NCLEX-RN | QB3 | Practice Exam #38 (50 questions)
All 50 questions are randomized each time you take the test, and do not appear in the same order.
1. The physician has ordered an intravenous infusion of Pitocin for the induction of labor. When caring for the obstetric client receiving intravenous Pitocin the nurse should monitor for:
- Maternal hypoglycemia
- Fetal bradycardia
- Maternal hyperreflexia
- Fetal movement
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2. The client, who is 2 weeks postburn with a 40% deep partial-thickness injury, still has open wounds. On taking the morning vital signs, the client is found to have a below-normal temperature, is hypotensive, and has diarrhea. What is the nurse's best action?
- Nothing, because the findings are normal for clients during the acute phase of recovery.
- Increase the temperature in the room and increase the IV infusion rate.
- Assess the client's airway and oxygen saturation.
- Notify the burn emergency team.
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3. The nurse is caring for a client with hypocalcemia. Which patterns would the nurse watch for on the electrocardiogram as a result of the laboratory value? Select all that apply. 1. U waves 2. Widened T wave 3. Prominent U wave 4. Prolonged QT interval 5. Prolonged ST segment
- 1,3
- 3,4
- 2,5
- 4,5
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4. During the change of shift the oncoming nurse notes a discrepancy in the number of percocet listed and the number present in the narcotic drawer. The nurses first action should be to:
- Notify the hospital pharmacist
- Notify the nursing supervisor
- Notify the Board of Nursing
- Notify the director of nursing
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5. Situation: Arnold, age 67, has had successfully treated depressive disease for more than 10 years. Lately he has been developing a plan of action. Arnold is admitted to hospital for reassessment Q. Which factor is most important in evaluating Arnold's risk for suicide?
- Presence of multiple personal problems
- Length of time the depression has existed
- Impending of the loss of a loved one
- development plans for discharge from hospital or program
6. A 3 year-old had a hip spica cast applied 2 hours ago. In order to facilitate drying, the nurse should
- Expose the cast to air and turn the child frequently
- Use a heat lamp to reduce the drying time
- Handle the cast with the abductor bar
- Turn the child as little as possible
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7. The nurse is assessing a patient who is 2-weeks postoperative a kyphoplasty of L2 and L3.The patient has been participating in physical therapy and has been doing daily stretching and strengthening. Which of the following would indicate that the patient has met discharge goals?
- Reports pain in legs while sitting
- Urinating every two hours while awake
- Fatigue after performing activities of daily living
- Ambulates outdoors without assistive devices
8. Aortic anyrism operation what type of surgical intervention:
- Elective
- Urgent
- Emergency
- Diagnostic
9. Mr. Duffy is admitted to the CCU with a diagnosis of R/O Ml. He presented in the ER with a typical description of pain associated with an Ml, and is now cold and clammy, pale and dyspneic. He has an IV of D5W running, and is complaining of chest pain. Oxygen therapy has not been started, and he is not on the monitor. He is frightened. Q. Mr. Duffy is placed on digitalis on discharge from the hospital. The nurse planning with him for his discharge should educate him as to the purpose and actions of his new medication. What should she or he teach Mr. Duffy to do at home to monitor his reaction to this medication?
- take his blood pressure
- take his radial pulse for one minute
- check his serum potassium (K) level
- weigh himself everyday
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10. Which client is at risk for the development of a potassium level of 5.5 mEq/L (5.5 mmol/L)?
- The client with colitis
- The client with Cushing's syndrome
- The client who has been overusing laxatives
- The client who has sustained a traumatic burn
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11. Which statement by the parent of a child with sickle cell anemia indicates an understanding of the disease?
- The pain he has is due to the presence of too many red blood cells.
- He will be able to go snow-skiing with his friends as long as he stays warm.
- He will need extra fluids in summer to prevent dehydration.
- There is very little chance that his brother will have sickle cell
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12. A client just had a thoracentesis. For which response is it most important for the nurse to observe the client?
- Signs of infection
- Expectoration of blood
- Increased breath sounds
- Decreased respiratory rate
13. A 60 year-old woman, with no previous medical history is diagnosed with an adenocarcinoma of the duodenum head of the pancreas and the distal end of the bile duct. Staging shows it has not grown into the large blood vessels and has not metastasized to any lymph node or distant site. The patient undergoes surgery. Which post-operative clinical finding is most likely?
- Increased serum glucose
- Constipation
- Weight loss >15%
- Paralytic ileus
14. Which of the following statements about diphtheria is false?
- Immunity is often acquired through a complete immunization series of Diphtheria
- infants born to immune mothers maybe protected up to 5 months
- Diphtheria transmission Is Increased in hospital households, schools and other crowded areas.
- Recovery from clinical attack is always followed by a lasting Immunity to the disease
15. Situation: Mastery of research design determination is essential in passing the Nurse Licensure Examination. Q. Anjo researched on TB. Its transmission, Causative agent and factors, treatment, sign and symptoms as well as medication and all other in depth information about tuberculosis. This study is best suited for which research design?
- Historical
- Case Study
- Phenomenological
- Ethnographic
16. Situation: Based on studies of nurses working in special units like the intensive care unit and coronary care unit it is important for nurses to gather as much information to be able to address their needs for nursing care. Q. Which of the following factors may inhibit learning in critically ill patients?
- Female patient
- Medication
- Educational level
- Previous knowledge of illness
17. The nurse is caring for four clients on a step down intensive care unit. The client at the highest risk for developing nosocomial pneumonia is the one who:
- has a respiratory infection
- is intubated and on a ventilator
- is receiving feedings through a jejunostomy tube
- has pleural chest tubes
18. As a manager, the nurse should:
- Initiates nursing action with co workers.
- Plans nursing care with the patient.
- Speaks in behalf of the patient.
- Works together with the team.
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19. Situation: Sexually Transmitted Diseases are important to identify during pregnancy because of their potential effect on the pregnancy, fetus, or newborn. The following questions pertain to STD's. Based on your past learnings in communicable diseases, you know that the causative agent of venereal warts is:
- Chlamydia Trachomatis
- Candida Moniliasis
- Human Papillomavirus
- Staphylococcus Aureus
20. SITUATION: John Lloyd, a 27 basketball player sustained inhalation burn that required him to have tracheostomy due to massive upper airway edema. Q. What size of suction catheter would Wilma use for John Lloyd, who is 6 feet 5 inches in height and weighing approximately 145 lbs?
- Fr. 5
- Fr. 10
- Fr. 12
- Fr. 18
21. Alzheimer's disease is the secondary diagnosis of a client admitted with myocardial infarction. Which nursing intervention should appear on this client's plan of care?
- Perform activities of daily living for the client to decrease frustration.
- Provide a stimulating environment.
- Establish and maintain a routine.
- Try to reason with the client as much as possible.
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22. A characteristic that would suggest to Nurse Anne that an adolescent may have bulimia would be:
- Frequent regurgitation & re-swallowing of food
- Previous history of gastritis
- Badly stained teeth
- Positive body image
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23. Which of the following tests measures the total quantity of prothrombin. In the blood and monitors the effectiveness of warfarin sodium (coumadin) therapy and prolonged defficiencies in the extrinsic factor?
- Thrombin time (TT)
- Prothrombin time (PT)
- Partial prothrombin time(PTT)
- Activated partial thrombo plastin time (aPTT)
24. What clinical finding should the nurse expect when assessing a client who had a splenectomy?
- Lung crackles
- Pain on inspiration
- Shortness of breath
- Excessive secretions
25. A client is diagnosed with glaucoma. Which piece of nursing assessment data identifies a risk factor associated with this eye disorder?
- Cardiovascular disease
- Frequent urinary tract infections
- A history of migraine headaches
- Frequent upper respiratory infections
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26. During the admission assessment of a client with advanced ovarian cancer, the nurse recognizes which manifestation as typical of the disease?
- Diarrhea
- Hypermenorrhea
- Abnormal bleeding
- Abdominal distention
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27. Situation: The patients chart is a legal documentation the is admissible in the court. In working with the client, The protection of the information on the chart and patient's privacy is one of the priority. You are caring for Ana, a 12 year old grade 6 pupil from manila and is one of the daughters of Maria, A 38 year old mother of 12. Q. The research teams from other countries are interested in investigating Ana's case. They want to read and gather information about Ana and the manifestation of her condition. For the sake of improving knowledge and the development of a cure, the nurse knows that research is very important. Permission in this case will be taken from:
- Ana
- Maria
- The hospital management
- The doctor in charge
28. What is the underlying rationale why a nurse assesses a client with emphysema for clinical indicators of hypoxia?
- Pleural effusion
- Infectious obstructions
- Loss of aerating surface
- Respiratory muscle paralysis
29. The chamber of the heart that receives oxygenated blood from the lungs is the:
- Left atrium
- Right atrium
- Left ventricle
- Right ventricle
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30. Situation As a nurse, you should be aware and prepared of the different roles you play. Q. The client complained of abdominal and pain. Your nursing intervention that can alleviate pain is:
- Instruct client to go to sleep and relax
- Advise the client to close the lips and avoid deep breathing and talking
- Offer hot and clear soup
- Turn to sides frequently and avoid too much talking
31. Which of the following represents the average amount of weight gained during pregnancy?
- 12 to 22 lb
- 15 to 25 lb
- 24 to 30 lb
- 25 to 40 lb
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32. Which of the following drugs would be ordered by the physician to improve the platelet count in a male client with idiopathic thrombocytopenic purpura (ITP)?
- Acetylsalicylic acid (ASA)
- Corticosteroids
- Methotrezate
- Vitamin K
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33. John is experiencing alcohol withdrawal exhibits tremors, diaphoresis and hyperactivity. Blood pressure is 190/87 mmhg and pulse is 92 bpm. Which of the medications would the nurse expect to administer?
- Naloxone (Narcan)
- Benzlropine (Cogentin)
- Lorazepam (Ativan)
- Haloperidol (Haldol)
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34. Nurse Celine is caring for a client with clinical depression who is receiving a MAO inhibitor. When providing instructions about precautions with this medication, the nurse should instruct the client to:
- Avoid chocolate and cheese
- Take frequent naps
- Take the medication with milk
- Avoid walking without assistance
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35. When measuring a client's fundal height, which of the following techniques denotes the correct method of measurement used by the nurse?
- From the xiphoid process to the umbilicus
- From the symphysis pubis to the xiphoid process
- From the symphysis pubis to the fundus
- From the fundus to the umbilicus
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36. A client is admitted with a higher than expected red blood cell count. What physiological alteration does the nurse expect will result from this clinical finding?
- Increased serum pH
- Decreased hematocrit
- Increased blood viscosity
- Decreased immune response
37. The anterior fontanelle is characterized as:
- 3-4 cm antero-posterior diameter and 2-3 cm transverse diameter, diamond shape
- 2-3 cm antero-posterior diameter and 3-4 cm transverse diameter and diamond shape
- 2-3 cm in both antero-posterior and transverse diameter and diamond shape
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38. Situation: Please respond as a professional nurse in the other health situations through the following question. Q.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
39. Mr. Mendoza who has suffered a cerebrovascular accident (CVA) is too weak to move on his own. To help the client avoid pressure ulcers, Nurse Celia should:
- Turn him frequently.
- Perform passive range-of-motion (ROM) exercises.
- Reduce the client's fluid intake.
- Encourage the client to use a footboard.
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40. While looking out the window, a client with schizophrenia remarks, "That school across the street has creatures in it that are waiting for me." Which of the following terms best describes what the creatures represent?
- Anxiety attack
- Projection
- Hallucination
- Delusion
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41. A woman, 6 months pregnant, came to the center for consultation. Which of the following substances is contraindicated?
- Tetanus toxoid
- Retinol 200,000 IU
- Ferrous sulfate 200mg
- Potassium iodate 200 mg, capsule
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42. A nurse is caring for a client with an infection caused by group A beta-hemolytic streptococci. The nurse should assess this client for responses associated with which illness?
- Hepatitis A
- Rheumatic fever
- Spinal meningitis
- Rheumatoid arthritis
43. A nurse obtained a client's pulse and found the rate to be above normal. The nurse document this findings as:
- Tachypnea
- Hyperpyrexia
- Arrhythmia
- Tachycardia
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44. A nurse is assessing an infant diagnosed with failure to thrive. In addition to accurate anthropometric measurements, complete nutritional history, infant feeding ability, and head-to-toe assessment the nurse should asses which of the following
- Parent-to-child interaction
- Number of sibling in the home
- Current sleep patterns
- Exposure to second hand smoke
45. Which of the following symptoms might a client with right-sided heart failure exhibit?
- Adequate urine output
- Polyuria
- Oliguria
- Polydipsia
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46. 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. Melamine is a synthetic resin used for whiteboards, hard plastics and jewellery box covers due to its fire retardant properties. Milk and food manufacturers add melamine in order to:
- It has a bacteriostatic property leading to increase food and milk life as a way of preserving the foods.
- Gives a glazy and more edible look on foods
- Make milks more tasty and creamy
- Create an illusion of a high protein content on their products
47. The nurse is assessing elderly clients at a community center. Which of the following findings would be the most cause for concern?
- Dry mouth
- Loss of one inch of height in the last year
- Stiffened joints
- Rales bilaterally on chest auscultation
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48. The best method of oxygen administration for client with COPD uses:
- Cannula
- Simple Face mask
- Non rebreather mask
- Venturi mask
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49. Situation: Survey and Statistics are important part of research that is necessary to explain the characteristics of the population. Q. An investigator wants to determine some of the problems that are experienced by diabetic clients when using an Insulin pump. The investigation went into a clinic where he personally knows several diabetic clients having problem with insulin pump. The type of sampling done by the investigator is called:
- Probability
- Purposive
- Snowball
- Incidental
50. Which obstetrical client is most likely to have an infant with respiratory distress syndrome?
- A 28-year-old with a history of alcohol use during the pregnancy
- A 24-year-old with a history of diabetes mellitus
- A 30-year-old with a history of smoking during the pregnancy
- A 32-year-old with a history of pregnancy-induced hypertension
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