NCLEX-RN | QB3 | Practice Exam #32 (50 questions)

All 50 questions are randomized each time you take the test, and do not appear in the same order.

 

1. An older client recently has been taking cimetidine. The nurse monitors the client for which most frequent central nervous system side effect of this medication?

• Tremors
• Dizziness
• Confusion
• Hallucinations

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2. Situation: In your professional nursing role, it is essential to establish a meaningful nurse­ patient relationship. Q. The client's past reactions to ending relationships is withdrawal The nurse assists her to practice better ways of coping termination by providing opportunities to:

• Test new patterns of behavior
• Plan for alternatives
• Conceptualize her problem
• Value and find meaning in experience

3. Monitoring the progress of labor in the delivery room is a standard activity. The. nurse prioritizes her work load by recognizing that a nulliparous mother in the first stage of labor would expect these;

• Latent phase is completed less than 20 hours
• Maximum slope averages 4 to 5 hrs
• Acceleration phase is 6 to 8 hours
• Transition phase lasting no longer than 4 hours

4. Situation: Please respond as a professional nurse in the other health situations through the following question. The medical record of a client reveals a condition in which the fetus cannot pass through the maternal pelvis. The nurse interprets this as:

• Contracted pelvis
• Maternal disproportion
• Cervical insufficiency
• Fetopelvic disproportion

5. Nurse Amy is providing care for a male client undergoing opiate withdrawal. Opiate withdrawal causes severe physical discomfort and can be life-threatening. To minimize these effects, opiate users are commonly detoxified with:

• Barbiturates
• Amphetamines
• Methadone
• Benzodiazepines

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6. Refers to the degree of resistance the potential host has against a certain pathogen:

• Susceptibility
• Immunity
• Virulence
• Etiology

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7. According to her, Nursing is a helping or assisting profession to persons who are wholly or partly dependent or when those who are supposedly caring for them are no longer able to give care.

• Henderson
• Orem
• Swanson
• Neuman

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8. Nurse Sarah ensures a therapeutic environment for all the client. Which of the following best describes a therapeutic milieu?

• A therapy that rewards adaptive behavior
• A cognitive approach to change behavior
• A living, learning or working environment.
• A permissive and congenial environment

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9. Five teaspoon is equivalent to how many milliliters (ml)?

• 12 ml
• 22 ml
• 25 ml
• 30 ml

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10. The nurse documents positive ballottement in the client's prenatal record. The nurse understands that this indicates which of the following?

• Palpable contractions on the abdomen
• Passive movement of the unengaged fetus
• Fetal kicking felt by the client
• Enlargement and softening of the uterus

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11. Situation: Jose seeks psychiatric counselling for his ritualistic behavior of counting his money as many as 10 times before leaving home. Q. The defense mechanism used by persons with obsessive compulsive disorder is undoing and it is best described in one of the following statements:

• Unacceptable feeling or behaviour are kept out of awareness by developing the opposite behaviour or emotion.
• Consciously unacceptable instinctual drives are diverted into personally and socially acceptable channels
• Something unacceptable already done is symbolically acted in reverse.
• Transfer of emotions associated with a particular person, object or situation to another less threatening person, object or situation.

12. The nurse is teaching a new group of mental health aides. The nurse should teach the aides that setting limits is most important for:

• a depressed client.
• a manic client.
• a suicidal client.
• an anxious client.

13. Which cast care instructions should the nurse provide to a client who just had a plaster cast applied to the right forearm? Select all that apply. 1. Keep the cast clean and dry. 2. Allow the cast 24 to 72 hours to dry. 3. Keep the cast and extremity elevated. 4. Expect tingling and numbness in the extremity. 5. Use a hair dryer set on a warm to hot setting to dry the cast. 6. Use a soft, padded object that will fit under the cast to scratch the skin under the cast.

• 2,3,4
• 1,2,3
• 3,4,5,6
• 1,3,5,6

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14. Situation: As a nurse you are expected to participate in initiating or participating in the conduct of research students to improve nursing practice. You to be updated on the latest trends and issues affected the profession and the best practices arrived at by the profession. Q. In any research study where individual persons are involved, it is important that an informed consent of the study is obtained. The following are essential information about the consent that you should disclose to the prospective subject except:

• Consent to incomplete
• Description of benefits, risks and discomforts
• Explaining of procedure
• Assurance of anonymity and confidentiality

15. Situation: In a disaster there must be a chain of command in place that defines the roles of each member of the response team. Within the health care group there are pre-assigned roles based on education, experience and training on disaster. Q. Which of the following categories of conditions should be considered first priority in a disaster?

• Intracranial pressure and mental status
• Lower gastrointestinal problems
• Respiratory infection
• Trauma

16. While assessing a newborn with cleft lip, the nurse would be alert that which of the following will most likely be compromised?

• Sucking ability
• Respiratory status
• Locomotion
• GI function

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17. Nurse Liza is assigned to care for a client who has returned to the nursing unit after left nephrectomy. Nurse Liza's highest priority would be:

• Hourly urine output
• Temperature
• Able to turn side to side
• Able to sips clear liquid

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18. Situation: ENTEROSTOMAL THERAPY is now considered a specialty in nursing. You are participating in the OSTOMY CARE CLASS. Q. You are aware that teaching about colostomy care is understood when Fermin states, "I will contact my physician and report:

• "If I have any difficulty inserting the irrigating tube into the stoma."
• "If I noticed a loss of sensation to touch in the stromal tissue.”
• "The expulsion of flatus while the irrigating fluid is running out"
• "When mucus is passed from the stoma between the irrigations."

19. Situation: You are assigned at the surgical ward and clients have been complaining of post pain at varying degrees. Pain as you know is very subjective. Q. Pentoxide 5 mg IV every 8 hours was prescribed for post abdominal pain, which will be your priority nursing action?

• Check abdominal dressing for possible swelling
• Explain the proper use of PCA to alleviate anxiety
• Avoid overdosing to prevent dependence/tolerance
• Monitor VS, more importantly RR

20. Situation: As a nurse you are expected to participate in initiating or participating in the conduct of research studies to improve nursing practice. You have to be updated on the latest trends and issues affecting profession and the best practices arrived at by the profession Q. In any research study where individual persons are involved, it is important that an informed consent for the Study is obtained. The following are essential information about the consent that you should disclose to the prospective subjects EXCEPT:

• Consent to incomplete disclosure
• Description of benefits, risks and discomforts
• Explanation of procedure
• Assurance of anonymity and confidentiality.

21. Situation: You are assigned to take care of a group of patients across the lifespan. In working with the caregivers of a client with an cute or chronic illness, the nurse would:

• Teach care daily and let the caregivers do a return demonstration just before discharge
• Difficulty swallowing, diminished or absent gag reflex and respiratory distress
• Difficulty sleeping, hypervigilant and arching of the back
• Paradoxical irritability, diarrhea and vomiting

22. Situation: ENTEROSTOMAL THERAPY is now considered especially in nursing. You are participating in the OSTOMY CARE CLASS. Q. You plan to teach Fermin how to irrigate the colostomy when:

• The perineal wound heals and Fermin can sit comfortably on the commode
• Fermin can lie on the side comfortably, about the 3rd postoperative day
• The abdominal incision is close and contamination is no longer a danger
• The stool starts to become formed, around the 7th postoperative day

23. The nurse has taught the client with a below the knee amputation about prosthesis and stump care. The nurse evaluates that the client states to:

• Wear a clean nylon stump sock daily
• Toughen the skin of the stump by rubbing it with alcohol
• Prevent cracking of the skin of the stump by applying lotion daily
• Using a mirror to inspect all areas of the stump each day

24. When a child is brought to the emergency department with acute epiglottitis, which of the following nursing diagnoses should receive PRIORITY?

• Ineffective airway clearance
• Activity intolerance
• Fluid volume deficit
• Impaired verbal communication

25. George who has undergone thoracic surgery has chest tube connected to a water-seal drainage system attached to suction. Presence of excessive bubbling is identified in water­ seal chamber, the nurse should.

• "Strip" the chest tube catheter
• Check the system for air leaks
• Recognize the system is functioning correctly
• Decrease the amount of suction pressure

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26. Situation: Nurses hold a variety of roles when providing care to a perioperative patient. Q. It is also the nurse's function to determine when infection is developing in the surgical incision. The perioperative nurse should observe for what signs of impending infection?

• Localized heat and redness
• Serosanguinous exudates and skin blanching
• Separation of the incision
• Blood clots and scar tissue are visible

27. Which of the following statements would be the nurse's response to a family member asking questions about a client's transient ischemic attack (TIA)?

• "I think you should ask the doctor. Would you like me to call him for you?”
• ”The blood supply to the brain has decreased causing permanent brain damage”
• "It Is a temporary interruption in the blood flow to the brain”
• "TIA means a transient ischemic attack”

28. The nurse in a labor room is preparing to care for a client with hypertonic uterine contractions. The nurse is told that the client is experiencing uncoordinated contractions that are erratic in their frequency, duration, and intensity. What is the priority nursing action?

• Provide pain relief measures.
• Prepare the client for an amniotomy.
• Promote ambulation every 30 minutes.
• Monitor the oxytocin infusion closely.

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29. Which is unlikely of Florence Nightingale?

• Born May 12,1840
• Built St. Thomas school of nursing when she was 40 years old
• Notes in nursing
• Notes in hospital

30. Nurse John recognizes that paranoid delusions usually are related to the defense mechanism of:

• Projection
• Identification
• Repression
• Regression

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31. The nurse was Instructed to watch out for the occurrence of normal physiologic changes of pregnancy. Which of the following is usually observed during pregnancy?

• Increased BP
• Palpitation
• Anemia
• Blurred vision

32. A new head nurse on a unit is distressed about the poor staffing on the 11 p.m. to 7 a.m. shift What should she do?

• Complain to her fellow nurses
• Wait until she knows more about the unit
• Discuss the problem with her supervisor
• Inform the staff that they must volunteer to rotate

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33. The nurse is teaching the mother regarding treatment for enterobiasis. Which instruction should be given regarding the medication?

• Treatment is not recommended for children less than 10 years of age.
• The entire family should be treated.
• Medication therapy will continue for one year.
• Intravenous antibiotic therapy will be ordered.

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34. Situation: Cancer of the prostate is the leading cancer in Men other than skin cancer. The following questions will assess your knowledge and theoretical foundation in dealing with clients with prostate cancer. Q. After the removal of the prostate tissue, the physician soaked the solution in formaldehyde in a sterile specimen container and asked you to send the specimen immediately. Which of the following is a correct nursing action?

• "Dr. Ruiz, I don't think this specimen is acceptable. Please redo the procedure and do not soak the specimen in any medium.”
• "Dr. Ruiz, I just want you to know that you soaked the specimen in formaldehyde wherein, it should not be soaked in any medium at all."
• Accept the specimen because there is nothing wrong with the physician's action
• "Dr. Ruiz, it should be soaked in NSS not formaldehyde. I am going to report you to the board of medicine for this could lead to a false result."

35. Mr. Liberatore, age 76, is admitted to your unit He has a past medical history of hypertension, DM, hyperlipidemia. Recently he has had several episodes where he stops talking mid sentence and stares into space. Today the episode lasted for 15 minutes. The admission diagnosis is impending CVA. Q. Upper motor neuron disease may be manifested in which of the following clinical signs?

• spastic paralysis, hyperreflexia, presence of babinski reflex
• flaccid paralysis, hyporeflexia
• muscle atrophy, fasciculations
• decreased or absent voluntary movement

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36. Which of the following nursing diagnoses would be inappropriate for the infant with gastroesophageal reflux (GER)?

• Fluid volume deficit
• Risk for aspiration
• Altered nutrition: less than body requirements
• Altered oral mucous membranes

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37. Which level of health facility is the usual point of entry of a client into the health care delivery system?

• Primary
• Secondary
• Intermediate
• Tertiary

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38. Which client is at risk for opportunistic diseases such as pneumocystis pneumonia?

• The client with cancer who is being treated with chemotherapy
• The client with Type I diabetes
• The client with thyroid disease
• The client with Addisons disease

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39. After insertion of a chest tube for a pneumothorax, a client becomes hypotensive with neck vein distention, tracheal shift, absent breath sounds, and diaphoresis. Nurse Amanda suspects a tension pneumothorax has occurred. What cause of tension pneumothorax should the nurse check for?

• Infection of the lung.
• Kinked or obstructed chest tube
• Excessive water in the water-seal chamber
• Excessive chest tube drainage

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40. Which one of the following observations would most indicate to the nurse that the skin over Mr. Heywood's coccyx is becoming impaired? The skin:

• Looks shiny over bony prominences
• Appears red when pressure is relieved
• Feels cool and clammy
• Is moist and warm

41. The district nurse attends a 73 year-old woman on a daily basis. The woman's husband had passed away three years previously and she now lives alone. Besides assisting in activities of daily living the nurse encourages the patient to talk about her past experiences and events. Which theoretical frame work is most likely guiding the nurse's care plan?

• Erickson's model of psychosocial development
• Piaget's theory of cognitive development
• Watson's theory of human caring
• Roy's adaptation model

42. The client arrives at the emergency department complaining of back spasms. The client states, "I have been taking 2 to 3 aspirin every 4 hours for the last week, and it hasn't helped my back." Since acetylsalicylic acid intoxication is suspected, the nurse should assess the client for which manifestation?

• Tinnitus
• Diarrhea
• Constipation
• Photosensitivity

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43. Situation: Mrs. Damian an immediate post op cholecystectomy and choledocholithotomy patient complained of severe pain at the wound site. Q. The simplest pain relieving technique is:

• Distraction
• Taking aspirin
• Deep breathing exercise
• Positioning

44. Situation: The preoperative nurse collaborates with the client significant others, and healthcare providers. Q. To control environmental hazards in the OR, the nurse collaborates with the following departments EXCEPT:

• Biomedical division
• Chaplaincy services
• Infection control committee
• Pathology department

45. Effective skin disinfection before a surgical procedure includes which of the following methods?

• Shaving the site on the day before surgery
• Applying a topical antiseptic to the skin on the evening before surgery
• Having the patient take a tub bath on the morning of surgery
• Having the patient shower with an antiseptic soap on the evening before and the morning of surgery

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46. A client with tuberculosis is to be admitted in the hospital. The nurse who will be assigned to care for the client must institute appropriate precautions. The nurse should:

• Place the client in a private room.
• Wear an N 95 respirator when caring for the client.
• Put on a gown every time when entering the room.
• Don a surgical mask with a face shield when entering the room.

47. The nurse prepares to give Ms. Edwards a vaginal suppository, which is inserted by means of a special applicator supplied with the drug. Which one of the following is correct?

• Ask the client to void prior to inserting the suppository
• Lubricate the tip of the suppository with petroleum jelly
• Insert the applicator tip gently and with an upward and forward motion
• Insert the applicator approximately 1/2 inch and depress the plunger

48. The nurse provides home care instructions to the parents of a child with heart failure regarding the procedure for administration of digoxin. Which statement made by the parent indicates the need for further instruction?

• "I will not mix the medication with food"
• "I will take my child's pulse before administering the medication"
• "If more than 1 dose is missed, I will call the health care provider"
• "If my child vomits after medication administration, I will repeat the dose"

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49. The charge nurse is planning the assignment for the day. Which factors should the nurse remain mindful of when planning the assignment? Select all that apply. 1. The acuity level of the clients 2. Specific requests from the staff 3. The clustering of the rooms on the unit 4. The number of anticipated client discharges 5. Client needs and workers needs and abilities

• 1,4,5
• 1,5
• 1,2,3
• 1,2,3,4,5

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50. The nurse-in-charge in labor and delivery unit administered a dose of terbutaline to a client without checking the client's pulse. The standard that would be used to determine if the nurse was negligent is:

• The physician's orders.
• The action of a clinical nurse specialist who is recognized expert in the field.
• The statement in the drug literature about administration of terbutaline.
• The actions of a reasonably prudent nurse with similar education and experience.

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NCLEX-RN | QB3 | Practice Exam #32 (50 questions)