NCLEX-RN | QB3 | Practice Exam #6 (50 questions)

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

 

1. A child who has undergone spinal fusion for scoliosis complains of abdominal discomfort and begins to have episodes of vomiting. On further assessment, the nurse notes abdominal distention. On the basis of these findings, the nurse should take which action?

• Administer an antiemetic.
• Increase the intravenous fluids.
• Place the child in a Sims'position.
• Notify the health care provider (HCP).

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2. A client with antisocial personality disorder tells a nurse "Life has been full of problems since childhood? Which of the following situations or conditions would the nurse explore in the assessment?

• Birth defects
• Distracted easily
• Hypoactive behavior
• Substance abuse

3. All of the followings are signs of HYPOXIA Except:

• Rapid pulse
• Cyanosis
• Rapid shallow respiration
• Diarrhea.

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4. A female client is taking Cascara Sagrada. Nurse Betty informs the client that the following maybe experienced as side effects of this medication:

• GI bleeding
• Peptic ulcer disease
• Abdominal cramps
• Partial bowel obstruction

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5. Phenazopyridine is prescribed for a client with a urinary tract infection. The nurse evaluates that the medication is effective based on which observation?

• Urine is clear amber
• Urination is not painful.
• Urge incontinence is not present.
• A reddish-orange discoloration of the urine is present.

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6. The physician has prescribed NPH insulin for a client with diabetes mellitus. Which statement indicates that the client knows when the peak action of the insulin occurs?

• I will make sure I eat breakfast within two hours of taking my insulin.
• I will need to carry candy or some form of sugar with me all the time.
• I will eat a snack around three o clock each afternoon.
• I can save my dessert from supper for a bedtime snack.

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7. When planning the discharge of a client with chronic anxiety, Nurse Chris evaluates achievement of the discharge maintenance goals. Which goal would be most appropriately having been included in the plan of care requiring evaluation?

• The client eliminates all anxiety from daily situations
• The client ignores feelings of anxiety
• The client identifies anxiety producing situations
• The client maintains contact with a crisis counselor

8. Thrombophlebitis typically develops in patients with which of the following conditions?

• Increases partial thromboplastin time
• Acute pulsus paradoxus
• An impaired or traumatized blood vessel wall
• Chronic Obstructive Pulmonary Disease (COPD)

9. The nurse is caring for a client who is 1 day postoperative for a total hip replacement. Which is the best position in which the nurse should place the client?

• Side-lying on the operative side
• On the non operative side with the legs abducted
• Side-lying with the affected leg internally rotated
• Side-lying with the affected leg externally rotated

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10. Which of the following landmarks is the correct one for obtaining an apical pulse?

• Left intercostal space, midaxillary line
• Left fifth intercostal space, midclavicular line
• Left second intercostal space, midclavicular line
• Left seventh intercostal space, midclavicular line

11. The nurse is caring for a client scheduled for a transsphenoidal hypophysectomy. The preoperative teaching instructions should include which statement?

• "Your hair will need to be shaved"
• "You will receive spinal anesthesia."
• "You will need to ambulate after surgery"
• "Brushing your teeth needs to be avoided for at least 2 weeks after surgery"

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12. A client with a urinary tract infection is receiving ciprofloxacin by the intravenous (IV) route. The nurse appropriately administers the medication by performing which action?

• Infusing slowly over 60 minutes
• Infusing in a light-protective bag
• Infusing only through a central line
• Infusing rapidly as a direct IV push medication

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13. The nurse should avoid the use of the dorsogluteal site for an intramuscular injection in children because of the risk of injury to which of the following nerves?

• Sciatic
• Llioinguinal
• Lumbar plexus
• Vagus

14. The nurse is working in the emergency room when a client arrives with severe burns of the left arm hands face and neck. Which action should receive priority?

• Starting an IV
• Applying oxygen
• Obtaining blood gases
• Medicating the client for pain

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15. Which of the following would be inappropriate to include when preparing a client for magnetic resonance imaging (MRI) to evaluate a rupture disc?

• Informing the client that the procedure is painless
• Taking a thorough history of past surgeries
• Checking for previous complaints of claustrophobia
• Starting an intravenous line at keep-open rate

16. The physician prescribes captopril (Capoten) 25mg po tid for the client with hypertension. Which of the following adverse reactions can occur with administration of Capoten?

• Tinnitus
• Persistent cough
• Muscle weakness
• Diarrhea

17. RTA. The patient appears restless confused and disoriented. He reports that he had hit his head against the steering wheel of the car when it had collided with the car directly in front of him. Blood pressure : 110/68 mmHg Heart rate : 100/min Respiratory rate : 22/min Body Temperature : 37.0 coral Oxygen saturation : 98% on room air What is the most important next step in management?

• Immobilize head and neck.
• Administer oxygen.
• Establish an intravenous line.
• Arrange for an MRI scan.

18. For a diabetic male client with a foot ulcer, the doctor orders bed rest, a wet-to-dry dressing change every shift, and blood glucose monitoring before meals and bedtime. Why are wet-to-dry dressings used for this client?

• They contain exudate and provide a moist wound environment.
• They protect the wound from mechanical trauma and promote healing.
• They debride the wound and promote healing by secondary intention.
• They prevent the entrance of microorganisms and minimize wound discomfort.

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19. On admission, a client has the following arterial blood gas (ABG) values: PaO2, 50 mm Hg; PaCO2, 70 mm Hg; pH, 7.20; HCO3-, 28 mEq/L Based on these values, the nurse should formulate which nursing diagnosis for this client?

• Risk for deficient fluid volume
• Deficient fluid volume
• Impaired gas exchange
• Metabolic acidosis

20. SITUATION: MARK Lester had been diagnosed with Stage 1 bronchogenic cancer He had undergone lobectomy on the left lower lung. A two-bottle drainage system is inserted. Water-seal chest drainage involves attaching the chest tube to a:

• Suction machine directly
• Rubber tube/glass tube that is submerged underwater
• Rubber tube that is left open to air
• A closed drainage bottle with sterile water and no external opening

21. A 16-year-oid primigravida arrives at the labor and birthing unit in her 38th week of gestation and states that she is labor. To verify that the client is in true labor nurse Trina should:

• Obtain sides for a fern test
• Time any uterine contractions
• Prepare her for a pelvic examination
• Apply nitrazine paper to moist vaginal tissue

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22. A 4-month old infant was brought to the health center of cough. Her respiratory rate is 42/ minute. Using the IMCI guidelines of assessment, her breathing is considered;

• Normal
• Insignificant
• Fast
• Slow

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23. Situation: Please continue responding as a professional nurse in varied health situations through the following questions. Q.Which of the following would the nurse include when describing the pathophysiology of gestational diabetes?

• Glucose levels decrease to accommodate fetal growth
• Hypoinsulinemia develops early in the first trimester
• Pregnancy fosters the development of carbohydrate cravings
• There is progressive resistance to the effects of insulin

24. A patient who has a diagnosis of multiple sclerosis speaks slowly with long pauses between syllables. The patient is MOST likely in what stage of multiple sclerosis?

• Prodromal
• Middle
• Early
• Late

25. According to C.E. Winslow, which of the following is the goal of Public Health?

• For people to attain their birthrights and longevity
• For promotion of health and prevention and diseases
• For people to have access to basic health services
• For people to be organized in their health efforts

26. Which of the following should the nurse do first for a 15-year-old boy with a full leg cast who is screaming in unrelenting pain and exhibiting right foot pallor signifying compartment syndrome?

• Medicate him with acetaminophen.
• Notify the physician immediately
• Release the traction
• Monitor him every 5 minutes

27. Which of the following laboratory test results would suggest to the nurse Len that a client has a corticotropin-secreting pituitary adenoma?

• High corticotropin and low cortisol levels
• Low corticotropin and high cortisol levels
• High corticotropin and high cortisol levels
• Low corticotropin and low cortisol levels

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28. The nursing diagnosis includes all the following except:

• Problem.
• Etiology.
• Time.
• Sign.

29. During the evening round Nurse Tina saw Mr. Toralba meditating and afterwards started singing prayerful hymns. What would be the best response of Nurse Tina?

• Call the attention of the client and encourage to sleep
• Report the incidence to head nurse
• Respect the client's action
• Document the situation

30. Situation: Nurse Gloria is the staff nurse assigned at the Emergency Department During her shift, a patient was rushed - in the ED complaining of severe heartburn, vomiting and pain that radiates to the flank. The doctor suspects gastric ulcer. Q. What other symptoms will validate the diagnosis of gastric ulcer?

• right epigastric pain
• pain occurs when stomach is empty
• pain occurs immediately after meal
• pain not relieved by vomiting

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31. 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. Who among the following are recipients of the tertiary level of care for cancer cases?

• Those under early treatment
• Those under supportive care
• Those under early detection
• Those scheduled for surgery

32. Situation: Nurse Michelle works with a Family Nursing Team in Calbayog Province specifically handling a UNICEF project for children. The following conditions pertain, to CARE OP THE FAMILIES PRESCHOOLERS. Ronnie asks constant questions. How many does a typical 3-year-old ask in a day's time?

• 1,200 or more
• Less than 50
• 100-200
• 300-400

33. A Spanish-speaking client arrives at the triage desk in the emergency department and states to the nurse, "No speak English, need interpreter.” Which is the best action for the nurse to take?

• Have one of the client's family members interpret.
• Have the Spanish-speaking triage receptionist interpret.
• Page an interpreter from the hospital's interpreter services.
• Obtain a Spanish-English dictionary and attempt to triage the client.

34. All of the following statement are true about donning sterile gloves except:

• The first glove should be picked up by grasping the inside of the cuff.
• The second glove should be picked up by inserting the gloved fingers under the cuff outside the glove.
• The gloves should be adjusted by sliding the gloved fingers under the sterile cuff and pulling the glove over the wrist
• The inside of the glove is considered sterile

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35. Situation: A group of nursing students were discussing the normal growth and development concepts when assigned to observe the school children. Q. Play for the preschool-age child is necessary for the emotional development of:

• Projection
• Introjection
• Competition
• Independence

36. The client presented with complaints of rapid and shallow breathing. Upon lung auscultation, breath sound is diminished on both lung bases and there's audible course crackles on the upper lobes. If the condition worsens, which of the following tests can be used to determine if intubation is necessary?

• Peak flow meter
• Partial Oxygen Saturation in Arterial Blood Gas
• Oxygen Saturation in Pulse Oximeter
• Lung Function test

37. A client on a mechanical ventilator begins to fight the ventilator. Which medication will be ordered for the client?

• Sublimaze (fentanyl)
• Pavulon (pancuronium bromide)
• Versed (midazolam)
• Atarax (hydroxyzine)

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38. A client has a history of hypothyroidism. Which skin condition should the nurse expect when performing a physical assessment?

• Dry
• Moist
• Flushed
• Smooth

39. A client diagnosed with terminal cancer says to the nurse, "I'm going to die, and I wish my family would stop hoping for a cure! 1 get so angry when they carry on like this. After all, I'm the one who's dying." Which response by the nurse is therapeutic?

• "Have you shared your feelings with your family?"
• "I think we should talk more about your anger with your family"
• "You're feeling angry that your family continues to hope for you to be cured?"
• "You are probably very depressed, which is understandable with such a diagnosis."

40. A patient is receiving intravenous fluids at a rate of 125 milliliters/hour (ml/hr). What volume fluids will the patient receive during an 8-hour shift?

• 1,500 ml
• 1 liter
• 1.5 liters
• 500 ml

41. For a client newly diagnosed with radiation-induced thrombocytopenia, the nurse should include which intervention in the plan of care?

• Administer aspirin if the temperature exceeds 38.8° C.
• Inspect the skin for petechiae once every shift.
• Provide for frequent periods of rest.
• Place the client in strict isolation.

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42. The nurse is reviewing the laboratory results for a client receiving tacrolimus. Which laboratory result would indicate to the nurse that the client is experiencing an adverse effect of the medication?

• Potassium level of 3.8 mEq/L (3.8 mmol/L)
• Platelet count of 300,000 mm3 (300x10⁹/L)
• Fasting blood glucose of 200 mg/dL (11.1 mmol/L)
• White blood cell count of 6000 mm3 (5 to 10x10⁹/L)

43. The normal range of pH in arterial blood is:

• 7.15-7.20
• 7.25-7.30
• 7.35-7.45
• 7.50-7.55

44. Ricky with chronic schizophrenia takes neuroleptic medication is admitted to the psychiatric unit. Nursing assessment reveals rigidity, fever, hypertension, and diaphoresis. These findings suggest which life threatening reaction:

• Tardive dyskinesia.
• Dystonia.
• Neuroleptic malignant syndrome.
• Akathisia.

45. The client is being evaluated for possible acute leukemia. Which inquiry by the nurse is most important?

• Have you noticed a change in sleeping habits recently?
• Have you had a respiratory infection in the last six months?
• Have you lost weight recently?
• Have you noticed changes in your alertness?

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46. This is the best patient care model when there are many nurses but few patients.

• Functional nursing
• Team nursing
• Primary nursing
• Total patient care

47. A 4 years old girl, was playing outside, she came to her mom crying and holding her right upper arm, she went to the hospital with swelling over the upper arm, pain and itching, the appropriate management is:

• Maintain patent airway
• Administer s/c epinephrine
• Prepare for intubation
• None of the above.

48. Situation: Respiration is one of the most important vital sign. This is usually the first Vital sign to be assessed more than anything for it is easily altered by the patient's consciousness. The nurse should be aware of the different changes and alteration in respiration. Q. Initially in asthma, you are expecting that the clients acid base disturbance

• Respiratory acidosis
• Metabolic acidosis
• Respiratory alkalosis
• Metabolic alkalosis

49. A mother is using Oresol in the management of diarrhea of her 3-year old child. She asked you what to do if her child vomits. You will tell her to:

• Bring the child to the nearest hospital for further assessment
• Bring the child to the health center for IV therapy
• Bring the child to the health center for assessment by the physician
• Let the child rest for 10 minutes then continue giving Oresol more slowly

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50. A woman is considered to be menopause if she has experienced cessation of her menses for a period of

• 6 months
• 12 months
• 18 months
• 24 months

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NCLEX-RN | QB3 | Practice Exam #6 (50 questions)