NCLEX-RN | QB3 | Practice Exam #5 (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 signs and symptoms indicate some dehydration?
- Drinks eagerly
- Restless and irritable
- Unconscious
- A and B
2. Mr. Duffy is admitted to the CCU with a diagnosis of R/0 Ml. He presented in the ER with a typical description of pain associated with an Ml, and is now cold and clammy, pale and dyspneic. He has an IV of D5W running, and is complaining of chest pain. Oxygen therapy has not been started, and he is not on the monitor. He is frightened. Q. Mr. Duffy is placed on digitalis on discharge from the hospital. The nurse planning with him for his discharge should educate him as to the purpose and actions of his new medication. What should she or he teach Mr. Duffy to do at home to monitor his reaction to this medication?
- take his blood pressure
- take his radial pulse for one minute
- check his serum potassium (K) level
- weigh himself everyday
3. Situation: Tony, 11 years old, has 'kissing tonsils' and is scheduled for tonsillectomy and adenoidectomy or T and A. Q. Tony is to be discharged in the afternoon of the same day after tonsillectomy and adenoidectomy. You as the RN will make sure that the family knows to:
- offer osterized feeding
- offer soft foods for a week to minimize discomfort while swallowing
- supplement his diet with vitamin C rich juices to enhance heating
- offer clear liquid for 3 days to prevent irritation
4. Which of the following is important when restraining a violent client?
- Have three staff members present, one for each side of the body and one for the head.
- Always tie restraints to side rails.
- Have an organized, efficient team approach after the decision is made to restrain the client.
- Secure restraints to the gurney with knots to prevent escape.
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5. The client tells the nurse he was involved in a car accident while he was intoxicated. What would be the most therapeutic response from the nurse?
- "Why didn't you get someone else to drive you?"
- "Tell me how you feel about the accident."
- "You should know better than to drink and drive"
- “I recommend that you attend an Alcoholics Anonymous meeting.”
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6. Population-focused nursing practice requires which of the following processes?
- Community organizing
- Nursing process
- Community diagnosis
- Epidemiologic process
7. Which of the following, if observed as a sudden change in the resident, is considered a possible warning sign of a stroke?
- Dementia
- Contractures
- Slurred speech
- Irregular heartbeat
8. The ELISA test is used to:
- Screen blood donors for antibodies to human immunodeficiency virus (HIV)
- Test blood to be used for transfusion for HIV antibodies
- Aid in diagnosing a patient with AIDS
- All of the above
9. Situation: The nurse-patient relationship is a modality through which the nurse meets the client's needs. Q. The mentally ill person responds positively to the nurse who is warm and caring. This demonstration of the nurse's role as:
- counselor
- mother surrogate
- therapist
- socializing agent
10. Situation: Two children were brought to you. One with chest indrawing and the other had diarrhea. The following questions apply: Carol is 15 months old and weighs 5.5kg and it is her initial visit. Her mother says that Carol is not eating well and unable to breastfeed, he has no vomiting, has no convulsion and not abnormally sleepy or difficult to awaken. Her temperature is 38.9 deg C. Using the integrated management of childhood illness or 1MCI strategy, if you were the nurse in charge of Carol, how will you classify her illness?
- a child at a general danger sign
- very severe febrile disease
- severe pneumonia
- severe malnutrition
11. Situation: Joanna Marie, a 40 year old client was diagnosed with breast cancer. Q. Joanna's tumor is said to be ERP+. You know that Estrogen receptor positive tumor is:
- A good indicator of the possibility of breast reconstruction
- A good indicator for giving an estrogen replacement therapy to decrease the tumor size
- An indicator that the client might respond to tamoxifen
- An indicator that metastasis has already occurred
12. When teaching a family and a client about the use of a hearing aid, the nurse will base the teaching on what information regarding the hearing aid?
- Provides mechanical transmission for damaged part of the ear
- Stimulates the neural network of the inner ear to amplify sound
- Amplifies sound but does not improve the ability to hear
- Tunes out extraneous noise in the lower-frequency sound spectrum
13. After routine patient contact, hand washing should last at least:
- 30 seconds
- 1 minute
- 2 minute
- 3 minutes
14. A nurse is caring for a patient who had a pneumonectomy 2 days ago for lung cancer. Which observation wouid indicate that the patient is progressing towards discharge goal?
- Cough productive of serosanguineous fluid
- 1+ pretibial edema
- Nap after completing bed bath
- Frequent premature ventricular contractions (PVC)
15. Before assessing the postpartum client's uterus for firmness and position in relation to the umbilicus and midline, which of the following shouldthe nurse do first?
- Assess the vital signs
- Administer analgesia
- Ambulate her in the hall
- Assist her to urinate
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16. A family member asks you, “Why can't you give more medicine? He is still having a lot of pain." What is your best response?
- The doctor ordered the medicine to be given every 4 hours
- If the medication is given too frequently he could suffer ill effects.
- Please tell him that I will be right there to check of him
- Lets wait about 30-40 minutes. If there is no relief I'll call the doctor
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17. Which of the following statement, if made by the nurse, is considered not therapeutic?
- "How did you deal with your anxiety before?"
- "It must be awful to feel anxious"
- "How does it feel to be anxious?"
- "What makes you feel anxious?"
18. When evaluating all forms of traction, the nurse knows the direction of pull is controlled by
- Client's position
- Rope/pulley system
- Amount of weight
- Point of friction
19. SITUATION: A 45 year old male construction worker was admitted to a tertiary hospital for incessant vomiting. Assessment disclosed: weak rapid pulse, acute weight loss of 0.5kg, furrows in his tongue, slow flattening of the skin was noted when the nurse released her pinch. Temperature: 35.8 C, BUN Creatinine ratio: 10:1, He also complains for postural hypotension. There was no infection. Q. Which of the following is the appropriate nursing diagnosis?
- Fluid volume deficit R/T furrow tongue
- Fluid volume deficit R/T uncontrolled vomiting
- Dehydration R/T subnormal body temperature
- Dehydration R/T incessant vomiting
20. A client has developed diabetes insipidous after removal of a pituitary tumor Which finding would the nurse expect?
- Polyuria
- Hypertension
- Polyphagia
- Hyperkalemia
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21. Situation: Nursing informatics is a way of using information technology, computers and the internet in the improvement of nursing care. The first nursing informatics conference was held during 1977. Q. A client insists that the practitioner use a treatment method discovered on an internet data base. Which of the following response is most appropriate?
- "The treatment must be examine to see if it is appropriate"
- "Most website treatments have not been studied or researched"
- "The person establishing the website is the only one who can use it on clients"
- "Websites are like advertising, they are biased and may not be legitimate."
22. The nurse is monitoring the status of a client's fat emulsion (lipid) infusion and notes that the infusion is 1hour behind.Which action should the nurse take?
- Adjust the infusion rate to catch up over the next hour
- Increase the infusion rate to catch up over the next 2 hours.
- Ensure that the fat emulsion infusion rate is infusing at the prescribed rate.
- Adjust the infusion rate to run wide open until the solution is back on time.
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23. While providing discharge teaching for the parents of a child newly diagnosed with cystic fibrosis, the nurse includes teaching regarding the role of salt in the disease. Which of the following statements by the patient indicates the need for further teaching?
- Salty foods may be eaten on occasion
- My child does not need to restrict salt intake
- Salt is lost more rapidly in hot weather
- Salt replacement should occur every day
24. Situation: The Gastrointestinal System is responsible for taking in and processing nutrients for all parts of the body, any problem can quickly affect other body systems and, if not adequately treated, can affect overall health, growth, and development. The following questions are about gastrointestinal disorders in a child. A nurse is monitoring for signs of dehydration in a 1-year-old child who has been hospitalized for diarrhea. The nurse prepares to take the child's temperature and avoids which method of measurement?
- Tympanic
- Axillary
- Rectal
- Electronic
25. The nurse in preparing to insert RYLE'S tube (NGT) into an infant, the nurse knows that the length of the tube should be taken as following:
- From the nose down to the chin and then to the umbilicus
- From the nose to the earlobe and then to the xiphoid process
- From the nose to the mouth to the xiphoid process
- From the nose to the earlobe to the umbilicus
26. While explaining an illness to a 10 year-old, what should the nurse keep in mind about the cognitive development at this age?
- They are able to make simple association of ideas
- They are able to think logically in organizing facts
- Interpretation of events originate from their own perspective
- Conclusions are based on previous experiences
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27. The nurse notes hypotonia, irritability, and a poor sucking reflex in a full-term newborn on admission to the nursery. The nurse suspects fetal alcohol syndrome and is aware that which additional sign would be consistent with this syndrome?
- Length of 19 inches
- Abnormal palmar creases
- Birth weight of 6 lb, 14 oz (3120 g)
- Head circumference appropriate for gestational age
28. Assuming that all have achieved normal cognitive and emotional development which of the following children is at greatest risk for accidental poisoning?
- A 6-month-old
- A 4-year-old
- A 12-year-old
- A 13-year-old
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29. Situation: The question with regards to the OPERATING ROOM. Q. The patient demonstrates knowledge of the psychological response to the operation and other invasive procedure when she asks about:
- Who will be with me in the OR?
- How is the post operative pain over the site like?
- Will I be naked during the operation?
- Is it cold inside?
30. With which of the following disorders is jugular vein distention most prominent?
- Abdominal aortic aneurysm
- Heart failure
- Myocardial infarction
- Pneumothorax
31. The nurse is aware that the following symptoms is most commonly an early indication of stage 1 Hodgkin's disease?
- Pericarditis
- Night sweat
- Splenomegaly
- Persistent hypothermia
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32. A patient recently under went coronary artery bypass graft surgery (CABG). The Nursing diagnosis includes sleep deprivation related to intensive care environment. The goal for this diagnosis would be that the patient:
- Gets 4 hours of uninterrupted sleep during the right
- Takes naps during the day
- Is free of pain in the first hour post surgery
- Ambulates 3 hours post surgery
33. During a routine prenatal visit, a client complains of gums that bleed easily with brushing. The nurse performs an assessment and teaches the client about proper nutrition to minimize this problem. Which client statement indicates an understanding of the proper nutrition to minimize this problem?
- "I will drink 8 oz of water with each meal"
- "I will eat 3 servings of cracked wheat bread each day"
- "I will eat 2 saltine crackers before I get up each morning."
- "I will eat fresh fruits and vegetables for snacks and for dessert each day"
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34. The nurse is caring for a newborn who is on strict intake and output. The used diaper weighs 73.5gm. The diapers dry weight was 62gm. The newborns urine output is:
- 10mL
- 11.5mL
- 10gm
- 12gm
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35. Among children aged 2 months to 3 years, the most prevalent form of meningitis is caused by which microorganism?
- Hemophilus Influenzae
- Morbillivirus
- Streptococcus Pneumoniae
- Neisseria meningitides
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36. Which activity would be most appropriate for a severely withdrawn client?
- Art activity with a staff member
- Board game with a small group of clients
- Team sport in the gym
- Watching TV in the dayroom
37. An anxious 24-year-old college student complains of tingling sensations, palpitations, and chest tightness. Deep, rapid breathing and carpal spasms are noted. What priority nursing action should you take?
- Notify the physician immediately.
- Administer supplemental oxygen.
- Have the student breathe into a paper bag.
- Obtain an order for an anxiolytic medication.
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38. A client with end-stage liver cancer tells the nurse he doesn't want extraordinary measures used to prolong his life. He asks what he must do to make these wishes known and legally binding. How should the nurse respond to the client?
- Tell him that it's a legal question beyond the scope of nursing practice.
- Give him a copy of the client's bill of rights.
- Provide information on active euthanasia.
- Discuss documenting his wishes in an advance directive.
39. The nurse is assessing the patency of a clients left arm arteriovenous fistula prior to initiating hemodialysis. Which finding indicates that the fistula is patent?
- Palpation of a thrill over the fistula
- Presence of a radial pulse in the left wrist
- Visualization of enlarged blood vessels at the fistula site
- Capillary refill less than 3 seconds in the nail beds of the fingers on the left hand
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40. Nurse Hazel is preparing to care for a client who is newly admitted to the hospital with a possible diagnosis of ectopic pregnancy. Nurse Hazel develops a plan of care for the client and determines that which of the following nursing actions is the priority?
- Monitoring weight
- Assessing for edema
- Monitoring apical pulse
- Monitoring temperature
41. A patient visits the clinic for the first time. In order to perform an accurate and complete assessment, which of the following would be the nurse first step?
- Obtain a temperature, pulse and respiration
- Obtain a complete history
- Obtain a blood pressure
- Perform a review of systems
42. Which assignment should not be performed by the nursing assistant?
- Feeding the client
- Bathing the client
- Obtaining a stool
- Administering a fleet enema
43. The nurse is caring for Kenneth experiencing an acute asthma attack. The client stops wheezing and breath sounds aren't audible. The reason for this change is that:
- The attack is over.
- The airways are so swollen that no air cannot get through.
- The swelling has decreased.
- Crackles have replaced wheezes.
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44. Nurse Maureen would expect the a client with mitral stenosis would demonstrate symptoms associated with congestion in the:
- Right atrium
- Superior vena cava
- Pulmonary
- Aorta
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45. In what level of prevention does the nurse encourage optimal health and increases person's susceptibility to illness?
- Primary
- Secondary
- Tertiary
- None of the above
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46. The nurse notes that the client's urinary appliance contains yellow urine with large amounts of mucus. How would the nurse best interpret these data?
- The client is developing an infection of the urinary tract
- The mucus is caused by elevated levels of glucose in the urine
- These findings are normal for a client with an ileal conduit
- There is irritation of the stoma
47. Situation: You are assigned to take care of a group of patients across the lifespan. Which of the following roles BEST exemplifies the expanded role of the nurse?
- Circulating nurse in surgery
- Obstetrical nurse
- Medication nurse
- Pediatric nurse practitioner
48. Which of the following should be given the highest priority before performing physical examination to a patient?
- Preparation of the room
- Preparation of the patient
- Preparation of the nurse
- Preparation of environment
49. Situation: The national objective for maintaining the health of all Filipinos is a primary responsibility of the DOH. You were able to identify factors that lead to respiratory problem in the community where your health facility serves. Your primary role therefore in order to reduce morbidity due to pneumonia is to?
- Seek assistance and mobilize the BHW's to have a meeting with mothers
- Refer cases to hospitals
- Make home visits to sick children
- Teach mothers how to recognize early signs and symptoms of pneumonia
50. 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. You are seeing more clients with diagnoses of mitral valve prolapse. You know those mitral valve prolapse is usually a benign cardiac condition, but may be associated with atypical chest pain. This chest pain is probably caused by:
- ventricular ischemia
- dysfunction of the left ventricle
- papillary muscle ischemia and dysfunction
- cardiac arrhythmias
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