain, what needle would you prepare?
- Round needle
- A traumatic needle
- Reverse cutting needle
- Tapered needle
48. A 6-month-old premature infant is being discharged from the neonatal intensive care unit after having no apneic periods for the past week. Although the child has had no apneic periods for the past week, an apnea monitor will be sent home with the parents. The BEST short term goal relating to the nursing diagnosis of ineffective breathing pattern related to apnea is that the:
- Apnea monitor will sound loudly and stimulate the child to breath with episodes of apnea
- Apnea monitor will sound loudly and alert the parents to stimulate the child to breath with episodes of apnea
- Child will have no episodes of apnea or cyanosis while on apnea monitor
- Child will sleep in their parent's bed each night until there is no apnea two weeks
49. A newborn was delivered pre-term weighing 2700 grams with. Apgar scores of 4 and 6, respectively. When the mother had presented to the Obstetrical Triage Unit, she was already 7 centimeters dilated and fully effaced. Her due date was unknown as she had no parental care. The infant showed signs of fetal distress and was finally delivered by Cesarean section. At birth a large, thin, membranous sac was protruding from the umbilical base. What is the priority nursing intervention at birth?
- Maintain cardio respiratory stability
- Protect the herniated viscera
- Manage fluid intake and output
- Establish vascular access
50. Situation: Mrs. Diaz is assigned in the female surgical ward. While on duty, an 15 year old client, married, was admitted for CS. The informed consent for the operation has to be obtained. Q. The person legally responsible for taking the informed consent is:
- The OR nurse who is going to assist with the operation
- Any doctor assigned with the team
- The doctor who is going to perform the procedure
- The ward nurse where the patient stayed before the operation