NCLEX-RN | QB3 | Practice Exam #19 (50 questions)
All 50 questions are randomized each time you take the test, and do not appear in the same order.
1. The nurse is using the Glascow coma scale to assess the client's motor response. The nurse places pressure at the base of the client's fingernail for 20 seconds. The client's only response is withdrawal of his hand. The nurse interprets the client's response as:
- A score of 6 because he follows commands
- A score of 5 because he localizes pain
- A score of 4 because he uses flexion
- A score of 3 because he uses extension
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2. 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. A child who has some palmar pallor can be classified as:
- moderate anemia/normal weight
- severe malnutrition/anemia
- anemia/very low weight
- not very low eight to anemia
3. Nurse Hazel will administer a unit of whole blood, which priority information should the nurse have about the client?
- Blood pressure and pulse rate.
- Height and weight.
- Calcium and potassium levels
- Hgb and Hct levels.
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4. Situation: The nurse is performing health education activities for Jane, a 30 years old Dentist with Insulin dependent diabetes Mellitus. Q. Jane is preparing a mixed dose of insulin. The nurse is satisfied with her performance when she:
- Draw insulin from the vial of clear insulin first
- Draw insulin from the vial of the intermediate acting insulin first
- Fill both syringes with the prescribed insulin dosage then shake the bottle vigorously
- Withdraw the intermediate acting insulin first before withdrawing the short acting insulin first.
5. The nurse is caring for a primigravid client in the labor and delivery area. Which condition would place the client at risk for disseminated intravascular coagulation (DIC)?
- Intrauterine fetal death.
- Placenta accreta.
- Dysfunctional labor.
- Premature rupture of the membranes.
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6. Marie with acute lymphocytic leukemia suffers from nausea and headache. These clinical manifestations may indicate all of the following except:
- effects of radiation
- chemotherapy side effects
- meningeal irritation
- gastric distension
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7. When planning Mr. Adam care (50 years) who demonstrates difficulty in breathing. Which of the following positions is most appropriate?
- On either side
- Flat on his back
- On his abdomen
- Mid-Flower's position
8. The nurse is caring for a 2 year-old who is being treated with chelation therapy, calcium disodium edetate, for lead poisoning. The nurse should be alert for which of the following side effects?
- Neurotoxicity
- Hepatomegaly
- Nephrotoxicity
- Ototoxicity
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9. The nurse is preparing to suction a client via a tracheostomy tube. The nurse should plan to limit the suctioning time to a maximum of which time period?
- 5 seconds
- 10 seconds
- 30 seconds
- 60 seconds
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10. A health care provider's prescription reads "ampicillin sodium 125 mg IV every 6 hours." The medication label reads "when reconstituted with 7.4 mL of bacteriostatic water, the final concentration is 1 g/7.4 mL.” The nurse prepares to draw up how many milliliters to administer 1 dose?
- 1.1mL
- 0.54mL
- 7.425mL
- 0.925mL
11. Situation: You were on duty at the medical ward when Zeny came in for admission for tiredness, cold intolerance, constipation, and weight gain. Upon examination, the doctor's diagnosis was hypothyroidism. Q. As a nurse, you know that the most common type of goiter is related to a deficiency
- thyroxine
- thyrotropin
- iron
- iodine
12. Barbiturates are usually not given for pain relief during active labor for which of the following reasons?
- The neonatal effects include hypotonia, hypothermia, generalized drowsiness, and reluctance to feed for the first few days.
- These drugs readily cross the placental barrier, causing depressive effects in the newborn 2 to 3 hours after intramuscular injection.
- They rapidly transfer across the placenta, and lack of an antagonist make them generally inappropriate during labor.
- Adverse reactions may include maternal hypotension, allergic or toxic reaction or partial or total respiratory failure.
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13. Intramedullary nailing is used in the treatment of:
- Slipped epiphysis of the femur
- Fracture of shaft of the femur
- Fracture of the neck of the femur
- Intertrochanteric fracture of the femur
14. Situation: Rene is a 3 y/o boy brought to the health center for fever and cough. You noted grayish pinpoint dots located at the buccal mucosa. A maculopapular rash was noted on his face. Q. The patient's disease is most likely:
- Rubeola
- Diphtheria
- Rubella
- Pneumonia
15. The nurse is assigned to give perineal care to an uncircumcised male client Which of the following is correct?
- The anal area is washed at a separate time
- The foreskin is retracted and the area beneath the foreskin is cleansed
- The foreskin should not be retracted except by a physician
- The scrotum is carefully washed with sterile normal saline
16. Realizing that the hypokalemia is a side effect of steroid therapy, nurse Monette should monitor a client taking steroid medication for:
- Hyperactive reflexes
- An increased pulse rate
- Nausea, vomiting, and diarrhea
- Leg weakness with muscle cramps
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17. Which of the following symptoms is most commonly associated with left-sided heart failure?
- Crackles
- Arrhythmias
- Hepatic engorgement
- Hypotension
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18. A 32 year-old man is brought to the Emergency Department by a friend with whom he had been playing football with earlier that evening. His symptoms came on after twenty minutes of the football match. He appears anxious and restless. Auscultation of the lungs reveals wheezing on exhalation. The patient states that he is unable to get a full breath of air. He had this problem as a child a couple of times after exercising in cold weather. Blood pressure: 126/72 mmHg. Heart rate: 90/min. Respiratory rate: 28/mm. Temperature: 37.0°C. Oxygen Saturation: 94% on room air. Which position is best for this patient?
- Supine
- Reverse Trendelenburg's
- Prone
- High fowler's
19. What is the most appropriate nursing intervention for clients who exhibit mild cognitive impairment?
- Reality orientation
- Behavioral confrontation
- Reflective communication
- Reminiscence group therapy
20. Nurse Gina is aware that the dietary implications for a client in manic phase of bipolar disorder is:
- Serve the client a bowl of soup, buttered French bread, and apple slices.
- Increase calories, decrease fat, and decrease protein.
- Give the client pieces of cut-up steak, carrots, and an apple.
- Increase calories, carbohydrates, and protein.
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21. A patient with long-standing diabetes mellitus (type I) is scheduled for surgical amputation of 4 gangrenous toes on the right foot Which surgical intervention would this be classified as?
- Palliative
- Curative
- Reconstructive
- Diagnostic
22. Situation: Nurse Lorena is a Family Planning and Infertility Nurse Specialist and is currently attending to a meeting. The following conditions pertain to meeting the nursing of this particular population group. Q. Client names Lilia is diagnosed as having endometriosis. This condition interferes with the fertility because:
- endometrial implants can block the fallopian tubes
- the uterine cervix becomes inflamed and swollen
- pressure on the pituitary leads to decreased FSH levels
- ovaries stop producing adequate estrogen
23. Situation: Mr. Reyes suffered head injuries in a motor vehicle accident Q. When caring for Mr. Reyes, the nurse should assess for
- Decreased carotid pulses
- Bleeding from oral cavity
- Altered level of consciousness
- Absence of deep tendon-reflexes
24. Situation: Brain tumor, whether malignant or benign, has serious management implications nurse, you should be able to understand the consequences of the disease and the treatment. Q. After you assessed Conrad, you suspected increased ICP. Your most appropriate respiratory goal is to:
- maintain partial pressure of arterial 02 (PaO2) above 80 mmHg
- lower arterial pH
- prevent respiratory alkalosis
- promote CO2 elimination
25. An infant is brought to the health care clinic for three immunizations at the same time. The nurse knows that hepatitis B, DPT, and Haemophilus influenzae type B immunizations should:
- Be drawn in the same syringe and given in one injection.
- Be mixed and inject in the same sites.
- Not be mixed and the nurse must give three injections in three sites.
- Be mixed and the nurse must give the injection in three sites.
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26. The nurse has reviewed with the preoperative client the procedure for the administration of an enema. Which statement by the client would indicate the need for further instruction?
- "The enema will be given while I am sitting on the toilet”
- "I should try and hold the fluid as long as possible after it is instilled."
- "I know that there will be some cramping after the enema administration."
- "I should tell the nurse if cramping occurs during the instillation of the fluid.”
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27. When cleansing the genital area during perineal care, the nurse aide should:
- cleanse the penis with a circular motion starting from the base and moving toward the tip.
- replace the foreskin when pushed back to cleanse an uncircumcised penis.
- cleanse the rectal area first, before cleansing the genital area.
- use the same area on the washcloth for each washing and rinsing stroke for a female resident.
28. A client is scheduled for a percutaneous transluminal coronary angioplasty (PTCA). The nurse knows that a PTCA is the
- Surgical repair of a diseased coronary artery
- Placement of an automatic internal cardiac defibrillator
- Procedure that compresses plaque against the wall of the diseased coronary artery to improve blood flow
- Non-invasive radiographic examination of the heart
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29. Situation: Brain tumor, whether malignant or benign, has serious management implications nurse, you should be able to understand the consequences of the disease and the treatment Q. You are caring for Conrad who has a brain tumor and increased intracranial Pressure (ICP). Which intervention should you include in your plan to reduce ICP?
- Administer bowel softener
- Position Conrad with his head turned toward the side of the tumor
- Provide sensory stimulation
- Encourage coughing and deep breathing
30. A client with depression has been hospitalized for treatment after taking a leave of absence from work. The client's employer expects the client to return to work following inpatient treatment. The client tells the nurse, "I'm no good. I'm a failure". According to cognitive theory, these statements reflect:
- Learned behavior
- Punitive superego and decreased self-esteem
- Faulty thought processes that govern behavior
- Evidence of difficult relationships in the work environment
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31. The nurse teaches a client with diabetes mellitus about differentiating between hypoglycemia and ketoacidosis. The client demonstrates an understanding of the teaching by stating that a form of glucose should be taken if which symptom or symptoms develop? Select all that apply. 1. Polyuria 2. Shakiness 3. Palpitations 4. Blurred vision 5. Lightheadedness 6. Fruity breath odor
- 1,2,4,6
- 1,2,3
- 2,3,5
- 2,3,4,6
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32. Mr. Duffy is admitted to the CCU with a diagnosis of R/0 Ml. He presented in the ER with a typical description of pain associated with an Ml, and is now cold and clammy, pale and dyspneic. He has an IV of D5W running, and is complaining of chest pain. Oxygen therapy has not been started, and he is not on the monitor. He is frightened. Q. One of the clients has noted a raised yellow plaque on the nasal side of the conjunctiva. You explain that this is called:
- A pinguecula, which is normal slightly raised fatty structure under the conjunctiva that may gradually increase with age.
- Icterus, which may be due to liver disease.
- A pterygium, which will interfere with vision.
- Ciliary flush caused by congestion of the ciliary artery.
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33. After the physician performs an amniotomy the nurses first action should be to assess the:
- Degree of cervical dilation
- Fetal heart tones
- Clients vital signs
- Clients level of discomfort
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34. Situation: During surgical operation, it is inevitable to utilize sutures. The nurse should know the basic principles in suturing as well as knowledge in selecting sutures and caring for clients with sutures. Q. Steel has the highest tensile strength among sutures in the non absorbable category. When you say tensile strength, it refers to:
- The amount of weight or force necessary to break the suture
- The cross sectional size of the suture
- The ability of the suture to absorb fluid
- The force necessary to cause the knot to slip
35. Situation: The OR is divided in three zones to control traffic flow and contamination. Q. What OR attires are worn in the restricted area?
- Scrub suit, OR shoes, head cap
- Head cap scrub suit, mask, OR shoes
- Mask, OR shoes, scrub suit
- Cap, Mask, gloves, shoes
36. Situation: You are assigned to take care of a group of patients across the lifespan. The nurse notes that the infant is wearing a plastic-coated diaper. If a topical medication were to be prescribed and it were to go on the stomachs or buttocks, the nurse would teach the caregivers to:
- Avoid covering the area of the topical medication with the diaper
- Avoid the use of clothing on top of the diaper
- Put the diaper on as usual
- Apply an icepack for 5 minutes to the outside of the diaper
37. Situation: Infection can cause debilitating consequences when host resistance is compromised and virulence of microorganisms and environmental factors are favorable. Infection control is one important responsibility of the nurse to ensure quality of care. Q. Conrad, who has been complaining of anorexia and feeling tired, develops jaundice, after a workup he is diagnosed of having Hepatitis A. his wife asks you about gamma globulin for herself and her household help. Your most appropriate response would be:
- "Don't worry your husband's type of hepatitis is no longer communicable"
- "Gamma globulin provides passive immunity for hepatitis B"
- "You should contact your physician immediately about getting gammaglobulin."
- "A vaccine has been developed for this type of hepatitis"
38. The mother of a two-year-old asks the nurse when she should schedule her son first dental visit The nurses response is based on the knowledge that most children have all their deciduous teeth by:
- 15 months
- 18 months
- 24 months
- 30 months
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39. A client has an order to administer cisplatin (Platinol). Which drug would the nurse expect to be ordered to reduce renal toxicity from the cisplatin infusion?
- Amifostine (Ethyol)
- Dexrazoxane (Zinecard)
- Mesna (Mesenex)
- Pamidronate (Aredia)
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40. Which of the following signs will indicate that a young child is suffering from severe pneumonia?
- Dyspnea
- Wheezing
- Fast breathing
- Chest indrawing
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41. The staff nurse calls a physician regarding an order to administer digoxin (Lanoxin) to a patient with a pulse of 55 and a serum potassium level of 2.9 mEq/L The physician says to give the medication, as ordered. The staff nurse's best response would be
- "I'll give the medication but you will still be responsible if anything happens to the patient"
- "I will not give this medication."
- "I think we should discuss this with the nursing supervisor."
- 'I'm sorry but if you want the medication given, you will have to give it yourself.”
42. Situation: You are assigned to take care of a group of patients across the lifespan. Which of the following is the MOST COMMON sign of infection among the elderiy?
- Decreased breath sounds with crackles
- Fever
- Pain
- Change in the mental status
43. After 10 days of lithium therapy, the client's lithium level is 1.0 mEq/L. The nurse knows that this value indicates which of the following?
- A laboratory error.
- An anticipated therapeutic blood level of the drug.
- An atypical client response to the drug.
- A toxic level.
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44. A patient is receiving from surgery using spinal anesthesia. The patient develops a spinal headache. Which of the following nursing actions would be MOST appropriate?
- Elevate the head of the bed 30 degrees
- Keep the patient well hydrated
- Limit intake of salty food
- Lower the temperature of the room
45. The nurse assists with a lumbar puncture on a child with suspect bacterial meningitis. If the diagnosis is correct, the cerebrospinalfluid, should have which of the following qualities?
- High glucose level
- Low protein level
- Cloudy or turbid appearance
- Pink or blood-tinged appearance
46. At 6-week postpartum visit what should this postpartum mother's fundic height be?
- Inverted and palpable at the cervix
- Six fingerbreadths below the umbilicus
- No longer palpable on her abdomen
- One centimeter above the symphysis pubis
47. SITUATION: Alfred, a 40 year old construction worker developed cough, night sweats and fever. He was brought to the nursing unit for diagnostic studies. He told the nurse he did not receive a BCG vaccine during childhood Q. Which of the following drugs is UNLIKELY given to Alfred during the maintenance phase?
- Rifampicin
- Isoniazid
- Ethambutol
- Pyridoxine
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48. The rationale for inserting a French catheter every hour for the client with epidural anesthesia is:
- The bladder fills more rapidly because of the medication used for the epiduraL
- Her level of consciousness is such that she is in a trance like state.
- The sensation of the bladder filling is diminished or lost.
- She is embarrassed to ask for the bedpan that frequently.
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49. An infant of a mother infected with human immunodeficiency virus (HIV) is seen in the clinic each month and is being monitored for symptoms indicative of HIV infection. With knowledge of the most common opportunistic infection of children infected with HIV, the nurse assesses the infant for which sign?
- Cough
- Liver failure
- Watery stool
- Nuchal rigidity
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50. George should be taught about testicular examinations during:
- when sexual activity starts
- After age 69
- After age 40
- Before age 20.