NCLEX-RN | QB3 | Practice Exam #36 (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 lab results of four clients. Which finding should be reported to the physician?

• A client with chronic renal failure with a serum creatinine of 5.6mg/dl_
• A client with rheumatic fever with a positive C reactive protein
• A client with gastroenteritis with a hematocrit of 52%
• A client with epilepsy with a white cell count of 3800mm3

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2. Which of the following is recognized for developing the concept of HIGH LEVEL WELLNESS?

• Erikson
• Madaw
• Peplau
• Dunn

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3. A surgeon instructs a nurse to serve as a witness to an elderly patient's informed consent for surgery. During the surgeon's explanation to the patient, it becomes dear that the patient is confused and does not understand the procedure, but reluctantly signs the consent from. The nurse should.

• Sign the form as a witness, making a notation that the patient did not appear to understand
• Not sign the form as a witness and notify the nurse supervisor
• Not sign the form and answer the patient's questions after the surgeon leaves the room
• Sign the form as a witness and notify the nurse supervisor.

4. For a patient scheduled for a total pancrectectomy, the nurse would be instruct the patient that the procedure work MOST likely cause

• Pancreatic ascites
• Chronic pancreatitis
• Diabetes mellitus
• Diabetes insipidus

5. To enhance milk production, a lactating mother must do the following interventions EXCEPT:

• Increase fluid intake including milk
• Eat foods that increases lactation which are called galactagues
• Exercise adequately like aerobics
• Have adequate nutrition and rest

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6. All of the following chart entries are correct except:

• V/S 36.8 C,80,16,120/80
• Complained of chest pain
• Seems agitated
• Able to ambulate without assistance

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7. Upon assessment of an obese patient's back, the nurse observes a forward curvature of the lumbar spine. These findings are indicative of.

• Kyphosis
• List
• Lordosis
• Scoliosis

8. 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. Grace sustained a laceration on her leg from automobile accident. Why are lacerations of lower extremities potentially more serious among pregnant women than other?

• lacerations can provoke allergic responses due to gonadotropic hormone release
• a woman is less able to keep the laceration clean because of her fatigue
• healing is limited during pregnancy so these will not heal until after birth
• increased bleeding can occur from uterine pressure on leg veins

9. Although a nurse is unable to identify any obvious signs or symptoms of bleeding, a client repeatedly has tested positive for occult blood in the stool. Which laboratory result is a concern considering this client’s history?

• Iron level 100 mcg/dL
• Uric acid level 6.5 mg/dL
• Hemoglobin level 8.5 g/dL
• Transferrin level 300 mg/dL

10. Situation: The question with regards to the OPERATING ROOM. Q. Which statement about a person's character is evident in the OR team?

• it assists in the control of feelings, thoughts and emotions in the face of difficulty
• it reflects the moral values and beliefs that are used as guides to personal behavior and actions
• it encourages the constructive use of the pleasure of the senses
• it refers to the quality of being righteous, correct, fair and impartial

11. Which type of endotracheal tube is recommended by the Centers for Disease Control (CDC) for reducing the risk of ventilator-associated pneumonia?

• Uncuffed
• CASS
• Fenestrated
• Nasotracheal

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12. A client in the PACU with a left below the knee amputation complains of pain in her left big toe. Which of the following would the nurse do first?

• Tell the client it is impossible to feel the pain
• Show the client that the toes are not there
• Explain to the client that the pain is real
• Give the client the prescribed narcotic analgesic

13. PROPRANOLOL (Inderal) is used in the mental health setting to manage which of the following conditions?

• Antipsychotic - induced akathisia and anxiety
• Obsessive - compulsive disorder (OCD) to reduce ritualistic behavior
• Delusions for clients suffering from schizophrenia
• The manic phase of bipolar illness as a mood stabilizer

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14. A patient with a spinal cord injury (SCI) complains about a severe throbbing headache that suddenly started a short time ago. Assessment of the patient reveals increased blood pressure (168/94) and decreased heart rate (48/minute), diaphoresis, and flushing of the face and neck. What action should you take first?

• Administer the ordered acetaminophen (Tylenol).
• Check the Foley tubing for kinks or obstruction.
• Adjust the temperature in the patient's room.
• Notify the physician about the change in status.

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15. Situation: Maintenance of sterility is an important function a nurse should perform in any OR setting. Q. Which of the following is true with regards to sterility?

• Sterility is time related items are not considered sterile after a period of 30 days of being not in use.
• for 9 months sterile items are considered sterile as long as they are covered with sterile muslin cover and stored in a dust proof covers.
• Sterility is event related, not time related.
• For 3 weeks, items double covered with muslin are considered sterile as long as they have undergone the sterilization process

16. A victim of domestic violence states, “If I were better, I would not have been beat." Which feeling best describes what the victim may be experiencing?

• Fear
• Helplessness
• Self-blame
• Rejection

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17. The public health nurse is responsible for presenting the municipal health statistics using graphs and tables. To compare the frequency of the leading causes of mortality in the municipality, which graph will you prepare?

• Line
• Bar
• Pie
• Scatter diagram

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18. Patient who is scheduled for a tonsillectomy is in the preoperative unit. The nurse notes an order for preanesthetic medication to be given "on call to operating room." The nurse should give this medication.

• Immediately upon being notified to prepare the patient for transport.
• When the operating room staff.
• arrives to transport the patient.
• Only if clearly needed after.

19. Which one of the following situations represents a maturational crisis for the family?

• A four-year-old entering nursery school
• Development of preeclampsia during pregnancy
• Loss of employment and health benefits
• Hospitalization of a grandfather with a stroke

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20. Situation: You are fortunate to be chosen as part of the research team in the hospital. A review of the following IMPORTANT nursing concepts was made. Q. Each nurse participants was asked to identify a problem. After the identification of the research problem, which of the following should be done?

• Methodology
• Review of related literature
• Acknowledgment
• Formulate hypothesis

21. A patient is diagnosed with peptic ulcer. What would be the long term goal for this patient?

• Patient remains free of signs and symptoms of gastrointestinal bleeding
• Patient maintains lifestyle alterations to prevent recurrence of ulcer
• Patient expresses decreased pain level
• Patient performs activities of daily living without difficulty

22. The nurse is assessing an infant with developmental dysplasia of the hip. Which finding would the nurse anticipate?

• Unequal leg length
• Limited adduction
• Diminished femoral pulses
• Symmetrical gluteal folds

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23. Nursing measures for the client who has had an Ml include helping the client to avoid activity that results in Valsalva's maneuver. Valsalva's maneuver may cause cardiac dysrhythmias, increased venous pressure, increased intrathoracic pressure and thrombi dislodgement. Which of the following actions would help prevent Valsalva's maneuver? Have the client:

• Assume a side-lying position
• Clench her teeth while moving in bed
• Drink fluids through a straw
• Avoid holding her breath during activity

24. A patient has a history of severe, uncontrolled epistaxis. The patient's blood pressure and patient count are normal. The nurse should teach the patient to:

• Sleep with the head elevated on at least two three pillows
• Apply firm pressure to the nostrils four times a day
• Use a cotton-filled applicator to apply a water-soluble lubricant to the nasal septum twice daily
• Minimize the intake of caffeine while increasing the intake of fluids rich in vitamin K

25. Which of the following recurring conditions most commonly occurs in clients with cardiomyopathy?

• Heart failure
• Pericardial effusion
• DM
• MI

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26. A 57-year-old patient in a hospital clinic is scheduled for a colon biopsy. The patient speaks a different language than the hospital staff, but does understand simple communication in the language of the staff. When conduction patient education prior to the procedure, the nurse should plan to:

• Write all communication and avoid speech
• Raise the volume and pitch of the voice
• Obtain an interpreter
• Smile and nod frequently

27. Situation: Joanna Marie, a 40 year old client was diagnosed with breast cancer. Q. In the Philippines, The use of this method is strongly suggested and recommended than any other methods to decrease death due to breast cancer:

• BSE
• Mammography
• Breast Biopsy
• Surgery

28. A client is learning about caring for her ileostomy. Which of the following statements would indicate that she understands how to care for her ileostomy pouch?

• I'll empty my pouch when it's about one-third full
• I can take my pouch off at night
• I should change my pouch immediately after lunch
• I must apply a new pouch system every day

29. When the bag of waters ruptures, the nurse should check the characteristic of the amniotic fluid. The normal color of amniotic fluid is:

• Clear as water
• Bluish
• Greenish
• Yellowish

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30. Situation: The Gastrointestinal System is responsible for taking in and processing nutrients for all parts of the body, any problem can quickly affect other body systems and, if not adequately treated, can affect overall health, growth, and development. The following questions are about gastrointestinal disorders in a child. A 4-year-old child is hospitalized because of persistent vomiting. As a nurse, you must monitor the child closely for:

• Diarrhea
• Metabolic Acidosis
• Metabolic Alkalosis
• Hyperactive bowel sounds

31. On a home visit the nurse finds four young children alone. The youngest of the children has bruises on the face and back and circular burns on the inner aspect of the right forearm. The nurse should:

• Contact child welfare services
• Transport the child to the emergency room
• Take the children to an abuse shelter
• Stay with the children until an adult arrives

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32. A pattern in which the nursing personnel divide the patient into groups and complete their care together is called:

• Primary method
• Team nursing
• Nursing managed care case method
• Case method

33. Refers to the moral values and beliefs that are used as guides to personal behavior and actions

• Philosophy
• Personality
• Charm
• Character

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34. Situation: Among common conditions found in children especially among poor communities are ear infection/problems. The following questions apply. A child with ear problem should be assessed for the following EXCEPT:

• is there any fever?
• ear discharge
• if discharge is present for how long?
• ear pain

35. When the client is lying supine, the nurse will prevent external rotation of the lower extremity by using a:

• Trochanter roll by the knee
• Sandbag to the lateral calf
• Trochanter roll to the thigh
• Footboard

36. A hospitalized client hurriedly approaches the nurse, saying that it sounds like there is a roaring fire in the bathroom. In reality, the client’s roommate has just turned the shower on full force. What term best describes this experience?

• Illusion
• Delusion
• Dissociation
• Hallucination

37. The nurse explains to a patient that a cough:

• Is a protective response to clear the respiratory tract of irritants
• Is primarily a voluntary action
• Is induced by the administration of an antitussive drug
• Can be inhibited by "splinting" the abdomen

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38. 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. In the prevention and control of cancer, which of the following activities is the most important function of the community health nurse?

• Conduct community assemblies.
• Referral to cancer specialist those clients with symptoms of cancer.
• Use the nine warning signs of cancer as parameters in our process of detection, control and treatment modalities.
• Teach women about proper/correct nutrition.

39. The client immobilized skeletal leg traction complains of being bored and restless. Based on these complaints, the nurse formulates which of the following nursing diagnoses for this client?

• Diversional activity deficit
• Powerlessness
• Self care deficit
• Impaired physical mobility

40. An intubated patient is receiving continuous enteral feedings through a Salem sump tube at a rate of 60ml/hr. Gastric residuals have been 30-40ml when monitored Q4H. You check the gastric residual and aspirate 220mL What is your first response to this finding?

• Notify the doctor immediately.
• Discard the 220ml and clamp the NG tube
• Give a prescribed GI stimulant such as metoclopramide (Reglan).
• Discontinue the feeding, and clamp the NG tube.

41. Situation: The body has regulatory mechanism to maintain the needed electrolytes. However there are conditions/surgical interventions that could compromise life. You have to understand how management of these conditions are done. Q. As Leda's nurse, you plan to set up an emergency equipment at her bedside following thyroidectomy. You should include:

• An airway and rebreather tube
• A tracheostomy set and oxygen
• A crush cart with bed board
• Two ampules of sodium bicarbonate

42. The nurse is caring for a client with osteoporosis who is being discharged on alendronate (Fosamax). Which statement would indicate a need for further teaching?

• I should take the medication immediately before bedtime every night.
• I should remain in an upright position for 30 minutes after taking Fosamax.
• The medication should be taken by mouth with water
• I should not have any food with this medication.

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43. A patient report difficulty sleeping through the night since the death of spouse 6 months ago which of the following is an appropriate LONG term goal?

• Feeling well rested each morning
• Not feeling tired each afternoon
• Taking brief nap in the middle of the day
• Using sleep aid on a nightly basis

44. Atherosclerosis impedes coronary blood flow by which of the following mechanisms?

• Plaques obstruct the vein
• Plaques obstruct the artery
• Blood clots form outside the vessel wall
• Hardened vessels dilate to allow the blood to flow through

45. The nurse is evaluating the patient with end stage chronic obstructive pulmonary disease (COPD).The patient has not achieved any of the goals in the plan of care. The spouse reports concerns about the patient's mood and increased dependency. What action should the nurse take FIRST?

• Continue the care plan for 1 more month
• Refer the patient to psychiatric services
• Collaborate with the patient and spouse to revise the care plan
• Revise the care plan based on the spouse's input

46. Which of the following sounds is distinctly heard on auscultation over the abdominal region of an abdominal aortic aneurysm client?

• Bruit
• Crackles
• Dullness
• Friction rubs

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47. A nurse for a child with celiac disease (CD). The patient would have a permanent inability to tolerate:

• Protein
• Dairy
• Glutens
• Fruits

48. Which statement made by the client with facial burns who has been prescribed to wear a facial mask pressure garment indicates correct understanding of the purpose of this treatment?

• "After this treatment, my ears will not stick out"
• "The mask will help protect my skin from sun damage."
• "Using this mask will prevent scars from being permanent"
• "My facial scars should be less severe with the use of this mask"

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49. Situation: Records and Records management is one of the core of professional nursing practice. Q. What is an example of a subjective data?

• Color of wound drainage
• Odor of breath
• Respiration of 14 breaths/minute
• The patient's statement of "I feel sick to my stomach"

50. A patient is transferred to the Intensive Care following a craniotomy. The patient is difficult to arouse and the pupils are pinpoint and non-reactive. Blood pressure: 118/70 mmHg Heart rate: 58/min Respiratory rate: 11/min Temperature: 37.2°C Which medication should the nurse prepare administer?

• Adrenaline
• Thiamine
• Naloxone
• Dextrose 50%

 

NCLEX-RN | QB3 | Practice Exam #36 (50 questions)