NCLEX-RN | QB3 | Practice Exam #16 (50 questions)
All 50 questions are randomized each time you take the test, and do not appear in the same order.
1. A 40 year-old man present to the clinic with a weight loss of three kilograms over the past month. His health problem produces moderate spastic body movements, hyperreflexia, muscular contractions followed by relaxation, and a positive Babinski reflex. He has difficulty speaking due to poor muscle tone and has recently developed swallowing difficulties. The nurse creates a care plan to address his developing problem. Which is the priority nursing intervention?
- Increase caloric intake
- Aspiration prevention
- Infection control
- Improved muscle control
2. Ricardo, an outpatient in psychiatric facility is diagnosed with dysthymic disorder. Which of the following statement about dysthymic disorder is true?
- It involves a mood range from moderate depression to hypomania
- It involves a single manic depression
- It's a form of depression that occurs in the fall and winter
- It's a mood disorder similar to major depression but of mild to moderate severity
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3. Mr. Snyder is admitted to your unit with a brain tumor. The type of tumor he has is currently unknown. You begin to think about the way brain tumors are classified. Q. Glioma is an intracranial tumor. Which of the following statements about gliomas do you know to be false?
- 50% of all intracranial tumors are gliomas
- gliomas are usually benign
- they grow rapidly and often cannot be totally excised from the surrounding tissue
- most glioma victims die within a year after diagnosis
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4. A 32 year old male graduate student, who has become increasingly withdrawn and neglectful of his work and personal hygiene, is brought to the psychiatric hospital by his parents. After detailed assessment, a diagnosis of schizophrenia is made. It is unlikely that the client will demonstrate:
- Low self esteem
- Concrete thinking
- Effective self boundaries
- Weak ego
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5. A child is admitted with a serious infection. After two days of antibiotics, he is severely neutropenic. The physician orders granulocyte transfusions for the next four days. The mother asks the nurse why? The nurse responds:
- "This is the only treatment left to offer the child.”
- "This therapy is fast and reliable in treating infections in children.”
- "The physician will have to explain his rationale to you.”
- "Granulocyte transfusions replenish the low white blood cells until the body can produce its own."
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6. The nurse is planning care for several children who were admitted during the shift Daily weights should be the plan of care for the child who is receiving:
- Total parenteral nutrition(TPN)
- Supplement oxygen
- Intravenous anti-ineffective
- Chest physiotherapy
7. When a client on labor experiences the urge to push a 9cm dilation, the breathing pattern that nurse Rhea should instruct the client to use is the:
- Expulsion pattern
- Slow paced pattern
- Shallow chest pattern
- Blowing pattern
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8. A community health care nurse visits a patient who had a cerebrovascular accident. The patient is at risk for deficient volume due to voluntary reduction intake fluid intake to avoid the use of the bathroom. The nurse educates the patient on the importance of drinking fluids and maintaining hydration. Which of the following indicates the efficacy of the nursing intervention?
- Amber color urine
- Respiration of 35
- Tachycardia
- Moist mucous membrane
9. Nimodipine (Nimotop) is ordered for the client with a ruptured cerebral aneurysm. What does the nurse recognize as a desired effect of this drug?
- Prevent the influx of calcium into cells.
- Restore a normal blood pressure reading.
- Prevent the inflammatory process.
- Dissolve the clot that has formed.
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10. Situation: Johnny, sought consultation to the hospital before Q. His diagnosis was hyperthyroidism, the following are expected symptoms except:
- Provision of comfortable space
- Palpitation
- Fine tremors of the hand
- Hyper alertness
11. Situation: The nurse is performing health education activities for Jane Segovia, a 30 years old Dentist with Insulin dependent diabetes Mellitus. Q. The nurse is teaching plan of care for Jane with regards to proper foot care. Which of the following should be included in the plan?
- Soak feet in hot water
- Avoid using mild soap on the feet
- Apply a moisturizing lotion to dry feet but not between the toes
- Always have a podiatrist to cut your toe nails; never cut them yourself
12. Jun approaches the nurse and tells that he hears a voice telling him that he's evil and deserves to die. Which of the following terms describes the client's perception?
- Delusion
- Disorganized speech
- Hallucination
- Idea of reference
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13. The nurse in preparing to insert RYLE'S tube (NGT) into an infant, the nurse knows that the length of the tube should be taken as following:
- From the nose down to the chin and then to the umbilicus
- From the nose to the earlobe and then to the xiphoid process
- From the nose to the mouth to the xiphoid process
- None.
14. A couple who wants to conceive but has been unsuccessful during the last 2 years has undergone many diagnostic procedures. When discussing the situation with the nurse, one partner states, "We know several friends in our age group and all of them have their own child already, Why can't we have one?". Which of the following would be the most pertinent nursing diagnosis for this couple?
- Fear related to the unknown.
- Pain related to numerous procedures.
- Ineffective family coping related to infertility
- Self-esteem disturbance related to infertility.
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15. A muscular enlarge pouch or sac that lies slightly to the left which is used for temporary storage of food
- Gallbladder
- Urinary bladder
- Stomach
- Lungs
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16. The nurse is monitoring a client in active labor and notes that the client is having contractions every 3 minutes that last 45 seconds. The nurse notes that the fetal heart rate between contractions is 100 beats/ minute. Which nursing action is most appropriate?
- Notify the health care provider (HCP).
- Continue monitoring the fetal heart rate.
- Encourage the client to continue pushing with each contraction.
- Instruct the client's coach to continue to encourage breathing techniques.
17. Penicillin G procaine, 1,000,000 units IM (intramuscularly), is prescribed for a child with an infection. The medication label reads "1,200,000 units per 2 mL." The nurse has determined that the dose prescribed is safe. The nurse administers how many milliliters per dose to the child?
- 0.8mL
- 1.2mL
- 1.4mL
- 1.7mL
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18. Situation: Nurse Dana is going to perform an abdominal examination to Mr. Lee who was admitted due to on and off pain since yesterday. Q. To identify any localized bulging, distention and peristaltic waves, Nurse Dana must perform which of the following?
- Auscultation
- Inspection
- Palpation
- Percussion
19. In Leopold's maneuver step #1, you palpated a soft broad mass that moves with the rest of the mass. The correct interpretation of this finding is:
- The mass palpated at the fundal part is the head part.
- The presentation is breech.
- The mass palpated is the back
- The mass palpated is the buttocks.
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20. A patient is receiving intravenous fluids at a rate of 125 milliliters/hour (ml/hr). What volume fluids will the patient receive during an 8-hour shift?
- 1,500 ml
- 1 liter
- 1.5 liters
- 500 ml
21. The nurse is providing instructions to a pregnant client with human immunodeficiency virus (HIV) infection regarding care to the newborn after delivery. The client asks the nurse about the feeding options that are available. Which response should the nurse make to the client?
- "You will need to bottle-feed your newborn.”
- "You will need to feed your newborn by nasogastric tube feeding.”
- "You will be able to breast-feed for 6 months and then will need to switch to bottle feeding."
- "You will be able to breast-feed for 9 months and then will need to switch to bottle feeding."
22. Client with a history of schizophrenia has been admitted for suicidal ideation. The client states "God is telling me to kill myself right now.” The nurse's best response is:
- I understand that god's voice are real to you, But I don't hear anything. I will stay with you.
- The voices are part of your illness; it will stop if you take medication
- The voices are all in your imagination, think of something else and it'll go away
- don't think of anything right now, just go and relax.
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23. The client has been taking the monoamine oxidase inhibitor (MAOI) phenelzine (Nardil), 10 mg bid. The physician orders a selective serotonin reuptake inhibitor (SSRI), paroxetine (Paxil), 20 mg given every morning. The nurse:
- Gives the medication as ordered.
- Questions the physician about the order.
- Questions the dosage ordered.
- Asks the physician to order benztropine (Cogentin) for the side effects.
24. Richard is admitted with a diagnosis of schizotypal personality disorder Which signs would this client exhibit during social situations?
- Aggressive behavior
- Paranoid thoughts
- Emotional affect
- Independence needs
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25. For a neurologicaliy injured client, the nurse would best assess motor strength by:
- Comparing equality of hand grasps
- Observing spontaneous movements
- Observing the client feed himself
- Asking him to signal if he feels pressure applied to his feet
26. A child is admitted to the hospital with congenital heart disease. Which of the following nursing diagnoses should receive PRIORITY?
- Decreased cardiac output related to decreased myocardial function
- Activity intolerance related to cachexia
- Impaired gas exchanged related to altered pulmonary blood flow
- Imbalanced nutrition: less than body requirements related to excessive energy demands
27. Several minutes after the delivery, the placenta is still intact The nurse will do which of these actions?
- Push gently, but firmly on the fundus
- Call the nursing supervisor for help
- Allow the infant to suck on the breast
- Initiate separation by gently pulling on the cord.
28. A patient is preparing for a total knee replacement. During the preoperative interview process the patient reports an allergic reaction to penicillin. Which of the following is considered a side effect and not a true allergy to medication?
- Shortness of breath
- Tingling lips and tongue
- Upset stomach
- Rash
29. Situation: ENTEROSTOMAL THERAPY is now considered especially in nursing. You are participating in the OSTOMY CARE CLASS. Q. When observing a rectum demonstration of colostomy irrigation, you know that more teaching is required if Fermin:
- Lubricates the tip of the catheter prior to inserting into the stoma
- Hands the irrigating bag on the bathroom door doth hook during fluid insertion
- Discontinues the insertion of fluid after only 500 ml of fluid had been insertion
- Clamps off the flow of fluid when feeling uncomfortable
30. A three-year-old is immobilized in a hip spica cast. Which discharge instruction should be given to the parents?
- Keep the bed flat with a small pillow beneath the cast.
- Provide crayons and a coloring book for play activity,
- Increase her intake of high-calorie foods for healing.
- Tuck a disposable diaper beneath the cast at the perineal opening.
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31. What response should a nurse be particularly alert for when assessing a client for side effects of long-term cortisone therapy?
- Hypoglycemia
- Severe anorexia
- Behavioral changes
- Anaphylactic shock
32. 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
- 1.25mL
- 0.5mL
- 1.0mL
33. Lydia undergoes a laryngectomy to treat laryngeal cancer. When teaching the client how to care for the neck stoma, the nurse should include which instruction?
- "Keep the stoma uncovered.”
- "Keep the stoma dry"
- "Have a family member perform stoma care initially until you get used to the procedure"
- "Keep the stoma moist"
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34. Situation: In a client with widespread colon cancer. A colectomy is the surgical procedure of choice instead of an Abdominal perineal resection. Q. Ileostomy is performed after a colectomy. The nurse will expect that the stool of the client will be:
- Mushy
- Spicy
- Liquid
- Soft
35. Isolation of a child with measles belongs to what level of prevention?
- Primary
- Secondary
- Intermediate
- Tertiary
36. Situation: Mr Roberto's condition continues to worsen and the doctor suggested Kidney Transplantation. Q. Steroids, if used following kidney transplantation would cause which of the following side effects?
- Alopecia
- Increase Cholesterol Level
- Orthostatic Hypotension
- Increase Blood Glucose Level
37. A client seeks care because she feels depressed and has gained weight. To treat her atypical depression, the physician prescribes tranylcypromine sulfate (Parnate), 10 mg by mouth twice per day. When this drug is used to treat atypical depression, what is its onset of action?
- 1 to 2 days
- 3 to 5 days
- 6 to 8 days
- 10 to 14 days
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38. A child with a diagnosis of tetralogy of fallot is scheduled to be discharged from the hospital the nurse planning discharge education should instruct the caregivers that during a hyper cyanotic spell the position MOST likely to benefit the child is:
- Supine
- Side-lying
- Knee-chest
- Prone
39. A patient with SLE (systemic lupus erythematous) report decreased urinary output during the past 2-4 days and chest pain that is aggravated by breathing and coughing. The patient vital signs remain within the baseline normal range s1 and s2 are present with audible friction rub. Which of the following statement would be appropriate for the nurse to make?
- It sounds like SLE is being well controlled
- I need to get some nitroglycerine for your chest pain
- There may be some inflammation surrounding your heart
- Your symptoms may be due to a urinary tract infection
40. When developing a plan of care for a female client with acute stress disorder who lost her sister in a car accident Which of the following would the nurse expect to initiate?
- Facilitating progressive review of the accident and its consequences
- Postponing discussion of the accident until the client brings it up
- Telling the client to avoid details of the accident
- Helping the client to evaluate her sister's behavior
41. A nurse is caring for a child with a very low platelet count related to chemotherapy. The nurse should monitor this child’s urine for the presence of which constituent?
- Protein
- Glucose
- Erythrocytes
- Lymphocytes
42. A patient presents to the emergency room with complaints of eye and drainage. In planning for the examination of the patients complaints, which of the following instruction would the nurse MOST likely select?
- Sphygmomanometer
- Thermometer
- Ophthalmoscope
- Otoscope
43. A patient presents to the clinic with "pins and needles" sensations of the left foot and complains that objects appear "Shimmering". The patient is diagnosed with optic neuritis and referred for further testing. The patient is MOST likely to be tested for:
- Glaucoma
- Multiple sclerosis
- Lesion of brain stem
- Psychosis
44. Immediately after liver biopsy, the client is placed on the right side, the nurse is aware that that this position should be maintained because it will:
- Help stop bleeding if any occurs
- Reduce the fluid trapped in the biliary ducts
- Position with greatest comfort
- Promote circulating blood volume
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45. Situation: Annie has a morbid fear of heights. She asks the nurse what desensitization therapy is: Q. Anti-anxiety medication should be used with extreme caution because long term use can lead to.
- Parkinsonian like syndrome
- Hypertensive crisis
- Hepatic failure
- Risk of addiction
46. The nurse administered a prescribed intramuscular medication to a patient during a home health visit. How should the nurse dispose of the used needle and syringe?
- Recap the needle, then place the needle and syringe into a waterproof container until safe disposal can be made
- Bend the needle back towards the barrel of the syringe before putting the needle and syringe in a metal trash container
- Wrap the needle and syringe in disposable paper before putting the needle and syringe into the dirty section of the nurse's equipment bag
- Put the needle and syringe directly into a puncture-resistant plastic container that has a lid
47. The nurse is assigned to care for a client with cytomegalovirus retinitis and acquired immunodeficiency syndrome who is receiving foscarnet, an antiviral medication. The nurse should monitor the results of which laboratory study while the client is taking this medication?
- CD4+ T cell count
- Lymphocyte count
- Serum albumin level
- Serum creatinine level
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48. Situation: Michelle is a 6 year old preschooler. She was reported by her sister to have measles but she is at home because of fever, upper respiratory problem and white sports in her mouth. Source of infection of measles is secretion of nose and throat of infection person. Filterable virus of measles is transmitted by:
- Water supply
- Droplet
- Food ingestion
- Sexual contact
49. Situation: Two children were brought to you. One with chest indrawing and the other had diarrhea. The following questions apply: Nina, the 2nd child has diarrhea for 5 days. There is no blood in the stool. She is irritable and her eyes are sunken. The nurse offered fluids and the child drinks eagerly. How would you classify Nina's illness?
- Some dehydration
- Dysentery
- Severe dehydration
- No dehydration
50. Which of the following activity would be best for a depressed client?
- Basketball
- Swimming
- Finger painting
- Chess