NCLEX-RN | QB3 | Practice Exam #22 (50 questions)
All 50 questions are randomized each time you take the test, and do not appear in the same order.
1. Which of the following constitutes a break in sterile technique while preparing a sterile field for a dressing change?
- Using sterile forceps, rather than sterile gloves, to handle a sterile item
- Touching the outside wrapper of sterilized material without sterile gloves
- Placing a sterile object on the edge of the sterile field
- Pouring out a small amount of solution (15 to 30 ml) before pouring the solution into a sterile container
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2. A nurse has just started total parenteral nutrition (TPN) as prescribed for a patient with severe dysphagia low prealbumin levels. In one to two hours, the nurse should anticipate assessing the patient's:
- Blood glucose level
- Weight
- Liver
- SpO2
3. After 1 week a client with acute renal failure moves, into the diuretic phase. During this phase the client must be carefully assessed for signs of:
- Hypovolemia
- Hyperkalemia
- Metabolic acidosis
- Chronic renal failure
4. Which of the following is incorrect with regards to proper urine testing using Benedict's Solution?
- Heat around 5ml of Benedict's solution together with the urine in a test tube
- Add 8 to 10 drops of urine
- Heat the Benedict's solution without the urine to check if the solution is contaminated
- If the color remains BLUE, the result is POSITIVE
5. All but one is true about digestion that occurs in the Stomach:
- Carbohydrates are the fastest to be digested, in about an hour
- Fat is the slowest to be digested, in about 5 hours
- HCI inhibits absorption of Calcium in the gastric mucosa
- HCI converts pepsinogen to pepsin, which starts the complex process of protein digestion
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6. Which among this food is the richest source of Iron?
- Ampalaya
- Broccoli
- Mongo
- Malunggay leaves
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7. The nurse administers cleansing enema. The common position for this procedure is:
- Sims left lateral
- Dorsal Recumbent
- Supine
- Prone
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8. A male client who has severe burns is receiving H2 receptor antagonist therapy. The nurse In-charge knows the purpose of this therapy is to:
- Prevent stress ulcer
- Block prostaglandin synthesis
- Facilitate protein synthesis.
- Enhance gas exchange
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9. The nurse is reviewing the prescription for a client admitted to the hospital with a diagnosis of acute pancreatitis. Which interventions would the nurse expect to be prescribed for the client? Select all that apply. 1. Maintain NPO (nothing by mouth) status. 2. Encourage coughing and deep breathing. 3. Give small, frequent high-calorie feedings. 4. Maintain the client in a supine and flat position. 5. Give hydromorphone intravenously as prescribed for pain. 6. Maintain intravenous fluids at 10 mL/hour to keep the vein open.
- 1,2,3,4
- 1,2,3,6
- 1,2,5
- 2,3,4,5
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10. Which of the following is inappropriate in collecting mid stream clean catch urine specimen for urine analysis?
- Collect early in the morning, First voided specimen
- Do perineal care before specimen collection
- Collect 5 to 10 ml for urine
- Discard the first flow of the urine
11. The nurse is caring for a nine-year-old child admitted with asthma. Upon the morning rounds the nurse finds an O2 sat of 78%. Which of the following actions should the nurse take first?
- Notify the physician
- Do nothing; this is a normal O2 sat for a nine-year-old
- Apply oxygen
- Assess the childs pulse
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12. As part of chemotherapy education, the nurse teaches a female client about the risk for bleeding and self-care during the period of greatest bone marrow suppression (the nadir). The nurse understands that further teaching is needed if the client makes which statement?
- "I should avoid blowing my nose.”
- "I may need a platelet transfusion if my platelet count is too low"
- "I'm going to take aspirin for my headache as soon as I get home”
- "I will count the number of pads and tampons I use when menstruating."
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13. A client hospitalized with cirrhosis has developed abdominal ascites. The nurse should provide the client with snacks that provide additional:
- Sodium
- Potassium
- Protein
- Fat
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14. Situation: Because of the serious consequences of severe burns management requires a multidisciplinary approach. You have important responsibilities as a nurse. Q. Once the flames are extinguished, it is most important to:
- cover Sergio with a warm blanket
- give him sips of water
- calculate the extent of his burns
- assess Sergio's breathing
15. A home health nurse visits a patient with diabetes and primary open-angle glaucoma. The patient takes metformin (Glucophage) 500 mg once a day for diabetes and timolol ophthalmic solution twice a day in each eye for glaucoma. Which of the following evaluations indicates that the patient is noncompliant with glaucoma management?
- Patient has not been taking glucophage
- Patient has tearing of the eye
- Patient has not refilled prescription for timolol in 3 months
- Patient has yellow discharge from the eyes
16. A nursing process which involves the performance of the nursing plan care is:
- Assessment
- Nursing diagnosis
- Implementation
- Evaluation
17. A nurse educates a patient about the use of incentive spirometry to prevent atiectasis after a surgery. The nurse is performing what step of the nursing process?
- Diagnosis
- Assessment
- Implementation
- Evaluation
18. Which action should take the highest priority when caring for a client with hemiparesis caused by a cerebrovascular accident (CVA)?
- Perform passive range-of-motion (ROM) exercises.
- Place the client on the affected side.
- Use hand rolls or pillows for support.
- Apply antiembolism stockings
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19. Which of the following amounts of blood loss following birth marks the criterion for describing postpartum hemorrhage?
- More than 200 ml
- More than 300 ml
- More than 400 ml
- More than 500 ml
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20. The nurse has instructed the family of a client with stroke (brain attack) who has homonymous hemianopsia about measures to help the client overcome the deficit. Which statement suggests that the family understands the measures to use when caring for the client?
- "We need to discourage him from wearing eyeglasses"
- "We need to place objects in his impaired field of vision."
- "We need to approach him from the impaired field of vision"
- "We need to remind him to turn his head to scan the lost visual field"
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21. A male client with a right pleural effusion noted on a chest X-ray is being prepared for thoracentesis. The client experiences severe dizziness when sitting upright. To provide a safe environment, the nurse assists the client to which position for the procedure?
- Prone with head turned toward the side supported by a pillow.
- Sims' position with the head of the bed flat
- Right side-lying with the head of the bed elevated 45 degrees.
- Left side-lying with the head of the bed elevated 45 degrees.
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22. An 83-year-old male client is in extended care facility is anxious most of the time and frequently complains of a number of vague symptoms that interfere with his ability to eat. These symptoms indicate which of the following disorders?
- Conversion disorder
- Hypochondriasis
- Sublimation
- Severe anxiety
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23. Nurse Kate would expect that a client with vascular dementia would experience:
- Loss of remote memory related to anoxia
- Loss of abstract thinking related to emotional state
- Inability to concentrate related to decreased stimuli
- Disturbance in recalling recent events related to cerebral hypoxia.
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24. Situation: Nurse Macarena is a Family Planning and Infertility Nurse Specialist and currently attends to FAMILY PLANNING CLIENTS AND INFERTILE COUPLES. The following conditions pertain to meeting the nursing needs of this particular population group. Daphne, 19 years old, asks nurse Macarena how can pregnancy be prevented through tubal ligation. Which would be the best answer?
- A Prostaglandins released from the cut fallopian tubes will lead to permanent closure of the vagina.
- Sperm can not 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.
25. Situation: Colostomy is a surgically created anus. It can be temporary or permanent, depending on the disease condition. Q. After ileostomy, which of the following condition is NOT expected?
- Increased weight
- Irritation of skin around the stoma
- Liquid stool
- Establishment of regular bowel movement
26. The nurse is assessing a pregnant client in the second trimester of pregnancy who was admitted to the maternity unit with a suspected diagnos is of abruptio placentae. Which assessment finding should the nurse expect to note if this condition is present?
- Soft abdomen
- Uterine tenderness
- Absence of abdominal pain
- Painless, bright red vaginal bleeding
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27. The skin in the diaper area of a 7 month old infant is excoriated and red. Nurse Hazel should instruct the mother to:
- Change the diaper more often.
- Apply talc powder with diaper changes.
- Wash the area vigorously with each diaper change.
- Decrease the infant's fluid intake to decrease saturating diapers.
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28. Ms. Garcia is responsible to the number of personnel reporting to her. This principle refers to:
- Span of control
- Unity of command
- Downward communication
- Leader
29. Clients with diabetes mellitus require frequent vision assessment. The nurse should instruct the client about which of the following eye problems most likely to be associated with diabetes mellitus?
- Cataracts
- Retinopathy
- Astigmatism
- Glaucoma
30. Situation: The nurse-patient relationship is a modality through which the nurse meets the client's needs. Q. One way to increase objectivity in dealing with one's fears and anxieties is through the process of:
- observation
- intervention
- validation
- collaboration
31. A young man is remanded by the courts for psychiatric treatment His police record, which dates to his early teenage years, includes delinquency, running away, auto theft, and vandalism. He dropped out of school at age 16 and has been living on his own since then. His history suggests maladaptive coping, which is associated with:
- antisocial personality disorder.
- borderline personality disorder.
- obsessive-compulsive personality disorder.
- narcissistic personality disorder.
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32. The client with varicella will most likely have an order for which category of medication?
- Antibiotics
- Antipyretics
- Antivirals
- Anticoagulants
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33. While monitoring a male client several hours after a motor vehicle accident, which assessment data suggest increasing intracranial pressure?
- Blood pressure is decreased from 160/90 to 110/70.
- Pulse is increased from 87 to 95, with an occasional skipped beat.
- The client is oriented when aroused from sleep, and goes back to sleep immediately.
- The client refuses dinner because of anorexia.
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34. The physician has ordered two units of whole blood for a client following surgery. To provide for client safety the nurse should:
- Obtain a signed permit for each unit of blood.
- Use a new administration set for each unit transfused.
- Administer the blood using a Y connector.
- Check the blood type and Rh factor three times before initiating the transfusion.
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35. The nurse assigned to care for a patient with a diagnosis of thrombotic stroke, the nurse knows that this type of stroke is MOST LIKELY caused by:
- Blockage of large vessels as a result of atherosclerosis
- Emboli produce from valvular heart disease.
- Decreased cerebral blood flow due to circulatory failure.
- A temporary disruption in oxygenation of the brain.
36. The main reason for an expected increased need for iron in pregnancy is:
- The mother may suffer anemia because of poor appetite
- The fetus has an increased need for RBC which the mother must supply
- The mother may have a problem of digestion because of pica
- The mother may have physiologic anemia due to the increased need for red blood cell mass as well as the fetal requires about 350-400 mg of iron to grow
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37. The nurse is providing dietary instructions to a client who has been prescribed cyclosporine. Which food item should the nurse instruct the client to exclude from the diet?
- Red meats
- Orange juice
- Grapefruit juice
- Green, leafy vegetables
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38. Which of the following would indicate to the nurse that the stationary thrombus in Ms. Fleming suddenly develops?
- Chest pains
- Leg cramps
- Numbness in the foot
- Swelling of the knee
39. The nurse is caring for a client with a gout Which of the following laboratory values does the nurse expect to note in the client?
- Uric acid level of 8 mg/dl
- Calcium level of 9 mg/dl
- Phosphorus level of 3 mg/dl
- Uric acid level of 5 mg/dl
40. John has a fever of 38.5 Deg. Celsius. It surges at around 40 Degrees and go back to 38.5 degrees 6 times today in a typical pattern. What kind of fever is John having?
- Relapsing
- Intermittent
- Remittent
- Constant
41. Which of the following articles would Kevin least consider for his review of literature?
- "Story-Telling and Anxiety Reduction Among Pediatric Patients"
- "Turnaround Time in Emergency Rooms"
- "Outcome Standards in Tertiary Health Care Institutions"
- "Environmental Manipulation and Client Outcomes"
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42. A male child has an intelligence quotient of approximately 40. Which kind of environment and interdisciplinary program most likely to benefit this child would be best described as:
- Habit training
- Sheltered workshop
- Custodial
- Educational
43. 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
44. Palpating the midclavicular line is the correct technique for assessing:
- Baseline vital signs
- Systolic blood pressure
- Respiratory rate
- Apical pulse
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45. When assessing the adequacy of sperm for conception to occur, which of the following is the most useful criterion?
- Sperm count
- Sperm motility
- Sperm maturity
- Semen volume
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46. The nurse is caring for a client with a nasogastric tube that is attached to low suction. The nurse monitors the client for manifestations of which disorder that the client is at risk for?
- Metabolic acidosis
- Metabolic alkalosis
- Respiratory acidosis
- Respiratory alkalosis
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47. A patient has multiple sclerosis and complains of over whelming fatigue. The nurse would be MOST correct in instruction the patient to:
- Conserve energy during activities of daily living
- Increase muscle strength through aerobic exercise
- Ignore fatigue and keep working
- Increase early afternoon intake of caffeine
48. The Mantoux text is used to determine whether a person has been exposed to tuberculosis. If the test is positive the nurse will find a:
- Fluid-filled vesicle
- Sharply demarcated erythema
- Central area of induration
- Circular blanched area
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49. Situation: Please continue responding as a professional nurse in varied health situations through the following questions. 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
50. The best position for any procedure that involves vaginal and cervical examination is:
- Dorsal recumbent
- Side lying
- Supine
- Lithotomy