NCLEX-RN | QB3 | Practice Exam #23 (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 reviewing the laboratory results for a child scheduled for a tonsillectomy. The nurse determines that which laboratory value is most significant to review?
- Creatinine level
- Prothrombin time
- Sedimentation rate
- Blood urea nitrogen level
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2. The nurse administered a dose of morphine sulfate, as prescribed to a patient who is in the post-anesthesia care unit (PACU). The patient appears to be resting comfortably; the respiratory rate is 8 and the 02 saturation on 2L of oxygen via nasal cannula is 86%. The nurse should IMMEDIETLY administer:
- Flumazenil (Romazicon)
- Midazolam (Versed)
- Naloxone (Narcan)
- Ondansetron (Zofran)
3. Situation: Nurse Minette is an independent nurse practitioner following-up referred clients in their respective homes. Here she handles a case of POSTPARTUM MOTHER AND FAMILY focusing on HOME CARE. Q. This postpartum mother wants to lose the weight she gained in pregnancy, so she is reluctant to increase her caloric intake for breast-feeding. By how much should a lactating mother increase her caloric intake during the first 6 months after birth?
- 350 kcal/day
- 500 kcal/day
- 200 kcal/day
- 1,000 kcal/day
4. A male client has undergone spinal surgery, the nurse should:
- Observe the client's bowel movement and voiding patterns
- Log-roll the client to prone position
- Assess the client's feet for sensation and circulation
- Encourage client to drink plenty of fluids
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5. The burned client's family ask at what point the client will no longer be at increased risk for infection. What is the nurse's best response?
- "When fluid remobilization has started."
- "When the burn wounds are closed."
- "When IV fluids are discontinued."
- "When body weight is normal."
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6. A patient with congestive heart failure and severe peripheral edema has a nursing diagnosis of fluid volume excess What are the two MOST important interventions for the nurse to initiate?
- Diuretic therapy and intake and output
- Nutritional education and low-sodium diet
- Daily weights and intake and output
- Low-sodium diet and elevate legs when in bed
7. A client has undergone right pneumonectomy. When turning the client, the nurse should plan to position the client either:
- Right side-lying position or supine
- High Fowler's position
- Right or left side lying position
- Low Fowler's position
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8. Which of the following groups of characteristics would the nurse expect to see in the client with schizophrenia?
- Loose associations, grandiose delusions, and auditory hallucinations
- Periods of hyperactivity and irritability alternating with depression
- Delusions of jealousy and persecution, paranoia, and mistrust
- Sadness, apathy, feelings of worthlessness, anorexia, and weight loss
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9. A patient to have an elective surgical procedure to repair an umbilical hernia. The patient is 68 year old, weighs 136 kg( 3001b), and has diabetis mellitus. Which of the following approaches would be the MOST beneficial in order to reduce the patient surgical risk?
- Monitor blood glucose level monthly
- Avoid fluid overload by restricting fluid
- Discourage any changes in routine before surgery
- Encourage weight reduction
10. The PHN bag is an important tool in providing nursing care during a home visit. The most important principle in bag technique states that it:
- Should save time and effort
- Should minimize if not totally prevent the spread of infection
- Should not overshadow concern for the patient and his family
- May be done in variety of ways depending on the home situation, etc.
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11. The nurse is caring for a patient who had major abdominal surgery under general anesthetic 4 hours ago. An appropriate goal for the patient includes:
- Having minimal fine crackles in the base of the lungs
- Using the incentive spirometry every 4 hours
- Expectorating minimal amount of secretions
- Performing Coughing Exercises every hour while awake
12. A nurse is assigned to do a home visit for an 81-year-old patient. The patient lives at home with an adult caretaker and is completely bed-bound following a Cerebrovascular accident (CVA) 2 weeks ago. In planning caregiver education. The nurse should be prepared to instruct the caretaker in:
- How to select a nursing home for the patient
- Performing passive range of motion exercises
- The importance of avoiding viscous drinks
- Forming a local chapter of a care giver support group
13. Situation: Prevention of Dengue is an important nursing responsibility and controlling it's spread is priority once outbreak has been observed. Community health nurses should be alert in observing a Dengue suspect. The following is NOT an indicator for hospitalization of H-fever suspects?
- Marked anorexia, abdominal pain and vomiting
- Increasing hematocrit count
- Cough of 30 days
- Persistent headache
14. A client has been diagnosed with hypertension. The nurse priority nursing diagnosis would be:
- Ineffective health maintenance
- Impaired skin integrity
- Deficient fluid volume
- Pain
15. Situation: Care of clients with tracheotosmy is often a challenge to a beginning nurse. The following questions will test your knowledge on Tracheostomy and its related care. Q. Which of the following is not considered as a regular part of a Tracheostomy tube?
- The outer cannula
- The inner cannula
- The obturator
- The cuff
16. Situation: Andrea is admitted to the ER following an assault where she was hit on the face and head. She was brought to the ER by a police woman. Emergency measures were stated. Q. Which of the following is true with the Cushing's Triad seen in head injuries?
- Virchow's Triad
- Widening Pulse pressure, Irregular respiration, Bradycardia
- Hypertension, Kussmaul's respiration, Tachycardia
- Hypotension, Irregular respiration, Bradycardia
17. A 70-year-old alcoholic patient with acute lethargy, confusion, and incontinence is admitted to the hospital ED. His wife tells you that he fell down the stairs about a month ago, but "he didn’t have a scratch afterward.” She feels that he has become gradually less active and sleepier over the last 10 days or so. Which of the following collaborative interventions will you implement first?
- Place on the hospital alcohol withdrawal protocol.
- Transfer to radiology for a CT scan.
- Insert a retention catheter to straight drainage.
- Give phenytoin (Dilantin) 100 mg PO.
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18. Situation: Basic knowledge on Intravenous solutions is necessary for care of clients with problems with fluids and electrolytes. Q. A client involved in a motor vehicle crash presents to the emergency department with severe internal bleeding. The client is severely hypotensive and unresponsive. The nurse anticipates which of the following intravenous solutions will most likely be prescribed to increase intravascular volume, replace immediate blood loss and increase blood pressure?
- 0.45 % sodium chloride
- Normal saline solution
- 0.33% sodium chloride
- Lactated ringer's solution
19. The nurse recognizes that which interventions are likely to facilitate effective communication between a dying client and family? Select all that apply. 1. The nurse encourages the client and family to identify and discuss feelings openly. 2. The nurse assists the client and family in carrying out spiritually meaningful practices. 3. The nurse removes autonomy from the client to alleviate any unnecessary stress for the client. 4. The nurse makes decisions for the client and family to relieve them of unnecessary demands. 5. The nurse maintains a calm attitude and one of acceptance when the family or client expresses anger.
- 1,2,5
- 2,3,4
- 2,3.5
- 1,2,3,4
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20. The nurse is caring for a client with diabetic ketoacidosis and documents that the client is experiencing Kussmaul's respirations. Which patterns did the nurse observe? Select all that apply. 1. Respirations that are shallow 2. Respirations that are increased in rate 3. Respirations that are abnormally slow 4. Respirations that are abnormally deep 5. Respirations that cease for several seconds
- 1,5
- 2,4
- 1,2,3,4
- 3,4,5
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21. A client is diagnosed with emphysema and cor pulmonale. Which findings are characteristic of cor pulmonale?
- Hypoxia shortness of breath and exertional fatigue
- Weight loss increased RBC and fever
- Rales edema and enlarged spleen
- Edema of the lower extremities and distended neck veins
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22. A 45 year-old man who is hospitalized feels the constant need to keep things in order, particularly whilst eating. The nurse observes him arranging the food on his plate into symmetrical and equal bite-sized pieces. He constantly worries that food served could be outdated and potentially cause illness. Which nursing diagnosis is most important?
- Ineffective verbal communication
- Self-esteem disturbance
- Impaired social interaction
- Anxiety
23. When performing tracheal suctioning for a client with a tracheotomy the nurse should:
- Pre-oxygenate the client before suctioning.
- Apply negative pressure as the catheter is being inserted.
- Be sure the cuff of the tracheotomy is inflated during suctioning.
- Instill normal saline into the tracheotomy prior to suctioning.
24. A conscious victim of motor vehicle accident arrives at the emergency department. The patient gasping of air, is extremely anxious , and has a deviated trachea. What diagnosis should the nurse anticipate?
- Pleural effusion
- Tension pneumothorax
- Pneumothorax
- Hemothorax
25. A client is admitted with suspected Hodgkins lymphoma. The diagnosis is confirmed by the:
- Overproliferation of immature white cells
- Presence of Reed-Sternberg cells
- Increased incidence of microcytosis
- Reduction in the number of platelets
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26. Which of the following combinations of foods is appropriate for an eight-month-old infant?
- Cocoa-flavored cereal orange juice and strained meat
- Graham crackers strained prunes and pudding
- Rice cereal bananas and strained carrots
- Mashed potatoes strained beets and whole milk
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27. The client has a chronic tissue injury. Upon examining the client's antibody for a particular cellular response, Which of the following WBC component is responsible for phagocytosis in chronic tissue injury?
- Neutrophils
- Basophils
- Eosinophils
- Monocytes
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28. Ivy, who is on the psychiatric unit is copying and imitating the movements of her primary nurse. During recovery, she says, "I thought the nurse was my mirror. I felt connected only when I saw my nurse.” This behavior is known by which of the following terms?
- Modeling
- Echopraxia
- Ego-syntonicity
- Ritualism
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29. Situation: Camila, 25 years old, was reported to be gradually withdrawing and isolating herself from friends and family members. She became neglectful of her personal hygiene. She was observed to be talking irrelevantly and incoherently. She was diagnosed as schizophrenia Q. Camila refuses to relate with others because she:
- is irritable
- feels superior of others
- anticipates rejection
- is depressed
30. A client with myasthenia gravis has been receiving Neostigmine (Prostigmin). This drug acts by:
- Stimulating the cerebral cortex
- Blocking the action of cholinesterase
- Replacing deficient neurotransmitters
- Accelerating transmission along neural swaths
31. The mother of a newborn calls the clinic and reports that when cleaning the umbilical cord, she noticed that the cord was moist and that discharge was present. What is the most appropriate nursing instruction for this mother?
- Bring the infant to the clinic.
- This is a normal occurrence and no further action is needed.
- Increase the number of times that the cord is cleaned per day.
- Monitor the cord for another 24 to 48 hours and call the clinic if the discharge continues.
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32. A client sustained a severe head injury to the occipital lobe. The nurse should carefully assess the client for:
- Changes in vision
- Difficulty in speaking
- Impaired judgment
- Hearing impairment
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33. The uterine fundus right after delivery of placenta is palpable at:
- Level of Xyphoid process
- Level of umbilicus
- Level of symphysis pubis
- Midway between umbilicus and symphysis pubis
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34. You are helping the patient with an SCI to establish a bladder-retraining program. What strategies may stimulate the patient to void? (Choose all that apply), a. Stroke the patient's inner thigh, b. Pull on the patient's pubic hair. c. Initiate intermittent straight catheterization. d. Pour warm water over the perineum, e. Tap the bladder to stimulate detrusor muscle.
- A, B, D & E
- A, B, C & D
- A, C, B, D & E
- B, C, D & E
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35. The newly admitted client has burns on both legs. The burned areas appear white and leather-like. No blisters or bleeding are present, and the client states that he or she has little pain. How should this injury be categorized?
- Superficial
- Partial-thickness superficial
- Partial-thickness deep
- Full thickness
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36. While caring for a child with in effective airway clearance related to increased mucus production, the nurse should encourage fluids to:
- Maintain nutrition
- Prevent boredom
- Stimulate coughing
- Thin secretions
37. The nurse is monitoring a patient's urine to determine hydration status what urine color would indicate the BEST hydration?
- Clear
- Amber
- Tea
- Pale gold
38. Which nursing interventions are appropriate for a hospitalized client with mania who is exhibiting manipulative behavior? Select all that apply. 1. Communicate expected behaviors to the client. 2. Ensure that the client knows that they are not in charge of the nursing unit. 3. Assist the client in identifying ways of setting limits on personal behaviors. 4. Follow through about the consequences of behavior in a nonpunitive manner. 5. Enforce rules by informing the client that he/she will not be allowed to attend therapy groups. 6. Have the client state the consequences for behaving in ways that are viewed as unacceptable.
- 1,3,4,5,6
- 1,2,3,4,5
- 1,3,5
- 1,3,4,6
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39. Which of the following is the exact order of the infection chain? 1. Susceptible host 2. Portal of entry 3. Portal of exit 4. Etiologic agent 5. Reservoir 6. Mode of transmission
- 1,2,3,4,5,6
- 5,2,3,6,1
- 4,5,3,6,2,1
- 6,5,4,3,2,1
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40. After a client's eye has been anesthetized, what instructions will be important for the nurse to give the client?
- Do not watch TV for at least one day
- Do not rub the eye for 15-20 minutes
- Irrigate the eye every hour to prevent dryness
- Wear sunglasses when in direct sunlight for the next 6 hours
41. Mr. Garcia, an attorney who throws books and furniture around the office after losing a case is referred to the psychiatric nurse in the law firm's employee assistance program. Nurse Beatriz knows that the client's behavior most likely represents the use of which defense mechanism?
- Regression
- Projection
- Reaction-formation
- Intellectualization
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42. A 16-year-old client is admitted to the hospital for acute appendicitis and an appendectomy is performed. Which nursing intervention is most appropriate to facilitate normal growth and development postoperatively?
- Encourage the client to rest and read.
- Encourage the parents to room in with the client.
- Allow the family to bring in the client's favorite computer games.
- Allow the client to interact with others in his or her (Adolescent) same age group.
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43. The nurse is caring for a client with a long leg cast. During discharge teaching about appropriate exercises for the affected extremity, the nurse should recommend:
- Isometric
- Range of motion
- Aerobic
- Isotonic
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44. Assuming a cup of rice provides 50 grams of carbohydrates. How many calories are there in that cup of rice?
- 150 calories
- 200 calories
- 250 calories
- 400 calories
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45. Which of the following is TRUE about respiration?
- I:E 2:1
- I:E 4:3
- I:E 1:1
- I:E 1:2
46. The nurse is assessing a patient recently diagnosed with acquired immune 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
47. Which of the following is NOT TRUE with regards to the concept of Modern Stress Theory?
- Stress is not a nervous energy
- Man, whenever he encounters stresses, always adapts to it
- Stress is not always something to be avoided
- Stress does not always lead to distress
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48. What clinical indicator is the nurse most likely to identify when completing a history and physical assessment of a client with complete heart block?
- Syncope
- Headache
- Tachycardia
- Hemiparesis
49. The resident's weight is obtained routinely as a way to check the resident's:
- growth and development.
- adjustment to the facility.
- nutrition and health.
- activity level.
50. The client is taking sertraline (Zoloft), 50 mg q AM. The nurse includes which of the following in the teaching plan about Zoloft?
- Zoloft causes erectile dysfunction in men.
- Zoloft causes postural hypotension
- Zoloft increases appetite and weight gain
- It may take 3-4 weeks before client will start feeling better.
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NCLEX-RN | QB3 | Practice Exam #23 (50 questions)