NCLEX-RN | QB3 | Practice Exam #8 (50 questions)
All 50 questions are randomized each time you take the test, and do not appear in the same order.
1. Situation: Mrs. Andres brought his son, Juanito, age 3 to the Pediatric clinic. She noticed that her son is not speaking and tend to repeat everything she says. The mother also told the nurse that Juanito prefers to be alone, will cry when someone will come near him and tend to rock himself from morning till he will fell asleep. Q. An essential clinical feature of autistic disorder is:
- Inability to concentrate in any task
- Easily Distracted
- Stereotyped motor behaviors
- Poor motor skills
2. The client with a benign lung tumor is treated in which of the following ways?
- The tumor is treated with radiation only
- The tumor is treated with chemotherapy only.
- The tumor is left alone unless symptoms are present.
- The tumor is removed, involving the least possible amount of tissue.
3. The nurse is caring for four 1-day postpartum clients. Which client assessment requires the need for follow-up?
- The client with mild afterpains
- The client with a pulse rate of 60 beats/minute
- The client with colostrum discharge from both breasts
- The client with lochia that is red and has a foul-smelling odor
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4. When teaching a mother about introducing solid foods to her child, which of the following indicates the earliest age at which this should be done?
- 1 month
- 2 months
- 3 months
- 4 months
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5. All of the following should be observed in home deliveries, EXCEPT:
- Clean hands
- Clean sheets
- Clean cord
- Clean surface
6. Situation: The infant and child mortality rate in the low to middle income countries is ten times higher than industrialized countries. In response to this the WHO and UNICEF launched protocol Integrated Management of Childhood Illness to reduce the morbidity and mortality against childhood illnesses. A child who is 7 weeks has had diarrhea for 14 days but has no sign of dehydration is classified as?
- Persistent diarrhea
- Severe dysentery
- Dysentery
- Severe Persistent diarrhea
7. 60 years age a patient weighed 73 kilograms (161 pounds). During the current clinic visit the nurse note the patient has an unintended weight loss. This weight loss over 6 months would be considered clinically significant as soon as it reaches the point of being more than a:
- 5% loss
- 8% loss
- 10% loss
- 20% loss
8. A heparin infusion at 1,500 unit/hour is ordered for a 64-year-old client with stroke in evolution. The infusion contains 25,000 units of heparin in 500 ml of saline solution. How many milliliters per hour should be given?
- 15 ml/hour
- 30 ml/hour
- 45 ml/hour
- 50 ml/hour
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9. The nurse is caring for the client following a cerebral vascular accident. Which portion of the brain is responsible for taste, smell, and hearing?
- Occipital
- Frontal
- Temporal
- Parietal
10. 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. Which of the following operative procedures of the thorax is paired with the correct definition?
- Pneumonectomy: removal of the entire lung
- Wedge resection: removal of one or more lobes of a lung
- Decortication: removal of the ribs or sections of ribs
- Thoracoplasty: removal of fibrous membrane that develops over visceral pleura as a result of emphysema
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11. The physician has ordered atropine sulfate 0.4mg IM before surgery. The medication is supplied in 0.8mg per milliliter. The nurse should administer how many milliliters of the medication?
- 0.25mL
- 0.5mL
- 1.0mL
- 1.25mL
12. Which of the following actions would be least effective in maintaining a neutral thermal environment for the newborn?
- Placing infant under radiant warmer after bathing
- Covering the scale with a warmed blanket prior to weighing
- Placing crib close to nursery window for family viewing
- Covering the infant's head with a knit stockinette
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13. SITUATION: Wide knowledge about the human ear, it's parts and it's functions will help a nurse assess and analyze changes in the adult client's health. Q. A client with Cataract is about to undergo surgery. Nurse Oca is preparing plan of care. Which of the following nursing diagnosis is most appropriate to address the long term need of this type of patient?
- Anxiety R/T to the operation and its outcome
- Sensory perceptual alteration R/T Lens extraction and replacement
- Knowledge deficit R/T the preoperative and post operative self care
- Body Image disturbance R/T the eye packing after surgery
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14. Situation: Carlo, 16 years old, comes to the ER with acute asthmatic attack RR is 46/min and he appears to be in acute respiratory distress. Q. You will give health instructions to Carlo, a case of bronchial asthma. The health instruction will include the following EXCEPT:
- Avoid emotional stress and extreme temperature
- Avoid pollution like smoking
- Avoid pollens, dust seafood
- Practice respiratory isolation
15. A patient who had abdominal surgery is in the post anesthesia care unit (PACU).Which of the following nursing diagnosis takes PRIORITY?
- Disturbed sleep pattern
- Acute pain
- Risk for infection
- Ineffective airway clearance
16. Situation: One of the realities that we are confronted with is mortality. It is important for us nurses to be aware of how we view suffering, pain, illness, and even our death as well as its meaning. That way we can help our patients cope with death and dying. Q. Irma is terminally ill she speaks to you in confidence. You now feel that Irma's family could be helpful if they knew what Irma has told you. What should you do first?
- Tell the physician who in turn could tell the family
- Obtain Irma's permission to share the information with the family
- Tell Irma that she has to tell her family what she told you
- Make an appointment to discuss the situation with the family
17. A home health nurse has completed the assessment of a 72-year-old patient with & gait disturbance that will begin home physical therapy. During the interview, the patient reported significant difficulty sleeping more than 4 hours at night Which of the following responses would be appropriate for the nurse to make?
- "Try doing some type of exercise two hours before bedtime"
- "Drink a cup of warm tea before you go to bed"
- "Make sure the bedroom is dark when you get in bed"
- "A nap in the middle of the day should help"
18. A 6-year-old child with human immunodeficiency virus (HIV) infection has been admitted to the hospital for pain management The child asks the nurse if the pain will ever go away. The nurse should make which best response to the child?
- "The pain will go away if you lie still and let the medicine work.”
- "Try not to think about it The more you think it hurts, the more it will hurt."
- "I know it must hurt, but if you tell me when it does, I will try to make it hurt a little less.”
- "Everytime it hurts press on the call button and I will give you something to make the pain go all away."
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19. Situation: ENTEROSTOMAL THERAPY is now considered a specialty in nursing. You are participating in the OSTOMY CARE CLASS. Q. You plan to teach Fermin how to irrigate the colostomy when:
- The perineal wound heals And Fermin can sit comfortably on the commode
- Fermin can lie on the side comfortably about the 3rd postoperative day
- The abdominal incision is closed and contamination is no longer a danger
- The stools starts to become formed, around the 7th postoperative day
20. The nurse is assigned a patient who had surgery under GA. The patient respiratory rate is 4/mnt and the O2 saturation on 3mL/mnt of 02 via nasal cannula is 84%. The nurse is awaiting the result of an ABG and anticipate that which of the following elevated?
- Arterial O2 saturation (SaO2)
- HYDROGEN ion concentration (PH)
- Partial pressure of arterial CO2 (PaCO2)
- None.
21. When assessing the newborn's heart rate, which of the following ranges would be considered normal if the newborn were sleeping?
- 80 beats per minute
- 100 beats per minute
- 120 beats per minute
- 140 beats per minute
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22. A 7 year old child is brought to the emergency room with complaints of feeling sick for 3 weeks with sore throat, cough, and muscle pain. Upon examination, the nurse notes a low grade fever, shortness of breath, and a wheeze on auscultation. The child lives with parents, 6 siblings, and grandfather in a 3 bedroom house. Based on these findings, which of the following diagnosis MOST likely?
- Staphylococcal pneumonia
- Pneumocystis carinii pneumonia
- Bronchiolitis
- Mycoplasma pneumonia
23. As a very anxious female client is talking to the nurse May, she starts crying. She appears to be upset that she cannot control her crying. The most appropriate response by the nurse would be:
- "Is talking about your problem upsetting you?"
- "It is OK to cry; I'll just stay with you for now"
- 'You look upset; lets talk about why you are crying."
- "Sometimes it helps to get it out of your system."
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24. All of the following measures are recommended to prevent pressure ulcers except:
- Massaging the reddened area with lotion
- Using a water or air mattress
- Adhering to a schedule for positioning and turning
- Providing meticulous skin care
25. She introduces the NATURE OF NURSING MODEL:
- Henderson
- Nightingale
- Orlando
- Parse
26. Which of the following is being used when the mother of a hospitalized child calls the student nurse and states, "You idiot, you have no idea how to care for my sick child"?
- Displacement
- Projection
- Repression
- Psychosis
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27. A client is admitted to the unit two hours after an explosion causes burns to the face. The nurse would be most concerned with the client developing which of the following?
- Hypovolemia
- Laryngeal edema
- Hypernatremia
- Hyperkalemia
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28. The nurse will conduct a psycho educational group for family members about depression. Which of the following topics would be of little help to the family members?
- Managing the depressed client at home.
- Drug classifications.
- Support and self-help groups.
- Education about depression.
29. The condition in which a person is aware of his or her own heart contraction without having to feel the pulse is called:
- Arrhythmia
- Dysrhythmia
- Pulse rhythm
- Palpitation
30. The doctor has ordered 80mg of furosemide (Lasix) two times per day. The nurse notes the patient’s potassium level to be 2.5meq/L. The nurse should:
- Administer the Lasix as ordered
- Administer half the dose
- Offer the patient a potassium-rich food
- Withhold the drug and call the doctor
31. The physician has ordered a thyroid scan to confirm the diagnosis of a goiter Before the procedure the nurse should:
- Assess the client for allergies.
- Bolus the client with IV fluid.
- Tell the client he will be asleep.
- Insert a urinary catheter.
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32. Nurse Angela, observe Joel who is very apprehensive over the impending operation. The client is experiencing dyspnea, diaphoresis and asks lots of questions. Angela made a diagnosis of ANXIETY R/T INTRUSIVE PROCEDURE. This is what type of Nursing Diagnosis?
- Actual
- Probable
- Possible
- Risk
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33. Situation: As a member of the health and nursing team you have a crucial role to play in ensuring that all the members participate actively is the various tasks agreed upon, Q. You are invited to participate in the medical mission activity of your alumni association. In the planning stage everybody is expected to identify what they can do during the medical mission and what resources are needed. You though it is also your chance to share what you can do for others. What will be your most important role where you can demonstrate the impact of nursing health?
- Conduct health education on healthy lifestyle
- Be a triage nurse
- Take the initial history and document findings
- Act as a coordinator
34. Which of the following statements explains the main difference between rheumatoid arthritis and osteoarthritis?
- Osteoarthritis is gender-specific, rheumatoid arthritis isn't
- Osteoarthritis is a localized disease rheumatoid arthritis is systemic
- Osteoarthritis is a systemic disease, rheumatoid arthritis is localized
- Osteoarthritis has dislocations and subluxations, rheumatoid arthritis doesn't
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35. The nurse is reading a health care provider's (HCP's) progress notes in the client's record and reads that the HCP has documented "insensible fluid loss of approximately 800 mL daily." The nurse makes a notation that insensible fluid loss occurs through which type of excretion?
- Urinary output
- Wound drainage
- Integumentary output
- The gastrointestinal tract
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36. A client is taking famotidine (Pepcid) asks the home care nurse what would be the best medication to take for a headache. The nurse tells the client that it would be best to take:
- aspirin (acetylsalicylic acid, ASA)
- ibuprofen (Motrin)
- acetaminophen (Tylenol)
- naproxen (Naprosyn)
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37. Which of the following statements describes Piagets stage of concrete operations?
- Reflex activity proceeds to imitative behavior.
- The ability to see anothers point of view increases.
- Thought processes become more logical and coherent.
- The ability to think abstractly leads to logical conclusion.
38. 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. Ms. Anna has been rushed to the hospital with ruptured membrane. Which of the following should the nurse check first?
- Check for the presence of infection
- Assess for Prolapse of the umbilical cord
- Check the maternal heart rate
- Assess the color of the amniotic fluid
39. The nurse is assigned to care for four clients. In planning client rounds, which client should the nurse assess first?
- A postoperative client preparing for discharge with a new medication
- A client requiring daily dressing changes of a recent surgical incision
- A client scheduled for a chest x-ray after insertion of a nasogastric tube
- A client with asthma who requested a breathing treatment during the previous shift
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40. Situation: You are assigned to take care of a group of patients across the lifespan. A woman has been rushed to the hospital with ruptured membrane. Which of the following should the nurse check first?
- Check for the presence of infarction.
- Assess for prolapse of the umbilical cord
- Check the maternal heart rate
- Assess the color of the amniotic fluid
41. The physician has ordered a low-residue diet for a client with Crohns disease. Which food is not permitted in a low-residue diet?
- Mashed potatoes
- Fried fish
- Smooth peanut butter
- Rice
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42. Which of the following complications during a breech birth the nurse needs to be alarmed?
- Abruption placenta.
- Caput succedaneum.
- Pathological hyperbilirubinemia.
- Umbilical cord prolapse.
43. The clinic nurse is providing instructions to a parent of a child with cystic fibrosis regarding the immunization schedule for the child. Which statement should the nurse make to the parent?
- "The immunization schedule will need to be altered”
- "The child should not receive any hepatitis vaccines”
- "The child will receive all of the immunizations except for the polio series”
- "The child will receive the recommended basic series of immunizations along with a yearly influenza vaccination”
44. Which of the following describes a health care team with the principles of participative leadership?
- Each member of the team can independently make decisions regarding the client's care without necessarily consulting the other members.
- The physician makes most of the decisions regarding the client's care.
- The team uses the expertise of its members to influence the decisions regarding the client's care.
- Nurses decide nursing care; physicians decide medical and other treatment for the client.
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45. Instructions for a client with systemic lupus erythematosus (SLE) would include information about which of the following blood dyscrasias?
- Dressier's syndrome
- Polycythemia
- Essential thrombocytopenia
- Von Willebrand's disease
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46. An elderly client with pneumonia may appear with which of the following symptoms first?
- Altered mental status and dehydration
- fever and chills
- Hemoptysis and dyspnea
- Pleuretic chest pain and cough
47. The nurse witnessed a vehicle hit a pedestrian. The victim is dazed and tries to get up. A leg appears fractured. Which intervention should the nurse take?
- Try to reduce the fracture manually.
- Assist the victim to get up and walk to the sidewalk
- Leave the victim for a few moments to call an ambulance.
- Stay with the victim and encourage him or her to remain still.
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48. An obese client asks nurse Julius how to lose weight Before answering, the nurse should remember that long-term weight loss occurs best when:
- Eating patterns are altered
- Fats are limited in the diet
- Carbohydrates are regulated
- Exercise is a major component
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49. Nikki a 5-month old infant was brought by his mother to the health center because of diarrhea for 4 to 5 times a day. Her skin goes back slowly after a skin pinch and her eyes are sunken. Using the IMCI guidelines, you will classify this infant in which category?
- No signs of dehydration
- Some dehydration
- Severe dehydration
- The data is insufficient
50. The home care nurse visits a pregnant client who has a diagnosis of mild preeclampsia. Which assessment finding indicates a worsening of the preeclampsia and the need to notify the health care provider (HCP)?
- Urinary output has increased.
- Dependent edema has resolved.
- Blood pressure reading is at the prenatal baseline.
- The client complains of a headache and blurred vision.