QB2 | Practice Exam #56 -> answers with explanation - Free NCLEX Exam Practice

NCLEX-RN | QB2 | Practice Exam #56 (50 questions)

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

 

1. Nurse Alexandra notices other clients on the unit avoiding a client diagnosed with antisocial personality disorder. When discussing appropriate behavior in group therapy, which of the following comments is expected about this client by his peers?

• Lack of honesty
• Belief in superstition
• Show of temper tantrums
• Constant need for attention

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2. Which of the following techniques would a nurse use when interviewing a 94-year-old patient?

• Using a low-pitched voice
• Enunciating each word slowly
• Varying voice intonations
• Reinforcing the words with pictures

3. How soon after chlorpromazine (Thorazine) administration should the nurse expect to see a client's delusional thoughts and hallucinations eliminated

• Several minutes
• Several hours
• Several days
• Several weeks

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4. A postoperative client has been placed on a clear liquid diet. The nurse should provide the client with which items that are allowed to be consumed on this diet? Select all that apply. 1. Broth 2. Coffee 3. Gelatin 4. Pudding 5. Vegetable juice 6. Pureed vegetables

• 1,2,3
• 2,3,4,5,6
• 2,3,4
• 1,5,6

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5. Nurse Aida, in spite of the incident, still consider Roger as worthwhile simply because he is human being. What major ingredient of a therapeutic communication is Nurse Aida using?

• Empathy
• Positive regard
• Comfortable sense of self
• Self awareness

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6. A client calls the emergency department and tells the nurse that he came directly into contact with poison ivy shrubs. The client tells the nurse that he cannot see anything on the skin and asks the nurse what to do. The nurse should make which response?

• "Come to the emergency department."
• "Apply calamine lotion immediately to the exposed skin areas."
• "Take a shower immediately, lathering and rinsing several times"
• "It is not necessary to do anything if you cannot see anything on your skin."

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7. To be the leading hospital in the Philippines is best illustrate in:

• Mission
• Philosophy
• Vision
• Objective

8. A school cafeteria worker comes to the physicians office complaining of severe scalp itching. On inspection, the nurse finds nail marks on the scalp and small light-colored round specks attached to the hair shafts close to the scalp. These findings suggest that the client suffers from:

• scabies
• head lice
• tinea capitis
• impetigo

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9. When interviewing the parents of an injured child, which of the following is the strongest indicator that child abuse may be a problem?

• The injury isn't consistent with the history or the child's age.
• The mother and father tell different stories regarding what happened.
• The family is poor.
• The parents are argumentative and demanding with emergency department personnel.

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10. Nurse John is caring for a male client receiving lidocaine IV. Which factor is the most relevant to administration of this medication?

• Decrease in arterial oxygen saturation (SaO2) when measured with a pulse oximeter.
• Increase in systemic blood pressure.
• Presence of premature ventricular contractions (PVCs) on a cardiac monitor
• Increase in intracranial pressure (ICP).

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11. A patient has a central line catheter and is receiving a three-in-one total parenteral nutrition that contains glucose, proteins and lipids. The pump is set to deliver the infusion over a 12- hour period. After how many hours should the intravenous administration set be changed?

• 12
• 24
• 48
• 72

12. Which of the following techniques is recommended for removing a tick from the skin?

• Grasping the tick with a tissue and quickly jerking it away from the skin
• Placing a burning match close the tick and watching for it to release
• Using tweezers grasp the tick close to the skin and pull the tick free using a steady firm motion
• Covering the tick with petroleum jelly and gently rubbing the area until the tick releases

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13. Tina who is manic, but not yet on medication, comes to the drug treatment center The nurse would not let this client join the group session because:

• The client is disruptive.
• The client is harmful to self.
• The client is harmful to others.
• The client needs to be on medication first.

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14. A client enters the emergency department, reporting shortness of breath and epigastric distress. What should be the triage nurse’s first intervention?

• Assess vital signs.
• Insert a saline lock.
• Place client on oxygen.
• Draw blood for troponins.

15. Mommy Lisa is playing with her infant, who is sitting securely alone on the floor of the clinic.The mother hides a toy behind her back and the infant looks for it. The nurse is aware that estimated age of the infant would be:

• 6 months
• 4 months
• 8 months
• 10 months

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16. Situation: One of the main fools of the nursing profession is the use of therapeutic communication. The following situation would require you of your communication skills. Q. A patient who is diagnosed to have terminal illness tells you. "I'm really scared. Am I dying?" What could be your most appropriate response?

• Tell me about what you think.
• I'm sure you are scared; other clients in your situation feel the same way.
• You should be careful not to let your family know you're scared
• Why are you scared?

17. 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. A nurse, who is proficient in computers and information technology that uses these advantages to promote effective and secured use of computerized record is referred to as:

• Information technician
• Nursing information technician
• Nursing IT
• Nurse Informaticist

18. Situation: With the improvement in life expectancies and the emphasis in the quality of life it is important to provide quality care to our older patients. There are frequently encountered situations and issues relevant to the older, patients. Q. Hypoxia may occur in the older patients because of which of the following physiologic changer associated with aging.

• Ineffective airway clearance
• Decreased alveolar surface area
• Decreased anterior-posterior chest diameter
• Hyperventilation

19. Nurse Emma is doing some patient education related to a patients central venous access device. Which of the following statements will the nurse make to the patient?

• "These type of devices are essentially risk free"
• "These devices seldom work for more than a week or two necessitating replacement"
• "The dressing should only the changed by your doctor"
• "Heparin in instilled into the lumen of the catheter to decrease the risk of clotting."

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20. Situation: Blood transfusion was ordered for Andre after an episode of severe bleeding. Q. Which of the following are signs of hemolytic reaction during blood transfusion?

• Itching, urticaria and wheezing
• Cough, dyspnea, pulmonary congestion
• High fever and chills
• Fever and backache

21. Situation: The following questions refer to common clinical encounters experienced by an entry level nurse. A female client asks the nurse about the use of cervical cap. Which statement is correct regarding the use of the cervical cap?

• It may affect Pap smear results
• It does not need to be fitted by the physician
• It does not require the use of spermicide
• It must be removed within 24 hours

22. A client is chronically short of breath and yet has normal lung ventilation, clear lungs, and an arterial oxygen saturation (SaO2) 96% or better. The client most likely has:

• poor peripheral perfusion
• possible Hematologic problem
• psychosomatic disorder
• left-sided heart failure

23. A client who was wandering aimlessly around the streets acting inappropriately and appeared disheveled and unkempt was admitted to a psychiatric unit and is experiencing auditory and visual hallucinations. The nurse would develop a plan of care based on:

• borderline personality disorder
• anxiety disorder
• schizophrenia
• depression

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24. The nurse has created a plan of care for a client experiencing dystocia and includes several nursing actions in the plan of care. What is the priority nursing action?

• Providing comfort measures
• Monitoring the fetal heart rate
• Changing the clients position frequently
• Keeping the significant other informed of the progress of the labor

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25. Katherine is a young Unit Manager of the Pediatric Ward. Most of her staff nurses are senior to her, very articulate, confident and sometimes aggressive. Katherine feels uncomfortable believing that she is the scapegoat of everything that goes wrong in her department. Which of the following is the best action that she must take?

• Identify the source of the conflict and understand the points of friction
• Disregard what she feels and continue to work independently
• Seek help from the Director of Nursing
• Quit her job and look for another employment.

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 26. The nurse is discussing the human immunodeficiency virus (HIV) with a group of high- risk patient The nurse should state that this virus is found MOSTcommoniy in which of the following body fluids?

• Blood
• Saliva
• Breast milk
• Vaginal secretions

27. 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. Jarisch-Herxheimer reaction may be experienced by the client with syphilis after therapy with benzathine penicillin G. The characteristic manifestations of Jarisch-Herxheimer reaction are:

• Rashes, itchiness, hives and pruritus
• Confusion, drowsiness and numbness of extremities
• sudden episode of hypotension, fever, tachycardia, and muscle aches
• Episodes of nausea and vomiting, with bradypnea and bradycardia

28. Which of the following takes place during the implementation phase of the nursing process?

• Development of a goals and a nursing care plan
• Identification of actual or potential health problems
• Actualization of the care plan through nursing interventions
• Determination of the patients responses to the nursing interventions

29. During the inflammation process, which of the following characteristics occur first:

• Swelling
• Pain
• Redness
• Decreased functioning

30. When assessing an 18-month-old, the nurse notes a characteristic protruding abdomen. Which of the following would explain the rationale for this finding?

• Increased food intake owing to age
• Underdeveloped abdominal muscles
• Bowlegged posture
• Linear growth curve

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31. Situation: During surgical operation, it is inevitable to utilize sutures. The nurse should know the basic principles in suturing as well as knowledge in selecting sutures and caring for clients with sutures. Q. Who holds the packet flaps of sutures to open it and place it in the sterile table for use?

• Scrub nurse
• Circulating nurse
• Assistant surgeon
• Surgeon

32. A client voluntarily admits himself to the substance abuse unit. He confesses that he drinks 1 qt or more of vodka each day and uses cocaine occasionally. Later that afternoon, he begins to show signs of alcohol withdrawal. What are some early signs of this condition?

• Vomiting, diarrhea, and bradycardia
• Dehydration, temperature above 101F (38.3C), and pruritus
• Hypertension, diaphoresis, and seizures
• Diaphoresis, tremors, and nervousness

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33. Situation: Milo 16 y/o has been diagnosed to have AIDS, he worked as entertainer in a cruise ship: What primary health teaching would you give to Milo?

• Daily exercise
• Prevent infection
• Reversal Isolation
• Proper nutrition

34. Nurse Hazel invites new clients parents to attend the psycho educational program for families of the chronically mentally ill. The program would be most likely to help the family with which of the following issues?

• Developing a support network with other families
• Feeling more guilty about the clients illness
• Recognizing the client's weakness
• Managing their financial concern and problems

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35. The client has Bucks extension applied to the right leg. The nurse plans which of the following interventions to prevent complications of the device?

• Massage the skin of the right leg with lotion every 8 hours
• Give pin care once a shift
• Inspect the skin on the right leg at least once every 8 hours
• Release the weights on the right leg for range of motion exercises daily

36. Following a precipitous delivery, examination of the clients vagina reveals a fourth-degree laceration. Which of the following would be contraindicated when caring for this client?

• Applying cold to limit edema during the first 12 to 24 hours.
• Instructing the client to use two or more peri pads to cushion the area.
• Instructing the client on the use of sitz baths if ordered.
• Instructing the client about the importance of perineal (kegel) exercises.

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37. Self monitoring of blood glucose for diabetic clients is on what level of prevention?

• Primary
• Secondary
• Tertiary
• None of the above

38. Situation: Human development is one of the important concepts that a nurse should learn to be able to deal appropriately with their clients of different developmental stages. During her prenatal visit, a 28 year old client expresses concern about nutrition during pregnancy. She wants to know what foods she should be eating to ensure the proper growth and development of her baby. Which step should the nurse take first?

• Give the client a sample diet plan for a 2,400 calorie diet.
• Emphasize the importance of avoiding salty and fatty foods.
• Instruct the client to continue to eat a normal diet.
• Assess the client's current nutritional status by taking a diet history.

39. Situation: An entry level nurse should be able to apply theoretical knowledge in the performance of the basic nursing skills. Q. The purpose of NGT IMMEDIATELY after operation is:

• For feeding or gavage
• For gastric decompression
• For lavage, or the cleansing of the stomach content
• For the rapid return of peristalsis

40. A client with osteomylitis has an order for a trough level to be done because he is taking Gentamycin. When should the nurse call the lab to obtain the trough level?

• Before the first dose
• 30 minutes before the fourth dose
• 30 minutes after the first dose
• 30 minutes before the first dose

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41. During tube feeding, how far above an infants stomach should the nurse hold the syringe with formula?

• 6 inches
• 12 inches
• 18 inches
• 24 inches

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42. Situation: Understanding different models of care is a necessary part of the nurse patient relationship. Q. Which intervention would be typical of a nurse using cognitive-behavioral approach to a client experiencing stress disorders?

• Use of unconditional positive regard
• Classical conditioning
• Analysis of free association
• Examination of negative thought patterns

43. The nurse is caring for a client who had a resection of an abdominal aortic aneurysm yesterday. The client has an intravenous (IV) infusion at a rate of 150 mL/hour, unchanged for the last 10 hours. The client's urine output for the last 3 hours has been 90, 50, and 28 mL (28 mL is most recent). The client's blood urea nitrogen level is 35 mg/dL (12.6 mmol/L) and the serum creatinine level is 1.8 mg/dL (159 mcmol/L), measured this morning. Which nursing action is the priority?

• Check the urine specific gravity.
• Call the health care provider (HCP).
• Put the Mine on a pump so that the infusion rate is sure to stay stable.
• Check to see if the client had a blood sample for a serum albumin level drawn.

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44. Before administering eardrops to a toddler the nurse should recognize that it is essential to consider which of the following?

• The age of the child
• The child's weight
• The developmental level of the child
• The IQ of the child

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45. The physician has prescribed Chloromycetin (chloramphenicol) for a client with bacterial meningitis. Which lab report should the nurse monitor most carefully?

• Serum creatinine
• Urine specific gravity
• Complete blood count
• Serum sodium

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46. You noticed the patient chart: ANXIETY +3 What will you expect to see in this client?

• An optimal time for learning, hearing and perception is greatly increased
• Dilated pupils
• Unable to communicate
• Palliative Coping Mechanism

47. The passageway in labor and deliver of the fetus include the following EXCEPT:

• Distensibility of lower uterine segment
• Cervical dilatation and effacement
• Distensibility of vaginal canal and introitus
• Flexibility of the pelvis

48. Nurse Trish is aware that temporary heterograft (pig skin) is used to treat burns because this graft will:

• Relieve pain and promote rapid epitheliahzation
• Be sutured in place for better adherence
• Debride necrotic epithelium
• Concurrently used with topical antimicrobials

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49. Nurse Trish would expect a child with a diagnosis of reactive attachment disorder to:

• Have more positive relation with the father than the mother
• Cling to mother & cry on separation
• Be able to develop only superficial relation with the others
• Have been physically abuse

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50. The nurse is preparing a client for surgery. Which item is most important to remove before sending the client to surgery?

• Hearing aid
• Contact lenses
• Wedding ring
• Artificial eye

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NCLEX-RN | QB2 | Practice Exam #56 (50 questions)