NCLEX-RN | QB3 | Practice Exam #10 (50 questions)

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

 

1. The clinic nurse is performing a psychosocial assessment of a client who has been told that she is pregnant. Which assessment findings indicate to the nurse that the client is at risk for contracting human immunodeficiency virus (HIV)? Select all that apply. 1. The client has a history of intravenous drug use. 2. The client has a significant other who is heterosexual. 3. The client has a history of sexually transmitted infections. 4. The client has had one sexual partner for the past 10 years. 5. The client has a previous history of gestational diabetes mellitus.

• 2,5
• 3,4,5
• 1,3
• 1,2

2. A client undergone spinal anesthetic, it will be important that the nurse immediately position the client in:

• On the side, to prevent obstruction of airway by tongue.
• Flat on back.
• On the back, with knees flexed 15 degrees.
• Flat on the stomach, with the head turned to the side.

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3. Situation: Burn is cause by transfer of heat source to the body. It can be thermal, electrical radiation or chemical. Q. A client who sustained deep partial thickness and full thickness burns of the face, whole anterior chest and both upper extremities two days ago begins to exhibit extreme restlessness. You recognize that this most likely indicates that the client is developing:

• Cerebral hypoxia
• Hypervolemia
• Metabolic acidosis
• Renal failure

4. Nurse Faith should recognize that fluid shift in an client with burn injury results from increase in the:

• Total volume of circulating whole blood
• Total volume of intravascular plasma
• Permeability of capillary walls
• Permeability of kidney tubules

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5. Situation: Jolina is an 18 year old beginning college student. Her mother observed that she is having problems relating with her friends. She is undecided about her future. She has lost insight, lost interest in anything and complained and complained of constant tiredness. Q. During the predischarge conference, the nurse suggests vocational guidance because it should help Jolina to:

• Find a good job
• Make some decision about her future
• Realistically assess her assets and limitations
• Solve her own problems

6. A client with parenteral nutrition (PN) infusing has disconnected the tubing from the central line catheter. The nurse assesses the client and suspects an air embolism. The nurse should immediately place the client in which position?

• On the left side, with the head lower than the feet
• On the left side, with the head higher than the feet
• On the right side, with the head lower than the feet
• On the right side with the head higher than the feet

7. The nurse prepares a teaching plan for the mother of a child diagnosed with bacterial conjunctivitis. Which, if stated by the mother, indicates a need for further teaching?

• "I need to wash my hands frequently."
• "I need to clean the eye as prescribed."
• "It is okay to share towels and washcloths"
• "I need to give the eye drops as prescribed"

8. The nurse is taking the history of a client with occupational lung disease (silicosis). The nurse should assess whether the client wears which item during periods of exposure to silica particles?

• Gloves
• Eye protection
• Mask
• Gown

9. Situation: You are assigned at the surgical ward and clients have been complaining of post pain at varying degrees. Pain as you know is very subjective. Q. The client complained of abdominal distention and pain. Your nursing intervention that can alleviate pain is:

• Instruct client to go to sleep and relax
• Advice the client to close the lips and avoid deep breathing and talking
• Offer hot and clear soup
• Turn to sides frequently and avoid too much talking

10. The client with color blindness will most likely have problems distinguishing which of the following colors?

• Orange
• Violet
• Red
• White

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11. Norma, with recent colostomy expresses concern about the inability to control the passage of gas. Nurse Oliver should suggest that the client plan to:

• Eliminate foods high in cellulose.
• Decrease fluid intake at meal times.
• Avoid foods that in the past caused flatus.
• Adhere to a bland diet prior to social events.

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12. The nurse is inserting a nasogastric [NG) tube into a patient as prescribed. The nurse has advanced the tube into patient's posterior pharynx. The nurse should ask the patient to:

• Hold the breath
• Stare upwards with eyes towards the ceiling
• Perform the valsalvas maneuver
• Lower the chin towards the chest

13. Which of the following would the nurse identify as a classic sign of PIH?

• Edema of the feet and ankles
• Edema of the hands and face
• Weight gain of 1 lb/week
• Early morning headache

14. A client with sickle cell anemia is admitted to the labor and delivery unit during the first phase of labor. The nurse should anticipate the clients need for:

• Supplemental oxygen
• Fluid restriction
• Blood transfusion
• Delivery by Caesarean section

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15. Parental actions which can help achieve the goal of adolescent years are all of the following, EXCEPT;

• permits increasing independence
• discusses future plans with the adolescent
• intolerance of .adolescent's need to be liked by peers
• permits and encourages peer relationships

16. The nurse is aware the early indicator of hypoxia in the unconscious client is:

• Cyanosis
• Increased respirations
• Hypertension
• Restlessness

17. When providing foot care to a resident it is important for the nurse aide to:

• remove calluses and corns.
• check the feet for skin breakdown.
• keep the water cool to prevent burns.
• apply lotion, including between the toes.

18. A female client with rheumatoid arthritis has been on aspirin grain TID and prednisone l0mg BID for the last two years. The most important assessment question for the nurse to ask related to the client's drug therapy is whether she has

• Headaches
• Tarry stools
• Blurred vision
• Decreased appetite

19. In planning for the care of a patient with Crohn's disease, the nurse and patient discuss the interventions. Which of the following treatment modalities would MOST likely be considered a primary intervention for this disease?

• Surgery
• Medications
• High-residue diet
• Blood replacement

20. A client with B positive blood is scheduled for a transfusion of whole blood. Which finding requires nursing intervention?

• The available blood has been banked for two weeks.
• The blood available for transfusion is Rh negative.
• The client has a peripheral IV of D5 1/2 normal saline.
• The blood available for transfusion is type 0 positive.

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21. The school nurse is assessing an elementary student with hemophilia who fell during recess. Which symptoms indicate hemarthrosis?

• Pain coolness and blue discoloration in the affected joint
• Tingling and pain without loss of movement in the affected joint
• Warmth redness and decreased movement in the affected joint
• Stiffness aching and decreased movement in the affected joint

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22. A nurse is caring for a 3-year-old child with a fractured arm. Which of the following interventions is the MOST appropriate for pain management?

• Administer analgesics when necessary
• Assess pain once a shift
• Anticipate pain and intervene early
• Encourage the use of self-quieting techniques

23. Mr. Vasquez 56-year-old client with a 40-year history of smoking one to two packs of cigarettes per day has a chronic cough producing thick sputum, peripheral edema and cyanotic nail beds. Based on this information, he most likely has which of the following conditions?

• Adult respiratory distress syndrome (ARDS)
• Asthma
• Chronic obstructive bronchitis
• Emphysema

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24. A tracheostomy cuff is to be deflated, which of the following nursing intervention should be implemented before starting the procedures?

• Suction the trachea and mouth.
• Have the obdurator available.
• Encourage deep breathing and coughing.
• Do a pulse oximetry reading.

25. The nurse is performing a neurological assessment on a client and elicits a positive Romberg's sign. The nurse makes this determination based on which observation?

• An involuntary rhythmic, rapid, twitching of the eyeballs
• A dorsiflexion of the ankle and great toe with fanning of the other toes
• A significant sway when the client stands erect with feet together, arms at the side, and the eyes closed
• Alack of normal sense of position when the client is unable to return extended fingers to a point of reference

26. The glycosylated hemoglobin of a 40-year-old client with diabetes mellitus is 2.5%. The nurse understands that:

• The client can have a higher-calorie diet.
• The client has good control of her diabetes.
• The client requires adjustment in her insulin dose.
• The client has poor control of her diabetes.

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27. What does a nurse explain to a pregnant client about the cause of her physiologic anemia?

• Erythropoiesis decreases.
• Plasma volume increases.
• Utilization of iron decreases.
• Detoxification by the liver increases.

28. A couple, who have been attempting to become pregnant for 5 years, is seeking assistance from an infertility clinic. The nurse assesses the clients' emotional responses to their infertility. Which of the following responses would the nurse expect to find? Select all that apply. 1. Anger at others who have babies. 2. Feelings of failure because they can't make a baby. 3. Sexual excitement because they want so desperately to conceive a baby. 4. Sadness because of the perceived loss of being a parent. 5. Guilt on the part of one partner because he or she is not able to give the other a baby.

• 1,2,3,4
• 2,3,5
• 1,2,4,5
• 1,3,5

29. A 42-year-old client admitted with an acute myocardial infarction asks to see his chart. What should the nurse do first?

• Allow the client to view his chart
• Contact the supervisor and physician for approval
• Ask the client if he has concerns about his care
• Tell the client that he isn't permitted to view his chart

30. Mrs. Hogan, a 43-year-old woman, is admitted to your unit for cholecystectomy. Q. You are responsible for teaching Mrs. Hogan deep breathing and coughing exercises. Why are these exercises especially important for Mrs. Hogan?

• they prevent postoperative atelectasis and pneumonia
• the incision in gallbladder surgery is in the subcostal area, which makes the client reluctant to take a deep breath and cough
• because she is probably overweight and will be less willing to breathe, cough, and move postoperatively
• NONE

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31. Which of the following conditions will lead to a small-for-gestational age fetus due to less blood supply to the fetus?

• Diabetes in the mother
• Maternal cardiac condition
• Premature labor
• Abruptio placenta

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32. The nurse is caring for a client hospitalized with acute exacerbation of chronic obstructive pulmonary disease. Which findings would the nurse expect to note on assessment of this client? Select all that apply. 1.A low arterial PCo2 level. 2.A hyperinfiated chest noted on the chest x-ray. 3.Decreased oxygen saturation with mild exercise. 4.A widened diaphragm noted on the chest x-ray. 5.Pulmonary function tests that demonstrate increased vital capacity

• 2,3,4,5
• 3,4,5
• 2,3
• 1,3,4,5

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33. Nurse Karen is revising a client plan of care. During which step of the nursing process does such revision take place?

• Planning
• Implementation
• Diagnosing
• Evaluation

34. Situation: Manuel seeks psychiatric counselling for his ritualistic behavior of counting his money as many as 10 times before leaving home. Q. To be more effective, the nurse who cares for persons with obsessive compulsive disorder must possess one of the following qualities:

• Compassion
• Consistency
• Patience
• Friendliness

35. Situation: Leo lives in the squatter area. He goes to nearby school. He helps his mother gather molasses after school. One day, he was absent because of fever, malaise, anorexia and abdominal discomfort. Q. Disaster control should be undertaken when there are 3 or more hepatitis A cases. Which of these measures is a priority?

• Eliminate fecal contamination from foods
• Mass vaccination of uninfected individuals
• Health promotion and education to families and communities about the disease it's cause and transmission.
• Mass administration of immunoglobulin

36. When feeding a resident, frequent coughing can be a sign the resident is

• getting full.
• needs to drink more fluids.
• having difficulty swallowing.
• choking.

37. A client is diagnosed with a disorder involving the inner ear. Which is the most common client complaint associated with a disorder involving this part of the ear?

• Pruritus
• Tinnitus
• Hearing loss
• Burning in the ear

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38. Situation: Because severe burn can affect the person's totality it is important that you apply interventions focusing on the various dimensions of man. You also have to understand the rationale of the treatment. Q. The major disadvantage of whirlpool cleansing of burn wounds is:

• patient hypothermia
• cross contamination of wound
• patient discomfort
• excessive manpower requirement

39. Situation: If a child with diarrhea registers one sign in the pink row and one in the yellow; row in the IMCI Chart Q. A child who has had diarrhea for 14 days but has no sign of dehydration is classified as:

• severe persistent diarrhea
• dysentery
• severe dysentery
• persistent diarrhea

40. Which of the following cluster of data belong to Maslow's hierarchy of needs:

• Love and belonging
• Physiologic needs
• Self actualization
• All of the above

41. After therapy with the thrombolytic alteplase (t-PA., what observation will the nurse report to the physician?

• 3+ peripheral pulses.
• Change in level of consciousness and headache.
• Occasional dysrhythmias.
• Heart rate of 100/bpm.

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42. The parents of an infant client ask the nurse to teach them how to administer Cortisporin eye drops. The nurse is correct in advising the parents to place the drops:

• In the middle of the lower conjunctival sac of the infant's eye.
• Directly onto the infant's sclera.
• In the outer canthus of the infant's eye.
• In the inner canthus of the infant's eye.

43. The nurse is assessing a client following a coronary artery bypass graft (CABG). The nurse should give priority to reporting:

• Chest drainage of 150mL in the past hour
• Confusion and restlessness
• Pallor and coolness of skin
• Urinary output of 40mL per hour

44. Martina, a tennis champ was devastated after many new competitors outpaced her in the Wimbledon event She became depressed and always seen crying. Martina is clearly on what kind of situation?

• Martina is just stressed out
• Martina is Anxious
• Martina is in the exhaustion stage of GAS
• Martina is in Crisis

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45. During a physical in the prenatal clinic the client’s vaginal mucosa is observed to have a purplish discoloration. What sign should the nurse document in the client’s clinical record?

• Hegar
• Goodell
• Chadwick
• Braxton Hicks

46. To facilitate self-care for a 2-year-old child with spastic cerebral palsy, the nurse should recommend:

• Placing straws into beverage containers
• Obtaining eating utensils that have large handles
• Replacing zippers on clothing with metal snaps
• Purchasing shoes that have an open heels area

47. Which of the following would the nurse expect to assess in a child with celiac disease having a celiac crisis secondary to an upper respiratory infection?

• Respiratory distress
• Lethargy
• Watery diarrhea
• Weight gain

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48. A child is treated for superficial (first-degree) thermal burns to the thigh. The child is in great discomfort and does not eat Which of the following diagnosis should receive PRIORITY?

• Altered nutrition
• Impaired skin integrity
• Risk for infection
• Acute pain

49. The nurse has given medication instructions to a client receiving phenytoin. Which statement indicates that the client has an adequate understanding of the instructions?

• "Alcohol is not contraindicated while taking this medication."
• "Good oral hygiene is needed, including brushing and flossing."
• "The medication dose may be self-adjusted, depending on side effects.”
• "The morning dose of the medication should be taken before a serum medication level is drawn.”

50. Situation: You are the nurse in the Out-Patient-Department and during your shift you encountered multiple children's condition. The following questions apply. Q. Which of the following statements about immunization is NOT true:

• A child with diarrhea who is due for OPV should receive the OPV and make extra dose on the next visit
• There is no contraindication to immunization if the child is well enough to go home
• There is no contraindication to immunization if the child is well enough to go home and a child should be immunized in the health center before referrals are both correct
• A child should be immunized in the center before referral

 

NCLEX-RN | QB3 | Practice Exam #10 (50 questions)