NCLEX-RN | QB3 | Practice Exam #21 (50 questions)
All 50 questions are randomized each time you take the test, and do not appear in the same order.
1. Situation: Mr. Pulan is 36 years old, was admitted to the hospital with complaints of a burning sensation in the epigastric area after eating and inability to sleep at night. He was placed on bed rest and schedule for diagnostic studies. A diagnosis of Peptic Ulcer was made. Q. Preparation of Mr. Pulan for occult blood examination is:
- Fluid intake is limited only 1 liter/day
- NPO for 12 hours prior to obtaining of specimen
- Fluid intake is increased
- Meatless diet for 48 hours prior to obtaining of specimen
2. After several hospitalizations for respiratory ailments a six-month-old has been diagnosed as having HIV. The infants respiratory ailments were most likely due to:
- Pneumocystis carinii
- Cytomegalovirus
- Cryptosporidiosis
- Herpes simplex
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3. Situation: NURSES are involved in maintaining a safe and healthy environment This is part of quality care management Q. Which of the following guidelines is not appropriate to helping family members cope with sudden death?
- Obtain orders for sedation of family members
- Provide details of the factors attendant to the sudden death
- Show acceptance of the body by touching it and giving the family permission to touch
- Inform the family that the patient has passed on
4. A nurse is caring for a client with a diagnosis of chronic kidney failure who has just been told by the health care provider that hemodialysis is necessary. Which clinical manifestation indicates the need for hemodialysis?
- Ascites
- Acidosis
- Hypertension
- Hyperkalemia
5. A patient is seen in the emergency room for a 20cm (7.8 inch) laceration to the right fore arm. The course prepares for which type of anesthesia to be administered before the laceration is repaired by the physician?
- Intravenous
- Regional
- General
- Local
6. The nurse is completing an assessment to a newborn baby boy. The nurse observes that the skin of the newborn is dry and flaking and there are several areas of an apparent macular rash. The nurse charts this as:
- Icterus neonatorum
- Multiple hemangiomas
- Erythema toxicum
- Milia
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7. A school nurse refers a child who failed the school vision screening for eye doctor. The child returns with glasses to be worn at all times. The nurse should monitor this child for:
- Redness of the eye
- Episodes of seizures
- Improved vision with glasses
- Lazy eye
8. Situation: Joanna Marie, a 40 year old client was diagnosed with breast cancer Q. All of the following are applicable nursing diagnosis for Joanna except:
- Pain upon lying down
- Body Image Disturbance
- Potential for sexual dysfunction
- Self care deficit r/t immobility of the arm
9. A 35 year-old woman with excessive facial and body hair and acne has had weight gain in the shoulder, upper back and face. She does not drink alcohol and does not have diabetes. She takes glucocorticoids regularly. Which dietary plan would be most beneficial for this patient?
- Increased calcium
- Decreased sodium
- Increased potassium
- Decreased protein
10. Situation: You are assigned to take care of a group of patients across the lifespan. A parent calls you and frantically reports that her child has gotten into her famous ferrous sulfate pills and ingested a number of these pills. Her child is now vomiting, has bloody diarrhea and is complaining of abdominal pain. You will tell the mother to:
- Call emergency medical services (EMS) and get the child to the emergency room
- Relax because these symptoms will pass and the child will be fine
- Administer syrup of ipecac
- Call the poison control center
11. The nurse is caring for a client with bulimia. Strict management of dietary intake is necessary. Which intervention is also important?
- Fill out the client's menu and make sure she eats at least half of what is on her tray.
- Let the client eat her meals in private. Then engage her in social activities for at least 2 hours after each meal.
- Let the client choose her own food. If she eats everything she orders, then stay with her for 1 hour after each meal.
- Let the client eat food brought in by the family if she chooses, but she should keep a strict calorie count.
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12. All of the following factors correctly influence respiration except one. Which of the following is incorrect?
- Hydrocodone decreases RR
- Stress increases RR
- Increase temperature of the environment, Increase RR
- Increase altitude, Increase RR
13. The client with a genetic enzyme deficiency had an abnormal and different response to the drug administered for the first time. This reaction is called as:
- Allergic reaction
- Cumulative effect
- Idiosyncratic effect
- Synergistic effect
14. According to her, A nurse patient relationship is composed of 4 stages: Orientation, Identification, Exploitation and Resolution
- Roy
- Peplau
- Rogers
- Travelbee
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15. A patient suffered a head trauma which resulted in a nasal fracture requiringsurgical intervention. Which of the following nursing diagnoses would MOST likely be a problem this patient?
- Delayed surgical recovery
- Impaired gas exchange system
- Ineffective breathing pattern
- Risk for perioperative-positioning injury
16. The x-ray reveals that the bones are intact The physician tells Ms. Elkins that she has severely sprained ankle. The physician directs the nurse to wrap Ms. Elkins foot with an elastic roller bandage referred to by some as an Ace bandage. Where should the nurse begin applying the bandage?
- Below the knee
- Above the knee
- Across the phalanges
- At the metatarsals
17. The patient with multiple sclerosis tells the nursing assistant that after physical therapy she is too tired to take a bath. What is your priority nursing diagnosis at this time?
- Fatigue related to disease state
- Activity Intolerance due to generalized weakness
- Impaired Physical Mobility related to neuromuscular impairment
- Self-care Deficit related to fatigue and neuromuscular weakness
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18. Situation: "Group Approach" in Nursing. Q. Which of the following questions illustrates the group role of encourager?
- What were you saying?
- Who wants to respond next?
- Where do you go from here?
- Why haven't we heard from you?
19. A breastfeeding mother asks the nurse what she can do to ease the discomfort caused by a cracked nipple. Nurse Tina should instruct the client to:
- Manually express milk and feed it to the baby in a bottle
- Stop breastfeeding for two days to allow the nipple to heal
- Use a breast shield to keep the baby from direct contact with the nipple
- Feed the baby on the unaffected breast first until the affected breast heals
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20. Sally Baker, a 40-year-old woman, is admitted to the hospital with an established diagnosis of mitral stenosis. She is scheduled for surgery to repair her mitral valve. Q. Chemotherapy may be used in combination with surgery in the treatment of lung cancer. Special nursing considerations with chemotherapy include all but which of the following?
- Helping the client deal with depression secondary to the diagnosis and its treatment
- Explaining that the reactions to chemotherapy are minimal
- Careful observation of the IV site of the administration of the drugs
- Careful attention to blood count results
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21. The RN is making assignments for the day. Which one of the following duties can be assigned to the unlicensed assistive personnel?
- Notifying the physician of an abnormal lab value
- Providing routine catheter care with soap and water
- Administering two aspirin to a client with a headache
- Setting the rate of an infusion of normal saline
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22. When the bag of waters ruptures spontaneously, the nurse should inspect the vaginal introitus for possible cord prolapse. If there is part of the cord that has prolapsed into the vaginal opening the correct nursing intervention is:
- Push back the prolapse cord into the vaginal canal
- Place the mother on semifowler's position to improve circulation
- Cover the prolapse cord with sterile gauze wet with sterile NSS and place the woman on Trendelenburg position
- Push back the cord into the vagina and place the woman on sims position
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23. A five-year-old is admitted to the unit following a tonsillectomy. Which of the following would indicate a complication of the surgery?
- Decreased appetite
- A low-grade fever
- Chest congestion
- Constant swallowing
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24. The nurse is assessing on the client who is admitted due to vehicle accident. Which of the following findings will help the nurse that there is internal bleeding?
- Frank blood on the clothing.
- Thirst and restlessness.
- Abdominal pain
- Confusion and altered of consciousness.
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25. The nurse is preparing to care for four assigned clients. Which client is at most risk for hemorrhage?
- A primiparous client who delivered 4 hours ago
- A multiparous client who delivered 6 hours ago
- A multiparous client who delivered a large baby after oxytocin induction
- A primiparous client who delivered 6 hours ago and had epidural anesthesia
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26. The nurse is providing dietary teaching for a client with hypertension. Which food should be avoided by the client on a sodium-restricted diet?
- Dried beans
- Swiss cheese
- Peanut butter
- Colby cheese
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27. A man is brought to the hospital by his wife, who states that for the past week her husband has refused all meals and accused her of trying to poison him. During the initial interview, the client's speech, only partly comprehensible, reveals that his thoughts are controlled by delusions that he is possessed by the devil. The physician diagnoses paranoid schizophrenia. Schizophrenia is best described as a disorder characterized by:
- disturbed relationships related to an inability to communicate and think clearly.
- severe mood swings and periods of low to high activity.
- multiple personalities, one of which is more destructive than the others.
- auditory and tactile hallucinations.
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28. Which of the following vital signs are normal?
- Temp: 37, RR: 22, HR: 90, BP: 135/85.
- Temp: 36.7, RR: 18, HR:75, BP: 125/80.
- Temp: 38, RR: 12, HR: 110, BP: 155/90.
- Temp: 37.2, RR: 16, HR: 50, BP: 115/65
29. A nurse is caring for a client who is admitted with ureteral colic and hematuria. The client also has stage 1 hypertension and is overweight. The decrease of which clinical indicator associated with this client’s status should the nurse be most concerned about at this time?
- Pain
- Weight
- Hematuria
- Hypertension
30. A male client has active tuberculosis (TB). Which of the following symptoms will be exhibit?
- Chest and lower back pain
- Chills, fever, night sweats, and hemoptysis
- Fever of more than 104°F (40°C) and nausea
- Headache and photophobia
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31. The most important instructions a nurse can give a patient regarding the use of the antibiotic ampicillin prescribed for her are to:
- call the physician if she has any breathing difficulties.
- take it with meals so it doesn't cause an upset stomach.
- take all of the medication prescribed even if the symptoms stop sooner
- not share the pills with anyone else.
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32. Situation: You are assigned to take care of a group of patients across the lifespan. Focus methodology stands for?
- Focus, Organize, Clarify, Understand and Solution
- Focus, Opportunity, Continuous, Utilize, Substantiate
- Focus, Organize, Clarify, Understand, Substantiate
- Focus, Opportunity, Continuous (process), Understand, Solution
33. In caring for a young child with pain, which assessment tool is the most useful?
- Simple description pain intensity scale
- 0-10 numeric pain scale
- Faces pain-rating scale
- McGill-Melzack pain questionnaire
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34. Nurse Ron is aware that unused BCG should be discarded after how many hours of reconstitution?
- 2 hours
- 4 hours
- 8 hours
- At the end of the day
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35. Imelda, was slashed and hacked by an unknown suspects. She suffered massive tissue loss and laceration on her arms and elbow in an attempt to evade the criminal. As a nurse, you know that the type of healing that will most likely occur to Miss Imelda is:
- First intention
- Second intention
- Third intention
- Fourth intention
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36. The nurse is visiting a home health client with osteoporosis. The client has a new prescription for alendronate (Fosamax). Which instruction should be given to the client?
- Rest in bed after taking the medication for at least 30 minutes.
- Take the medication with water only.
- Avoid rapid movements after taking the medication.
- Allow at least one hour between taking the medicine and taking other medications.
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37. Hormones secreted by Islets of Langerhans:
- Progesterone
- Testosterone
- Insulin
- Hemoglobin
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38. A client has undergone esophagogastroduodenoscopy. The nurse should place highest priority on which item as part of the client's care plan?
- Monitoring the temperature
- Monitoring complaints of heartburn
- Giving warm gargles for a sore throat
- Assessing for the return of the gag reflex
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39. A framework for health assessment that evaluates the effects of stressors to the mind, body and environment in relation with the ability of the client to perform ADL.
- Functional health framework
- Head to toe framework
- Body system framework
- Cephalocaudal framework
40. The nurse is preparing a teaching plan for a client who had a cataract extraction with intraocular implantation. Which home care measures should the nurse include in the plan? Select all that apply. 1. Avoid activities that require bending over. 2. Contact the surgeon if eye scratchiness occurs. 3. Take acetaminophen for minor eye discomfort. 4. Expect episodes of sudden severe pain in the eye. 5. Place an eye shield on the surgical eye at bedtime. 6. Contact the surgeon if a decrease in visual acuity occurs.
- 1,3,4,6
- 1,2,3,4,5
- 1,3,5,6
- 2,3,4,5
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41. What is the nurse’s primary consideration when caring for a client with rheumatoid arthritis?
- Surgery
- Comfort
- Education
- Motivation
42. A patient undergoing cancer treatment has developed acute hypocalcaemia with sign of weakness, nausea and vomiting. Which of the following would the nurse anticipate to be the initial treatment?
- Thiazide diuretic
- Intravenous normal saline(0.9% NaCl)
- A potassium supplement
- Broad-spectrum antibiotic
43. Among the following components thorough pain assessment, which is the most significant?
- Effect
- Cause
- Causing factors
- Intensity
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44. The nurse is caring for a client who is postoperative following a pelvic exenteration and the health care provider changes the client's diet from NPO (nothing by mouth) status to clear liquids. The nurse should check which priority item before administering the diet?
- Bowel sounds
- Ability to ambulate
- Incision appearance
- Urine specific gravity
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45. A client is walking down the hall and begins to experience vertigo. What is the most important nursing action when this occurs?
- Have the client sit in a chair and lower his head
- Administer meclizine (Antivert) PO
- Assist the client to sit or lie down
- Assess if the occurrence is vertigo or dizziness
46. During the first 48 hours after a severe burn of 40% of the clients body surface, the nurse's assessment should include observations for water intoxication. Associated adaptations include:
- Sooty-colored sputum
- Frothy pink-tinged sputum
- Twitching and disorientation
- Urine output below 30ml per hour
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47. At what point after a burn injury should the nurse be most alert for the complication of hypokalemia?
- Immediately following the injury
- During the fluid shift
- During fluid remobilization
- During the late acute phase
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48. A patient with conjunctivitis reports the presence of photophobia and moderate eye drainage. The nurse should teach patient to:
- Avoid touching the eye
- Use sterile gauze to remove the drainage
- Darken the room
- rest in the prone position
49. A 4-year-old child brought to the community health clinic for scheduled immunizations. The child should receive:
- Varicella, rotavirus, pneumococcal and hepatitis B
- Measles, mumps, rubella and varicella
- Rotavirus and inactivated polio virus
- Varicella and haemophilus influenza
50. Situation: Among common conditions found in children especially among poor communities are ear infection/problems. The following questions apply. Q. An ear discharge that has been present for less than 14 days can be classified as:
- chronic ear infection
- mastoiditis
- acute ear infection
- complicated ear infection