NCLEX-RN | QB3 | Practice Exam #42 (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 evaluating the neurological signs of a client in spinal shock following spinal cord injury. Which observation indicates that spinal shock persists?
- Hyperreflexia
- Positive reflexes
- Flaccid paralysis
- Reflex emptying of the bladder
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2. The nurse in a maternity unit is providing emotional support to a client and her significant other who are preparing to be discharged from the hospital after the birth of a dead fetus. Which statement made by the client indicates a component of the normal grieving process?
- "We want to attend a support group."
- "We never want to try to have a baby again."
- "We are going to try to adopt a child immediately"
- "We are okay and we are going to try to have another baby immediately."
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3. To ensure that the baby will breath as soon as the head is delivered, the nurse's priority action is to
- Suction the nose and mouth to remove mucous secretions
- Slap the baby's buttocks to make the baby cry
- Clamp the cord about 6 inches from the base
- Check the baby's color to make sure it is not cyanotic
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4. Situation: You are assigned to take care of a group of patients across the lifespan. A client is 7 months pregnant and has just been diagnosed as having a partial placenta previa. She is able and has minimal spotting and is being sent home. Which of these instructions to the client may indicate a need for further teaching?
- Maintain bed rest with bathroom privileges
- Avoid intercourse for three days
- Call if contractions occur
- Stay on left side as much as possible when lying down
5. The nurse is caring for a client who is receiving IV fluids, Which observation the nurse makes best indicates that the IV has infiltrated?
- Pain at the site
- A change in flow rate
- Coldness around the insertion site
- Redness around the insertion site
6. Gloves should be worn for which of the following procedures?
- Emptying a urinary drainage bag
- Brushing a residents hair
- Ambulating a resident
- Feeding a resident
7. A male client brings a list of his prescribed medications to the clinic. During the initial assessment, he tells the nurse that he has been experiencing delayed ejaculation. Which drug class is associated with this problem?
- Anticoagulants
- Antibiotics
- Antihypertensive
- Steroids
8. The nurse is assigned to give Ms. Milton perineal care. When cleansing the perineum, the cotton ball or wash cloth is gently directed:
- Side to side across the labia majora
- Downward from the pubic area to the anus
- Upward from the anus to the pubic area
- Prom the urinary meatus to the vagina
9. Situation: Rosanna 20 y/0 unmarried patient believes that the toilet for the female patient in contaminated with AIDS virus and refuses to use it unless she flushes it three times and wipes the toilet seat the same number of times with antiseptic solution. Q. Psychotherapy which is prescribed for Rosana is described as:
- Establishing an environment adapted to an individual patient needs
- Sustained interaction between the therapist and client to help her develop more functional behaviour
- Using dramatic techniques to portray interpersonal conflicts
- Biologic treatment for mental disorder
10. When planning care for a client who has ingested phencyclidine (PCP), which of the following is the highest priority?
- Client's physical needs
- Client's safety needs
- Client's psychosocial needs
- Client's medical needs
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11. Which food is included in a BLAND DIET?
- Steamed broccoli
- Creamed potato
- Spinach in garlic
- Sweet potato
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12. A client has been placed on levodopa to treat Parkinson's disease. Which of the following is a common side effects of levodopa that the nurse should include in the client's teaching plan?
- Pancytopenia
- Peptic ulcer
- Postural hypotension
- Weight loss
13. A client with a peptic ulcer is diagnosed with a Helicobacter pylori infection. The nurse is teaching the client about the medications prescribed, including clarithromycin, esomeprazole, and amoxicillin. Which statement by the client indicates the best understanding of the medication regimen?
- "My ulcer will heal because these medications will kill the bacteria"
- "These medications are only taken when I have pain from my ulcer."
- "The medications will kill the bacteria and stop the acid production.”
- "These medications will coat the ulcer and decrease the acid production in my stomach."
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14. A newborn weighing 3000 grams and feeding every 4 hours needs 120 calories/kg of body weight every 24 hours for proper growth and development. How many ounces of 20 cal/oz formula should this newborn receive at each feeding to meet nutritional needs?
- 2 ounces
- 3 ounces
- 4 ounces
- 6 ounces
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15. When planning the care for a client after a posterior fossa (infratentorial) craniotomy which action is contraindicated?
- Keeping the client fiat on one side
- Elevating the head of the bed 30°
- Log-rolling or turning as a unit
- Keeping the neck in a neutral position
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16. A mother brings her 26 month-old to the well-child clinic. She expresses frustration and anger due to her child's constantly saying "no" and his refusal to follow her directions. The nurse explains this is normal for his age, as negativism is attempting to meet which developmental need?
- Trust
- Initiative
- Independence
- Self-esteem
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17. A health care provider prescribes laboratory studies for an infant of a woman positive for human immunodeficiency virus (HIV). The nurse anticipates that which laboratory study will be prescribed for the infant?
- Chest x-ray
- Western blot
- CD4+ cell count
- p24 antigen assay
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18. Following a total abdominal hysterectomy Ms. Sara Fleming develops a slightly elevated temperature and swelling in the right call of her leg. The physician prescribes warm moist compresses for the client’s affected leg. Which of the following nursing actions is correct when applying the warm moist compress? The nurse:
- Heats the water to 120F
- Uses a sterile technique
- Inspect the skin every 4 hours
- Covers the wet gauze with a towel
19. Situation: A group of nursing students were discussing the normal growth and development concepts when assigned to observe the school children. Q. The stage of growth and development basically concerned with the role identification is the:
- Oral Stage
- Genital-Stage
- Oedipal Stage
- Latency stage
20. Situation: As a nurse you are expected to participate in initiating or participating in the conduct of research studies to improve nursing practice. You have to be updated on the latest trends and issues affecting profession and the best practices arrived at by the profession Q. You would like to compare the support system of patients with chronic illness to those with acute illness. How will you best state your problem?
- A descriptive study to compare the support system of patients with chronic illness and those with acute illness in terms of demographic data and knowledge about interventions
- The effect of the Type of Support system of patients with chronic illness and those with acute illness
- A comparative analysis of the support: system of patients with chronic illness and those with acute illness
- A study to compare the support system of patients with chronic illness and those with acute illness
21. Which assignment should not be performed by the licensed practical nurse?
- Inserting a Foley catheter
- Discontinuing a nasogastric tube
- Obtaining a sputum specimen
- Starting a blood transfusion
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22. The nurse is giving Instruction about neonatal care. Which of the following instruction is most critical?
- proper feeding
- provide bathing
- provide warm clothing
- prevent infection
23. A 68 year old client is diagnosed with a right-sided brain attack and is admitted to the hospital. In caring for this client, the nurse should plan to:
- Application of elastic stockings to prevent flaccid by muscle
- Use hand roll and extend the left upper extremity on a pillow to prevent contractions
- Use a bed cradle to prevent dorsiflexion of feet
- Do passive range of motion exercise
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24. SITUATION: Mr. Bond, a client with early Dementia exhibits thought process disturbances. Q. Which of the following is most important discharge teaching for Mr. Bond
- Emergency Numbers
- Drug Compliance
- Relaxation technique
- Dietary prescription
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25. Situation: For more than a month now, Cecilia is persistently feeling restless, worried and feeling as if something dreadful is going to happen. She fears being alone in places and situations where she thinks that no one might come to rescue her just in case something happens to her. Q. Cecilia is demonstrating:
- acrophobia
- claustrophobia
- agoraphobia
- xenophobia
26. As a care provider, The nurse should do first:
- Provide direct nursing care.
- Participate with the team in performing nursing intervention.
- Therapeutic use of self.
- Early recognition of the client's needs.
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27. Situation: The preoperative nurse collaborates with the client significant others, and healthcare providers. Q. Rosie, 57, who is diabetic is for debridement if incision wound. When the circulating nurse checked the present IV fluid, she found out that there is no insulin incorporated as ordered. What should the circulating nurse do?
- Double check the doctor's order and call the attending MD
- Communicate with the ward nurse to verify if insulin was incorporated or not
- Communicate with the client to verify if insulin was incorporated
- Incorporate insulin as ordered
28. One morning a female client on the inpatient psychiatric service complains to nurse Hazel that she has been waiting for over an hour for someone to accompany her to activities. Nurse Hazel replies to the client "We're doing the best we can. There are a lot of other people on the unit who needs attention too." This statement shows that the nurse's use of:
- Defensive behavior
- Reality reinforcement
- Limit-setting behavior
- Impulse control
29. The fetal heart rate is checked following rupture of the bag of waters in order to:
- Check if the fetus is suffering from head compression
- Determine if cord compression followed the rupture
- Determine if there is utero-placenta I insufficiency
- Check if fetal presenting part has adequately descended following the rupture
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30. A client comes to the emergency department with chest pain, dyspnea, and an irregular heartbeat. An electrocardiogram shows a heart rate of 110 beats/minute (sinus tachycardia) with frequent premature ventricular contractions. Shortly after admission, the client has ventricular tachycardia and becomes unresponsive. After successful resuscitation, the client is taken to the intensive care unit. Which nursing diagnosis is appropriate at this time?
- Deficient knowledge related to interventions used to treat acute illness
- Impaired physical mobility related to complete bed rest
- Social isolation related to restricted visiting hours in the intensive care unit
- Anxiety related to the threat of death
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31. A 10-year-old child with asthma is treated for acute exacerbation in the emergency department. The nurse caring for the child should monitor for which sign, knowing that it indicates a worsening of the condition?
- Warm,dryskin
- Decreased wheezing
- Pulse rate of 90 beats/minute
- Respirations of 18 breaths/minute
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32. A patient has been assessed and found to have severe dysphagia and will need longterm nutritional support,which one of the following types of feeding would MOST likely to be beneficial for this patient?
- Gastrostomy
- Patenteral
- Nasogastric
- Nasoduodenal
33. The school nurse is performing pediculosis capitis (head lice) assessments. Which assessment finding indicates that a child has a "positive" head check?
- Maculopapular lesions behind the ears
- Lesions in the scalp that extend to the hairline or neck
- White flaky particles throughout the entire scalp region
- White sacs attached to the hair shafts in the occipital area
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34. A client with B negative blood requires a blood transfusion during surgery. If no B negative blood is available the client should be transfused with:
- A positive blood
- B positive blood
- O negative blood
- AB negative blood
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35. A patient is seen in the emergency department with complaints of angina. Nitroglycerin (Nitrostat) is ordered by the physician. This medication is to be administered via which of the following routes?
- Intradermal
- Buccal
- Parental
- Topical
36. The most safe and non-invasive site to measure the temperature is:
- Oral site.
- Auxiliary site.
- Rectal site.
- Tympanic site.
37. The nurse in the substance abuse unit is trying to encourage a client to attend Alcoholics Anonymous meetings. When the client asks the nurse what he must do to become a member, the nurse should respond:
- "You must first stop drinking."
- "Your physician must refer you to this program"
- "Admit you're powerless over alcohol and that you need help.”
- "You must bring along a friend who will support you."
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38. A community health nurse screens a group of high-risk adults for tuberculosis. Which gauge needle should the nurse use for an intradermal injection on the volar surface of the forearm?
- 16 gauge needle
- 20 gauge needle
- 22 gauge needle
- 26 gauge needle
39. Primary health care is a total approach to community development Which of the following is an indicator of success in the use of the primary health care approach?
- Health services are provided free of charge to individuals and families
- Local officials are empowered as the major decision makers in matters of health
- Health workers are able too provide care based on identified health needs of the people
- Health programs are sustained according to the level of development of the community
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40. Situation: Brain tumor, whether malignant or benign, has serious management implications nurse, you should be able to understand the consequences of the disease and the treatment. Q. Conrad underwent craniotomy. As his nurse; you know that drainage on a craniotomy dressing must be measured and marked. Which findings should you report immediately to the surgeon?
- Foul-smelling drainage
- yellowish drainage
- Greenish drainage
- Bloody drainage
41. On admission to the emergency department the burned client's blood pressure is 90/60, with an apical pulse rate of 122. These findings are an expected result of what thermal injury-related response?
- Fluid shift
- Intense pain
- Hemorrhage
- Carbon monoxide poisoning
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42. A 33-year old female client came for consultation at the health center with the chief complaint of fever for a week. Accompanying symptoms were muscle pains and body malaise. A week after the start of fever, the client noted yellowish discoloration of his sclera. History showed that he waded in flood waters about 2 weeks before the onset of symptoms. Based on her history, which disease condition will you suspect?
- Hepatitis A
- Hepatitis B
- Tetanus
- Leptospirosis
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43. Respiratory depression is a potentially life-threatening adverse effect of:
- Opioids
- Anticoagulants
- Immune modulators
- Non-steroidal (NSAIDS)
44. What is the most common cause of abdominal aortic aneurysm?
- Atherosclerosis
- HPN
- Syphilis
- DM
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45. Mario is admitted to the emergency room with drug-included anxiety related to over ingestion of prescribed antipsychotic medication. The most important piece of information the nurse in charge should obtain initially is the:
- Length of time on the med.
- Reason for the suicide attempt
- Name of the ingested medication & the amount ingested
- Name of the nearest relative & their phone number
46. The nurse provides instructions to a malnourished pregnant client regarding iron supplementation. Which client statement indicates an understanding of the instructions?
- "Iron supplements will give me diarrhea."
- "Meat does not provide iron and should be avoided."
- "The iron is best absorbed if taken on an empty stomach"
- "On the days that I eat green leafy vegetables or calf liver I can omit taking the iron supplement"
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47. Situation: Mr. Sean is admitted to the hospital with a bowel obstruction. He complained of colicky pain and inability to pass stool. Q. Mr. Sean has undergone surgery. Postoperatively, which of the following findings is normal?
- absent bowel sounds
- bleeding
- hemorrhage
- bowel movement
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48. Nurse Myrna develops a counter-transference reaction. This is evidenced by:
- Revealing personal information to the client
- Focusing on the feelings of the client.
- Confronting the client about discrepancies in verbal or nonverbal behavior
- The client feels angry towards the nurse who resembles his mother.
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49. The nurse is instructing a client with Parkinson's disease about preventing falls. Which client statement reflects a need for further teaching?
- "I can sit down to put on my pants and shoes.”
- "I try to exercise every day and rest when I'm tired "
- "My son removed all loose rugs from my bedroom."
- "I don't need to use my walker to get to the bathroom."
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50. A client suspected of having Aizheimers disease is evaluated using the Mini-Mental State Examination. At the beginning of the evaluation the examiner names three objects. Later in the evaluation he asks the client to name the same three objects. The examiner is testing the clients:
- Attention
- Orientation
- Recall
- Registration
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