NCLEX-RN | QB2 | Practice Exam #58 (50 questions)

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

 

1. Aldo, with a somatoform pain disorder may obtain secondary gain. Which of the following statement refers to a secondary gain?

• It brings some stability to the family
• It decreases the preoccupation with the physical illness
• It enables the client to avoid some unpleasant activity
• It promotes emotional support or attention for the client

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2. Hemoptysis may be present in the client with a pulmonary embolism because of which of the following reasons?

• Alveolar damage in the infarcted area
• Involvement of major blood vessels in the occluded area
• Loss of lung parenchyma
• Loss of lung tissue

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3. The mother of an 8-year-old child tells the clinic nurse that she is concerned about the child because the child seems to be more attentive to friends than anything else. Using Erikson's psychosocial development theory, the nurse should make which response?

• "You need to be concerned"
• "You need to monitor the child's behavior closely."
• "At this age, the child is developing his own personality."
• "You need to provide more praise to the child to stop this behavior."

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4. A new diabetic is learning to administer his insulin. He receives 10U of NPH and 12U of regular insulin each morning. Which of the following statements reflects understanding of the nurses teaching?

• When drawing up my insulin I should draw up the regular insulin first.
• When drawing up my insulin I should draw up the NPH insulin first
• It doesn't matter which insulin I draw up first.
• I cannot mix the insulin so I will need two shots.

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5. 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. Which of the following is the MOST COMMON sign of infection among the elderly?

• decreased breath sounds with crackles
• Increase body temperature
• pain
• Restlessness, confusion, irritability

6. A client with Parkinsons disease complains of choking when he swallows. Which intervention will improve the clients ability to swallow?

• Withholding liquids until after meals
• Providing semi-liquids when possible
• Providing a full liquid diet
• Offering small more frequent meals

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7. Which of the following statements, if made by a four year old child whose brother just died of cancer, would be age-appropriate?

• "I know I will never see my mother again”
• 'I'm glad my mother isn't crying anymore"
• "I can't wait to go get pizza with my brother"
• "I know where my brother is buried."

8. A nurse is implementing nursing interventions to monitor a patient following kidney surgery. Which of the following complications would be the MOST likely post operative risk after renal surgery?

• Deep vein thrombosis
• Hemorrhage
• Nausea
• Hemiparesis

9. A client with shortness of breath has decreased to absent breath sounds on the right side, from the apex to the base. Which of the following conditions would best explain this?

• Acute asthma
• Chronic bronchitis
• Pneumonia
• Spontaneous pneumothorax

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10. Where should you put Mr Alejar, with Category II TB?

• In a room with positive air pressure and at least 3 air exchanges an hour
• In a room with positive air pressure and at least 6 air exchanges an hour
• In a room with negative air pressure and at least 3 air exchanges an hour
• In a room with negative air pressure and at least 6 air exchanges an hour

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11. A client taking lithium reports vomiting, abdominal pain, diarrhea, blurred vision, tinnitus, and tremors. The lithium level is 2.5 mEq/L (2.5mmol/L). The nurse plans care based on which representation of this level?

• Toxic
• Normal
• Slightly above normal
• Excessively below normal

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12. A patient returning from a 3-hour shoulder repair with general anesthesia is being transported from the operating room (OR) to the post-anesthesia care unit (PACU). The nurse knows that the patient is at high risk for injury related to residual anesthesia. During this time period the patient is at LOWEST risk for

• Airway Obstruction
• Vomiting
• Impaired Circulation
• Fluid volume deficit

13. The client presents to the emergency room with a hyphema. Which action by the nurse would be best?

• Elevate the head of the bed and apply ice to the eye.
• Place the client in a supine position and apply heat to the knee.
• Insert a Foley catheter and measure the intake and output.
• Perform a vaginal exam and check for a discharge.

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14. The nurse is formulating a plan of care for a client with a goiter. The priority nursing diagnosis for the client with a goiter is:

• Body image disturbance related to enlargement of the neck
• Activity intolerance related to fatigue
• Nutrition imbalance less than body requirements related to increased metabolism
• Risk for ineffective airway clearance related to pressure of goiter on the trachea

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15. Which medication can control the extrapyramidal effects associated with antipsychotic agents?

• perphenazine (Trilafon)
• doxepin (Sinequan)
• amantadine (Symmetrel)
• clorazepate (Tranxene)

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16. An important intervention in monitoring the dietary compliance of a client with bulimia is:

• Allowing the client privacy during mealtimes
• Praising her for eating all her meal
• Observing her for 1-2 hours after meals
• Encouraging her to choose foods she likes and to eat in moderation

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17. Patient has swelling on both legs, to assess and diagnosis this, which of the following I should do?

• auscultation
• palpitation
• inspection
• None of the above.

18. Nurse Ron is aware that the gestational age of a conceptus that is considered viable (able to live outside the womb) is:

• 8 weeks
• 12 weeks
• 24 weeks
• 32 weeks

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19. Situation: Mr. Bald , 36 years old patient complaints of fatigue, weight loss, and low-grade fever. He also has pain his fingers, elbows, and ankles. Q. Which of the following symptoms is a classic sign of systemic lupus erythematosus (SLE)?

• Vomiting
• Weight loss
• Difficulty urinating
• Superficial lesions over the cheek and nose

20. A nurse is assessing a child with cystic fibrosis. After thoroughly assessing respiratory status, the nurse should assess which of the following?

• Level of pain
• Skin turgor
• Genitourinary status, clarity of urine
• Nutritional status, characteristics of stool

21. The nurse is planning care for a client being admitted to the nursing unit who attempted suicide. Which priority nursing intervention should the nurse include in the plan of care?

• One-to-one suicide precautions
• Suicide precautions with 30-minute checks
• Checking the whereabouts of the client every 15 minutes
• Asking the client to report suicidal thoughts immediately

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22. A male client with tuberculosis asks Nurse Brian how long the chemotherapy must be continued. Nurse Brian's accurate reply would be:

• 1 to 3 weeks
• 6 to 12 months
• 3 to 5 months
• 3 years and more

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23. An eight year-old boy presents with abdominal cramping and a feeling of fullness. He frequently passes semi-formed stools that are light yellow colored and oily with an abnormally foul odor. His mother states that the child has lost his appetite lately and is concerned about weight loss. Endoscopic examination reveals villous atrophy. Which food would be most suitable for this child?

• Rye
• Oats
• Barley
• Wheat

24. Caring is healing, it is communicated through the consciousness of the nurse to the individual being cared for. It allows access to higher human spirit:

• Benner
• Watson
• Leininger
• Swanson

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25. A client receiving fluphenazine decanoate (Prolixin Decanoate) therapy develops pseudoparkinsonism. The physician is likely to prescribe which drug to control this extrapyramid al effect?

• phenytoin (Dilantin)
• amantadine (Symmetrel)
• benztropine (Cogentin)
• diphenhydramine (Benadryl)

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26. Among the following, which client is autotransfusion possible?

• Client with AIDS
• Client with ruptured bowel
• Client who is in danger of cardiac arrest
• Client with wound infection

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27. A client has a tentative diagnosis of myasthenia gravis. The nurse recognizes that myasthenia gravis involves:

• Loss of the myelin sheath in portions of the brain and spinal cord
• An interruption in the transmission of impulses from nerve endings to muscles
• Progressive weakness and loss of sensation that begins in the lower extremities
• Loss of coordination and stiff cogwheel rigidity

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28. Nurse Reese is teaching a female client with peripheral vascular disease about foot care; Nurse Reese should include which instruction?

• Avoid wearing cotton socks.
• Avoid using a nail clipper to cut toenails.
• Avoid wearing canvas shoes.
• Avoid using cornstarch on feet.

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29. Cyclobenzaprine is prescribed for a client for muscle spasms and the nurse is reviewing the client's record. Which disorder, if noted in the record, would indicate a need to contact the health care provider about the administration of this medication?

• Glaucoma
• Emphysema
• Hypothyroidism
• Diabetes mellitus

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30. Situation: Mrs. Smith is admitted to your ward. The MD ordered Prepare for thoracentesis this pm to remove excess air from the pleural cavity." Q. Chest x-ray was ordered after thoracentesis. When your client asks what is the reason for another chest x~ ray you will explain:

• to rule out pneumothorax
• to rule out any possible perforation
• to decongest
• to rule out any foreign body

31. Nurse Bea recognizes that a pacemaker is indicated when a client is experiencing:

• Angina
• Chest pain
• Heart block
• Tachycardia

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32. A four-month-old is brought to the well-baby clinic for immunization. In addition to the DPT and polio vaccines the baby should receive:

• HibTITER
• Mumps vaccine
• Hepatitis B vaccine
• MMR

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33. A client with primary sclerosing cholangitis has received a liver transplant The nurse should give priority to assessing the client for complications. Which findings are associated with an acute rejection of the new liver?

• Increased jaundice and prolonged prothrombin time
• Fever and foul-smelling bile drainage
• Abdominal distention and clay-colored stools
• Increased uric acid and increased creatinine

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34. Nurse Amy is aware that the following is true about functional nursing

• Provides continuous, coordinated and comprehensive nursing services.
• One-to-one nurse patient ratio.
• Emphasize the use of group collaboration.
• Concentrates on tasks and activities.

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35. Nurse Michelle witnesses a female client sustain a fall and suspects that the leg may be broken. The nurse takes which priority action?

• Takes a set of vital signs.
• Call the radiology department for X-ray.
• Reassure the client that everything will be alright.
• Immobilize the leg before moving the client.

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36. While visiting a patient who had a left hip replacement surgery one week ago, the Patient complains to the home care nurse of episodic numbness and tingling of the lower left extremities. Assessment of the patient shows that the lower left extremities are slightly cool to touch when compared to the lower right extremities. There is no swelling or redness on assessment. What would be the NEXT nursing intervention?

• Reassure the patient that this normal after surgery
• Refer the patient to the surgeon immediately
• Encourage the patient to decrease activities involving the left hip and extremities
• Refer the patient to a physical therapist immediately

37. The nurse prepare IM injection that is irritating to the subcutaneous tissue. Which of the following is the best action in order to prevent tracking of the medication

• Use a small gauge needle
• Apply ice on the injection site
• Administer at a 45° angle
• Use the Z-track technique

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38. Which of the following completely describes PULSUS PARADOXICUS?

• A greater-than-normal increase in systolic blood pressure with inspiration
• A greater-than-normal decrease in systolic blood pressure with inspiration
• Pulse is paradoxically low when client is in standing position and high when supine.
• Pulse is paradoxically high when client is in standing position and low when supine.

39. Resonance is best describe as:

• Sounds created by air filled lungs
• Short, high pitch and thudding
• Moderately loud with musical quality
• Drum-like

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40. Situation: Lizbeth 20 year-old college student is brought to the hospital by her mother who states that for the past week her behavior has become very strange. She has become more and more withdrawn - Diagnosis: Schizophrenia Catatonic. Q. One evening, Lizbeth suddenly begins running up and down the hall. She strips her clothing and strikes out widely at anyone she sees. All of the following interventions would be appropriate except:

• Restrain me patient and call for help
• Call for the assistance of at least three staff members
• Clear the area of other patients
• Obtain me order and prepare chlorpromazine (thorazine)

41. A client develops an anaphylactic reaction after receiving morphine. The nurse should plan to institute which actions? Select all that apply. 1. Administer oxygen. 2. Quickly assess the client's respiratory status. 3. Document the event, interventions, and client's response. 4. Leave the client briefly to contact a health 5. care provider (HOP). Keep the client supine regardless of the blood pressure readings. 6. Start an intravenous (IV) infusion of D5W and administer a 500-mL bolus.

• 1,2,3
• 1,2,3,4
• 3,4,5
• 1,2,4,6

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42. The client tells the nurse that her last menstrual period started on January 14 and ended on January 20. Using Nagele's rule, the nurse determines her EDO to be which of the following?

• September 27
• October 21
• November 7
• December 27

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43. The nurse is caring for the client following a laryngectomy when suddenly the client becomes nonresponsive and pale with a BP of 90/40. The initial nurses action should be to:

• Place the client in Trendelenburg position.
• Increase the infusion of normal saline.
• Administer atropine intravenously.
• Move the emergency cart to the bedside.

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44. The physician has ordered a minimal-bacteria diet for a client with neutropenia. The client should be taught to avoid eating:

• Fruits
• Salt
• Pepper
• Ketchup

45. After a tonsillectomy, the nurse reviews the health care provider's (HCP's) postoperative prescriptions. Which prescription should the nurse question?

• Monitor for bleeding.
• Suction every 2 hours.
• Give no milk or milk products.
• Give clear, cool liquids when awake and alert.

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46. Where does the digestion of carbohydrates start?

• Mouth
• Esophagus
• Small intestine
• Stomach

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47. The stage of GAS where the adaptation mechanism begins

• Stage of Alarm
• Stage of Resistance
• Stage of Homeostasis
• Stage of Exhaustion

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48. The doctor has ordered a Transcutaneous Electrical Nerve Stimulation (TENS) unit for the client with chronic back pain. The nurse teaching the client with a TENS unit should tell the client:

• You may be electrocuted if you use water with this unit.
• Please report skin irritation to the doctor.
• The unit may be used anywhere on the body without fear of adverse reactions.
• A cream should be applied to the skin before applying the unit.

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49. The nurse should plan to implement which intervention in the care of a client experiencing neutropenia as a result of chemotherapy?

• Restrict all visitors.
• Restrict fluid intake.
• Teach the client and family about the need for hand hygiene.
• Insert an indwelling urinary catheter to prevent skin breakdown.

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50. A client undergoes right mastectomy for carcinoma. When teaching the client post­ mastectomy exercises, it is important for the nurse to:

• Exercise both arms simultaneously
• Exercise the right arm only
• Have the client wear a sling between exercise periods
• Wait until the incision has healed

 

NCLEX-RN | QB2 | Practice Exam #58 (50 questions)