NCLEX-RN | QB3 | Practice Exam #41 (50 questions)

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

 

1. A client with a spinal cord injury is prone to experiencing autonomic dysreflexia. The nurse should include which measures in the plan of care to minimize the risk of occurrence? Select all that apply. 1.Keeping the linens wrinkle-free under the client. 2.Preventing unnecessary pressure on the lower limbs 3.Limiting bladder catheterization to once every 12hours. 4.Turning and repositioning the client at least every 2 hours. 5.Ensuring that the client has a bowel movement at least once a week

• 1,2,3
• 1,2,4,5
• 1,2,4
• 2,3,5

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2. Situation: Joanna Marie, a 40 year old client was diagnosed with breast cancer. Q. The nurse is teaching a group of women to perform breast self-examination. The nurse should explain that the purpose of performing the examination is to discover:

• Thickness and Fullness
• Malignant or Benign Lumps
• changes from previous self-examinations.
• Fibrocystic masses

3. Shrinkage device is applied after surgery for amputation of the leg. The goal of the shrinkage device is to from the residual limb into what shape?

• Cone
• Oval
• Mushroom
• Cylinder with blunt end

4. A client is admitted for an overdose of amphetamines. When assessing this client, the nurse should expect to see:

• tension and irritability.
• slow pulse.
• hypotension
• constipation

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5. A home care patient with chronic obstructive pulmonary disease (COPD) reports an upset stomach. The patient is taking theophylline(Theo-Dur) and triamcinoloneacetonide (Azmacort) The nurse should instruct the patient to take:

• Theo-dur an empty stomach
• Theo-dur and azmacortat the same time
• Theo-dur and azmacort 12 hours apart
• Theo-dur milk or crackers

6. The nurse, listening to the morning report, learns that an assigned client received a unit of granulocytes the previous evening. The nurse makes a note to assess the results of which daily serum laboratory studies to assess the effectiveness of the transfusion?

• Hematocrit level
• Erythrocyte count
• Hemoglobin level
• White blood cell count

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7. Ronald plans to conduct a research on the use of a new method of pain assessment scale. Which of the following is the second step in the conceptualizing phase of the research process?

• Formulating the research hypothesis
• Review related literature
• Formulating and delimiting the research problem
• Design the theoretical and conceptual framework

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8. A parent brings a preschooler to the emergency department for treatment of a dislocated shoulder, which allegedly happened when the child fell down the stairs. Which action should make the nurse suspect that the child was abused?

• The child cries uncontrollably throughout the examination.
• The child pulls away from contact with the physician.
• The child doesn't cry when the shoulder is examined.
• The child doesn't make eye contact with the nurse.

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9. The nurse is developing a plan of care for a client with acromegaly. Which nursing diagnosis should receive priority?

• Alteration in body image related to change in facial features
• Risk for immobility related to joint pain
• Risk for ineffective airway clearance related to obstruction of airway by tongue
• Sexual dysfunction related to altered hormone secretion

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10. Nurse Hazel is preparing to care for a client who is newly admitted to the hospital with a possible diagnosis of ectopic pregnancy. Nurse Hazel develops a plan of care for the client and determines that which of the following nursing actions is the priority?

• Monitoring weight
• Assessing for edema
• Monitoring apical pulse
• Monitoring temperature

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11. Mrs. Hogan, a 43-year-old woman, is admitted to your unit for cholecystectomy. Q. Mrs. Hogan is scheduled for surgery 2 days later and is to be given atropine 0.3 mg IM and Demerol 50 mg IM one hour preoperatively. Which nursing actions follow the giving of the preop medication?

• have her void soon after receiving the medication
• allow her family to be with her before the medication takes effect
• bring her valuables to the nursing station
• reinforce preop teaching

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12. In reducing the risk of endocarditis, good dental care is an important measure. To promote good dental care in client with mitral stenosis in teaching plan should include proper use of

• Dental floss
• Electric toothbrush
• Manual toothbrush
• Irrigation device

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13. Information in the patients chart is inadmissible in court as evidence when:

• The client objects to its use
• Handwriting is not legible
• It has too many unofficial abbreviations
• The clients parents refuses to use it

14. A client has just had a hemorrhoidectomy. Which nursing interventions are appropriate for this client? Select all that apply. 1. Administer stool softeners as prescribed. 2. Instruct the client to limit fluid intake to avoid urinary retention. 3. Encourage a high-fiber diet to promote bowel movements without straining. 4. Apply cold packs to the anal-rectal area over the dressing until the packing is removed. 5. Help the client to a Fowler's position to place pressure on the rectal area and decrease bleeding.

• 1,2,3
• 2,3,4
• 1,3,4
• 1,3,5

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15. A nurse educates a group of people about hyper-active, and said this how can be releaved?

• x-ray
• has no investigation or blood test
• through blood
• None of the above.

16. The nurse is caring for a patient with parkinson's disease. Which of the following is an expected outcome related to the nursing diagnosis of constipation related to diminished motor function, inactivity and medications?

• The patient will use a laxative every other day
• The patient will have a soft bowel movement daily
• The patient will report minimal pain with bowel movements
• The patient will limit the intake of complex carbohydrates

17. When continuous bladder irrigation is used following prostate surgery, the rate of flow is adjusted:

• To run at 60 drops per minutes
• According to the client's oral intake
• To maintain an output of 500 ml every 8 hours
• To keep the drainage to light pink

18. The client complained of abdominal discomfort on the first postoperative day. Upon percussion of the lower abdomen, the nurse expects to hear:

• Dull
• Flat
• Tympanic
• Resonant

19. The infant is admitted to the unit with tetralogy of Fallot The nurse would anticipate an order for which medication?

• Digoxin
• Epinephrine
• Aminophyline
• Atropine

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20. A patient hospitalized with Crohn's disease has developed fever Increased respiratory rate, increased heart rate, chills, diaphoreses, and increased abdominal discomfort The nurse knows that patient has MOST likely developed

• Intestinal obstruction
• Intestinal parasite infestation
• Intestinal perforation
• Ascites

21. Situation: Infection can cause debilitating consequences when host resistance is compromised and virulence of microorganisms and environmental factors are favorable. Infection control is one important responsibility of the nurse to ensure quality of care. Q. Adam develops a nosocomial respiratory tract infection. He asks you what that means.

• "You acquired the infection after you have been admitted to the hospital."
• "This is a highly contagious infection requiring complete isolation.”
• "The infection you had prior to hospitalization flared up"
• "As a result of medical treatment, you have acquired a secondary infection."

22. Where would nurse Kristine place the call light for a male client with a right-sided brain attack and left homonymous hemianopsia?

• On the clients right side
• On the clients left side
• Directly in front of the client
• Where the client like

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23. A 10-year-old is being treated for asthma. Before administering Theo-dur the nurse should check the:

• Urinary output
• Blood pressure
• Pulse
• Temperature

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24. The mother of a hospitalized 2-year-old child with viral laryngotracheobronchitis (croup) asks the nurse why the health care provider did not prescribe antibiotics. Which response should the nurse make?

• "The child may be allergic to antibiotics."
• "The child is too young to receive antibiotics."
• "Antibiotics are not indicated unless a bacterial infection is present."
• "The child still has the maternal antibodies from birth and does not need antibiotics"

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25. A preterm infant with sepsis is receiving Gentamycin (garamycin). Which physiological alteration places the preterm infant at increased risk for toxicity related to aminoglycoside therapy?

• Lack of subcutaneous fat deposits
• Immature central nervous system
• Presence of fetal hemoglobin
• Immaturity of the renal system

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26. When Henry uses team nursing as a care delivery system, he and his team need to assess the priority of care for a group of patients, which of the following should be a priority?

• Each patient as listed on the worksheet
• Patients who needs least care
• Medications and treatments required for all patients
• Patients who need the most care

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27. This is the paranasal sinus found between the eyes and the nose that extends backward into the skull

• Ethmoid
• Sphenoid
• Maxillary
• Frontal

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28. A client hospitalized with MRSA is placed on contact precautions. Which statement is true regarding precautions for infections spread by contact?

• The client should be placed in a room with negative pressure.
• Infection requires close contact; therefore the door may remain open.
• Transmission is highly likely so the client should wear a mask at all times.
• Infection requires skin-to-skin contact and is prevented by hand washing gloves and a gown.

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29. Which of the following roommates would be most suitable for the client with myasthenia gravis?

• A client with hypothyroidism
• A client with Crohns disease
• A client with pylonephritis
• A client with bronchitis

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30. 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

31. The nurse is caring for a client with an autoimmune disorder at a medical clinic, where alternative medicine is used as an adjunct to traditional therapies. Which information should the nurse teach the client to help foster a sense of control over his symptoms?

• Pathophysiology of disease process
• Principles of good nutrition
• Side effects of medications
• Stress management techniques

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32. Which of the following is a OBJECTIVE data?

• Dizziness
• Chest pain
• Anxiety
• Blue nails

33. A client has been diagnosed with hyperthyroidism. The nurse monitors for which signs and symptoms indicating a complication of this disorder? Select all that apply. 1. Fever 2. Nausea 3. Lethargy 4. Tremors 5. Confusion 6. Bradycardia

• 1,2,4,5
• 1,2,3,4,5
• 1,2,3
• 2,3,5

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34. A child who has undergone spinal fusion for scoliosis complains of abdominal discomfort and begins to have episodes of vomiting. On further assessment, the nurse notes abdominal distention. On the basis of these findings, the nurse should take which action?

• Administer an antiemetic.
• Increase the intravenous fluids.
• Place the child in a Sims' position.
• Notify the health care provider (HCP).

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35. When a pregnant woman goes into a convulsive seizure, the MOST immediate action of the nurse to ensure safety of the patient is:

• Apply restraint so that the patient will not fall out of bed
• Put a mouth gag so that the patient will not bite her tongue and the tongue will not fall back
• Position the mother on her side to a low the secretions to drain from her mouth and prevent aspiration
• Check if the woman is also having a precipitate labor

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36. Which of the following liquids would the nurse administer to a female client who is intoxicated with phencyclidine (POP) to hasten excretion of the chemical?

• Shake
• Tea
• Cranberry Juice
• Grape juice

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37. Situation: Agnes, a client with Leukemia is in the clinic for her routine check up. Q. Which finding is unlikely when assessing Agnes?

• Small abdomen
• Bruises and Petechiae
• Increased WBC Counts
• Dyspnea during exercise or exertion

38. Hospitalized patient eats 20% of the meal and states being too tired to eat more. What should the nurse do?

• offer to feed the patient after short rest period
• encouraged the patient to finish the fluids
• Remove the meal tray and allow the patient to rest
• Encourage the patient to finish the protein portion of the meal

39. The nurse is preparing to care for a client with a potassium deficit The nurse reviews the client's record and determines that the client is at risk for developing the potassium deficit because of which situation?

• Sustained tissue damage
• Requires nasogastric suction
• Has a history of Addison's disease
• Uric acid level of 9.4 mg/dL (559 µmol/L.)

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40. The nurse is performing wound care using surgical asepsis. Which of the following practices violates surgical asepsis?

• Holding sterile objects above the waist
• Pouring solution onto a sterile field cloth
• Considering a 1" (2.5-cm) edge around the sterile field contaminated
• Opening the outermost flap of a sterile package away from the body

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41. A client has been on treatment for rheumatoid arthritis for 3 weeks. During the administration of etanercept, which is most important for the nurse to assess?

• The injection site for itching and edema
• The white blood cell counts and platelet counts
• Whether the client is experiencing fatigue and joint pain
• Whether the client is experiencing a metallic taste in the mouth, and a loss of appetite

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42. Situation: Care of clients with tracheotosmy is often a challenge to a beginning nurse. The following questions will test your knowledge on Tracheostomy and its related care. Q. Which of the following is the reason why will a surgeon select a cuffed tube over a non cuffed Tracheostomy tube?

• Cuffed tube offers efficient securing
• Cuffed tube is mainly used to prevent coughing
• Cuff tube offers excellent attachment
• For mechanical ventilation

43. The nurse is developing a plan of care for the client with multiple myeloma. The nurse includes which priority intervention in the plan of care?

• Coughing and deep breathing
• Encouraging fluids
• Monitoring red blood cell count
• Providing frequent oral care

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44. The physician has ordered a serum aminophylline level for a client with chronic obstructive lung disease. The nurse knows that the therapeutic range for aminophylline is:

• 1-3 micrograms/mL
• 4-6 micrograms/mL
• 7-9 micrograms/mL
• 10-20 micrograms/mL

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45. When implementing a feeding schedule for a full term 2-weeks old infant, the nurse should expect the infant to be fed:

• 2-4 times per day
• 6-8 times per day
• 10-12times per day
• 14-16 times per day

46. A 6-month-old boy is admitted with a diagnosis of failure to thrive. According to the growth chart at 3 months of age the infant's weight is in which percentile?

• 25th
• 5th
• 10th
• Below the 5th

47. Situation: During surgical operation, it is inevitable to utilize sutures. The nurse should know the basic principles in suturing as well as knowledge in selecting sutures and caring for clients with sutures. Q. Non absorbable suture material such as cotton, nylon and silk are best used in suturing which of the following abdominal layer?

• Skin
• Peritoneum
• Fascia
• Muscle

48. She defined health as the soundness and wholeness of developed human structure and bodily mental functioning.

• Orem
• Henderson
• Neuman
• Clark

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49. Mode of transmission of leprosy aside from skin contact is by:

• Oral fecal
• Sexual contact
• Borrowing utensil
• Droplet infection

50. Ruby is receiving thyroid replacement therapy develops the flu and forgets to take her thyroid replacement medicine. The nurse understands that skipping this medication will put the client at risk for developing which of the following life threatening complications?

• Exophthalmos
• Thyroid storm
• Myxedema coma
• Tibial myxedema

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NCLEX-RN | QB3 | Practice Exam #41 (50 questions)