NCLEX-RN | QB3 | Practice Exam #11 (50 questions)
All 50 questions are randomized each time you take the test, and do not appear in the same order.
1. Nursing care for a female client includes removing elastic stockings once per day. The Nurse Betty is aware that the rationale for this intervention?
- To increase blood flow to the heart
- To observe the lower extremities
- To allow the leg muscles to stretch and relax
- To permit veins in the legs to fill with blood.
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2. A patient is admitted to the medical unit with a diagnosis of fluid volume deficit would the nurse expect the doctor to order?
- 0.9% Sodium chloride
- 0.45% Sodium chloride
- Dextran in normal saline
- 5% Sodium chloride
3. Early adult age is particularly focused on achieving:
- independence from parental control
- greater stability and life style
- self-direction and self-appraisal
4. The postpartum nurse is providing instructions to the mother of a newborn with hyperbilirubinemia who is being breast-fed. The nurse should provide which instruction to thmother?
- Feed the newborn less frequently.
- Continue to breast-feed every 2 to 4 hours.
- Switch to bottle-feeding the infant for 2 weeks.
- Stop breast-feeding and switch to bottle-feeding permanently.
5. The nurse is reviewing an electrocardiogram rhythm strip. The P waves and QRS complexes are regular. The PRinterval is 0.16 seconds, and QRScomplexes measure 0.06 seconds. The overall heart rate is 64 beats/minute. Which action should the nurse take?
- Check vital signs.
- Check laboratory test results.
- Notify the health care provider
- Continue to monitor for any rhythm change.
6. Nurse Mary assesses a postpartum client who had an abruption placentae and suspects that disseminated intravascular coagulation (DIC) is occurring when assessments demonstrate:
- A boggy uterus
- Multiple vaginal clots
- Hypotension and tachycardia
- Bleeding from the venipuncture site
7. A client scheduled for an atherectomy asks the nurse about the procedure. The nurse understands that:
- Plaque will be removed by rotational or directional catheters.
- Plaque will be destroyed by a laser.
- A balloon-tipped catheter will compress fatty lesions against the vessel wall.
- Medication will be used to dissolve the build-up of plaque.
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8. Situation: You are assigned to take care of a group of patients across the lifespan. Grace sustained a laceration on her leg from automobile accident Why are lacerations of lower extremities potentially more serious among pregnant women than other?
- lacerations can provoke allergic responses due to gonadotropic hormone release
- a woman is less able to keep the laceration clean because of her fatigue
- healing is limited during pregnancy so these will not heal until after birth
- increased bleeding can occur from uterine pressure on leg veins
9. Situation: Mrs. Lim has had confirmation of her pregnancy. She presents the emergency room with abdominal pain not yet diagnosed. Q. The nurse would suspect an ectopic pregnancy if Mrs Lim complained of:
- An adherent painful ovarian mass
- Lower abdominal cramping for a long period of time
- Leukorrhea and dysuria a few days after the first missed period
- Sharp lower right or left abdominal pain radiating to the shoulder
10. The Nurse is aware that the following tasks can be safely delegated by the nurse to a nonnurse health worker except:
- Taking vital signs
- Change IV infusions
- Transferring the client from bed to chair
- Irrigation of NGT
11. A 13-month-old child recently arrived in the United States from a foreign country with his parents and needs childhood immunizations. His mother reports that he is allergic to eggs. Upon further questioning, you determine that the allergy to eggs is anaphylaxis. Which of the following vaccines should he not receive?
- Hepatitis B
- inactivated polio
- diphtheria, acellular pertussis, tetanus (DTaP)
- mumps, measles, rubella (MMR)
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12. When moving a resident up in bed who is able to move with assistance, the nurse aide should
- position self with knees straight and bent at waist.
- use a gait or transfer belt to assist with the repositioning.
- pull the resident up holding onto one side of the drawsheet at a time.
- bend the resident's knees and ask the resident to push with his/her feet.
13. Situation: Burn is cause by transfer of heat source to the body. It can be thermal, electrical radiation or chemical. Q. The doctor incorporated insulin on the client's fluid during the emergent phase. The nurse knows that insulin is given because:
- Clients with burn also develops Metabolic Acidosis
- Clients with burn also develops hyperglycemia
- Insulin is needed for additional energy and glucose burning after the stressful incidence to hasten wound healing, regain of consciousness and rapid return of hemodynamic stability.
- For hyperkalemia
14. A client complains of fever, perineal pain, and urinary urgency, frequency, and dysuria. To assess whether the client's problem is related to bacterial prostatitis, the nurse reviews the results of the prostate examination for which characteristic of this disorder?
- Soft and swollen prostate gland
- Swollen, and boggy prostate gland
- Tender and edematous prostate gland
- Tender, indurated prostate gland that is warm to the touch
15. A 25-year-old male is admitted in sickle cell crisis. Which of the following interventions would be of highest priority for this client?
- Taking hourly blood pressures with mechanical cuff
- Encouraging fluid intake of at least 200mL per hour
- Position in high Fowlers with knee gatch raised
- Administering Tylenol as ordered
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16. Situation: Sexually Transmitted Diseases are important to identify during pregnancy because of their potential effect on the pregnancy, fetus, or newborn. The following questions pertain to STD's. Based on your learnings, you know that the causative agent of Reynaid ita's infection is:
- Monistat Candida
- Candida Albicans
- Albopictus Candidiasis
- Monakiki
17. Hospitalized patient eats 20% of the meal and states being too tired to eat more what should the nurse do?
- Offer to feed the patient after short rest period.
- Encourage the patient to finish the fluids.
- Remove the meal tray and allow the patient to rest.
- Encourage the patient to finish the protein portion of the meal
18. PPD In occupational health nursing is what type of prevention?
- Primary
- Secondary
- Tertiary
- None of the above
19. Situation: At the medical-surgical ward, the nurse must also be concerned about drug interactions. Q. You have a client with TPN. You know that in TPN, like blood transfusion, there should be no drug incorporation. However, the MD's order read; incorporate insulin to present TPN. Will you follow the order?
- No, because insulin will induce hyperglycemia in patients with TPN
- Yes, because insulin is chemically stable with TPN and can enhance blood glucose level
- No, because insulin is not compatible with TPN
- Yes, because it was ordered by the MD
20. TT4 provides how many percentage of protection against tetanus?
- 70
- 80
- 90
- 99
21. What clinical finding does a nurse anticipate when admitting a client with an extracellular fluid volume excess?
- Rapid, thready pulse
- Distended jugular veins
- Elevated hematocrit level
- Increased serum sodium level
22. An adolescent client with type 1 diabetes mellitus is admitted to the emergency department for treatment of diabetic ketoacidosis. Which assessment findings should the nurse expect to note?
- Sweating and tremors
- Hunger and hypertension
- Cold, clammy skin and irritability
- Fruity breath odor and decreasing level of consciousness
23. A pregnant client is seen for a regular prenatal visit and tells the nurse that she is experiencing irregular contractions. The nurse determines that she is experiencing Braxton Hicks contractions. On the basis of this finding, which nursing action is appropriate?
- Contact the health care provider.
- Instruct the client to maintain bed rest for the remainder of the pregnancy.
- Inform the client that these contractions are common and may occur throughout the pregnancy.
- Call the maternity unit and inform them that the client will be admitted in a preterm labor condition.
24. The staff nurse on the labor and delivery unit is assigned to care to a primigravida in transition complicated by hypertension. A new pregnant woman in active labor is admitted in the same unit The nurse manager assigned the same nurse to the second client. The nurse feels that the client with hypertension requires one-to-one care. What would be the initial action of the nurse?
- Accept the new assignment and complete an incident report describing a shortage of nursing staff.
- Report the incident to the nursing supervisor and request to be floated.
- Report the nursing assessment of the client in transitional labor to the nurse manager and discuss misgivings about the new assignment.
- Accept the new assignment and provide the best care.
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25. Postulated that health is reflected by the organization, interaction, interdependence and integration of the subsystem of the behavioral system.
- Henderson
- Neuman
- Orem
- Johnson
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26. A 5 years old patient who underwent abdominal surgery suffers from deficient fluid volume related to nothing by mouth (NPO) status; intravenous fluid therapy is given for hydration. Which of the following indicates that the treatment is effective?
- Urinary output of 15ml/hr.
- Respiration rate, 35
- Heart rate 100
- Good skin turgor
27. A client with pregnancy-induced hypertension is scheduled for a C-section. Before surgery the nurse should keep the client:
- On her right side
- Supine with a small pillow
- On her left side
- In knee chest position
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28. The nurse observes that the client's knee is swollen and painful. Consequently; which one of the following nursing measures should be carried out?
- Perform passive range of motion during each shift
- Help to change positions to achieve comfort
- Ambulate with him at frequent intervals
- Encourage quadriceps setting exercises
29. Oliguria is:
- Production of abnormally large amount of urine by kidneys.
- Lack of urine production, with no effective urine production.
- voiding that either painful or difficult.
- Low urine output, usually less than 500 ml a day. or 30 ml an hour.
30. A surgery procedure that must be done within 24 hours is called:
- Selective surgery
- Elective surgery
- Urgent surgery
- Emergency surgery
31. Nursing care for a client with schizophrenia must be based on valid psychiatric and nursing theories. The nurse's interpersonal communication with the client and specific nursing interventions must be:
- clearly identified with boundaries and specifically defined roles.
- warm and nonthreatening.
- centered on clearly defined limits and expression of empathy.
- flexible enough for the nurse to adjust the plan of care as the situation warrants.
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32. A client is admitted with a diagnosis of meningitis caused by Neisseria meningitidis. The nurse should institute which type of isolation precautions?
- Contact precautions
- Droplet precautions
- Airborne precautions
- Standard precautions
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33. Which observation in the newborn of a diabetic mother would require immediate nursing intervention?
- Crying
- Wakefulness
- Jitteriness
- Yawning
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34. Which information is most important for the nurse to include in a teaching plan for a schizophrenic client taking clozapine (Clozaril)?
- Monthly blood tests will be necessary.
- Report a sore throat or fever to the physician immediately.
- Blood pressure must be monitored for hypertension.
- Stop the medication when symptoms subside.
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35. When administering an intramuscular injection to an infant, which of the following sites appropriate for the nurse to use?
- Rectus fennoris
- Deltoid
- Dorsogluteal
- Ventrogluteal
36. While preparing post operative paper work for a patient scheduled for neurosurgery, the nurse asks about the patient's use of medications, the patient reports taking an aspirin tablet every day, but has not taken it today. The patient has had nothing by mouth since midnight of the day before, the nurse should:
- Inform the anesthesiologist immediately
- Tell the patient the surgery must be rescheduled
- Record the information on the form in red ink
- Obtain blood sample and notify the attending physician
37. A nurse is preparing to perform an otoscopic examination on an adult client. The nurse does which of the following to perform this examination?
- Pulls the pinna up and back before inserting the speculum
- Pulls the earlobe down and back before inserting the speculum
- Uses the smallest speculum available to decrease the discomfort of the exam
- Tilts the client's head forward and down before inserting the speculum
38. Which of the following is considered as a benefit of bathing:
- Improving self-image.
- Eliminating body odor
- Stimulating circulation.
- All of the above.
39. A patient hospitalized with tuberculosis (TB) has a productive cough and hemoptysis. Which of the following types of isolation room would be the best choice for the patient?
- Reverse isolation
- Standard isolation
- Positive-pressure
- Negative-pressure
40. A client with advanced cirrhosis of the liver is not tolerating protein well, as eveidenced by abnormal laboratory values. The nurse anticipates that which of the following medications will be prescribed for the client?
- lactulose (Chronulac)
- ethacrynic acid (Edecrin)
- folic acid (Folvite)
- thiamine (Vitamin Bl)
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41. A client with schizophrenia has been taking Clozaril (clozapine) for the past six months. This morning the clients temperature was elevated to 102A/F. The nurse should give priority to:
- Placing a note in the chart for the doctor
- Rechecking the temperature in four hours
- Notifying the physician immediately
- Asking the client if he has been feeling sick
42. 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. What type of debridement involves proteolytic enzymes?
- Interventional
- Mechanical
- Surgical
- Chemical
43. A paranoid male client with schizophrenia is losing weight, reluctant to eat, and voicing concerns about being poisoned. The best intervention by nurse Dina would be to:
- Allow the client to open canned or pre-packaged food
- Restrict the client to his room until 2 lbs are gained
- Have a staff member personally taste all of the client's food
- Tell the client the food has been x-rayed by the staff and is safe
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44. Parents bring their 2-week-old infant to a clinic for treatment after a diagnosis of clubfoot made at birth. Which statement by the parents indicates a need for further teaching regarding this disorder?
- "Treatment needs to be started as soon as possible?"
- "I realize my infant will require follow-up care until fully grown?"
- "I need to bring my infant back to the clinic in 1 month for a new cast."
- "I need to come to the clinic every week with my infant for the casting?"
45. David, an adolescent boy was admitted for substance abuse and hallucinations. The client's mother asks Nurse Armando to talk with his husband when he arrives at the hospital. The mother says that she is afraid of what the father might say to the boy. The most appropriate nursing intervention would be to:
- Inform the mother that she and the father can work through this problem themselves.
- Refer the mother to the hospital social worker.
- Agree to talk with the mother and the father together.
- Suggest that the father and son work things out.
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46. The definition of nihilistic delusions is:
- a false belief about the functioning of the body
- belief that the body is deformed or defective in a specific way.
- false ideas about the self, others, or the world
- the inability to carry out motor activities.
47. The home health nurse is visiting a client who plans to deliver her baby at home. Which statement by the client indicates an understanding regarding screening for phenylketonuria (PKU)?
- I will need to take the baby to the clinic within 24 hours of delivery to have blood drawn.
- I will need to schedule a home visit for PKU screening when the baby is three-days-old.
- I will remind the midwife to save a specimen of cord blood for the PKU test.
- I will have the PKU test done when I take her for her first immunizations.
48. The nurse teaches skin care to a client receiving external radiation therapy. Which client statement indicates the need for further instruction?
- "I will handle the area gently"
- "I will wear loose-fitting clothing"
- "I will avoid the use of deodorants"
- "I will limit sun exposure to 1 hour daily"
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49. The nurse is instructing the client about early detection of cancer. The nurse should instruct the client to perform breast self-examination during:
- The first day of every month
- The first day of menstruation
- Before menstruation
- After menstruation
50. He describes the WELLNESS-ILLNESS Continuum as interaction of the environment with well being and illness.
- Cannon
- Bernard
- Dunn
- Clark