NCLEX-RN | QB3 | Practice Exam #18 (50 questions)
All 50 questions are randomized each time you take the test, and do not appear in the same order.
1. A child is admitted to the emergency room following ingestion of a bottle of Childrens Tylenol The nurse is aware that Tylenol (acetaminophen) overdose is treated with:
- Acetylcysteine
- Deferoxamine
- Edetate calcium disodium
- Activated charcoal
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2. 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 functions.
- Activity intolerance related to cachexia
- Impaired gas exchange related to altered pulmonary blood flow
- Imbalanced nutrition: less than body requirement related to excessive energy demands
3. Situation: Mental Retardation is an increasingly common childhood disorder that impairs learning. Q. A tranquilizing agent given in calming a hyperactive mentally retarded is:
- Chlorpromazine [Thorazine]
- Haloperidol [Haldol]
- Imipramine [Tofranil]
- Diazepam [Valium]
4. Mr. Liberatore, age 76, is admitted to your unit He has a past medical history of hypertension, DM, hyperlipidemia. Recently he has had several episodes where he stops talking mid sentence and stares into space. Today the episode lasted for 15 minutes. The admission diagnosis is impending CVA. Q. A client with muscle contraction headache will exhibit a pattern different for Julie's. Which of the following is more compatible with tension headache?
- severe aching pain behind both eyes
- headache worse when bending over
- a bandlike burning around the neck
- feeling of tightness bitemporally, occipitally, or in the neck
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5. Isotretinoin is prescribed for a client with severe acne. Before the administration of this medication, the nurse anticipates that which laboratory test will be prescribed?
- Potassium level
- Triglyceride level
- Hemoglobin A1C
- Total cholesterol level
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6. The nurse is assessing a client with a closed reduction of a fractured femur Which finding should the nurse report to the physician?
- Chest pain and shortness of breath
- Ecchymosis on the side of the injured leg
- Oral temperature of 99.2F
- Complaints of level two pain on a scale of five
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7. The nurse is caring for an elderly client who has been diagnosed as having sundown syndrome. He is alert and oriented during the day but becomes disoriented and disruptive around dinnertime. He is hospitalized for evaluation. The nurse asks the client and his family to list all of the medications, prescription and nonprescription, he is currently taking. What is the primary reason for this action?
- Multiple medications can lead to dementia
- The medications can provide clues regarding his medical background
- Ability to recall medications is a good assessment of the client's level of orientation.
- Medications taken by a client are part of every nursing assessment.
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8. A logical approach used by the nurse in providing community health and communicable nursing is:
- problem solving
- nursing process
- logical nursing intervention
- nursing assessment
9. Which of the following variables will he likely EXCLUDE in his study?
- Competence of nurses
- Caring attitude of nurses
- Salary of nurses
- Responsiveness of staff
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10. Ms. Rizal has acute rheumatoid arthritis. Her hands and spine are involved. When the nurse admits Ms. Rizal is most likely to tell the nurse that the first symptoms that caused her to seek health care was:
- Stiff, sore joints
- Generalized fatigue
- Stabbing hand pain
- Disuse of fingers
11. Situation: Ensuring safety is one of your most important responsibilities. You will need to provide instructions and information to your clients to prevent complications. Q. To prevent recurrent attacks on Terry who has acute glumerulonephritis, you should instruct her to:
- seek early treatment for respiratory infections
- take showers instead of tub bath
- continue to take the same restrictions on fluid intake
- avoid situations that involve physical activity
12. A patient is to receive heparin sodium, 5,000 U, subcutaneous on call to the operating room. Prior to administering this medication, the nurse should advise patient that this will help to prevent:
- Infections
- Atelectasis
- Thrombosis formation
- Positioning injuries
13. The nurse assesses a patient who is 16-weeks pregnant. The patient states that she had taken isotretinoin (Accutane) , a known teratogen for acne during her third, fourth, and fifth week of pregnancy According to the chart, the nurse CAN expect fetal damage to the central nervous system as well as the:
- Palate and eare.
- Heart lower limbs, and palate.
- Limbs, eyes, and teeth.
- Heart, eyes, and limbs.
14. The nurse assesses an elderly patient for health problem. The family reports that the patient has trouble remembering and they are concerned about Alzheimer's. Which of the following are risk factors for Alzheimer's disease?
- Genetic history and male gender
- Ethnic group and dietary habits
- Genetic history and female gender
- Dietary habits and male gender
15. A patient comes to the emergency department complaining of severe crushing substernal pain that radiates to the left arm and jaw. The patient is diaphoretic and pale with cool clammy skin. The patient is diagnosed with acute myocardial infarction. The nursing diagnosis would be decreases cardiac output related to:
- Structural factors (incompetent valves)
- Impaired ventricular expansion
- Impaired contractility
- Fluid volume deficit
16. The nurse is caring for a patient with a coronary thrombosis who is receiving prescribed streptokinase (streptase). The patient reports the onset of a rash as well as feeling hot while experiencing chills. The nurse should IMMEDIATELY implemented the plan of care for:
- A medication side effect
- An allergic embolus
- A Pulmonary embolus
- Peripheral artery occlusion
17. Which client is at highest risk for developing a pressure ulcer?
- 23 year-old in traction for fractured femur
- 72 year-old with peripheral vascular disease, who is unable to walk without assistance
- 75 year-old with left sided paresthesia and is incontinent of urine and stool
- 30 year-old who is comatose following a ruptured aneurysm
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18. A 38-year-old client is admitted for alcohol withdrawal. The most common early sign or symptom that this client is likely to experience is:
- impending coma.
- manipulating behavior.
- suppression
- perceptual disorders.
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19. The nurse is performing an otoscopic examination on a client with mastoiditis. On examination of the tympanic membrane, which finding should the nurse expect to observe?
- A pink-colored tympanic membrane
- A pearly colored tympanic membrane
- A transparent and clear tympanic membrane
- A red, dull, thick, and immobile tympanic membrane
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20. The nurse assesses the client's home environment for the safe use crutches. Which one of the following would pose the greatest hazard to the client's safe use of crutches at home?
- A 4-year old cocker spaniel
- Scatter rugs
- Snack tables
- Diet high in fat
21. The nurse is assessing 16-month old girl. The nurse observes poor hygiene, diaper rash and bruises over the child's body that is at different stages of healing. Which of the following interventions would reduce fear and promotes the trust of the child?
- Avoid scaring the child by saying No or setting limits
- Challenge the information the parents give regarding the injury
- Question the parents of the child regarding the abuse
- Assign one nurse to care for the child over the course of hospital stay
22. A client develops kidney damage as a result of a transfusion reaction. What is the most significant clinical response that the nurse should assess when determining kidney damage?
- Glycosuria
- Blood in the urine
- Decreased urinary output
- Acute pain over the kidney
23. The nurse is monitoring a client admitted to the hospital with a diagnosis of appendicitis who is scheduled for surgery in 2 hours. The client begins to complain of increased abdominal pain and begins to vomit. On assessment, the nurse notes that the abdomen is distended and bowel sounds are diminished. Which is the most appropriate nursing intervention?
- Notify the health care provider (HCP).
- Administer the prescribed pain medication.
- Call and ask the operating room team to perform surgery as soon as possible.
- Reposition the client and apply a heating pad on the warm setting to the client's abdomen.
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24. The chart indicates that a client has expressive aphasia following a stroke. The nurse understands that the client will have difficulty with:
- Speaking and writing
- Comprehending spoken words
- Carrying out purposeful motor activity
- Recognizing and using an object correctly
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25. A nurse makes a home visit to a patient recently diagnosed with chronic obstructive pulmonary disease (COPD), which of the following should the nurse teach the patient about managing COPD?
- Recognizing signs of impending respiratory infection
- Limiting fluids intake minimize bronchial secretions
- Correct technique to auscultate the lung fields
- Importance of starting antibiotic therapy
26. When giving post operative discharge instructs a patient who had abdominal surgery all of the following regarding wound healing are true EXCEPT:
- Bathing to soak abdomen is preferred
- Avoid tight belts and cloths with seams that may rub the wound
- Pain medication may effect ability to drive.
- Irregular bowel habits can be expected
27. Which statement is true regarding the infants susceptibility to pertussis?
- If the mother had pertussis the infant will have passive immunity.
- Most infants and children are highly susceptible from birth.
- The newborn will be immune to pertussis for the first few months of life.
- Infants under one year of age seldom get pertussis.
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28. A 4-year old client was brought to the health center with chief complaint of severe diarrhea and the passage of "rice water”. The client is most probably suffering from which condition?
- Giardiasis
- Cholera
- Amebiasis
- Dysentery
29. A resident who is inactive is at risk of constipation. In addition to increased activity and exercise, which of the following actions helps to prevent constipation?
- Adequate fluid intake
- Regular mealtimes
- High protein diet
- Low fiber diet
30. A nurse assessing a client with SIADH would expect to find laboratory values of:
- Serum Na= 150 mEq/L and low urine osmolality
- Serum K= 5 mEq/L and low serum osmolality
- Serum Na=120 mEq/L and low serum osmolality
- Serum K= 3 mEq/L and high serum osmolality
31. The client has a deep partial-thickness injury to the posterior neck. Which intervention is most important to use during the acute phase to prevent contractures associated with this injury?
- Place a towel roll under the client's neck or shoulder.
- Keep the client in a supine position without the use of pillows.
- Have the client turn the head from side to side 90 degrees every hour while awake.
- Keep the client in a semi-Fowler's position and actively raise the arms above the head every hour while awake.
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32. The client has been taking clomipramine (Anafranil) for his obsessive-compulsive disorder. He tells the nurse, "I'm not really better, and I’ve been taking the medication faithfully for the past 3 days just like it says on this prescription bottle." Which of the following actions would the nurse do first?
- Tell the client to continue taking the medication as prescribed because it takes 5 to 10 weeks for a full therapeutic effect.
- Tell the client to stop taking the medication and to call the physician.
- Encourage the client to double the dose of his medication.
- Ask the client if he has resumed smoking cigarettes.
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33. The following are interventions to make the fundus contract postpartally EXCEPT:
- Make the baby suck the breast regularly
- Apply ice cap on fundus
- Massage the fundus vigorously for 15 minutes until contracted
- Give oxytocin as ordered
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34. When administering total parenteral nutrition the nurse should assess the client for signs of rebound hypoglycemia. The nurse knows that rebound hypoglycemia occurs when:
- The infusion rate is too rapid.
- The infusion is discontinued without tapering.
- The solution is infused through a peripheral line.
- The infusion is administered without a filter.
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35. A nurse assesses a client recently admitted to an alcohol-detoxification unit. What common clinical manifestation should the nurse expect during the initial stage of alcohol detoxification?
- Nausea
- Euphoria
- Bradycardia
- Hypotension
36. Situation: One of the realities that we are confronted with is mortality. It is important for us nurses to be aware of how we view suffering, pain, illness, and even our death as well as its meaning. That way we can help our patients cope with death and dying. Q. Leo who is terminally ill and recognizes that he is in the process of losing, everything and everybody he loves, is depressed. Which of the following would best help him during depression?
- Arrange for visitors who might cheer him
- Sit down and talk with him for a while
- Encourage him to look at the brighter side of things
- Sit silently with him
37. Situation: Please continue responding as a professional nurse in varied health situations through the following questions. Q. RhoGAM is given to Rh-negative women to prevent maternal sensitization from occurring. The nurse is aware that in addition to pregnancy, Rh-negative women would also receive this medication after which of the following?
- Unsuccessful artificial insemination procedure
- Blood transfusion after hemorrhage
- Therapeutic or spontaneous abortion
- Head injury from a car accident
38. The most important thing should be done after any nursing action is:
- Documentation
- Nursing diagnosis
- Planning
- All of the above
39. Situation: Ronald 23 years old was voluntarily admitted to the in-patient unit with a diagnosis of paranoid schizophrenia. Q. As the nurse approaches Ronald he says, "If come any closer. I'll die." This is an example of:
- Hallucination
- Delusion
- Illusion
- Idea of reference
40. A home health nurse is teaching a family member about the care of a patient's peripherally inserted central catheter (PICC). Which of the following would be appropriate for the nurse to make?
- "Place the used intravenous tubing in a leak proof container and then this in sealed container inside a second leak proof container".
- "You will need to put on a disposable face mask before you connect the port of the PICC"
- "The port of the PICC catheter will need to be cleansed with providence-iodine Betadine) after the insulin is completed."
- "The empty medication container can be placed inthe same container as your house hold refuses."
41. The physician has ordered intravenous fluid with potassium for a client admitted with gastroenteritis and dehydration. Before adding potassium to the intravenous fluid the nurse should:
- Assess the urinary output.
- Obtain arterial blood gases,
- Perform a dextro stick.
- Obtain a stool culture.
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42. Acromolyn sodium inhaler is prescribed for a client with allergic asthma. The nurse provides instructions regarding the adverse effects of this medication and should tell the client that which undesirable effect is associated with this medication?
- Insomnia
- Constipation
- Hypotension
- Bronchospasm
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43. The nurse is assessing a patient recently diagnosed with acquired immuno deficiency syndrome(AIDS). Which of the following nursing diagnosis has PRIORITY?
- Fear of disease progression, treatment effects, isolation and death related having aids
- Risk for infection related immunodeficiency
- Ineffective breathing pattern related to opportunistic infection
- Disturbed body image related to rapid body changes from debilitating disease
44. A patient with pneumonia experiences ineffective airway clearance related to the presence of thick secretions secondary to infection. Oxygen saturation is 89% on room air. Which of the following nursing interventions takes priority?
- Deliver oxygen with humidity
- Encourage fluid intake
- Assist patient into position of comfort
- Inspect sputum for odor and color
45. It is best describe as a systematic, rational method of planning and providing nursing care for individual, families, group and community
- Assessment
- Nursing Process
- Diagnosis
- Implementation
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46. Situation: Basic knowledge on Intravenous solutions is necessary for care of clients with problems with fluids and electrolytes. Q. One patient has a runaway IV of 50 % dextrose. To prevent temporary excess of insulin or transient hyperinsulin reaction what solution you prepare in anticipation of the doctor's order?
- Any IV solution available to KVO
- Isotonic solution
- Hypertonic solution
- Hypotonic solution
47. Nurse Jamie should explain to male client with diabetes that self-monitoring of blood glucose is preferred to urine glucose testing because
- More accurate
- Can be done by the client
- It is easy to perform
- It is not influenced by drugs
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48. What is the primary action of insulin in the body?
- Enhances the transport of glucose across cell walls
- Aids in the process of gluconeogenesis
- Stimulates the pancreatic beta cells
- Decreases the intestinal absorption of glucose
49. A clinical nurse specialist is a nurse who has:
- Been certified by the National League for Nursing
- Received credentials from the Philippine Nurses' Association
- Graduated from an associate degree program and is a registered professional nurse
- Completed a master's degree in the prescribed clinical area and is a registered professional nurse.
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50. The term "blue bloater" refers to a male client which of the following conditions?
- Adult respiratory distress syndrome (ARDS)
- Asthma
- Chronic obstructive bronchitis
- Emphysema
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