NCLEX-RN | QB2 | Practice Exam #59 (50 questions)
All 50 questions are randomized each time you take the test, and do not appear in the same order.
1. The nurse has just reassessed the condition of a postoperative client who was admitted 1 hour ago to the surgical unit. The nurse plans to monitor which parameter most carefully during the next hour?
- Urinary output of 20 mL/hour
- Temperature of 37.6 °C (99.6 °F)
- Blood pressure of 100/70 mmHg
- Serous drainage on the surgical dressing
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2. When suctioning an unconscious client, which nursing intervention should the nurse prioritize in maintaining cerebral perfusion?
- Administer diuretics
- Administer analgesics
- Provide hygiene
- Hyperoxygenate before and after suctioning
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3. What is the major cause of maternal death?
- Infection
- Hemorrhage
- Prolonged labor
- Retained placenta
4. The nurse is assessing a post craniotomy client and finds the urine output from a catheter is 1500 ml for the 1 st hour and the same for the 2nd hour. The nurse should suspect:
- Cushing's syndrome
- Diabetes melitus
- Adrenal crisis
- Diabetes insipidus
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5. Situation: Nurses are generalist, in order to cope up with the works demand you must have broad knowledge on anything. Nurse Joan was assigned in the medical ward. During the endorsement she found out that she was assigned to several patients of different case Q. When developing a teaching session on glaucoma for the community, which of the following statements would the nurse stress
- Glaucoma is easily corrected with eye glasses
- White and Asian individuals are the highest risk of glaucoma
- Yearly screening for people ages 20 to 40 years is recommended
- Glaucoma can be painless and visions may be lost before the person is aware of the problem.
6. A 55 year-old man has become very anxious about skin lesions he has developed. On the lower right forearm, there is a well demarcated round patch of skin that he feels could be cancerous. It is 2.5 centimeters in diameter and slightly raised. On palpation it is scaly, dry and rough. The affected area appears sun tanned and reddened. The condition has been persistent for the past four years but has only recently become itchy. What is the most likely underlying problem?
- Seborrheic keratosis
- Actinic keratosis
- Eczematous dermatitis
- Lupus erythematosus
7. The nurse is planning care for a postpartum client who had a vaginal delivery 2 hours ago. The client required an episiotomy and has several hemorrhoids. What is the priority nursing consideration for this client?
- Client pain level
- Inadequate urinary output
- Client perception of body changes
- Potential for imbalanced body fluid volume
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8. Which of the following is TRUE about the human needs?
- May not be deferred
- Are not interrelated
- Met in exact and rigid way
- Priorities are alterable
9. Terence suffered from burn injury. Using the rule of nines, which has the largest percent of burns?
- Face and neck
- Right upper arm and penis
- Right thigh and penis
- Upper trunk
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10. Nurse Cathy applies a fetal monitor to the abdomen of a client in active labor. When the client has contractions, the nurse notes a 15 beat per minute deceleration of the fetal heart rate below the baseline lasting 15 seconds. Nurse Cathy should:
- Change the maternal position
- Prepare for an immediate birth
- Cali the physician immediately
- Obtain the client's blood pressure
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11. Situation: Lizbeth 20 year-old college student is brought to the hospital by her mother who states that f or the past week her behavior has become very strange. She has become more and more withdrawn - Diagnosis: Schizophrenia Catatonic. Q. During the physical assessment Lizbeth's arms remains outstretched after her pulse and blood pressure were taken and the nurse has to reposition it for her. Lizbeth is showing;
- Distractibility
- Muscle rigidity
- Waxy flexibility
- Echopraxia
12. Rhina, who has Menieres disease, said that her environment is moving. Which of the following is a valid assessment? 1. Rhina is giving an objective data 2. Rhina is giving a subjective data 3. The source of the data is primary 4. The source of the data is secondary
- 1,3
- 2,3
- 2,4
- 1,4
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13. Situation: Harriet, a 38 year-old schoolteacher with rheumatoid arthritis, is admitted to the hospital with severe and swelling of the joints of both hands. Q. A regimen of rest, exercises and physical therapy is ordered for Hariet. This regimen will:
- Prevent arthritic pain
- Halt me inflammatory process
- Help prevent the crippling effects of the disease
- Provide for the return of joint motion after prolonged loss
14. Which intervention is most important for the nurse to use to prevent infection by cross contamination in the client who has open burn wounds?
- Handwashing on entering the clients room
- Encouraging the client to cough and deep breathe
- Administering the prescribed tetanus toxoid vaccine
- Changing gloves between cleansing different burn areas
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15. A health care provider prescribes 3000 mL of D5W to be administered over a 24-hour period. The nurse determines that how many milliliters per hour will be administered to the client?
- 100 mL per hour.
- 125 mL per hour
- 110 mL per hour.
- 80 mL per hour.
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16. Situation: Annie has a morbid fear of heights. She asks the nurse what desensitization therapy is: Q. In this level of anxiety, cognitive capacity diminishes. Focus becomes limited and client experiences turned vision. Physical signs of anxiety become more pronounced.
- Severe anxiety
- Panic
- Mild anxiety
- Moderate anxiety
17. Andy, a newly hired nurse, starts to learn the new technology and electronic devices at the hospital. Which of the following mode of adaptation is Andy experiencing?
- Biologic/Physiologic adaptive mode
- Psychologic adaptive mode
- Sociocultural adaptive mode
- Technological adaptive mode
18. The nurse is planning care for a client admitted to the psychiatric unit with a diagnosis of paranoid schizophrenia. Which nursing diagnosis should receive the highest priority?
- Risk for violence toward self or others
- Imbalanced nutrition: Less than body requirements
- Ineffective family coping
- Impaired verbal communication
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19. Situation: Please continue responding as a professional nurse in varied health situations through the following questions. Q. Which of the following conditions would cause an insulin-dependent diabetic client the most difficulty during her pregnancy?
- Rh incompatibility
- Placenta previa
- Hyperemesis gravidarum
- Abruptio placentae
20. The sputum of a client remains positive for the tubercle bacillus even though the client has been taking Laniazid (isoniazid). The nurse recognizes that the client should have a negative sputum culture within:
- 2 weeks
- 6 weeks
- 8 weeks
- 12 weeks
21. When caring for a patient who is receiving anticoagulant medications, the nurse MUST monitor the patient, for signs of:
- Skin breakdown
- Bleeding
- Pain
- Confusion
22. A patient with poor wound healing and poor appetite has an order to begin total parental nutrition (TPN).
- A pair of sterile gloves
- An infusion pump
- IV tubing with a micro-drip chamber
- Povidine-iodine (Beta dine)swabs
23. Situation: Mariah is a 31 year old lawyer who has been married for 6 months. She is now pregnant. She consults you for guidance. The following month, Mariah suspects she is pregnant Her urine is positive for Human Chorionic Gonadotrophin. Which structure produce HCG?
- Pituitary Gland
- Trophoblastic cells of the embryo
- Uterine deciduas
- Ovarian follicles
24. Following a bilateral lumbar sympathectomy a client has a sudden drop in blood pressure but no. evidence of bleeding. The nurse recognizes that this is most likely caused by:
- An inadequate fluid intake
- The after effects of anesthesia
- A reallocation of the blood supply
- An increased level of epinephrine
25. When walking a resident, a gait or transfer belt is often:
- worn around the nurse aide's waist for back support.
- used to keep the resident positioned properly in the wheelchair.
- used to help stand the resident, and then removed before walking.
- put around the resident's waist to provide a way to hold onto the resident.
26. The nurse is conducting a prenatal class on the female reproductive system. When a client in the class asks why the fertilized ovum stays in the fallopian tube for 3 days, what is the nurse's best response?
- "It promotes the fertilized ovum's chances of survival"
- "It promotes the fertilized ovum's exposure to estrogen and progesterone"
- "It promotes the fertilized ovum's normal implantation in the top portion of the uterus"
- "It promotes the fertilized ovum's exposure to luteinizing hormone and follicle-stimulating hormone"
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27. The nurse should know that, following a fracture of the neck of the femur, the desirable position for the
- Internal rotation with extension of the knee
- Internal rotation with flexion of the knee and hip
- External rotation with flexion of the knee and hip
- External rotation with extension of the knee and hip
28. Situation: Because of the serious consequences of severe burns management requires a multidisciplinary approach. You have important responsibilities as a nurse. Q. Teddy, who sustained deep partial thickness and full thickness burns of the face, whole anterior chest and both upper extremities two days ago, begins to exhibit extreme restlessness. You recognize that this most likely indicates that Teddy is developing:
- Cerebral hypoxia
- Hypervolemia
- Metabolic acidosis
- Renal failure.
29. A client receiving Vancocin (vancomycin) has a serum level of 20mcg/mL. The nurse knows that the therapeutic range for vancomycin is:
- 5–10mcg/mL
- 10–25mcg/mL
- 25–40mcg/mL
- 40–60mcg/mL
30. The nurse is ware that the most relevant knowledge about oxygen administration to a male client with COPD is
- Oxygen at 1-2L/min is given to maintain the hypoxic stimulus for breathing.
- Hypoxia stimulates the central chemoreceptors in the medulla that makes the client breath.
- Oxygen is administered best using a non-rebreathing mask
- Blood gases are monitored using a pulse oximeter.
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31. Intra-arterial chemotherapy primarily benefits the client by applying greater concentrations of medication directly to the malignant tumor. An additional benefit of intra-arterial chemotherapy is:
- Blood pressure
- Temperature
- Heart rate
- Respirations
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32. All of the following are post procedural nursing responsibilities except
- The nurse has to attend the patient for comfort and rest.
- Care of specimens.
- Assist the examiner.
- Record and report of information.
33. A man with a 5-year history of multiple psychiatric admissions is brought to the emergency department by the police. He was found wandering the streets disheveled, shoeless, and confused. Based on his previous medical records and current behavior, he is diagnosed with chronic undifferentiated schizophrenia. The nurse should assign highest priority to which nursing diagnosis?
- Anxiety
- Impaired verbal communication
- Disturbed thought processes
- Self-care deficit: Dressing/grooming
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34. Which of the following lab studies should be done periodically if the client is taking warfarin sodium (Coumadin)?
- Stool specimen for occult blood
- White blood cell count
- Blood glucose
- Erthyrocyte count
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35. A client has begun medication therapy with pancrelipase. The nurse evaluates that the medication is having the optimal intended benefit if which effect is observed?
- Weight loss
- Relief of heartburn
- Reduction of steatorrhea
- Absence of abdominal pain
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36. The clinic nurse is instructing the parent of a child with human immunodeficiency virus (HIV) infection regarding immunizations. The nurse should provide which instruction to the parent?
- The hepatitis B vaccine will not be given to the child.
- The inactivated influenza vaccine will be given yearly.
- The varicella vaccine will be given before 6 months of age.
- A Western blot test needs to be performed and the results evaluated before immunizations.
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37. Nurse Lynette is working in the triage area of an emergency department She sees that several pediatric clients arrive simultaneously. The client who needs to be treated first is:
- A crying 5 year old child with a laceration on his scalp.
- A 4 year old child with a barking coughs and flushed appearance.
- A 3 year old child with Down syndrome who is pale and asleep in his mother's arms.
- A 2 year old infant with stridorous breath sounds, sitting up in his mothers arms and drooling.
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38. A client is taking Humulin NPH insulin and regular insulin every morning. The nurse should provide which instructions to the client? Select all that apply. 1. Hypoglycemia may be experienced before dinnertime. 2. The insulin dose should be decreased if illness occurs. 3. The insulin should be administered at room temperature. 4. The insulin vial needs to be shaken vigorously to break up the precipitates. 5. The NPH insulin should be drawn into the syringe first, then the regular insulin.
- 1,2,3
- 1,3
- 1,3,5
- 2,3,4
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39. Sally Baker, a 40-year-old woman, is admitted to the hospital with an established diagnosis of mitral stenosis. She is scheduled for surgery to repair her mitral valve. Q. Of the four basic cell types of lung cancer listed below, which is always associated with smoking?
- adenocarcinoma
- squamous cell carcinoma (epidermoid)
- undifferentiated carcinoma
- bronchoalveolar carcinoma
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40. The nurse prepares to administer an intramuscular injection to a 4-month-old infant. The nurse selects which best site to administer the injection?
- Ventrogluteal
- Lateral deltoid
- Rectus femoris
- Vastus lateralis
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41. A client is having frequent premature ventricular contractions. The nurse should place priority on assessment of which item?
- Sensation of palpitations
- Causative factors, such as caffeine
- Blood pressure and oxygen saturation
- Precipitating factors, such as infection
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42. The nurse creates a plan of care for a child at risk for tonic-clonic seizures. In the plan of care, the nurse Identifies seizure precautions and documents that which item(s) need to be placed at the child's bedside?
- Emergency cart
- Tracheotomy set
- Padded tongue blade
- Suctioning equipment and oxygen
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43. All of the followings are normal characteristics of feces Except:
- Brown color.
- Very hard and solid.
- Amount varies with diet.
- Odor affected by digested food
44. Situation: ENTEROSTOMAL THERAPY is now considered a specialty in nursing. You are participating in the OSTOMY CARE CLASS. Q. When preparing to teach Fermin how to irrigate colostomy, you should plan to do the procedure:
- When Fermin would have normal bowel movement
- At least 2 hours before visiting hours
- Prior to breakfast and morning care
- After Fermin accepts alteration in body image
45. Situation: Records are vital tools in any institution and should be properly maintained for specific use and time. Q. You readmitted a client who was in another department a month ago. Since you will need the previous chart, from whom do you request the old chart?
- Central supply section
- Previous doctor's clinic
- Department where the patient was previously admitted
- Medical records section
46. The nurse is participating in a health class for young women. One subject is cancer of the ovary. Which of the following statements is correct?
- Early symptoms of cancer of the ovary are vague
- This type of cancer has a high cure rate
- Chemotherapy is not used for treating ovarian cancer
- The most prominent early symptoms is an irregular menstrual cycle
47. Which of the following nutrients provides a little over half of the energy needed during sleep?
- Protein
- Carbohydrate
- Fat
- Water
48. A client with breast cancer is returned to the room following a right total mastectomy. The nurse should:
- Elevate the clients right arm on pillows.
- Place the clients right arm in a dependent sling.
- Keep the clients right arm on the bed beside her.
- Place the clients right arm across her body.
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49. A patient is 24 hours post-operative after having a right total hip arthroplasty, the patient complains of pain in the right calf rated 6 on a scale of 0 no pain l0 severe pain. The nurse observes that the right calf is warm and tender to touch, while the right foot is pale and cool. There is edema from the toes up the knee. The nurse recognizes that these are the classic signs of:
- Ineffective tissue perfusion
- Fluid overload
- Arterial occlusion
- Deep vein thrombosis
50. An example of subjective data is:
- Size of wounds
- VS
- Lethargy
- The statement of patient My hand is painful