NCLEX-RN | QB2 | Practice Exam #57 (50 questions)
All 50 questions are randomized each time you take the test, and do not appear in the same order.
1. A 5-month old infant was brought by his mother to the health center because of diarrhea occurring 4 to 5 times a day. His skin goes back slowly after a skin pinch and his eyes are sunken. Using the IMCI guidelines, you will classify this infant in which category?
- No signs of dehydration
- Some dehydration
- Severe dehydration
- The data is insufficient
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2. The client has a prescription for a calcium carbonate compound to neutralize stomach acid. The nurse should assess the client for:
- Constipation
- Hyperphosphatemia
- Hypomagnesemia
- Diarrhea
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3. Situation: The physician has ordered 3 units of whole blood to be transfused to Wally following a repair of a dissecting aneurysm of the aorta. Q. You are preparing the first unit of whole blood for transfusion. From the time you obtain it from the blood bank, how long should you infuse it?
- 6 hours
- 1 hour
- 4 hours
- 2 hours
4. The nurse assess the client with cholecystitis for the development of obstructive jaundice, which would be evidenced by:
- Inadequate absorption of fat-soluble K
- Light amber urine, dark brown stools, yellow skin
- Dark-colored urine, clay colored stools, itchy skin
- Straw-colored urine, putty-colored stools, yellow sclerae
5. After seeking help at an outpatient mental health clinic, Ruby who was raped while walking her dog is diagnosed with posttraumatic stress disorder (PTSD). Three months later, Ruby returns to the clinic, complaining of fear, loss of control, and helpless feelings. Which nursing intervention is most appropriate for Ruby?
- Recommending a high-protein, low-fat diet.
- Giving sleep medication, as prescribed, to restore a normal sleep-wake cycle.
- Allowing the client time to heal.
- Exploring the meaning of the traumatic event with the client.
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6. When the baby s head is out, the immediate action of the nurse is
- Cut the umbilical cord
- Wipe the baby's face and suction mouth first
- Check if there is cord coiled around the neck
- Deliver the anterior shoulder
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7. Damage to the VII cranial nerve results in:
- Facial pain
- Absence of ability to smell
- Absence of eye movement
- Tinnitus
8. Which of the following stage the carcinogen is irreversible?
- Progression stage
- Initiation stage
- Regression stage
- Promotion stage
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9. The nurse caring for a client with a pneumothorax and who has had a chest tube inserted notes continuous gentle bubbling in the water seal chamber What action is most appropriate?
- Do nothing, because this is an expected finding.
- Check for an air leak, because the bubbling should be intermittent.
- Increase the suction pressure so that the bubbling becomes vigorous.
- Clamp the chest tube and notify the health care provider immediately.
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10. Nurse Lynette is preparing a site for the insertion of an I.V. catheter The nurse should treat excess hair at the site by:
- Leaving the hair intact
- Shaving the area
- Clipping the hair in the area
- Removing the hair with a depilatory.
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11. Situation: Two children were brought to you. One with chest indrawing and the other had diarrhea. The following questions apply: When patients cannot make decisions for themselves, the nurse advocate relies on the ethical principle of:
- justice and beneficence
- fidelity and nonmaleficence
- beneficence and nonmaleficence
- fidelity and justice
12. A patient is seen in the emergency room for a 20cm (7.8 inch) laceration to the right fore arm. The course prepares for which type of anesthesia to be administered before the laceration is repaired by the physician?
- intravenous
- Regional
- General
- Local
13. A client with a history of substance abuse has been attending Alcoholics Anonymous meetings regularly in the psychiatric unit One afternoon, the client tells the nurse, "I'm not going to those meetings anymore. I'm not like the rest of those people. I'm not a drunk. "What is the most appropriate response?
- "If you aren't an alcoholic, why do you keep drinking and ending up in the hospital?"
- "You seem upset about the meetings."
- "You have to go to the meetings. It's part of your treatment plan."
14. Which of the following types of cardiomyopathy does not affect cardiac output?
- Dilated
- Hypertrophic
- Restrictive
- Obliterative
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15. A gastrectomy is performed on a client with gastric cancer In the immediate postoperative period, the nurse notes bloody drainage from the nasogastric tube. The nurse should take which most appropriate action?
- Measure abdominal girth.
- Irrigate the nasogastric tube.
- Continue to monitor the drainage.
- Notify the health care provider (HCP).
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16. A 10-year-old child with hemophilia A has slipped on the ice and bumped his knee. The nurse should prepare to administer which prescription?
- Injection of factor X
- Intravenous infusion of iron
- Intravenous infusion of factor VII
- Intramuscular injection of iron using the Z-track method.
17. Studies have shown that about 40% of patients fall out of bed despite the use of side rails; this has led to which of the following conclusions?
- Side rails are ineffective
- Side rails should not be used
- Side rails are a deterrent that prevent a patient from falling out of bed.
- Side rails are a reminder to a patient not to get out of bed
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18. Which of the following factors is the underlying cause of dystocia?
- Nurtional
- Mechanical
- Environmental
- Medical
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19. A 22 years-old man is brought to the Emergency Department after falling four meters from a rooftop. He complains of coldness, numbness and tingling in the right lower leg and foot He is unable to move the right leg and there is an angular deformity over the thigh muscle Blood pressure: 90/68 mmHg. Heart rate: 110/min. Respiratory rate: 26/min. Temperature: 36.3°C. Oxygen saturation: 94% on room air. Which type of intravenous fluid administration is most appropriate?
- Lactated Ringers solution
- 5% dextrose in water solution
- 3.3% glucose in 0.3% sodium chloride
- 5% dextrose in 0.45% normal saline
20. The nurse is assessing a client who is experiencing an acute episode of cholecystitis. Which of these clinical manifestations support this diagnosis? Select ail that apply. 1. Fever 2. Positive Cullen's sign 3. Complaints of indigestion 4. Palpable mass in the left upper quadrant 5. Pain in the upper right quadrant after a fatty meal 6. Vague lower right quadrant abdominal discomfort
- 1,3,5
- 1,2,3,6
- 2,3,4,6
- 3,4,5
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21. Nurse Ryan is aware that the best initial approach when trying to take a crying toddlers temperature is:
- Talk to the mother first and then to the toddler.
- Bring extra help so it can be done quickly.
- Encourage the mother to hold the child.
- Ignore the crying and screaming.
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22. The nurse is caring for a client being treated for fat embolus after multiple fractures. Which data would the nurse evaluate as the most favorable indication of resolution of the fat embolus?
- Clear mentation
- Minimal dyspnea
- Oxygen saturation of 85%
- Arterial oxygen level of 78 mm Hg (10.3 kPa)
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23. The nurse assessing a male client who has been admitted for treatment of alcoholism. Which question by the nurse is least appropriate?
- How much do you think?
- What other drugs do you use?
- How is your general health?
- Why do you drink so much?
24. Which developmental milestone puts the four-month-old infant at greatest risk for injury?
- Switching objects from one hand to another
- Crawling
- Standing
- Rolling over
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25. When an order reads that a drug be administered q.i.d, how often should this drug be given?
- Every three hours
- Three times a day
- Four times a day
- Every other day
26. The following are signs and symptoms of fetal distress EXCEPT:
- Fetal heart rate (FHR) decreased during a contraction and persists even after the uterine contraction ends
- The FHR is less than 120 bpm or over 160 bpm
- The pre-contract ion FHR is 130 bpm, FHR during contraction is 118 bpm and FHR after uterine contraction is 126 bpm
- FHR is 160 bpm, weak and irregular
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27. In a horizontal chart, the lowest level worker is located at the
- Left most box
- Middle
- Right most box
- Bottom
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28. A patient is who is prepared for hip surgery has an order for external pneumatic compression devices. The nurse teaches the patient that pneumatic compression can help prevent:
- Upper respiratory infection
- Decreased breath sounds
- Deep vein thrombosis
- Bleeding at the surgical site
29. A client with a total hip replacement requires special equipment Which equipment would assist the client with a total hip replacement with activities of daily living?
- High-seat commode
- Recliner
- TENS unit
- Abduction pillow
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30. Which of the following signs and symptoms would Nurse Maureen include in teaching plan as an early manifestation of laryngeal cancer?
- Stomatitis
- Airway obstruction
- Hoarseness
- Dysphagia
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31. Which of the following is considered as the main muscle of respiration?
- Lungs
- Intercostal Muscles
- Diaphragm
- Pectoralis major
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32. The nurse on an orthopedic unit is assigned to care for four clients with displaced bone fractures. Which client will not be treated with the use of traction?
- A client with fractures of the femur
- A client with fractures of the cervical spine
- A client with fractures of the humerus
- A client with fractures of the ankle
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33. The most serious adverse effect of Alprostadil (Prostin VR pediatric injection) administration in neonates is:
- Apnea.
- Bleeding tendencies.
- Hypotension.
- Pyrexia.
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34. Asking the questions to determine if the person understands the health teaching provided by the nurse would be included during which step of the nursing process?
- Assessment
- Evaluation
- Implementation
- Planning and goals
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35. During the physical examination of a young child, what is the earliest sign of xerophthalmia that may observe?
- Keratomalacia
- Corneal opacity
- Night blindness
- Conjunctival xerosis
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36. A client is hospitalized for the first time, which of the following actions ensure the safety of the client?
- Keep unnecessary furniture out of the way
- Keep the lights on at all time
- Keep side rails up at all time
- Keep all equipment out of view
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37. A nurse will need to change the dressing on a patients central venous catheter during the shift. The nurse should plan to:
- Limit the patients activity for an hour dressing change
- Position the patient on to the left side before removing the old dressing
- Put on sterile gloves after explaining the procedure to the patient
- Cleanse the insertion site using a circular motion
38. A client with TPN suddenly develops tremors, dizziness, weakness and diaphoresis. The client said "1 feel weak" You saw that his TPN is already empty and another TPN is scheduled to replace the previous one but its provision is already 3 hours late. Which of the following is the probable complication being experienced by the client?
- Hyperglycemia
- Hypoglycemia
- Infection
- Fluid overload
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39. Cherry notes down ideas that were derived from the description of an investigation written by the person who conducted it Which type of reference source refers to this?
- Footnote
- Bibliography
- Primary source
- Endnotes
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40. The nurse is assigned to administer a vaginal irrigation (douche). Which of the following is correct?
- The irrigation is best administered with the client standing in a bathtub
- Before inserting, the nozzle is lubricated with petroleum jelly
- The temperature of the solution should be between SOT and 84*
- The nozzle is inserted downward and backward within the vagina
41. A neonatal nurse performs Apgar assessment at 1 minute of birth to evaluate the physical condition of the newborn and immediate need for resuscitation. At 1 minute, Apgar score is 7. At 5 minutes Apgar score is to the progression of scores suggests:
- A healthy newborn
- The need for supplement oxygen
- A genetic defect
- The infant is becoming stable
42. Situation: A patient was admitted in the Medical Floor at St. Lukes Hospital. He was asymptomatic. The doctor suspects diverticulosis. Q. Which of the following types of diet is implicated in the development of diverticulosis?
- Low - fiber diet
- High - fiber diet
- High - protein diet
- Low - carbohydrate diet
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43. A home care nurse reviews the laboratory results for a postpartum patient who had caesarean section . Which of the following indicates possible wound infection?
- Increased WBC
- Decreased haematocrit level
- Increased haemoglobin
- Decreased platelet
44. Right after birth, when the skin of the baby s trunk is pinkish but the soles of the feet and palm of the hands are bluish this is called:
- Syndactyly
- Acrocyanosis
- Peripheral cyanosis
- Cephalo-caudal cyanosis
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45. An infant who weighs 8 pounds at birth would be expected to weigh how many pounds at 1 year?
- 14 pounds
- 16 pounds
- 18 pounds
- 24 pounds
46. In a 24 hour urine specimen started Friday 9:00 A.M, which of the following if done by Nurse indicate a NEED for further procedural debriefing?
- The nurse ask the client to urinate at 9:00 A.M, Friday and she included the urine in the 24 hour urine specimen
- The nurse discards the Friday 9:00 A M urine of the client
- The nurse included the Saturday 9:00 A.M urine of the client to the specimen collection
- The nurse added preservatives as per protocol and refrigerates the specimen
47. Situation: The abuse of dangerous drug is a serious public health concern that nurses need to address, Q. The nurse evaluates that-.her health teaching to a group of high school boys is effective if these students recognize which of the following dangers of inhalant abuse.
- Sudden death from cardiac or respiratory depression
- Danger of acquiring hepatitis or AIDS
- Experience of "blackout"
- Psychological dependence after prolonged use
48. A hospitalized client had a tonic-clonic seizure while walking in the hall. During the seizure the nurse priority should be:
- Hold the clients arms and leg firmly
- Place the client immediately to soft surface
- Protects the clients head from injury
- Attempt to insert a tongue depressor between the clients teeth
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49. Situation: Nurse Macarena is a Family Planning and Infertility Nurse Specialist and currently attends to FAMILY PLANNING CLIENTS AND INFERTILE COUPLES. The following conditions pertain to meeting the nursing needs of this particular population group. Cindy submits herself to Fatima Medical Center and is scheduled to have a hysterosalpingogram. Which of the following instructions would you give her regarding this procedure?
- Menstruation will be irregular for few months as an effect of the dye but it is just normal
- The sonogram of the uterus will reveal any tumors present
- The women may experience some itchiness in the vagina as an after effect.
- Cramping may be felt when the dye is inserted
50. In analyzing the need for teaching regarding sexual health in a client who is sexually active, which of the following questions is the most important for a nurse to ask?
- "How old are your children?"
- "Did you have intercourse last evening?"
- "With whom do you have intercourse?"
- "Do you use vaginal lubricant?"
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