NCLEX-RN | QB2 | Practice Exam #55 (50 questions)
All 50 questions are randomized each time you take the test, and do not appear in the same order.
1. Situation: Breast cancer is the 2nd most common type of cancer after lung cancer and 99% of which, occurs in women. Survival rate is 98% if this is detected early and treated promptly. Carmen is a 53 year old patient in the high risk group for breast cancer was recently diagnosed with Breast Cancer. Q. The purpose of performing the breast self examination (BSE) regularly is to discover:
- fibrocystic masses
- cancerous lumps
- areas of thickness or fullness
- changes from previous BSE
2. Which early morning activity helps to reduce the symptoms associated with rheumatoid arthritis?
- Brushing the teeth
- Drinking a glass of juice
- Holding a cup of coffee
- Brushing the hair
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3. A client is admitted to the hospital with a diagnosis of benign prostatic hyperplasia, and transurethral resection of the prostate is performed. Four hours after surgery, the nurse takes the client's vital signs and empties the urinary drainage bag. Which assessment finding indicates the need to notify the health care provider (HOP)?
- Red, bloody urine
- Pain rated as 2 on a 0-10 pain scale
- Urinary output of 200 mL higher than intake
- Blood pressure, 100/50 mm Hg; pulse, 130 beats/minute
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4. Situation: Colorectal cancer can affect old and younger people. Surgical procedures and other modes of treatment are done to ensure quality of life. You are assigned in the Cancer institute to care of patients with this type of cancer. Q. Larry 55 years old, who is suspected of having colorectal cancer, is admitted to the CL After taking the history and vital signs the physician does which test as a screening test for colorectal cancer.
- Barium enema
- Annual digital rectal examination
- Carcinoembryonig antigen
- Proctosigmoidoscopy
5. An 80-year-old male client is admitted to the hospital with a diagnosis of pneumonia. Nurse Oliver learns that the client lives alone and hasn't been eating or drinking. When assessing him for dehydration, nurse Oliver would expect to find:
- Hypothermia
- Hypertension
- Distended neck veins
- Tachycardia
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6. A child with asthma has an order for albuterol, before administration of the medication the nurse MUST:
- Pre-oxygenate the patient
- Assess the patients heart rate
- Obtain venous Access
- Feed the patient a snack
7. Situation: Susan is a patient in the clinic where you work She is inquiring about pregnancy. Susan typically has menstrual cycle of 34 days. She told you she had a coitus on days 8,10 and 20 of her menstrual cycle. Which is the day on which she is most likely to conceive?
- 8th day
- 10th day
- Day 15
- Day 20
8. During postoperative neuromuscular assessment of a patient who had a total knee replacement nurse assesses the peroneal nerve by testing sensation:
- On the bottom of the foot
- In the space between great and second toe
- I n the anterior to the rectum
- I n the anterior portion of the calf
9. A patient is scheduled for an abdominal aneurysm repair. This is what type of surgical intervention?
- Diagnostic
- Transplant
- Curative
- Palliative
10. When performing surgical hand scrub, which of the following nursing action is required to prevent contamination? 1. Keep fingernail short, clean and with nail polish 2. Open faucet with knee or foot control 3. Keep hands above the elbow when washing and rinsing 4. Wear cap, mask, shoe cover after you scrubbed
- 1,2
- 2,3
- 2,3,4
- 1,2,3
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11. Situation: Mr. Bond, 50, is to undergo cystoscopy due to multiple problems like scantly urination, hematuria, and dysuria. Q. Leg cramps are NOT uncommon post cystoscopy. Nursing intervention includes:
- Bed rest
- Warm moist soak
- Early ambulation
- Hot sitz bath
12. A 39 year old mother with obsessive-compulsive disorder has become immobilized by her elaborate hand washing and walking rituals. Nurse Trish recognizes that the basis of O.C. disorder is often:
- Problems with being too conscientious
- Problems with anger and remorse
- Feelings of guilt and inadequacy
- Feeling of unworthiness and hopelessness
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13. The nurse is caring for a client with a diagnosis of hepatitis who is experiencing pruritis. Which would be the most appropriate nursing intervention?
- Suggest that the client take warm showers two times per day.
- Add baby oil to the clients bath water.
- Apply powder to the clients skin.
- Suggest a hot-water rinse after bathing.
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14. Which is the most frequent reason for postpartum hemorrhage?
- Perineal lacerations
- Frequent internal examination (IE)
- Uterine atony
- CS
15. Celia, was diagnosed with cancer of the cervix. You noticed that the radioactive internal implant protrudes to her vagina where supposedly, it should be in her cervix. What should be your initial action?
- Using a long forceps, Push it back towards the cervix then call the physician
- Wear gloves, remove it gently and place it on a lead container
- Using a long forceps, Remove it and place it on a lead container
- Call the physician, You are not allowed to touch, re insert or remove it
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16. The nurse is caring for a client following craniotomy for removal of an acoustic neuroma. Assessment of which cranial nerve would identify a complication specifically associated with this surgery?
- Cranial nerve I, olfactory
- Cranial nerve IV, trochlear
- Cranial nerve III, oculomotor
- Cranial nerve VII, facial nerve
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17. A patient has the following order: cephalexin (keflex) 500 milligrams (mg) by mouth 4 times a day. The pharmacy has the following dose: 250mg per 5 milliliters (ml). The nurse should administer:
- 5 ml
- 10 ml
- 15 ml
- 20 ml
18. Situation: Health education and Health Promotion is an important part of nursing responsibility in the community. Immunization is a form of health promotion that aims at preventing the common childhood illnesses. How many percent of measles are prevented by immunization at 9 months age?
- 0.8
- 0.9
- 0.99
- 0.95
19. Therapeutic nurse client relationship is describes as follows T, Based on friendship and mutual interest 2. It is a professional relationship 3. It is focused on helping the patient solve problems and achieve health-related goals 4. Maintained only as long as the patient requires professional help
- 1,2,3
- 1,2,4
- 2,3,4
- 1,3,4
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20. An elderly patient with a long history of diabetes mellitus comes in for a routine check-up. Which of the following nursing diagnosis would the nurse anticipate?
- Risk for impaired skin integrity related to decreases sensation and circulation
- Excess fluid volume related to disease process
- Risk for injury to decrease gastric mobility and stress response
- Deficient fluids volume related to diarrhea and loss of fluids and electrolytes
21. According to Rubins theory of maternal role adaptation, the mother will go through 3 stages during the post partum period. These stages are:
- Going through, adjustment period, adaptation period
- Taking-in, taking-hold and letting-go
- Attachment phase, adjustment phase, adaptation phase
- Taking-hold, letting-go, attachment phase
22. The nurse is assessing a client who has a new ureterostomy. Which statement by the client indicates the need for more education about urinary stoma care?
- "I change my pouch every week."
- "I change the appliance in the morning."
- "I empty the urinary collection bag when it is two-thirds full."
- "When I'm in the shower I direct the flow of water away from my stoma."
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23. A client with small cell lung cancer is being treated with etoposide. The nurse monitors the client during administration, knowing that which adverse effect is specifically associated with this medication?
- Alopecia
- Chest pain
- Pulmonary fibrosis
- Orthostatic hypotension
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24. The nurse caring for a client with anemia recognizes which clinical manifestation as the one that is specific for a hemolytic type of anemia?
- Jaundice
- Anorexia
- Tachycardia
- Fatigue
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25. A client with Guillain-Barre syndrome has ascending paralysis and is intubated and receiving mechanical ventilation. Which strategy should the nurse incorporate in the plan of care to help the client cope with this illness?
- Giving client full control over care decisions and restricting visitors
- Providing positive feedback and encouraging active range of motion
- Providing information, giving positive feedback, and encouraging relaxation
- Providing intravenously administered sedatives, reducing distractions, and limiting visitors
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26. Developed the ROLE MODELING and MODELING theory
- Erickson, Tomlin, Swain
- Neuman
- Newman
- Benner and Wrubel
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27. Which medication is used to treat iron toxicity?
- Narcan (naloxone)
- Digibind (digoxin immune Fab)
- Desferal (deferoxamine)
- Zinecard (dexrazoxane)
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28. A patient with a weight loss of 12 in 60 days has a nursing care plan written interventions including offering a dietary supplement three times per day. After 2 weeks, the patient has had another 1% weight loss. The patient indicates no likely the supplements. The nurse should:
- Continue the plan of care as written
- Replace the supplement with a high calorie food that the patient likes
- Encourage the patient drink supplements
- Offer smaller amounts of supplement more frequently
29. When planning discharge teaching for a young female client who has had a pneumothorax, it is important that the nurse include the signs and symptoms of a pneumothorax and teach the client to seek medical assistance if she experiences:
- Substernal chest pain
- Episodes of palpitation
- Severe shortness of breath
- Dizziness when standing up
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30. The nurse notes that a post-operative clients respirations have dropped from 14 to 6 breaths per minute. The nurse administers Narcan (naloxone) per standing order. Following administration of the medication the nurse should assess the client for:
- Pupillary changes
- Projectile vomiting
- Wheezing respirations
- Sudden intense pain
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31. Kris periodically has acute panic attacks. These attacks are unpredictable and have no apparent association with a specific object or situation. During an acute panic attack, Kris may experience:
- Heightened concentration
- Decreased perceptual field
- Decreased cardiac rate
- Decreased respiratory rate
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32. Situation: The Gastrointestinal System is responsible for taking in and processing nutrients for all parts of the body any problem can quickly affect other body systems and, if not adequately treated, can affect overall health, growth, and development. The following questions are about gastrointestinal disorders in a child. The exact cause of pyloric stenosis is unknown, but multifactorial inheritance is the likely cause. Being knowledgeable about this disease, you know that pyloric stenosis is more common in which gender?
- Male
- Female
- Incidence is equal for both sexes
- None of the above
33. The nurse is administering an intravenous vesicant chemotherapeutic agent to a client Which assessment would require the nurse's immediate action?
- Stomatitis lesion in the mouth
- Severe nausea and vomiting
- Complaints of pain at site of infusion
- A rash on the clients extremities
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34. A client is admitted to the hospital with a diagnosis of a right hip fracture. She complains of right hip pain and cannot move her right leg. Which of the following assessments made by the nurse indicates that the client has a typical sign of hip fracture? The client's right leg is:
- Rotated internally
- Held in a flexed position
- Adducted
- Shorter than the leg on the unaffected side
35. Jessie weighed 210 pounds on admission to the hospital. After 2 days of diuretic therapy Jessie weighs 205.5 pounds. The nurse could estimate the amount of fluid Jessie has lost:
- 0.3 L
- 1.5 L
- 2.0 L
- 3.5 L
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36. Which of the following nursing intervention is needed before teaching a client post spleenectomy deep breathing and coughing exercises?
- Tell the patient that deep breathing and coughing exercises is needed to promote good breathing, circulation and prevent complication.
- Tell the client that deep breathing and coughing exercises is needed to prevent Thrombophlebitis, hydrostatic pneumonia and atelectasis.
- Medicate client for pain.
- Tell client that cooperation is vital to improve recovery.
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37. The nurse teaches the client, who is newly diagnosed with diabetes insipidus, about the prescribed intranasal desmopressin. Which statements by the client indicate understanding? Select all that apply. 1. "This medication will turn my urine orange." 2. "I should decrease my oral fluids when 1 start this medication." 3. "The amount of urinel make should increase if this medicine is working " 4. "1 need to follow a low-fat diet to avoid pancreatitis when taking this medicine." 5. "I should report headache and drowsiness to my health care provider since these symptoms could be related to my desmopressin."
- 2,4,5
- 3,4,5
- 2,5
- 1,2,3
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38. Situation: Still in your self-managed Child Health Nursing Clinic, your encounter these cases pertaining to the CARE OF CHILDREN WITH PULMONARY AFFECTIONS. Which of the following is the most important responsibility of a nurse in the prevention of necessary deaths from pneumonia and other severe diseases?
- Giving of antibiotics
- Taking of the temperature of the sick child
- Provision of Careful Assessment
- Weighing of the sick child
39. When the shiny portion of the placenta comes out first, this is called the ___ mechanism.
- Schultze
- Ritgens
- Duncan
- Marmets
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40. Which of the following is TRUE about the blood pressure determinants?
- Hypervolemia lowers BP
- Hypervolemia increases GFR
- HCT of 70% might decrease or increase BP
- Epinephrine decreases BP
41. A 31 years-old woman with diabetes type 1 presents to the clinic with fatigue, blurred vision, and loss of appetite. Her breath smells like fruit and she leaves the room twice during the examination to use the toilet She has brought a little bottle of water with her that she finishes while at the clinic. She reports that she has had a cold for the past three days, but has not taken additional insulin during the illness Blood pressure: 130/70 mmHg Heart rate: 90/min Respiratory rate: 20/min Body temperature: 38.0 Coral What is the most appropriate nursing diagnosis
- Risk for impaired skin integrity related to circulation
- Deficient knowledge related to illness management
- Risk for fluid volume excess related to fluid intake
- Imbalanced nutrition related to decreased appetite
42. A client who is human immunodeficiency virus seropositive has been taking stavudine. The nurse should monitor which most closely while the client is taking this medication?
- Gait
- Appetite
- Level of consciousness
- Gastrointestinal function
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43. The nurse is creating a plan of care for a newborn diagnosed with fetal alcohol syndrome. The nurse should include which priority intervention in the plan of care?
- Allow the newborn to establish own sleep-rest pattern.
- Maintain the newborn in a brightly lighted area of the nursery.
- Encourage frequent handling of the newborn by staff and parents.
- Monitor the newborns response to feedings and weight gain pattern.
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44. An 87-year-old woman is brought to the emergency department for treatment of a fractured arm. On physical assessment, the nurse notes old and new ecchymotic areas on the client's chest and legs and asks the client how the bruises were sustained. The client, although reluctant, tells the nurse in confidence that her son frequently hits her if supper is not prepared on time when he arrives home from work. Which is the most appropriate nursing response?
- "Oh, really? I will discuss this situation with your son."
- "Let's talk about the ways you can manage your time to prevent this from happening."
- "Do you have any friends who can help you out until you resolve these important issues with your son?"
- "As a nurse, I am legally bound to report abuse. I will stay with you while you give the report and help find a safe place for you to stay."
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45. Situation: Mr. Ramos is a 60 year old male client admitted to the hospital with the diagnosis of pneumonia. He complains of pain when coughing. Q. Laboratory reports shows RBC : 2,000,000, WBC: 5,000 and Platelets: 300,000. Considering the above findings which of the following clinical manifestation is the most likely manifestation Mr. Ramos is to exhibit?
- Decrease respiration and increase pulse
- Normal Respiration and increase pulse
- Increase respiration and normal pulse
- Increase pulse and increase respiration
46. A patient with pneumonia has a temperature, 40 C (104 F); heart rate 20;respiratory rate 32 and dyspnea patient has an ineffective airway clearance related to excessive tracheobronchial secretions. Which of the following interventions would the nurse implement to enhance the patients airway clearance?
- Administer oxygen as ordered
- Maintain a comfortable position
- Increase fluid intake
- Administer prescribed analgesic
47. The following are true in the preparation of herbal medicines, EXCEPT:
- Avoid the use of Insecticides as may poison on plants
- Stop giving the medication in case reaction such as allergy occurs
- Use only the part of the plant being advocated
- Use a day pot and cover while boiling at low heat.
48. Nurse Angela is about to make a diagnosis but very unsure because the S/S the client is experiencing is not specific with her diagnosis of POWERLESSNESS R/T DIFFICULTY ACCEPTING LOSS OF LOVED ONE. She then focus on gathering data to refute or prove her diagnosis but her plans and interventions are already ongoing for the diagnosis. Which type of Diagnosis is this?
- Actual
- Probable
- Possible
- Risk
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49. Which of the following diagnostic tools is most commonly used to determine the location of myocardial damage?
- Cardiac catheterization
- Cardiac enzymes
- Echocardiogram
- Electrocardiogram
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50. Situation: In the hospital, you are aware that we are helped by the use of a variety of equipment/devices to enhance quality patient care delivery. Q. Kyle is diagnosed to have measles. What will your protective personal attire include?
- Gown
- Eyewear
- Face mask
- Gloves