NCLEX-RN | QB3 | Practice Exam #4 (50 questions)

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

 

1. Which of the following technique involves the sense of sight?

• Inspection
• Palpation
• Percussion
• Auscultation

2. Which of the following types of health care services is an example of the primary level of care?

• Diagnosis
• Acute care
• Restoration
• Immunization

3. A home health nurse visits a patient who is newly diagnosed with diabetes. The glucose level ranges from 120mg/dl to 150mg/dl while current glycosylated hemoglobin (hbA1C) level is 6.9 %. The patient is complaint with taking prescribed hypoglycemic medications and eats 3 meals a day followed by desserts sweetened with granulated sugar. The patient also exercises 30 minutes a day 3 times a week. Which of the following educational intervention takes PRIORITY?

• Glucose monitoring
• Medications
• Dietary requirements
• Exercise regimen

4. The nurse reviews the record of a newborn infant and notes that a diagnosis of esophageal atresia with tracheoesophageal fistula is suspected. The nurse expects to note which most likely sign of this condition documented in the record?

• Incessant crying
• Coughing at nighttime
• Choking with feedings
• Severe projectile vomiting

5. Louie who is to receive a blood transfusion asks the nurse what is the most common type of infection he could receive from the transfusion. The nurse teaches him that approximately 1 in 250,000 patients contract:

• Human immunodeficiency disease (HIV).
• Hepatitis C infection.
• Hepatitis B infection.
• West Nile viral disease.

6. The nurse is instituting seizure precautions for a client who is being admitted from the emergency department. Which measures should the nurse include in planning for the client's safety? Select all that apply. 1. Padding the side rails of the bed 2. Placing an airway at the bedside 3. Placing the bed in the high position 4. Putting a padded tongue blade at the head of the bed 5. Placing oxygen and suction equipment at the bedside 6. Flushing the intravenous catheter to ensure that the site is patent

• 1,2,3,4
• 2,3,4,5,6
• 1,2,5,6
• 3,4,5

7. The nurse is assessing a trauma client in the emergency room when she notes a penetrating abdominal wound with exposed viscera. The nurse should:

• Apply a clean dressing to protect the wound.
• Cover the exposed viscera with a sterile saline gauze.
• Gently replace the abdominal contents.
• Cover the area with a petroleum gauze.

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8. A client is 1 day postoperative after a total hip replacement. The client should be placed in which of the following position?

• Supine
• Semi Fowler's
• Orthopneic
• Trendelenburg

9. The nurse manager has implemented a change in the method of the nursing delivery system from functional to team nursing. An unlicensed assistive personnel (UAP) is resistant to the change and is not taking an active part in facilitating the process of change. Which is the best approach in dealing with the UAP?

• Ignore the resistance.
• Exert coercion on the UAP
• Provide a positive reward system for the UAP
• Confront the UAP to encourage verbalization of feelings regarding the change.

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10. A 23 year-old male comes to the Emergency Department in a sickle cell crisis. He reports that his pain level is a 10/10 in all extremities. During the assessment, he cannot lie still because of the pain. There is no cyanosis or clubbing in the extremities and all examination findings are normal. The vital signs recorded were Blood pressure: 132/82 mmHg Heart rate: 110/min Respiratory rate: 18/mm Temperature: 38.4°C Oxygen Saturation: 94 % an room air. Which nursing diagnosis is first priority?

• Acute pain
• Fluid volume deficit
• Ineffective tissue perfusion
• Ineffective airway clearance

11. When providing health maintenance teaching to new employees in the food-handling department, the nurse emphasizes the need to perform hand hygiene after using the bathroom to prevent

• Spread of hepatitis A
• Spread of hepatitis E
• Salmonella contamination
• Cholera contamination

12. Nurse Cecile is teaching a female client about preventing osteoporosis. Which of the following teaching points Is correct?

• Obtaining an X-ray of the bones every 3 years is recommended to detect bone loss.
• To avoid fractures, the client should avoid strenuous exercise.
• The recommended daily allowance of calcium may be found in a wide variety of foods.
• Obtaining the recommended daily allowance of calcium requires taking a calcium supplement.

13. When evaluating a growth and development of a 6 month old infant, nurse Patty would expect the infant to be able to:

• Sit alone, display pincer grasp, wave bye bye
• Pull self to a standing position, release a toy by choice, play peek-a-boo
• Crawl, transfer toy from one hand to the other, display of fear of strangers
• Turn completely over, sit momentarily without support, reach to be picked up

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14. Situation: Transurethral resection prostatectomy, (TURP) is performed to Mr. Recto, 60 years old, due to prostate enlargement. Post operatively he has continuous irrigation (Cystoclysis). Q. Which of the following measures should you encourage Mr. Recto to do, in order to regain urinary control?

• Wear scrotal support
• Take warm bath 2 times daily
• Ambulate frequently
• Alternately tense and relax the perineal muscles

15. 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

16. Procedure that involves the insertion of a needle between lumber vertebra in the spine but below the spinal cord itself is called:

• Lumber puncture.
• Paracentesis.
• Pelvic Examination.
• Electromyography.

17. Which of the following is the most likely effect on the fetus if the woman is severely anemic during pregnancy?

• Large for gestational age (LGA) fetus
• Hemorrhage
• Small for gestational age (SGA) baby
• Erythroblastosis fetalis

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18. The nurse is creating a plan of care for a postpartum client with a small vulvar hematoma. The nurse should include which specific action during the first 12 hours after delivery?

• Encourage ambulation hourly.
• Assess vital signs every 4 hours.
• Measure fundal height every 4 hours.
• Prepare an ice pack for application to the area.

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19. Hormonal agents are used to treat some cancers. An example would be:

• Thyroxine to treat thyroid cancer
• ACTH to treat adrenal carcinoma.
• Estrogen antagonists to treat breast cancer.
• Glucagon to treat pancreatic carcinoma.

20. To reduce the risk of treatment methicillin resistant staphylococcus aureus from an infectious wound which of the following standard precautions should be implemented

• Airborne
• Contact
• Droplet
• Reverse isolation

21. Situation: Salome, 80 year old widow, has been observed to be irritable, demanding and speaking louder than usual. She would prefer to be alone and take her meals by herself, minimized receiving visitors at home and no longer bothers to answer telephone calls because of deterioration of her hearing. ‘She was brought by her daughter to, the Geriatic clinic for assessment and treatment Q. The nurse counsels Salome's daughter that Salome's becoming very loud and tendency to become aggressive is a/an:

• beginning indifference to the world around her
• attempt to maintain authoritative role
• overcompensation for hearing loss
• behavior indicative of unresolved repressed conflict of the part

22. Before being discharged, Mr. Heywood must be taught principles of good body mechanics. The nurse would be correct in telling Mr. Heywood that when he picks up something, he should:

• Flex both his knees
• Keep his feet together
• Lift with arms extended
• Bend from the waist

23. A client with a renal failure is prescribed a low potassium diet. Which food choice would be best for this client?

• 1 cup rice
• 1/2 cup raisins
• 1 baked potato with the skin
• 1 cup beef broth

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24. The nurse is assessing the adaptation of a client to changes in functional status after a stroke (brain attack). Which observation indicates to the nurse that the client is adapting most successfully?

• Gets angry with family if they interrupt a task
• Experiences bouts of depression and irritability
• Has difficulty with using modified feeding utensils
• Consistently uses adaptive equipment in dressing self

25. A client with obsessive-compulsive behavior is admitted in the psychiatric unit. The nurse taking care of the client knows that the primary treatment goal is to:

• Provide distraction.
• Support but limit the behavior
• Prohibit the behavior
• Point out the behavior

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26. The geriatric client with a history of heart attack and hypertension presented with complaints of unusual weakness and fatigue. Upon examination, the nurse noted diminished breath sounds throughout the lung fields and crackles on both the lower lobes. Which of the following should be the next action of the nurse?

• Notify the physician and document initial findings.
• Facilitate chest x-ray
• Start a thorough physical examination and history.
• Recheck the client after five minutes and see if there are changes.

27. A client with a history of abusing barbiturates abruptly stops taking the medication. The nurse should give priority to assessing the client for:

• Depression and suicidal ideation
• Tachycardia and diarrhea
• Muscle cramping and abdominal pain
• Tachycardia and euphoric mood

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28. The nurse assesses an elderly patient for health problem. The family reports that the patient has trouble remembering and they are concerned about Alzheimer's. Which of the following are risk factors for Alzheimer's disease?

• Genetic history and male gender
• Ethnic group and dietary habits
• Genetic history and female gender
• Dietary habits and male gender

29. Situation: Emma is pregnant with her first baby. She went to the clinic for check-up Q. She is so concerned about the development of varicose veins, which of the statement below indicates a need for further education?

• "I should wear support hose"
• "I should be wearing flat, non-slip shoes that have an arch support"
• "I should wear a pantyhose"
• "I can wear knee-high as long as I don't leave them on longer than 8 hours"

30. The nurse is performing an assessment on a client who has been diagnosed with an allergy to latex. In determining the client's risk factors, the nurse should question the client about an allergy to which food item?

• Yogurt
• Bananas
• Eggs
• Milk

31. A urinalysis is best evaluated for accurate result if specimen is analyzed within:

• 1 hour of collection or refrigerated until analyzed
• 1 hour of collection or left at room temperature
• 2 hours of collection
• 4 hours of collection

32. A 25-year-old female presents to the emergency room with lethargy, decreased reflexes, hypoventilation, hypotension, and fixed and dilated pupils. A family member who is accompanying the patient has an empty bottle of diazepam (Valium) which the label states was recently refilled. The family member also indicates that the patient has a history of depression what intervention should the nurse expect to administer?

• Flumazenil or (activated charcoal)
• A tap water enema
• Magnesium sulphate to reduce the risk of seizure
• Nalaxazone

33. You are about to write an information on the Kardex. There are four (4) available writing instruments to use. Which of the following should you use?

• Mongol #2
• Permanent ink
• A felt or fountain pen
• Pilot Pentel Pen marker

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34. Methotrexate, the most widely used antimetabolite in cancer chemotherapy does not penetrate the central nervous system 'CNS). To treat CNS disease this drug must be administered:

• Intravenously.
• Subcutaneously.
• Intrathecally.
• By inhalation.

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35. In developing care plan for a hospitalized 3 year old child with asthma, the nurse plans to talk calmly in an appropriate language and explains all procedures. Which of the following statements by the BEST demonstrates implementation of the approach?

• "You can use the stethoscope to listen to your heart and your doll's, and then I will listen"
• "You must not wiggle while listen to your heart. You can hold your doll"
• "The stethoscope will feel cold on your chest. You can tell your doll how cold it feels"
• "Let go of your doll and place your hands on your tummy while I use the stethoscope"

36. A lendronate is prescribed for a client with osteoporosis and the nurse is providing instructions on administration of the medication. Which instruction should the nurse provide?

• Take the medication at bedtime.
• Take the medication in the morning with breakfast,
• Lie down for 30 minutes after taking the medication.
• Take the medication with a full glass of water after rising in the morning.

37. To prevent pressure on the feet of a bed-bound patient with decreased tissue perfusion, the BEST intervention the nurse should take is:

• Place sheep skin under the heels
• Place a foot cradle on the bed
• Pad the side rails with foamtubing
• Use only natural fiber linens

38. Beri beri is caused by the deficiency of which Vitamin?

• Vitamin B1
• Vitamin B2
• Vitamin B3
• Vitamin C

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39. Situation: Infection can cause debilitating consequences when host resistance is compromised and virulence of microorganisms and environmental factors are favorable. Infection control is one important responsibility of the nurse to ensure quality of care. Q. Which of the following is most reliable in diagnosing a wound infection?

• Culture and sensitivity
• Purulent drainage from a wound
• WBC count of 20,000/p
• Gram stain testing

40. A 16 year-old boy is in the Post-Operative Care Unit two hours after a tonsillectomy. He is alert and oriented but complains of severe throat pain and difficulty swallowing. He rates the pain at a level 7, on a scale of 1-10. The urine output from the folly catheter is 45 ml over the past two hours.Blood pressure 130/74 mmHg Heart rate 64/min Respiratory rate 18/min Oxygen saturation 98 % on room air, Which clinical finding is most important to report to the doctor?

• Oxygen saturation
• Difficulty swallowing
• Urinary output
• Pain level

41. The nurse is caring for a child with Down syndrome. Which characteristics are commonly found in the child with Down syndrome?

• Fragile bones blue sclera and brittle teeth
• Epicanthal folds broad hands and transpalmar creases
• Low posterior hairline webbed neck and short stature
• Developmental regression and cherry-red macula

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42. Which of the following post-operative diets is most appropriate for the client who has had a hemorrhoidectomy?

• High-fiber
• Lactose free
• Clear-liquid
• Bland

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43. Situation: Team efforts is best demonstrated in the OR. Q. When surgery is on-going, who coordinates the activities outside, including the family?

• Orderly/clerk
• Nurse supervisor
• Circulating nurse
• Anaesthesiologist

44. After teaching the client about risk factors for rheumatoid arthritis, which of the following, if stated by the client as a risk factor, would indicate to the nurse that the client needs additional teaching?

• History of Epstein-Barr virus infection
• Female gender
• Adults between the ages 60 to 75 years
• Positive testing for human leukocyte antigen (HLA) DR4 allele

45. Situation: Agnes, a client with Leukemia is in the clinic for her routine check up. Q. You noticed that Agnes' nose is bleeding, You would instruct Agnes to:

• lie supine with his neck extended.
• sit upright, leaning slightly forward.
• blow his nose and then put lateral pressure on his nose.
• hold his nose while bending forward at the waist.

46. Mr. Liberatore, age 76, is admitted to your unit He has a past medical history of hypertension, DM, hyperlipidemia. Recently he has had several episodes where he stops talking mid sentence and stares into space. Today the episode lasted for 15 minutes. The admission diagnosis is impending CVA. Q. Upper motor neuron disease may be manifested in which of the following clinical signs?

• spastic paralysis, hyperreflexia, presence of babinski reflex
• flaccid paralysis, hyporeflexia
• muscle atrophy, fasciculations
• decreased or absent voluntary movement

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47. Lisa was given morphine sulfate for pain. She is sleeping and her respiratory rate is 4 breaths/minute. If action isn't taken quickly, she might have which of the following reactions?

• Asthma attack
• Respiratory arrest
• Seizure
• Wake up on her own

48. After 5 days of diuretic therapy with 20mg of furosemide (Lasix) daily, a patient begins to exhibit fatigue, muscle cramping and muscle weakness. These symptoms probably indicate that the patient is experiencing:

• Hypokalemia
• Hyperkalemia
• Anorexia
• Dysphagia

49. A nurse instructs a community education class on breast health. Which statement BEST described understanding of the appropriate age to start screening mammograms is a woman of average risk?

• At menopause
• At 65-years-old
• At the cessation of breast feeding
• At 40-years-old

50. The following manifestations are commonly associated with a fever, EXCEPT:

• Headache
• Pinkish and red skin color Bradycardia
• Bradycardia
• Convulsions in infants and child

 

NCLEX-RN | QB3 | Practice Exam #4 (50 questions)