NCLEX-RN | QB3 | Practice Exam #14 (50 questions)

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

 

1. Nurse Anna is aware that early adaptation of client with renal carcinoma is:

• Nausea and vomiting
• flank pain
• weight gain
• intermittent hematuria

2. A patient with congestive heart failure and severe peripheral edema has a nursing diagnosis of fluid volume excess. What are the two MOST important interventions for the nurse to initiate?

• Diuretic therapy and intake and output
• Nutritional education and low-sodium diet
• Daily weights and intake output
• Low-sodium diet and elevate legs when in bed

3. Nurse Alexandra teaches a client about elastic stockings. Which of the following statements, if made by the client, indicates to the nurse that the teaching was successful?

• "I will wear the stockings until the physician tells me to remove them."
• "I should wear the stockings even when I am sleep."
• "Every four hours I should remove the stockings for a half hour"
• "I should put on the stockings before getting out of bed in the morning?"

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4. Nurse Penny is aware that the symptoms that distinguish post traumatic stress disorder from other anxiety disorder would be:

• Avoidance of situation & certain activities that resemble the stress
• Depression and a blunted affect when discussing the traumatic situation
• Lack of interest in family & others
• Re-experiencing the trauma in dreams or flashback

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5. When teaching a patient how to use a cane after a cerebral vascular accident (CVA), the nurse should make sure the patient

• Uses the cane on the unaffected side
• Advances the cane simultaneously with affected limb
• Holds the cane away from the body
• Moves the cane past the toes of the affected limb

6. The client has severe burns around the right hip. Which position is most important to be emphasized by the nurse that the client maintain to retain maximum function of this joint?

• Hip maintained in 30-degree flexion, no knee flexion
• Hip flexed 90 degrees and knee flexed 90 degrees
• Hip, knee, and ankle all at maximum flexion
• Hip at zero flexion with leg flat

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7. A client suffered from a lower leg injury and seeks treatment in the emergency room. There is a prominent deformity to the lower aspect of the leg, and the injured leg appears shorter that the other leg. The affected leg is painful, swollen and beginning to become ecchymotic. The nurse interprets that the client is experiencing:

• Fracture
• Strain
• Sprain
• Contusion

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8. The physician has diagnosed a client with cirrhosis characterized by asterixis. If the nurse assesses the client with asterixis he can expect to find:

• Irregular movement of the wrist
• Enlargement of the breasts
• Dilated veins around the umbilicus
• Redness of the palmar surfaces

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9. You are a new B.S.N. graduate. You want to become a Public Health Nurse. Where will you apply?

• Department of Health
• Provincial Health Office
• Regional Health Office
• Rural Health Unit

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10. An adolescent client with anorexia nervosa refuses to eat, stating, "I'll get too fat." Nurse Andrea can best respond to this behavior initially by:

• Not talking about the fact that the client is not eating
• Stopping all of the client's privileges until food is eaten
• Telling the client that tube feeding will eventually be necessary
• Pointing out to the client that death can occur with malnutrition.

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11. Situation: Understanding different models of care is a necessary part of the nurse patient relationship. Q. A client state, "I get down on myself when I make mistake " Using Cognitive therapy approach, the nurse should:

• Teach the client relaxation exercise to diminish stress
• Provide the client with Mastery experience to boost self esteem
• Explore the clients past experiences that causes the illness
• Help client modify the belief that anything less than perfect is horrible.

12. When you assess the respiratory rate for the patient, you should do all of the following EXCEPT:

• Instruct the patient to breath in and out from his mouth.
• Count each inspiration followed by expiration as one breath.
• Make sure that the patient is not aware that you are counting his respiratory rate.
• Count the respiratory rate for 30 seconds.

13. Stephanie delegates effectively if she has authority to act which is BEST defined as:

• having responsibility to direct others
• being accountable to the organization
• having legitimate right to act
• telling others what to do

14. The nurse has just admitted to the nursing unit a client with a basilar skull fracture who is at risk for increased intracranial pressure. Pending specific health care provider prescriptions, the nurse should safely place the client in which positions? Select all that apply. 1.Head midline. 2.Neck in neutral position. 3.Head of bed elevated 30 to 45 degrees. 4.Head turned to the side when flat in bed. 5.Neck and jaw flexed forward when opening the mouth

• 1,2,3
• 2,3,5
• 3,4,5
• 1,3,4

15. An anticipated outcome for the client after cataract removal surgery would include which of the following?

• The client states her vision is clear
• The client states her infection is under control
• The client describes methods to prevent an increase in intraocular pressure
• The client states she is able to administer parenteral pain medication

16. Honey, a 23-year old client complains of substernal chest pain and states that her heart feels like "it's racing out of the chest". She reports no history of cardiac disorders. The nurse attaches her to a cardiac monitor and notes sinus tachycardia with a rate of 136beats/minutes. Breath sounds are clear and the respiratory rate is 26 breaths/minutes. Which of the following drugs should the nurse question the client about using?

• Barbiturates
• Opioids
• Cocaine
• Benzodiazepines

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17. The parents of a child with juvenile idiopathic arthritis call the clinic nurse because the child is experiencing a painful exacerbation of the disease. The parents ask the nurse if the child can perform range-of-motion exercises at this time. The nurse should make which respond

• "Avoid all exercise during painful periods"
• "Range-of-motion exercises must be performed every day”
• "Have the child perform simple isometric exercises during this time”
• "Administer additional pain medication before performing range-of-motion exercises”

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18. Which of the following would the nurse identify as the initial priority for a child with acute lymphocytic leukemia?

• Instituting infection control precautions
• Encouraging adequate intake of iron-rich foods
• Assisting with coping with chronic illness
• Administering medications via IM injections

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19. Situation: You are fortunate to be chosen as part of the research team in the hospital. A review of the following IMPORTANT nursing concepts was made. Q. This expresses the variability of the data in reference to the mean. It provides as with a numerical estimate of how far, on the average the separate observation are from the mean:

• Standard deviation
• Median
• Frequency
• Mode

20. The client asks Nurse Annie the causes of peptic ulcer. Nurse Annie responds that recent research indicates that peptic ulcers are the result of which of the following:

• Genetic defect in gastric mucosa
• Stress
• Diet high in fat
• Helicobacter pylori infection

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21. The nurse is preparing a client for surgery. Which lab finding should be reported to the physician?

• Potassium 2.5mEq/L
• Hemoglobin 14.5g/dL
• Blood glucose 75mg/dL
• White cell count 8000mm3

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22. The nurse manager is observing a new nursing graduate caring for a burn client in protective isolation. The nurse manager intervenes if the new nursing graduate planned to implement which unsafe component of protective isolation technique?

• Using sterile sheets and linens
• Performing strict hand-washing technique
• Wearing gloves and a gown only when giving direct care to the client
• Wearing protective garb, including a mask, gloves, cap, shoe covers, gowns, and plastic

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23. A client is in a state of uncompensated acidosis. What approximate arterial blood pH does the nurse expect the client to have?

• 7.20
• 7.35
• 7.45
• 7.48

24. A 23 year-old male comes to the Emergency Department in a sickle cell crisis. He reports that his pain level is a 10/10 in all extremities. During the assessment, he cannot lie still because of the pain. There is no cyanosis or clubbing in the extremities and all examination findings are normal. The vital signs recorded were: Blood pressure: 132/82 mmHg. Heart rate: 110/min. Respiratory rate: 18/mm. Temperature: 38.4°C. Oxygen Saturation: 94 % an room air. Which nursing diagnosis is first priority?

• Acute pain
• Fluid volume deficit
• Ineffective tissue perfusion
• Ineffective airway clearance

25. The nurse is caring for a client being treated for alcoholism. Before initiating therapy with disulfiram (Antabuse), the nurse teaches the client that he must read labels carefully on which of the following products?

• Carbonated beverages
• Aftershave lotion
• Toothpaste
• Cheese

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26. Situation: Milo, a 16-year-oid male, has been diagnosed to have AIDS. He worked as entertainer in a cruise ship. Which method of transmission is common to contract AIDS:

• Syringe and needles
• Body fluids
• Sexual contact
• Transfusion

27. The nurse is caring for a client following a myocardial infarction. Which of the following enzymes are specific to cardiac damage?

• SGOT and LDH
• SGOT and CK BB
• LDH and CK MB
• LDH and CK BB

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28. A patient with chronic liver disease secondary to hepatitis C has been admitted with malnutrition. With a nursing diagnosis of alteration in nutrition, less than body requirements, the BEST long-term goal is the patient will:

• Gain at least 10% of bodyweight
• Attain and maintain ideal weight
• Verbalize understanding nutritional needs
• Include high quality protein in diet

29. Discharge instructions for a male client receiving tricyclic antidepressants include which of the following information?

• Restrict fluids and sodium intake
• Don't consume alcohol
• Discontinue if dry mouth and blurred vision occur
• Restrict fluid and sodium intake

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30. Nurse Rose is aware that the statement that best explains why furosemide (Lasix) is administered to treat hypertension is:

• It dilates peripheral blood vessels.
• It decreases sympathetic cardioacceleration.
• It inhibits the angiotensin-converting enzymes
• It inhibits reabsorption of sodium and water in the loop of Henle.

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31. Situation: Two children were brought to you. One with chest indrawing and the other had diarrhea. The following questions apply: Why are small for gestational age newborns at risk for difficulty maintaining body temperature?

• their skin is more susceptible to conduction of cold
• they are preterm so are born relatively small in size
• they do not have as many fat stored as other infants
• they are more active than usual so they throw off comes

32. A nurse is caring for a patient receiving total parenteral nutrition(TPN). The patient reports the sudden on set of feeling short of breath and anxious. The nurse hears crackles in bilateral lower lobes of the lungs and the patient's 02 saturation is 90% on room air. The nurse must IMMEDIATELY:

• Turn off the TPN
• Notify the physician
• Asses the patient's capillary blood glucose level
• Attempt to suction the patient's airway

33. Patrick is treated in the emergency department for a Colles' fracture sustained during a fall. What is a Colles' fracture?

• Fracture of the distal radius
• Fracture of the olecranon
• Fracture of the humerus
• Fracture of the carpal scaphoid

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34. A client who has had a plaster of Paris cast applied to his forearm is receiving pain medication. To detect early manifestations of compartment syndrome, which of these assessments should the nurse make?

• Observe the color of the fingers
• Palpate the radial pulse under the cast
• Check the cast for odor and drainage
• Evaluate the response to analgesics

35. What is the most common characteristic of a stage IV pressure ulcer?

• Pink skin
• Presence of sinus tracts
• Exposure of bone
• Infection

36. A patient has pulmonary embolism. Which of the following nursing diagnoses has PRORITY?

• Anxiety related to pain, dyspnea, and concern of illness
• Risk for injury related to altered hemodynamic status
• Acute pain related to congestion and possible lung infarction
• Ineffective breathing pattern related to acute increase in alveolar dead air space

37. A client is admitted to the psychiatric unit with a diagnosis of anorexia nervosa. Although she is 5' 8" (1.7 m) tall and weighs only 103 lb (46.7 kg), she talks incessantly about how fat she is. Which measure should the nurse take first when caring for this client?

• Teach the client about nutrition, calories, and a balanced diet.
• Establish a trusting relationship with the client.
• Discuss cultural stereotypes regarding thinness and attractiveness.
• Explore the reasons why the client doesn't eat.

38. The nurse is preparing to receive a client from admitting with tumor lysis syndrome (TLS). Which of the following would the nurse expect to find on the laboratory and patient history sections of the chart?

• Hyperkalemia
• Hyperuricemia
• Mental changes
• Low blood pressure

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39. The nurse is giving health education to Felicity about discomfort of pregnancy. Which of the following conditions is brought about by increased absorption of phosphorus?

• Back pain
• Leg cramps
• Constipation
• Heartburn

40. Larry's anterior trunk, both front upper extremities, both lower extremities sustained second and third degree burn. Estimate the total percentage of body surface area burned using the Rule of Nines.

• 0.6
• 0.63
• 0.62
• 0.61

41. The least serious form of brain trauma, characterized by a brief loss of consciousness and period of confusion, is called:

• contusion
• concussion
• contrecoup
• coup

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42. A vaginal exam reveals a footling breech presentation. The nurse should take which of the following actions at this time?

• Anticipate the need for a Caesarean section.
• Apply an internal fetal monitor.
• Place the client in Genu Pectoral position.
• Perform an ultrasound.

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43. During a group therapy session in the psychiatric unit, a client constantly interrupts with impulsive behavior and exaggerated stories that cast her as a hero or princess. She also manipulates the group with attention-seeking behaviors, such as sexual comments and angry outbursts. The nurse realizes that these behaviors are typical of:

• paranoid personality disorder.
• avoidant personality disorder.
• histrionic personality disorder.
• borderline personality disorder.

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44. A set of monozygotic twins who are 23 years old have begun attending groups at mental health center. One twin is diagnosed with schizophrenia. Her twin has no diagnoses but has been experiencing significant anxiety since becoming engaged. In counseling the engaged twin, it would be crucial to include which of the following tactics?

• Her future children will be at risk for developing schizophrenia
• She may have a predisposition for schizophrenia
• One of her parents may develop schizophrenia later in life
• It is unlikely that she will develop schizophrenia, at her age

45. Nurse Josefina is caring for a client who has been diagnosed with delirium. Which statement about delirium is true?

• It's characterized by an acute onset and lasts about 1 month.
• It's characterized by a slowly evolving onset and lasts about 1 week.
• It's characterized by a slowly evolving onset and lasts about 1 month.
• Its characterized by an acute onset and lasts hours to a number of days.

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46. Which home care instructions should the nurse provide to the parent of a child with acquired immunodeficiency syndrome (AIDS)? Select all that apply. 1. Monitor the child's weight 2. Frequent hand washing is important. 3. The child should avoid exposure to other illnesses. 4. The child's immunization schedule will need revision. 5. Clean up body fluid spills with bleach solution (10:1 ratio of water to bleach). 6. Fever, malaise, fatigue, weight loss, vomiting, and diarrhea are expected to occur and do not require special intervention.

• 1,2,3,5
• 1,2,4,5
• 2,3,4,
• 1,3,5,6

47. A client has approached the nurse asking for advice on how to deal with his alcohol addiction. The nurse should tell the client that the only effective treatment for alcoholism is:

• psychotherapy
• total abstinence.
• Alcoholics Anonymous (AA).
• aversion therapy.

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48. The nurse prepares to administer a cleansing enema. What is the most common client position used for this procedure?

• Lithotomy
• Supine
• Sims' left lateral
• Prone

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49. The emergency department nurse is caring for a client who has been identified as a victim of physical abuse, in planning care for the client, which is the priority nursing action?

• Adhering to the mandatory abuse-reporting laws
• Notifying the case worker of the family situation
• Removing the client from any immediate danger
• Obtaining treatment for the abusing family member

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50. An elderly client with glaucoma has been prescribed Timoptic (timolol) eyedrops. Timoptic should be used with caution in clients with a history of:

• Diabetes
• Gastric ulcers
• Emphysema
• Pancreatitis

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NCLEX-RN | QB3 | Practice Exam #14 (50 questions)