NCLEX-RN | QB3 | Practice Exam #9 (50 questions)

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

 

1. After a hearing restoration operation, a patient has no signs of complications and soon recovers which of the following is an expected outcome 5 days after the hearing restoration surgery?

• Regain full hearing
• Minimal facial nerve paralysis
• Minimal urinary incontinence
• Ambulate without difficulty

2. Before helping a male client who has been sexually assaulted, nurse Maureen should recognize that the rapist is motivated by feelings of:

• Hostility
• Inadequacy
• Incompetence
• Passion

3. The nurse is taking the vital signs of the client admitted with cancer of the pancreas. The nurse is aware that the fifth vital sign is:The nurse is taking the vital signs of the client admitted with cancer of the pancreas. The nurse is aware that the fifth vital sign is:

• Anorexia
• Pain
• Insomnia
• Fatigue

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4. Prior to initiating therapy with unfractionated heparin for a patient hospitalized with a deep vein thrombosis, the nurse should plan to:

• Weigh the patient
• Administer aspirin
• Limit fluid intake
• Undress the patient

5. A 32 year-old woman with diabetes mellitus type 1 underwent a cholecystectomy and is now on day two of recovery. The patient's bowel sounds have returned and she has resumed a normal diet but has been finishing less than half of each meal on the tray. The nurse enters the room to perform a routine assessment and finds the patient confused and shaky Blood pressure: 110/60 mmHg Heart rate: 96/min Respiratory rate: 22/mm Temperature: 37.0°C. What is the most appropriate initial intervention?

• Administer glucagon
• Notify the physician
• Given an insulin injection
• Offer a glass of juice

6. During the administration of chemotherapy agents, Nurse Oliver observed that the IV site is red and swollen, when the IV is touched Stacy shouts in pain. The first nursing action to take is:

• Notify the physician
• Flush the IV line with saline solution
• Immediately discontinue the infusion
• Apply an ice pack to the site, followed by warm compress.

7. In patient with renal failure, the diet should be:

• Low protein, low sodium, low potassium
• Low protein, high potassium
• High carbohydrate, low protein
• High calcium, high protein

8. Situation: Jose seeks psychiatric counselling for his ritualistic behavior of counting his money as many as 10 times before leaving home. Q. Obsessive compulsive disorder is BEST described by:

• Uncontrollable impulse to perform an act or ritual repeatedly
• Persistent thoughts
• Recurring unwanted and disturbing thoughts alternating with a behaviour.
• Pathological persistence of unwilled thought, feeling or impulse

9. 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. Headbanging is a common manifestation of an autistic child. A relevant nursing diagnosis would be:

• Activity intolerance
• Impaired physical mobility
• Risk for Injury
• Impaired skin integrity

10. Situation: You are the nurse in the Out-Patient-Department and during your shift you encountered multiple children's condition. The following questions apply. You assessed a child with visible severe wasting, he has:

• kwashiorkor
• marasmus
• LBM
• edema

11. A nursing is caring for a 3-weeks-old infant who was just admitted to the hospital Which of the following nursing interventions does NOT support this infants basic emotional and social needs?

• Provide for continual contact between parents and infant
• Activity involve parents in caring for the infant
• Keep the infant's environment quiet dim, and free of sensory stimulation
• Foster infant-sibling relationship as appropriate

12. A client taking antiretroviral drugs reports his last blood work showed a drop of 3 units in the viral load. The nurse understands that:

• The virus is no longer detectable.
• 90% of the viral load has been eliminated.
• 95% of the viral load has been eliminated.
• 99% of the viral load has been eliminated.

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13. When planning care for Dory with schizotypal personality disorder, which of the following would help the client become involved with others?

• Attending an activity with the nurse
• Leading a sing a long in the afternoon
• Participating solely in group activities.
• Being involved with primarily one to one activities

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14. The nurse is caring for a patient with stage III pressure ulcer to the coccyx. Three days after initiating the plan of care, the nurse observes that the ulcer has hard black crust covering the center of the ulcer. The nurse should understand that this indicates

• Healing
• Need for debridement
• Inadequate nutrition
• Infection

15. A nurse is caring for a client with Parkinson's disease who has been taking carbidopa/ levodopa (Sinemet) for a year. Which of the following adverse reactions will the nurse monitor the client for?

• dykinesia
• glaucoma
• hypotension
• respiratory depression

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16. If nurse administers an injection to a patient who refuses that injection, she has committed:

• Assault and battery
• Negligence
• Malpractice
• None of the above

17. Vitamin K. 10 mg given IM is ordered. Vitamin K is available as 5 mg/ml. How much would the nurse administer?

• 2 ml
• 6 ml
• 4 ml
• 8 ml

18. Tommy, with dependent personality disorder is working to increase his self-esteem. Which of the following statements by the Tommy shows teaching was successful?

• "I'm not going to look just at the negative things about myself”
• "I'm most concerned about my level of competence and progress”
• "I'm not as envious of the things other people have as I used to be"
• "I find I can't stop myself from taking over things other should be doing”

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19. Situation: Rene is a 3 y/o boy brought to the health center for fever and cough. You noted grayish pinpoint dots located at the buccal mucosa. A maculopapular rash was noted on his face. Q. Measles vaccine is given at how many months?

• At birth
• 1 1/2 months
• 6 months
• 9 months

20. A voluntary client has been taking haloperidol (Haldol) as prescribed. One morning, she refuses to take the Haldol. Which of the following actions should the nurse take?

• Summon another nurse to help ensure that the client takes her medicine.
• Tell the client that she can take the medication either orally or by injection.
• Withhold the medication until it is determined why the client is refusing to take it.
• Tell the client that she needs to take her "vitamin" to stay healthy.

21. A type of record wherein each person or department makes notation in separate records. A nurse will use the nursing notes, the doctor will use the Physician's order sheet etc. Data is arranged according to information source.

• POMR
• POR
• Traditional
• Resource oriented

22. The nurse is caring for a client with a Brown-Sequard spinal cord injury. The nurse should expect the client to have:

• Total loss of motor sensory and reflex activity
• Incomplete loss of motor function
• Loss of sensory function with potential for recovery
• Loss of sensation on the side opposite the injury

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23. The nurse is preparing a client for cervical uterine radiation implant insertion. Which will be included in the teaching plan?

• TV or telephone use will not be allowed while the implant is in place.
• A Foley catheter is usually inserted.
• A high-fiber diet is recommended.
• Excretions will be considered radioactive.

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24. A patient is being followed in the clinic for hypertension, adult onset diabetes, and obesity. The patient is apathetic about learning about nutritional guidelines to reach the goals of weight loss and consumption of a healthy diet The patient admitted to eating "whatever is put in front of me" Which of the following actions would the nurse take?

• Collaborate with the patient to set goals
• Add a nursing diagnosis of non-compliance
• Refer for psychiatric screening for depression
• Discuss nutritional interventions with the spouse

25. Henry is a Unit Manager I the Medical Unit. He is not satisfied with the way things are going in his unit. Patient satisfaction rate is 60% for two consecutive months and staff morale is at its lowest He decides to plan and initiate changes that will push for a turnaround in the condition of the unit. Which of the following actions is a priority for Henry?

• Call for a staff meeting and take this up in the agenda.
• Seek help from her manager.
• Develop a strategic action on how to deal with these concerns.
• Ignore the issues since these will be resolved naturally.

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26. Clients with sickle cell anemia are taught to avoid activities that cause hypoxia and hypoxemia. Which of the following activities would the nurse recommend?

• A family vacation in the Rocky Mountains
• Chaperoning the local boys club on a snow-skiing trip
• Traveling by airplane for business trips
• A bus trip to the Museum of Natural History

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27. A client has sustained a fracture of the femur and balanced skeletal traction with a Thomas splint has been applied. To prevent pressure points from occurring around the top of the splint, the most important intervention is to:

• Protect the skin with lotion
• Keep the client pulled up in bed
• Pad the top of the splint with washcloths
• Provide a footplate in the bed

28. Situation Records are vital tools in any institution and should be properly maintained for specific use and time. Q. In the hospital, when you need-the medical record of a discharged patient for research, you will request permission through:

• Doctor in charge
• The hospital director
• The nursing Service
• Medical records section

29. The chief complaint in a client with Vincent's Angina is:

• Chest pain
• Shortness of breath
• Shoulder discomfort
• Bleeding oral ulcerations

30. The single most effective way to prevent nosocomial infections is to:

• Isolate patients with infections
• Cover the mouth and nose when coughing
• Wash all equipment detergents
• Practice continuous hand washing

31. St. Raphael Medical Center just opened its new Performance Improvement Department Ms. Valencia is appointed as the Quality Control Officer. She commits herself to her new role and plans her strategies to realize the goals and objectives of the department. Which of the following is a primary task that they should perform to have an effective control system?

• Make an interpretation about strengths and weaknesses
• identify the values of the department
• Identify structure, process, outcome standards & criteria
• Measure actual performances

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32. Which medication is used to treat iron toxicity?

• Narcan (naloxane)
• Digibind (digoxin immune Fab)
• Desferal (deferoxamine)
• Zinecard (dexrazoxane)

33. A client 12 weeks' pregnant come to the emergency department with abdominal cramping and moderate vaginal bleeding. Speculum examination reveals 2 to 3 cms cervical dilation.The nurse would document these findings as which of the following?

• Threatened abortion
• Imminent abortion
• Complete abortion
• Missed abortion

34. The nurse is closely monitoring the intake and output of an infant with heart failure who is receiving diuretic therapy. The nurse should use which most appropriate method to assess the urine output?

• Weighing the diapers
• Inserting a urinary catheter
• Comparing intake with output
• Measuring the amount of water added to formula

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35. The nurse is observing a graduate nurse as she assesses the central venous pressure. Which observation would indicate that the graduate needs further teaching?

• The graduate places the client in a supine position to read the manometer.
• The graduate turns the stop-cock to the off position from the IV fluid to the client.
• The graduate instructs the client to perform the Valsalva maneuver during the CVP reading.
• The graduate notes the level at the top of the meniscus.

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36. When caring for a dying client who is in the denial stage of grief, the best nursing approach would be to:

• Agree and encourage the client's denial
• Allow the denial but be available to discuss death
• Reassure the client that everything will be OK
• Leave the client alone to confront the feelings of impending loss

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37. A client with cirrhosis has developed signs of heptorenal syndrome. Which diet is most appropriate for the client at this time?

• High protein moderate sodium
• High carbohydrate moderate sodium
• Low protein low sodium
• Low carbohydrate high protein

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38. A community health nurse assesses a 68 year-old patient who lives in a group home. During physical assessment nurse notice that patient skin and mucus membrane are dry and and pale. What type of data is the nurse collecting from the above information?

• Subjective
• Objective
• Medical History
• Analytical

39. A patient on a medical floor is diagnosed with pneumonia. Which of the following interventions is appropriate for a nursing diagnosis of ineffective airway clearance related to tracheobronchial secretions secondary to infection?

• Explain diagnostic procedures and address any of patient's concerns
• Assess patient for signs of discomfort and pain
• Monitor oxygen therapy and encourage to cough and deep breathe
• Monitor patient for shock

40. A pneumonectomy is performed on a client with lung cancer Which of the following would probably be omitted from the clients plan of care?

• Closed chest drainage
• Pain-control measures
• Supplemental oxygen administration
• Coughing and deep-breathing exercises

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41. Situation: Cancer of the prostate is the leading cancer in Men other than skin cancer The following questions will assess your knowledge and theoretical foundation in dealing with clients with prostate cancer. Q. Which among the following is NOT a risk factor for prostate cancer?

• A family member with prostate cancer
• Advancing age
• High fat and diet high in red meats
• Smoking

42. Region IV Hospital is classified as what level of facility?

• Primary
• Secondary
• Intermediate
• Tertiary

43. A client has been receiving chlorpromazine (Thorazine), an antipsychotic, to treat his psychosis. Which findings should alert the nurse that the client is experiencing pseudoparkinsonism?

• Restlessness, difficulty sitting still, and pacing
• Involuntary rolling of the eyes
• Tremors, shuffling gait, and masklike face
• Extremity and neck spasms, facial grimacing, and jerky movements

44. A client with bacterial pneumonia is admitted to the pediatric unit. What would the nurse expect the admitting assessment to reveal?

• High fever
• Nonproductive cough
• Rhinitis
• Vomiting and diarrhea

45. Situation: You are actively practicing nurse who just finished your Graduate Studies. You earned the value of Research and would like to utilize the knowledge and skills gained in the application of research to Nursing service. The following questions apply to research. Which of the following studies is based on qualitative research?

• A study examining clients reactions to stress after open heart surgery
• A study measuring nutrition and weight, loss/gain in clients with cancer
• A study examining oxygen levels after endotracheal suctioning
• A study measuring differences in blood pressure before during and after a procedure

46. The nurse is caring for a client with ascites. Which is the best method to use for determining early ascites?

• Inspection of the abdomen for enlargement
• Bimanual palpation for hepatomegaly
• Daily measurement of abdominal girth
• Assessment for a fluid wave

47. The nurse is making initial rounds at the beginning of the shift and notes that the parenteral nutrition (PN) bag of an assigned client is empty. Which solution should the nurse hang until another PN solution is mixed and delivered to the nursing unit?

• 5% dextrose in water
• 10% dextrose in water
• 5% dextrose in Ringer's lactate
• 5% dextrose in 0.9% sodium chloride

48. Kathleen knows that one of her staff is experiencing burnout Which of the following is the best thing for her to do?

• Advise her staff to go on vacation.
• Ignore her observations; it will be resolved even without intervention
• Remind her to show loyalty to the institution.
• Let the staff ventilate her feelings and ask how she can be of help

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49. To prevent the formation of thrombi in the postoperative patient, the nurse should:

• Teach foot and leg exercises
• Have the patient lie still
• Place pillows under the knee
• Lie in lateral position

50. Nurse Judy is aware that following condition would reflect presence of congenital G.I. anomaly?

• Cord prolapse
• Polyhydramios
• Placenta previa
• Oligohydramnios

 

NCLEX-RN | QB3 | Practice Exam #9 (50 questions)