NCLEX-RN | QB3 | Practice Exam #20 (50 questions)
All 50 questions are randomized each time you take the test, and do not appear in the same order.
1. A nurse is assessing to care for a child with a seizure disorder The nurse observes the child becomes stiff and lose consciousness, following by jerking movements for 1 minute after which the child becomes very sleepy, which of the following types of seizures occurred?
- Absence (petit mal)
- Generalized (tonic-clonic)
- Partial Psychomotor(temporal lobe)
- Status epilepticus
2. The health care provider has determined that a client has contracted hepatitis A based on flu-like symptoms and jaundice. Which statement made by the client supports this medical diagnosis?
- "I have had unprotected sex with multiple partners.”
- "I ate shellfish about 2 weeks ago at a local restaurant.”
- "I was an intravenous drug abuser in the past and shared needles."
- "I had a blood transfusion 30 years ago after major abdominal surgery."
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3. The nurse is assessing the laboratory results of a client scheduled to receive phenytoin sodium (Dilantin). The Dilantin level drawn two hours ago is 30mcg/mL. What is the appropriate nursing action?
- Administer the Dilantin as scheduled.
- Hold the scheduled dose and notify the physician.
- Decrease the dosage from 100mg to 50mg.
- Increase the dosage to 200mg from 100mg.
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4. The registered nurse is making assignments for the day. Which client should be assigned to the pregnant nurse?
- The client with HIV
- The client with a radium implant for cervical cancer
- The client with RSV (respiratory synctial virus)
- The client with cytomegalovirus
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5. When removing gloves, which of the following is an inappropriate nursing action?
- Wash gloved hand first
- Peel off gloves inside out
- Use glove to glove skin to skin technique
- Remove mask and gown before removing gloves
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6. Which of the following will alert the nurse as an early sign of hypoxia?
- Client is tired and dyspneic
- The client is coughing out blood
- The clients heart rate is 50 BPM
- Client is frequently turning from side to side
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7. The leaking fluid is tested with nitrazine paper. Nurse Kelly confirms that the client's membrane have ruptures when the paper turns into a:
- Pink
- Violet
- Green
- Blue
8. A client with Addisons disease has been admitted with a history of nausea and vomiting for the past three days. The client is receiving IV glucocorticoids (Solu-Medrol). Which of the following interventions would the nurse implement?
- Glucometer readings as ordered
- Intake/output measurements
- Evaluating the sodium and potassium levels
- Daily weights
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9. The nurse monitoring a client receiving peritoneal dialysis notes that the client's outflow is less than the inflow. Which actions should the nurse take? Select all that apply. 1. Check the level of the drainage bag. 2. Reposition the client to his or her side. 3. Contact the health care provider (HCP). 4. Place the client in good body alignment 5. Check the peritoneal dialysis system for kin ks. 6. Increase the flow rate of the peritoneal dialysis solution.
- 1,2,4,5
- 2,3,4,5
- 1,3,4,6
- 1,2,5
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10. 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. Dina, 17 years old, asks you how a tubal ligation prevents pregnancy. Which would be the best answer?
- Prostaglandins released from the cut fallopian tubes can kill sperm
- Sperm cannot enter the uterus, because the cervical entrance is blocked
- Sperm can no longer reach the ova, because the fallopian tubes are blocked
- The ovary no longer releases ova, as there is no where for them to go
11. 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. During the physical examination of the well adult client, the health care provider auscultates the heart. When the stethoscope is placed on the 5th intercostal space along the left sternal border, which valve closure is best evaluated?
- Tricuspid
- Pulmonic
- Aortic
- Mitral
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12. When administering an oral medication to a toddler, which of the following interventions should the nurse plan to use?
- Depress the child's chin with thumb to open the child's mouth
- Place the medication in a nipple for the child to suck
- Give the child a small plastic medication cup for day
- Tell the child that the medication tastes good
13. After a cerebrovascular accident, a 75 yr old client is admitted to the health care facility. The client has left-sided weakness and an absent gag reflex. He's incontinent and has a tarry stool. His blood pressure is 90/50 mmHg, and his hemoglobin is 10 g/dL Which of the following is a priority for this client?
- checking stools for occult blood
- performing range-of-motion exercises to the left side
- keeping skin clean and dry
- elevating the head of the bed to 30 degrees
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14. A health care provider's prescription reads morphine sulfate, 8 mg stat. The medication ampule reads morphine sulfate, 10 mg/mL. The nurse prepares how many milliliters to administer the correct dose?
- 0.5 mL.
- 1.5 mL.
- 1.0 mL.
- 0.8 mL.
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15. What Specific gravity lab result is compatible with a dehydrated client?
- 1.007
- 1.02
- 1.039
- 1.029
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16. The nurse is changing the central line dressing of a client receiving parenteral nutrition (PN) and notes that the catheter insertion site appears reddened. The nurse should next assess which item?
- Client's temperature
- Expiration date on the bag
- Time of last dressing change
- Tightness of tubing connections
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17. Nurse May is aware that the main advantage of using a floor stock system is:
- The nurse can implement medication orders quickly.
- The nurse receives input from the pharmacist.
- The system minimizes transcription errors.
- The system reinforces accurate calculations.
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18. A client had surgery for a perforated appendix with localized peritonitis. In which position should the nurse place this client?
- Sims
- Semi-Fowler
- Trendelenburg
- Dorsal recumbent
19. The nurse is caring for a post-surgical client at risk for developing deep vein thrombosis. Which intervention is an effective preventive measure?
- Place pillows under the knees
- Use elastic stockings continuously
- Encourage range of motion and ambulation
- Massage the legs twice daily
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20. A moderately depressed client who was hospitalized 2 days ago suddenly begins smiling and reporting that the crisis is over. The client says to the nurse, "I'm finally cured." How should the nurse interpret this behavior as a cue to modify the treatment plan?
- Suggesting a reduction of medication
- Allowing increased "in-room" activities
- Increasing the level of suicide precautions
- Allowing the client off-unit privileges as needed
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21. What herbal medication for depression, widely used in Europe, is now being prescribed in the United States?
- Ginkgo biloba
- Echinacea
- St. John's wort
- Ephedra
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22. The physician has ordered a lumbar puncture for a client with suspected Guillain-Barre syndrome. The spinal fluid of a client with Guillain-Barre syndrome typically shows:
- Decreased protein concentration with a normal cell count
- Increased protein concentration with a normal cell count
- Increased protein concentration with an abnormal cell count
- Decreased protein concentration with an abnormal cell count
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23. A client who is recovering from surgery has been advanced from a clear liquid diet to a full liquid diet. The client is looking forward to the diet change because he has been " bored" with the clear liquid diet The nurse should offer which full liquid item to the client?
- Tea
- Gelatin
- Custard
- Ice pop
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24. Situation: Team efforts is best demonstrated in the OR Q. While team effort is needed in the OR for efficient and quality patient care delivery, we should limit the number of people in the room for infection control. Who comprise this team?
- Surgeon, anesthesiologist scrub nurse, radiologist orderly
- Surgeon, assistants, scrub nurse, circulating nurse, anesthesiologist
- Surgeon, assistant surgeon, anesthesiologist, scrub nurse, pathologist
- Surgeon, assistant surgeon, anesthesiologist, intern, scrub nurse
25. Before birth, which of the following structures connects the right and left auricles of the heart?
- Umbilical vein
- Foramen ovale
- Ductus arteriosus
- Ductus venosus
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26. A client with mania is unable to finish her dinner. To help her maintain sufficient nourishment the nurse should:
- Serve high-calorie foods she can carry with her.
- Encourage her appetite by sending out for her favorite foods.
- Serve her small attractively arranged portions.
- Allow her in the unit kitchen for extra food whenever she pleases.
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27. Situation: Leo lives in the squatter area. He goes to nearby school. He helps his mother gather molasses after school. One day, he was absent because of fever, malaise, anorexia and abdominal discomfort. Q. Upon assessment, Leo was diagnosed to have hepatitis A. Which mode of transmission has the infection agent taken?
- Fecal oral
- Droplet
- Airborne
- Sexual contact
28. The nurse is discussing the techniques of chest physiotherapy and postural drainage (respiratory treatments) to a client having expectoration problems because of chronic thick, tenacious mucus production in the lower airway. The nurse explains that after the client is positioned for postural drainage the nurse will perform which action to help loosen secretions?
- Palpation and clubbing
- Percussion and vibration
- Hyperoxygenation and suctioning
- Administer a bronchodilator and monitor peak flow
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29. Stephanie is often seen interacting with the medical intern during coffee breaks and after duty hours. What type of organizational structure is this?
- Formal
- Informal
- Staff
- Line
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30. Situation: Burn is cause by transfer of heat source to the body. It can be thermal, electrical radiation or chemical. Q. The MOST effective method of delivering pain medication during the emergent phase is:
- intramuscularly
- subcutaneously
- orally
- intravenously
31. One morning, nurse Diane finds a disturbed client curled up in the fetal position in the corner of the dayroom. The most accurate initial evaluation of the behavior would be that the client is:
- Physically ill and experiencing abdominal discomfort
- Tired and probably did not sleep well last night
- Attempting to hide from the nurse
- Feeling more anxious today
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32. Represents inner feeling that a person do not like talking about.
- Overt communication
- Covert communication
- Verbal communication
- Non verbal communication
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33. A female nurse is assigned to obtain a history from & client with a urinary tract problem an sexual dysfunction. Which of the following statements might place the client more at ease and willing to give a. history of his problem?
- "When did you first notice this problem?
- "Why do you think you have a problem?"
- "Do you think you sexual dysfunction is psychological?"
- "Does your sexual dysfunction seem to be related to your urinary tract problem?"
34. A home care nurse visits a patient diagnose with diabetes mellitus whose current glucose level ranges from 150mg/dl to 200mg/dl. The patient has not been able to self-administer prescribed insulin and complains of blurred vision and an inability to read the marking on the syringe for proper insulin dosage. Which of the following referrals would be MOST beneficial to the patient?
- A dietician
- An endocrinologist
- An ophthalmologist
- A physical therapist
35. The nurse chooses to inject a prescribed intramuscular medication into the ventrogluteal site. If the nurse selects the site correctly, the injection is administered into the:
- Hip
- Arm
- Thigh
- Buttock
36. Anthony suffers burns on the legs, which nursing intervention helps prevent contractures?
- Applying knee splints
- Elevating the foot of the bed
- Hyperextending the client's palms
- Performing shoulder range-of-motion exercises
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37. When assessing the client with acute arterial occlusion the nurse would expect to find:
- Peripheral edema in the affected extremity
- Minute blackened areas on the toes
- Pain above the level of occlusion
- Redness and warmth over the affected area
38. The nurse employed in the emergency room is responsible for triage of four clients injured in a motor vehicle accident. Which of the following clients should receive priority in care?
- A 10-year-old with lacerations of the face
- A 15-year-old with sternal bruises
- A 34-year-old with a fractured femur
- A 50-year-old with dislocation of the elbow
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39. When assessing a client with partial thickness burns over 60% of the body, which of the following should the nurse report immediately?
- Complaints of intense thirst
- Moderate to severe pain
- Urine output of 70 ml the 1st hour
- Hoarseness of the voice
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40. SITUATION: A 45 year old male construction worker was admitted to a tertiary hospital for incessant vomiting. Assessment disclosed: weak rapid pulse, acute weight loss of 0.5kg, furrows in his tongue, slow flattening of the skin was noted when the nurse released her pinch. Temperature: 35.8 C, BUN Creatinine ratio: 10:1, He also complains for postural hypotension. There was no infection. Q. Which of the following measures will not help correct the patient's condition
- Offer large amount of oral fluid intake to replace fluid lost
- Give enteral or parenteral fluid
- Frequent oral care
- Give small volumes of fluid at frequent interval
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41. The chart of a client with schizophrenia states that the client has echolalia. The nurse can expect the client to:
- Speak using words that rhyme
- Repeat words or phrases used by others
- Include irrelevant details in conversation
- Make up new words with new meanings
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42. A client has a prescription to receive a unit of packed red blood cells. The nurse should obtain which intravenous (IV) solution from the IV storage area to hang with the blood product at the client's bedside?
- Lactated Ringer's
- 0.9% sodium chloride
- 5% dextrose in 0.9% sodium chloride
- 5% dextrose in 0.45% sodium chloride
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43. During which of the following would the focus of classes be mainly on physiologic changes, fetal development, sexuality, during pregnancy, and nutrition?
- Prepregnant period
- First trimester
- Second trimester
- Third trimester
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44. A client had a colon resection and formation of a colostomy 2 days ago. What color does the nurse expect the stoma to be when assessing its viability?
- Pink
- Gray
- Brick red
- Dark purple
45. Situation: Margie has been diagnosed with Bipolar I disorder The client demonstrates extreme psychomotor agitation, flight of ideas, loud talking and elated mood. Q. Lithium has a narrow therapeutic range of:
- 0.1 to 1.0 mEq/L
- 0.6 to 1.2 mEq/L
- 10 to 50 mEq/L
- 50 to 100 mEq/L
46. The following are nursing interventions to relieve episiotomy wound pain EXCEPT
- Giving analgesic as ordered
- Sitz bath
- Perineal heat
- Perineal care
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47. 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. To render comfort measure is one of the priorities, Which includes care of the skin, eyes, ears, mouth and nose. To clean the mouth, your antiseptic solution is in some form of which one below?
- Water
- Sulfur
- Alkaline
- Salt
48. She wants to ensure that every task is carried out as planned. Which of the following tasks is NOT included in the controlling process?
- Instructing the members of the standards committee to prepare policies
- Reviewing the existing policies of the hospital
- Evaluating the credentials of all nursing staff
- Checking if activities conform to schedule
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49. SITUATION: John Smith was diagnosed with Acute Close Angle Glaucoma. He is being seen by Nurse Jet. Q. Nurse Jet wants to measure Mr. Smith's CN II Function. What test would Nurse Jet implement to measure CN II's Acuity?
- Slit lamp
- Snellen's Chart
- Wood's light
- Gonioscopy
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50. After falling down the basement steps in his house, a client is brought to the emergency room. His physician confirms that his leg is fractured. Following application of a leg cast, the nurse will first check the client's toes for:
- Increase in the temperature
- Change in color
- Edema
- Movement