NCLEX-RN | QB3 | Practice Exam #37 (50 questions)

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

 

1. Situation: You are assigned in the Orthopedic Ward where clients are complaining of pain in varying degrees upon movement of body parts. Q. You continuously evaluate the client's adaptation to pain. Which of the following behaviors-indicate appropriate adaptation?

• The client reports pain reduction and decreased activity
• The client denies existence of pain
• The client can distract himself during pain episodes
• The client reports independence from watchers

2. A nurse is caring for a post-operative patient who is on subcutaneous, low dose of heparin. When administering injection on the abdomen, the nurse avoids the umbilicus area because of the possibility of:

• Entering a larger body vessel
• Causing increased pain
• Precipitating hyperventilation
• umbilical infection

3. A child with asthma has an order for albuterol, before administration of the medication the nurse MUST.

• Pre-oxygenate the patient
• Assess the patient's heart rate
• Obtain venous Access
• Feed the patient a snack

4. It is described as a collection of people who share some attributes of their lives.

• Family
• Illness
• Community
• Nursing

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5. The low-pressure alarm sounds on a ventilator. The nurse assesses the client and then attempts to determine the cause of the alarm. If unsuccessful in determining the cause of the alarm, the nurse should take what initial action?

• Administer oxygen
• Check the client's vital signs
• Ventilate the client manually
• Start cardiopulmonary resuscitation

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6. Situation: Nurse Lorna is a Family Planning and Infertility Nurse Specialist and is currently attending to a meeting. The following conditions pertain to meeting the nursing of this particular population group. The Smiths are a couple undergoing testing for infertility, infertility is said to exist when:

• a woman has no uterus
• a woman has no children
• a couple has been trying to conceive for 1 year
• a couple has wanted a child for 6 months

7. Patient with nausea/aspiration what's the position of the patient?

• Lt lateral
• Rt lateral
• Sim fowler
• None of the above.

8. A nurse in a community health clinic is in charges of immunizations. When patients visits the clinic the nurse knows that immunizations should be reviewed:

• At the age they are scheduled to be administered
• One month prior to recommended immunization schedule
• At every clinic visit
• At monthly intervals

9. A nurse is caring for a postoperative patient who is on subcutaneous, low dose heparin. This medication is used to prevent:

• Deep vein thrombosis
• Congestive heart failure
• Paralytic Ileus
• Pneumonia

10. A nurse administers an albuterol nebulizer on a child with asthma exacerbation. Which of following indicates effectiveness of the treatment?

• Adventitious breath sound with cough
• O2 saturation 94%
• Nasal flaring
• Respiration rate 28

11. Nurse Judy knows that statistics show that in adolescent suicidal behavior:

• Females use more dramatic methods than males
• Males account for more attempts than do females
• Females talk more about suicide before attempting it
• Males are more likely to use lethal methods than are females

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12. In order to reduce the risk of disease transmission from a patient with diphtheria, which of the following standard precautions would be the nurse implemented?

• Airborne
• Contact
• Droplets
• Ventilatory

13. A preoperative patient has a large volume cleansing enema ordered. In order to facilitate the flow of the solution into the rectum and colon, the nurse should position the patient in the:

• Supine position with legs flexed to chest
• Right lateral position with left sharply flexed
• Supine position with legs spread
• Left lateral position with right leg sharply flexed

14. 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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15. SITUATION: MARK Lester had been diagnosed with Stage 1 bronchogenic cancer. He had undergone lobectomy on the left lower lung. A two-bottle drainage system is inserted. If the nurse sees vigorous and continuous bubbling in the second bottle, she should:

• Momentarily clamp the tube to note for air leak
• Administer oxygen to the patient
• Attempt to change a new bottle
• Pull the chest tube out to remove the air leak

16. Situation: As a Nurse, you have specific responsibilities as professional. You have to demonstrate specific competencies. Q. Which barrier should you avoid, to manage your time wisely?

• Practical planning
• Procrastination
• Setting limits
• Realistic personal expectation

17. Which of the following diets would be most appropriate for a client with COPD?

• Low fat low cholesterol
• Bland, soft diet
• Low-Sodium diet
• High calorie, high-protein diet

18. Situation: Margie has been diagnosed with Bipolar I disorder. The client demonstrates extreme psychomotor agitation, flight of ideas, loud talking and elated mood. Q. What specimen is taken from a client when checking the lithium level of the body?

• Blood
• Stool
• Urine
• Sweat

19. The nurse should visit which of the following clients first?

• The client with diabetes with a blood glucose of 95mg/dL
• The client with hypertension being maintained on Lisinopril
• The client with chest pain and a history of angina
• The client with Raynauds disease

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20. The nurse instructs a client to use the pursed-lip method of breathing and evaluates the teaching by asking the client about the purpose of this type of breathing. The nurse determines that the client understands if the client states that the primary purpose of pursed-lip breathing is to promote which outcome?

• Promote oxygen intake
• Strengthen the diaphragm
• Strengthen the intercostal muscles
• Promote carbon dioxide elimination

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21. Enzyme secreted by the small intestine after it detects a bolus of fatty food. This will contract the gallbladder to secrete bile and relax the sphincter of Oddi to aid in the emulsification of fats and its digestion.

• Lipase
• Amylase
• Cholecystokinin
• Pancreozymin

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22. During the intra operative period of surgical procedure a 39 year old male has the following vital signs: core temperature 37 C(98.6F)( heart rate 62, blood pressure 126/78 mm Hg, and an 02 saturation level of 89%. The patient has received two units of packed cell volume (PRBs) and is intubated. Which of the vital signs is considered out of normal range?

• heart rate
• O2 saturation
• Core temperature
• Blood pressure

23. SITUATION: A 45 year old male construction worker was admitted to a tertiary hospital for incessant vomiting. Assessment disclosed: weak rapid pulse, acute weight loss of 0.5kg, furrows in his tongue, slow flattening of the skin was noted when the nurse released her pinch. Temperature: 35.8 C, BUN Creatinine ratio: 10:1, He also complains for postural hypotension. There was no infection. Q. Postural Hypotension is

• A drop in systolic pressure less than 10 mmHg when patient changes position from lying to sitting.
• A drop in systolic pressure greater than 10 mmHg when patient changes position from lying to sitting
• A drop in diastolic pressure less than 10 mmHg when patient changes position from lying to sitting
• A drop in diastolic pressure greater than 10 mmHg when patient changes position from lying to sitting

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24. A nurse observes that an infant has head control and can roll over but can neither sit up without support nor transfer an object from one hand to the other. What devel­opmental age should the nurse estimate based on these observations?

• 1 to 2 months
• 3 to 4 months
• 5 to 6 months
• 8 to 9 months

25. The nurse has completed discharge instructions for a client with application of a halo device. Which statement indicates that the client needs further clarification of the instructions?

• "I will use a straw for drinking.”
• "I will drive only during the daytime.”
• "I will be careful because the device alters balance.”
• "I will wash the skin daily under the lamb's wool liner of the vest."

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26. A client complained of nausea, a metallic taste in her mouth, and fine hand tremors 2 hours after her first dose of lithium carbonate (Lithane). What is the nurse's best explanation of these findings?

• These side effects are common and should subside in a few days
• The client is probably having an allergic reaction and should discontinue the drug
• Taking the lithium on an empty stomach should decrease these symptoms
• Decreasing dietary intake of sodium and fluids should minimize the side effects

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27. When Nurse Trish is providing care to his patient, she must remember that her duty is bound not to do doing any action that will cause the patient harm. This is the meaning of the bioethical principle:

• Non-maleficence
• Beneficence
• Justice
• Solidarity

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28. The physician ordered: Mannerix a.c, what does a.c means?

• As desired
• After meals
• Before meals
• Before bedtime

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29. Situation: Melamine contamination in milk has brought world wide crisis both in the milk production sector as well as the health and economy. Being aware of the current events is one quality that a nurse should possess to prove that nursing is a dynamic profession that will adapt depending on the patient's needs. Q. infants are the most vulnerable to melamine poisoning. Which of the following is NOT a sign of melamine poisoning?

• Irritability, Backache, Urolithiasis
• High blood pressure, fever
• Anuria, Oliguria or Hematuria
• Fever, Irritability and a large output of diluted urine

30. A client rescued from a burning building has partial- and full-thickness burns over 40% of the body. Which is the initial physiologic change that the nurse can expect?

• An increase in blood volume
• An increase in serum potassium
• A decrease in capillary permeability
• A decrease in urinary specific gravity

31. The clinic nurse prepares to perform a focused assessment on a client who is complaining of symptoms of a cold, a cough, and lung congestion. Which should the nurse include for this type of assessment? Select all that apply. 1. Auscultating lung sounds 2. Obtaining the client's temperature 3. Assessing the strength of peripheral pulses 4. Obtaining information about the client's respirations 5. Performing a musculoskeletal and neurological examination 6. Asking the client about a family history of any illness or disease

• 1,2,3,4,5
• 2,4,5,6
• 1,3,5
• 1,2,4

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32. Is the term used to administered undiluted medication quickly into a vein:

• Bolus
• Secondary infusion
• Intermittent
• Continuous

33. Management of a child with measles includes the administration of which of the following?

• Gentian violet on mouth lesions
• Antibiotic to prevent pneumonia
• Tetracycline eye ointment for corneal opacity
• Retinol capsule regardless of when the last dose was given

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34. A client with three children who is still in the childbearing years is admitted for surgical repair of a prolapsed bladder. The nurse would find that the client understood the surgeon's preoperative teaching when the client states:

• "If I should become pregnant again, the child would be delivered by cesarean delivery"
• "If I have another child, the procedure may need to be repeated."
• "This surgery may render me incapable of conceiving another child.”
• "This procedure is accomplished in two separate surgeries.”

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35. SITUATION: Knowledge of the drug prophantheline bromide [Probanthine] Is necessary in treatment of various disorders. Q. Which of the following drugs are not compatible when taking Probanthine?

• Caffeine
• NSAID
• Acetaminophen
• Alcohol

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36. A patient presents to the clinic for a routine visit and has the following vital signs: temperature 37.00C (98.60F), heart rate 82, respiration rate 18 and blood pressure level of 130/94 mmHg. Which vital sign is abnormal?

• Temperature
• Pulse
• Respiration
• Blood pressure

37. A gravida II para 0 is admitted to the labor and delivery unit The doctor performs an amniotomy. Which observation would the nurse expect to make immediately after the amniotomy?

• Fetal heart tones 160 beats per minute
• A moderate amount of clear fluid
• A small amount of greenish fluid
• A small segment of the umbilical cord

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38. A patient presents with pneumonia. Which of the following intervention would the nurse implement to improve the patient's gas exchange? Heart rate: 80/min Respiratory rate: 32/ min Temperature: 40"C

• Encourage the patient to increase fluid intake
• Position the patient in an upright position
• Instruct the patient the patient to splint when coughing
• Apply heat and or cold to the chest as ordered

39. A client with in situ bladder cancer is receiving intravesical therapy using BCG. During treatment the nurse should

• Ask the client to remain still after the medication is instilled.
• Offer the client additional oral fluids.
• Ask the client to change positions every fifteen minutes.
• Ask the client to void every hour.

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40. Mr. Snyder is admitted to your unit with a brain tumor. The type of tumor he has is currently unknown. You begin to think about the way brain tumors are classified. Q. Mr Snyder is scheduled for surgery in the morning, and you are surprised to find out that there is no order for an enema. You assess the situation and conclude that the reason for this is:

• Mr. Snyder has had some mental changes due to the tumor and would find an enema terribly traumatic
• Straining to evacuate the enema might increase the intracranial pressure
• Mr. Snyder had been on clear liquids and then was NPO for several days, so an enema is not necessary
• An oversight and you call the physician to obtain the order

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41. When performing oral care on a comatose client, Nurse Krina should:

• Apply lemon glycerin to the client's lips at least every 2 hours.
• Brush the teeth with client lying supine.
• Place the client in a side lying position, with the head of the bed lowered.
• Clean the client's mouth with hydrogen peroxide.

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42. Tamoxifen citrate is prescribed for a client with metastatic breast carcinoma. The client asks the nurse if her family member with bladder cancer can also take this medication. The nurse most appropriately responds by making which statement?

• "This medication can be used only to treat breast cancer."
• "Yes, your family member can take this medication for bladder cancer as well."
• "This medication can be taken to prevent and treat clients with breast cancer."
• "This medication can be taken by anyone with cancer as long as their health care provider approves it."

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43. A client was diagnosed as having Dengue Fever. You will say that there is slow capillary refill when the color of the nailbed that you pressed does not return within how many seconds?

• 3
• 5
• 8
• 10

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44. The nurse is creating a plan of care for a client who was experiencing anxiety after the loss of a job. The client is now verbalizing concerns regarding the ability to meet role expectations and financial obligations. What is the priority nursing problem for this client?

• Anxiety
• Unrealistic outlook
• Lack of ability to cope effectively
• Disturbances in thoughts and ideas

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45. Which of the following examples represents parallel play?

• Jenny and Tommy share their toys.
• Jimmy plays with his car beside Mary who is playing with her doll.
• Kevin plays a game of Scrabble with Kathy and Sue.
• Mary plays with a handheld game while sitting in her mothers lap.

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46. When planning discharge teaching for a patient hospitalized for treatment of third-degree burns over 30% of the body, the nurse knows it is MOST important to include which of the following instruction regarding the loss of large amounts of serum occurring with burns and the resulting loss of immune function?

• Wash hands frequently each day
• Wear masks while in public spaces
• Wear supplement oxygen at night
• Take a multiple vitamin tablet each night

47. The primary nursing diagnosis for a female client with a medical diagnosis of major depression would be:

• Situational low self-esteem related to altered role
• Powerlessness related to the loss of idealized self
• Spiritual distress related to depression
• Impaired verbal communication related to depression

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48. A 68 year-old male patient has a chest tube and properly fixed following cardiac surgery. The chest tube is patent and functioning. When the nurse removes the dressing the tube falls out of the chest. Which is the most appropriate initial intervention the nurse should take?

• Reinsert the chest tube and notify the surgeon
• Apply an occlusive dressing to the insertion site
• Place the open end of the tube in 20 cm of water
• Administer 02 at 10L/min via non-rebreather mask

49. He knows that there are external forces that influence changes in his unit Which of the following is NOT an external force?

• Memo from the CEO to cut down on electrical consumption
• Demands of the labor sector to increase wages
• Low morale of staff in his unit
• Exacting regulatory and accreditation standards

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50. The nurse is monitoring the amount of lochia drainage in a client who is 2 hours postpartum and notes that the client has saturated a perineal pad in 15 minutes. How should the nurse respond to this finding initially?

• Document the finding.
• Encourage the client to ambulate.
• Encourage the client to increase fluid intake.
• Contact the health care provider (HCP) and inform the HCP of this finding.

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NCLEX-RN | QB3 | Practice Exam #37 (50 questions)