NCLEX-RN | QB3 | Practice Exam #34 (50 questions)
All 50 questions are randomized each time you take the test, and do not appear in the same order.
1. Situation: it is the first day of clinical experience of nursing students at the Psychiatry Ward. During the orientation, the nurse emphasizes that the team members including nursing students are legally responsible to safeguard patient's records from loss or destruction or from people not authorized to bead it. Q. Nursing care plans provide very meaningful data for the patient profile and initial plan because the focus is on the:
- Summary of chronological notations made by individuals health team members
- Identification of patient's responses to medical diagnosis and treatment
- Patient's responses to health: and illness as a total person in interaction with the environment
- Step procedures for the management of common problems
2. Which is the primary goal of community health nursing?
- To support and supplement the efforts of the medical profession in the promotion of health and prevention of
- To enhance the capacity of individuals, families and communities to cope with their health needs
- To increase the productivity of the people by providing them with services that will increase their level of health
- To contribute to national development through promotion of family welfare, focusing particularly on mothers and children
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3. The nurse is teaching a patient about spironolactone (aldactone). Which of the following instructions should the nurse review with the patient?
- Increasing intake of foods that are high in potassium
- Taking the medication right before going to sleep
- Avoiding seasoning that are labeled as salt substitutes
- Scheduling the medication so that a multi vitamin is taken an hour later
4. The nurse is preparing to care for a 5-year-old who has been placed in traction following a fracture of the femur The nurse plans care, knowing that which is the most appropriate activity for this child?
- A radio
- A sports video
- Large picture books
- Crayons and a coloring book
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5. Situation: One important toot a community health nurse uses in the conduct of his/her activities is the CHN Bag. Which of the following BEST DESCRIBES the use of this vital facility for our practice? Q. The Community/Public Health Bag is:
- a requirement for home visits
- an essential and indispensable equipment of the community health nurse
- contains basic medications and articles used by the community health nurse
- a tool used by the Community health nurse is rendering effective nursing procedure during a home visit
6. A client has been diagnosed with pernicious anemia what will the nurse teach this client regarding medication he will need to take after he goes home?
- Monthly Vit. B12 injections will be necessary
- Ferrous sulfate PO daily will be prescribed
- Coagulation studies are important to evaluate medications
- Decrease intake of leafy green vegetables because of increased Vit. K
7. A 67-year-old client develops acute shortness of breath and progressive hypoxia requiring right femur. The hypoxia was probably caused by which of the following conditions?
- Asthma attack
- Bronchitis
- Atelectasis
- Fat embolism
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8. Hypoxia is a common complication of laryngotracheobronchitis. Nurse Oliver should frequently assess a child with laryngotracheobronchitis for:
- Drooling
- Muffled voice
- Restlessness
- Low-grade fever
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9. Situation: Burn is cause by transfer of heat source to the body. It can be thermal, electrical radiation or chemical. Q. A 165 lbs trauma client was rushed to the emergency room with full thickness burns on the whole face, right and left arm, and at the anterior chest sparing the abdominal area. He also has superficial partial thickness burn at the posterior trunk and at the half upper portion of the left leg. He the emergent phase of burns using the parkland's formula, you know that during the first 8 hours of burn the amount of fluid will be given is:
- 5,400ml
- 10,500 ml
- 9,450 ml
- 6,750 ml
10. To assist with the prevention of urinary tract infections the teenage girl should be taught to:
- Drink citrus fruit juices
- Avoid using tampons
- Take showers instead of tub baths
- Clean the perineum from front to back
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11. The nurse is caring for a client with a balanced suspension traction with a Thomas splint. The nurse observes that the left leg of the client is externally rotated. Which of the following is the priority of the nurse?
- Place a trochanter roll outside the thigh.
- Perform resistive range of motion of the affected leg
- Adduct and internally rotate the left leg.
- Maintain the left leg in a neutral position.
12. An elderly client with glaucoma is scheduled for a cholecystectomy. Which medication order should the nurse question?
- Demerol (meperidine)
- Tagamet (cimetadine)
- Atropine (atropine)
- Phenergan (promethazine)
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13. The client arrives in the emergency department after a motor vehicle accident Nursing assessment findings include BP 68/34 pulse rate 130 and respirations 18. Which is the clients most appropriate priority nursing diagnosis?
- Alteration in cerebral tissue perfusion
- Fluid volume deficit
- Ineffective airway clearance
- Alteration in sensory perception
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14. 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. 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
15. A 13-year-old child is hospitalized for treatment of sickle cell crisis. The nurse finds the child is crying and does not answer the nurse when addressed. What should nurse do FIRST?
- Interview the parents about the child's pain tolerance and usual medication requirements
- Medicate the patient with the medication ordered for breakthrough pain as soon as possible, the resume the evaluation
- Ask the child to describe the pain, it is located, and to rate it on the wong/baker pain scale.
- Tell the child to rest while and the nurse will return at another time for the evaluation
16. When removing a contaminated gown, the nurse should be careful that the first thing she touches is the:
- Waist tie and neck tie at the back of the gown
- Waist tie in front of the gown
- Cuffs of the gown
- Inside of the gown
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17. A client's laboratory tests indicate that the client has hypocalcemia. Which of the following symptoms should the nurse look for in the client?
- Flushed skin
- Depressed reflexes
- Tingling in extremities
- Diarrhea
18. Which assignment should not be performed by the registered nurse?
- Inserting a Foley catheter
- Inserting a nasogastric tube
- Monitoring central venous pressure
- Inserting sutures and clips in surgery
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19. Situation: In the OR, there are safety protocols that should be followed. The OR nurse should be well versed with all these to safeguard the safety and quality of patient delivery outcome. Q. Another nursing check that should not be missed before the induction of general anesthesia is:
- check for presence underwear
- check for presence dentures
- check patient's ID
- check baseline vital signs
20. The nurse has just received the shift report and is preparing to make rounds. Which client should be seen first?
- The client with a history of a cerebral aneurysm with an oxygen saturation rate of 99%
- The client three days postcoronary artery bypass graft with a temperature of 100.2°F
- The client being prepared for discharge following a femoral popliteal bypass graft
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21. The nurse walks into the room of a client who has had surgery for testicular cancer. The client says that he'll be undesirable to his wife, and he becomes tearful. He expresses that he has spoiled a happy, satisfying sex life with his wife, and says that he thinks it might be best if he would just die. Based on these signs and symptoms, which nursing diagnosis would be most appropriate for planning purposes?
- Situational low self-esteem
- Unilateral neglect
- Social isolation
- Risk for loneliness
22. The nurse is providing instructions to a pregnant client with a history of cardiac disease regarding appropriate dietary measures. Which statement, if made by the client, indicates an understanding of the information provided by the nurse?
- "I should increase my sodium intake during pregnancy"
- "I should lower my blood volume by limiting my fluids."
- "I should maintain a low-calorie diet to prevent any weight gain."
- "I should drink adequate fluids and increase my intake of high-fiber foods"
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23. The difference between the systolic and diastolic pressure is termed as:
- Apical rate
- Cardiac rate
- Pulse deficit
- Pulse pressure
24. A7-year-old child is seen in a clinic, and the health care provider documents a diagnosis of primary nocturnal enuresis. The nurse should provide which information to the parents?
- Primary nocturnal enuresis does not respond to treatment.
- Primary nocturnal enuresis is caused by a psychiatric problem.
- Primary nocturnal enuresis requires surgical intervention to improve the problem.
- Primary nocturnal enuresis is usually outgrown without therapeutic intervention.
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25. The nurse is performing discharge teaching on a client with polycythemia vera. Which would be included in the teaching plan?
- Avoid large crowds and exposure to people who are III.
- Keep the head of the bed elevated at night.
- Wear socks and gloves when going outside.
- Recognize clinical manifestations of thrombosis.
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26. Situation: Nursing informatics is a way of using information technology, computers and the internet in the improvement of nursing care. The first nursing informatics conference was held during 1977. Q. The ANA recognized nursing informatics heralding its establishment as a new field in nursing during what year?
- 1992
- 1994
- 2001
- 2004
27. A nurse is caring for a child with spasmodic croup. Which clinical finding alerts the nurse that immediate nursing intervention is required?
- Irritability
- Hoarseness
- Barking cough
- Rapid respirations
28. A 12-year-old child who has been diagnosed with insulin dependant mellitus (IDDM) since age 3. Comes to the clinic for a routine visit. The patient has begun to self manage care with parental supervision. The patient injects 28 units of NPH insulin every morning and 8 units at bedtime. The patient checks blood sugar 4 times every day.The patient's weight is stable and diet is unchanged. However, the patient reports several hypoglycemic reactions every week. The nurse knows the MOST likely cause is that:
- The patient is not eating the adequate number of calories reported
- The dosages of insulin may need to be decreased as the patient continues to grow
- There may be changes in exercise or stress levels or the beginning of a growth Spurt
- The patient may not be competent in techniques of drawing up and injecting insulin
29. A client diagnosed with delirium becomes disoriented and confused at night. Which intervention should the nurse implement initially?
- Move the client next to the nurses' station.
- Use an indirect light source and turn off the television.
- Keep the television and a soft light on during the night.
- Play soft music during the night, and maintain a well-lit room.
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30. A pregnant client with severe preeclampsia is receiving IV magnesium sulfate. What should the nurse keep at the bedside to prepare for the possibility of magnesium sulfate toxicity?
- Oxygen
- Naloxone
- Calcium gluconate
- Suction equipment
31. Rabies virus can be transmitted through:
- Penetration of broken skin
- contact with a pre-existing wound or scratch
- penetration of intact mucosa
- any of these modes of transmission
32. Which of the following is NOT a characteristic of an effective Nurse-Client relationship?
- Focused on the patient
- Based on mutual trust
- Conveys acceptance
- Discourages emotional bond
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33. The client with acquired immunodeficiency syndrome and Pneumocystis jiroveci infection has been receiving pentamidine. The client develops a temperature of 101 °F (38.3 °C). The nurse continues to assess the client, knowing that this sign most likely indicates which condition?
- That the dose of the medication is too low
- That the client is experiencing toxic effects of the medication
- That the client has developed inadequacy of thermoregulation
- That the client has developed another infection caused by leukopenic effects of the medication
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34. The nurse is monitoring a client following a lung resection. The hourly output from the chest tube was 300mL. The nurse should give priority to:
- Turning the client to the left side
- Milking the tube to ensure patency
- Slowing the intravenous infusion
- Notifying the physician
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35. The nurse is teaching a class on reproduction. When asked about the development of the ova, the nurse would include which of the following?
- Meiotic divisions begin during puberty.
- At the end of meiosis, four ova are created.
- Each ovum contains the diploid number of chromosomes.
- Like sperm, ova have the ability to propel themselves.
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36. For a client in Addisonian crisis, it would be very risky for a nurse to administer:
- potassium chloride
- normal saline solution
- hydrocortisone
- fludrocortisone
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37. Situation: Mr. Gerald Liu, 19 y/o, is being admitted to a hospital unit complaining of severe pain in the lower abdomen. Admission vital signs reveal an oral temperature of 101.2 OF. Q. After a few minutes, the pain suddenly stops without any intervention. Nurse Ray might suspect that:
- the appendix is still distended
- the appendix may have ruptured
- an increased in intrathoracic pressure will occur
- signs and symptoms of peritonitis occur
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38. Which nursing intervention would be most appropriate if a male client develop orthostatic hypotension while taking amitriptyline (Elavil)?
- Consulting with the physician about substituting a different type of antidepressant.
- Advising the client to sit up for 1 minute before getting out of bed.
- Instructing the client to double the dosage until the problem resolves.
- Informing the client that this adverse reaction should disappear within 1 week.
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39. The nurse reviews the laboratory results for a child with a suspected diagnosis of rheumatic fever, knowing that which laboratory study would assist in confirming the diagnosis?
- Immunoglobulin
- Red blood cell count
- White blood cell count
- Anti-streptolysin O titer
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40. The physician has ordered an IV bolus of Solu-Medrol (methylprednisolone sodium succinate) in normal saline for a client admitted with a spinal cord injury. Solu-Medrol has been shown to be effective in:
- Preventing spasticity associated with cord injury
- Decreasing the need for mechanical ventilation
- Improving motor and sensory functioning
- Treating post injury urinary tract infections
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41. A home health nurse is preparing to administer a subcutaneous injection of heparin.When site on the abdomen, the nurse will choose a site:
- More than 6 inches from the umbilicus
- More than 2 inches from the umbilicus
- As close as possible to the umbilicus
42. The nurse is providing care for a 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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43. After an anterior wall myocardial infarction, which of the following problems is indicated by auscultation of crackles in the lungs?
- Left-sided heart failure
- Pulmonic valve malfunction
- Right-sided heart failure
- Tricuspid valve malfunction
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44. A nurse is assessing the neurovascular of a client who has returned to the surgical nursing unit 4 hours ago after undergoing aortoiliac bypass graft. The affected leg is warm, and the nurse notes redness and edema. The pedal pulse is palpable and unchanged from admission. The nurse interprets that the neurovascular status is:
- Slightly deteriorating and should be monitored for another hour
- Moderately impaired, and the surgeon should be called
- Normal because of increased blood flow through the leg
- Adequate from an arterial approach, but venous complications are arising.
45. A 20 year old client was diagnosed with dependent personality disorder. Which behavior is not most likely to be evidence of ineffective individual coping?
- Recurrent self-destructive behavior
- Avoiding relationship
- Showing interest in solitary activities
- Inability to make choices and decision without advise
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46. Nurse prepares to delegate tasks to the nursing assistant Among her patients is a 50 year- old woman who is day two of recovery following a laparoscopic resection of the colon post-operative orders are follow: Ambulate every six hours. Evaluate vital signs every two hours. Lactated Ringer's IV at 50 ml/hour. Wound assessment every eight hours. Nasogastric tube until bowel sounds present Which is most appropriate to delegate?
- Ambulate the patient.
- Evaluation of vital signs.
- Change intravenous fluid bags.
- Assess nasogastric tube placement.
47. Nurse Emma provides teaching to a patient with recurrent urinary tract infection includes the following:
- Increase intake of tea, coffee and colas
- Void every 6 hours per day
- Void immediately after intercourse
- Take tub bath everyday
48. A child with deformity (broken) nose, the child went to the school and his friends find this funny, the child was upset and went to the nurse in the school and told him, he will stop coming to school, the nurse toke a paper and draw the child face and nose and tell him that 'he will look like them after the procedure', in which step the nurse perform:
- Self-confidence
- Self-deception
49. George, age 8, is admitted with rheumatic fever. Which clinical finding indicates to the nurse that George needs to continue taking the salicylates he had received at home?
- Chorea.
- Polyarthritis.
- Subcutaneous nodules.
- Erythema marginatum.
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50. Situation: Developing countries such as the Philippines suffer from high infant and child mortality rates. Thus, as a management to the existing problem, the WHO and UNICEF launched the IMCL A child with ear problem should be assessed for the following, except:
- Ear pain
- if discharge is present for how long?
- Ear discharge
- Is there any fever?