NCLEX-RN | QB3 | Practice Exam #1 (50 questions)

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

 

1. Which client is at highest risk for retinal detachment?

• 4-year old with amblyopia
• 17 y/o who plays physical contact
• 33 y/o with severe ptosis and diplopia
• 72 y/o with nystagmus and Bell's palsy

2. The nurse is evaluating the status of a client who had a craniotomy 3 days ago. Which assessment finding would indicate that the client is developing meningitis as a complication of surgery?

• A negative Kernig's sign
• Absence of nuchal rigidity
• A positive Brudzinski’s sign
• A Glasgow Coma Scale score of 15

3. She tries to design an organizational structure that allows communication to flow in all directions and involve workers in decision making. Which form of organizational structure is this?

• Centralized
• Decentralized
• Matrix
• Informal

4. Nurse Carla should know that the most common causative factor of dermatitis in infants and younger children is:

• Baby oil
• Baby lotion
• Laundry detergent
• Powder with cornstarch

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5. The physician has ordered cooling measures for a child with fever who is likely to be discharged when the temperature comes down. Which of the following would be appropriate to delegate to the nursing assistant?

• Assist the child to remove outer clothing.
• Advise the parent to use acetaminophen instead of aspirin
• Explain the need for cool fluids.
• Prepare and administer a tepid bath.

6. A 65-year-old client is admitted after a stroke. Which nursing intervention would best improve tissue perfusion to prevent skin problems?

• Assessing the skin daily for breakdown
• Massaging any erythematous areas on the skin
• Changing incontinence pads as soon as they become soiled with urine or feces
• Performing range-of-motion exercises and turning and repositioning the client

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7. A home care nurse visits a patient who is discharged from a hospital after a treatment of urosepsis. Which of the following post discharge normal laboratory result BEST indicates desired outcome?

• WBC count
• Hematocrit
• Platelet level
• Potassium level

8. Situation: In the OR, there are safety protocols that should be followed. The OR nurse should be well versed with all these to safeguard the safety and quality of patient delivery outcome. Q. Some lifetime habits and hobbies affect postoperative respiratory function. If your client smokes 3 packs of cigarettes a day for the past 10 years, you will anticipate increased risk for:

• perioperative anxiety and stress
• delayed coagulation time
• delayed wound healing
• postoperative respiratory function

9. A client with manic episodes is taking lithium. Which electrolyte level should the nurse check before administering this medication?

• Calcium
• Sodium
• Chloride
• Potassium

10. The nurse is caring for a client after hypophysectomy and notes clear nasal drainage from the client's nostril. The nurse should take which initial action?

• Lower the head of the bed.
• Test the drainage for glucose.
• Obtain a culture of the drainage.
• Continue to observe the drainage.

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11. The nurse is reviewing the results of serum laboratory studies drawn on a client with acquired immunodeficiency syndrome who is receiving didanosine. The nurse interprets that the client may have the medication discontinued by the health care provider if which elevated result is noted?

• Serum protein level
• Blood glucose level
• Serum amylase level
• Serum creatinine level

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12. This type of disinfection is best done in sterilizing drugs, foods and other things that are required to be sterilized before taken in by the human body

• Boiling Water
• Radiation
• Gas sterilization
• Steam under pressure

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13. Situation: Elvira is a 26 year old woman you admit to a birthing room. She's been having contractions 45 seconds long and 3 minutes apart for the last 6 hours. She tells you she want to have her baby "naturally" without any analgesia or anesthesia. Her husband is in the Army and assigned overseas, so he is not with her. Although her sister lives only two blocks from the hospital, Elvira doesn't want her called. She asks if she can talk to her mother on the telephone instead. You assess Elvira's uterine contractions. In relation to the contraction, when does a late deceleration begin?

• Forty-five seconds after the contraction is over.
• Thirty seconds after the start of a contraction.
• After every tenth or more contraction.
• After a typical contraction ends.

14. Nurse Tristan is caring for a male client in acute renal failure. The nurse should expect hypertonic glucose, insulin infusions, and sodium bicarbonate to be used to treat:

• hypernatremia.
• hypokalemia.
• hyperkalemia.
• hypercalcemia.

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15. Situation: The patients chart is a legal documentation the is admissible in the court. In working with the client, The protection of the information on the chart and patient's privacy is one of the priority. You are caring for Ana, a 12 year old grade 6 pupil from manila and is one of the daughters of Maria, A 38 year old mother of 12. Q. If Ana reaches the age of majority, 18 years of age, and Maria asks for her chart, which of the following is the best nursing action?

• Ignore Maria's request
• Decline Maria's request
• Give the chart to the Mother of Ana
• Tell Maria to ask permission from Ana

16. The nurse knows that the physician has ordered the liquid form of the drug chlorpromazine (Thorazine) rather than the tablet form because the liquid:

• has a more predictable onset of action.
• produces fewer anticholinergic effects.
• produces fewer drug interactions.
• has a longer duration of action.

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17. Which of the following, if seen on the Nurses notes, violates characteristic of good recording?

• The client has a blood pressure of 120/80, Temperature of 36.6 C, Pulse rate of 120 and Respiratory rate of 22
• Ate 50% of food served
• Refused administration of betaxolol
• Visited and seen by Dr. Santiago

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18. All the following can cause hypertension except:

• Excessive exercise and activity
• Pain and emotions
• Diseases such as atherosclerosis
• Hemorrhage

19. The hormone secreted by the small intestine that stimulates the production of pancreatic juice which primarily aids in buffering the acidic bolus passed by the stomach

• Enterogastrone
• Ghrelin
• Pancreozymin
• Enterokinase

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20. The nurse is assisting to defibrillate a client in ventricular fibrillation. After placing the pad on the client's chest and before discharge, which intervention is a priority?

• Ensure that the client has been intubated.
• Set the defibrillator to the "synchronize" mode.
• Administer an amiodarone bolus intravenously.
• Confirm that the rhythm is actually ventricular fibriiiation.

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21. Which type of isolation category is indicated for patient with diphtheria:

• Airborne
• Droplet
• Contact
• Blood

22. The client is admitted to the hospital in chronic renal failure. A diet low in protein is ordered. The rationale for a low-protein diet is:

• Protein breaks down into blood urea nitrogen and other waste.
• High protein increases the sodium and potassium levels.
• A high-protein diet decreases albumin production.
• A high-protein diet depletes calcium and phosphorous.

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23. A client with severe preeclampsia is admitted with of BP 160/110, proteinuria, and severe pitting edema. Which of the following would be most important to include in the client's plan of care?

• Daily weights
• Seizure precautions
• Right lateral positioning
• Stress reduction

24. Cassandra asked you: How many air is there in the oxygen and how many does human requires? Which of the following is the best response:

• God is good, Man requires 21% of oxygen and we have 21% available in our air
• Man requires 16% of oxygen and we have 35% available in our air
• Man requires 10% of oxygen and we have 50% available in our air
• Human requires 21% of oxygen and we have 21% available in our air

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25. Situation: A nurse is working with an aggressive client in the psychiatric unit Q. To maintain a therapeutic eye contact and body posture while interacting with angry and aggressive individual, the nurse should:

• keep an eye contact while staring at the client
• keep his/her hands behind his/her back or in one's pockets
• fold his/her arms across his/her chest
• keep an "open" posture, e.g. Hands by sides but palms turned outwards

26. Situation: Among common conditions found in children especially among poor communities are ear infection/problems. The following questions apply. If the child has severe classification because of ear problem, what would be the best thing that you as the nurse can do?

• instruct mother when to return immediately
• refer urgently
• give an antibiotic for 5 days
• dry the ear by wicking

27. Situation: Francis, age 46 is admitted to the hospital with diagnosis of Chronic Lymphocytic Leukemia. Q. After several days of admission, Francis becomes disoriented and complains of frequent headaches. The nurse in-charge first action would be:

• Call the physician
• Document the patient's status in his charts
• Prepare oxygen treatment
• Raise the side rails

28. Mario comes to the clinic complaining of fever, drenching night sweats, and unexplained weight loss over the past 3 months. Physical examination reveals a single enlarged supraclavicular lymph node. Which of the following is the most probable diagnosis?

• Influenza
• Sickle cell anemia
• Leukemia
• Hodgkin's disease

29. Situation: Two children were brought to you. One with chest indrawing and the other had diarrhea. The following questions apply: In assessing the patient's condition using the Integrated Management of Childhood Illness approach strategy, the first thing that a nurse should do is to:

• ask what are the child's problem
• check the patient's level of consciousness
• check for the four main symptoms
• check for the general danger signs

30. A client is to receive Pergonal (menotropins) injections for infertility prior to in vitro fertilization. Which of the following is the expected action of this medication?

• Prolongation of the luteal phase.
• Stimulation of ovulation.
• Suppression of menstruation.
• Promotion of cervical mucus production.

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31. Tranylcypromine sulfate (Parnate) is prescribed for a depressed client who has not responded to the tricyclic antidepressants. After teaching the client about the medication, Nurse Marian evaluates that learning has occurred when the client states, "I will avoid:

• Citrus fruit, tuna, and yellow vegetables."
• Chocolate milk, aged cheese, and yogurt"'
• Green leafy vegetables, chicken, and milk.”
• Whole grains, red meats, and carbonated soda."

32. A patient is prepared for hemodialysis. He receives heparin before therapy before primarily to help:

• Relieve discomfort
• Prevent blood clotting
• Maintain blood pressure
• Stimulate the production of urine

33. Which characteristic of nursing process addresses the INDIVIDUALIZED care a client must receive?

• Organized and Systematic
• Humanistic
• Efficient
• Effective

34. Situation: You are assigned to take care of a group of patients across the lifespan. The nurse is working with an adolescent who complains of being lonely and having a lack of fulfillment in her life. This adolescent shies away from intimate relationships at times yet at other times she appears promiscuous. The nurse will likely work with this adolescent in which of the areas?

• Isolation
• Loneliness
• Lack of fulfillment
• Identity

35. A 19 year-old client is paralyzed in a car accident. Which statement used by the client would indicate to the nurse that the client was using the mechanism of "suppression"?

• "I don't remember anything about what happened to me."
• "I'd rather not talk about it right now"
• "It's the other entire guy's fault! He was going too fast."
• "My mother is heartbroken about this"

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36. A 52-years-old is admitted to the nursing unit from the physician's office with a diagnosis of acute cholecystitis. Physician orders on admission include: monitor vital sign every 4 hours; IV of ringer's lactate 125ml per hour; 1500 calorie, low-fat liquid diet, morphine sulfate 2mg IV every 2 hours as needed for pain, notify physician for sudden increase in frequency or intensity of pain, promethazine12.5 mg IV every 4 hours as needed for nausea or vomiting. Which of the following should the nurse plan to do FIRST?

• Remove any high-foods from the patient's room
• Notify the dietitian of the diet order
• Obtain venous access and start Ringer's lactate infusion

37. The nurse is performing discharge teaching to a client who is on isoniazid (INH). Which diet selection by the client indicates to the nurse that further instruction is needed?

• Tuna casserole
• Ham salad sandwich
• Baked potato
• Broiled beef roast

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38. The nurse is assigned to care for a patient who has recently been diagnosed with Crohn's disease. The initial treatment is usually:

• Dietary changes
• Reversible colostomy
• Permanent colostomy
• Watchful waiting

39. A 35 year-old man twisted his right ankle. Since then, he has had swelling and stiffness of the ankle in the morning hours. He presented to the clinic six months after the injury and complains that he is in too much pain to participate in sports. An arthroscopy reveals thickening and inflammation of the lining of the ankle joint. Which treatment is most likely to be ordered for this client?

• Aspiration of fluids
• Surgical intervention
• Physical therapy
• NSAID administration

40. The nurse is conducting a physical assessment on a client with anemia. Which of the following clinical manifestations would be most indicative of the anemia?

• BP 146/88
• Respirations 28 shallow
• Weight gain of 10 pounds in six months
• Pink complexion

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41. Which of the following is the BEST method in assessing for the correct placement of the NGT?

• Immerse tip of the tube in water to check for bubbles produced
• Aspirating gastric content to check if the content is acidic
• Instilling air in the NGT and listening for a gurgling sound at the epigastric area
• X-Ray

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42. An order is written to start an IV on a 74-year-old client who is getting ready to go to the operating room for a total hip replacement. What gauge of catheter would best meet the needs of this client?

• 21 butterfly
• 18
• 20
• 25

43. You are about to set the suction pressure to be used to Mr. Hamilton. You are using a Wall unit suction machine. How much pressure should you set the valve before suctioning Mr. Hamilton?

• 50-95 mmHg
• 200-350 mmHg
• 100-120 mmHg
• 10-15 mmHg

44. Situation: You are going to participate in a Cancer Consciousness Week. You are assigned to take charge of the women to make them aware of cervical cancer. You reviewed its manifestations and management. Q. A common complication of hysterectomy is: thrombophlebitis of the pelvic and thigh vessels

• diarrhea due to over stimulating
• atelectasis
• thrombophlebitis of the pelvic and thigh vessels
• wound dehiscence

45. Mike with epilepsy is having a seizure. During the active seizure phase, the nurse should:

• Place the client on his back remove dangerous objects, and insert a bite block.
• Place the client on his side, remove dangerous objects, and insert a bite block.
• Place the client o his back, remove dangerous objects, and hold down his arms.
• Place the client on his side, remove dangerous objects, and protect his head.

46. The nurse assesses a client with the admitting diagnosis of bipolar affective disorder, mania. Which client symptoms require the nurse's immediate action?

• Incessant talking and sexual innuendos
• Grandiose delusions and poor concentration
• Outlandish behaviors and inappropriate dress
• Nonstop physical activity and poor nutritional intake

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47. A 48 year old male client is brought to the psychiatric emergency room after attempting to jump off a bridge. The client's wife states that he lost his job several months ago and has been unable to find another job. The primary nursing intervention at this time would be to assess for:

• A past history of depression
• Current plans to commit suicide
• The presence of marital difficulties
• Feelings of excessive failure

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48. Which of the following statement describes the role of a nurse as a client advocate?

• A nurse may override clients' wishes for their own good.
• A nurse has the moral obligation to prevent harm and do well for clients.
• A nurse helps clients gain greater independence and self-determination.
• A nurse measures the risk and benefits of various health situations while factoring in

49. The nurse is aware that the most important nursing action when a client returns from surgery is:

• Assess the IV for type of fluid and rate of flow.
• Assess the client for presence of pain
• Assess the Foley catheter for patency and urine output
• Assess the dressing for drainage.

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50. Situation: Emma is experiencing left sharp pain and occasional hematuria. She was advised to undergo IVP by her physician. Q. Post IVP, Emma should excrete the contrast medium. You instructed the family to include more vegetables in the diet and

• increase fluid intake
• barium enema
• cleansing enema
• gastric lavage

NCLEX-RN | QB3 | Practice Exam #1 (50 questions)