NCLEX-RN | QB3 | Practice Exam #43 (50 questions)

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

 

1. The mother of a 3-year-old is concerned because her child still is insisting on a bottle at nap time and at bedtime. Which is the most appropriate suggestion to the mother?

• Allow the bottle if it contains juice.
• Allow the bottle if it contains water.
• Do not allow the child to have the bottle.
• Allow the bottle during naps but not at bedtime.

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2. The nurse is performing an admission assessment on a client with a diagnosis of detached retina. Which sign or symptom is associated with this eye disorder?

• Total loss of vision
• Pain in the affected eye
• A yellow discoloration of the sclera
• A sense of a curtain falling across the field of vision

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3. The nurse is caring for a client with amyotrophic lateral sclerosis (ALS Lou Gehrig disease). The nurse should give priority to:

• Assessing the clients respiratory status
• Providing an alternate means of communication
• Referring the client and family to community support groups
• Instituting a routine of active range-of-motion exercises

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4. According to her, Caring is defined as a nurturant way of responding to a valued client towards whom the nurse feels a sense of commitment and responsibility.

• Benner
• Watson
• Leininger
• Swanson

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5. The nurse analyzes the laboratory values of a child with leukemia who is receiving chemotherapy. The nurse notes that the platelet count is 19,500 mm3 (19.5 A109/L). On the basis of this laboratory result, which intervention should the nurse include in the plan of

• Initiate bleeding precautions.
• Monitor closely for signs of infection.
• Monitor the temperature every 4 hours.
• Initiate protective isolation precautions.

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6. A 28 year old male is recovering from a moderate concussion following a motor vehicle accident 2 weeks ago, when he suddenly develops an increased thirst, craving cold water. The patient urinates very large amount of dilute, water like urine with a specific gravity of 1.001 to 1.005 the patient is MOST likely developing

• Diabetic mellitus
• Diabetic insipidus
• Hypothyroidism
• Thyroid storm

7. The physician calls the nursing unit to leave an order. The senior nurse had conversation with the other staff. The newly hired nurse answers the phone so that the senior nurses may continue their conversation. The new nurse does not know the physician or the client to whom the order pertains. The nurse should:

• Ask the physician to call back after the nurse has read the hospital policy manual.
• Take the telephone order.
• Refuse to take the telephone order.
• Ask the charge nurse or one of the other senior staff nurses to take the telephone order.

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8. The mother of a 2-month-old is concerned that she may be spoiling her baby by picking her up when she cries. Which of the following would be the nurse's best response?

• "Let her cry for a while before picking her up, so you don't spoil her"
• "Babies need to be held and cuddled; you won't spoil her this way"
• "Crying at this age means the baby is hungry; give her a bottle"
• "If you leave her alone she will learn how to cry herself to sleep"

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9. A client with hemophilia has a nosebleed. Which nursing action is most appropriate to control the bleeding?

• Place the client in a sitting position.
• Administer acetaminophen (Tylenol).
• Pinch the soft lower part of the nose.
• Apply ice packs to the forehead.

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10. During the initial interview, a client with schizophrenia suddenly turns to the empty chair beside him and whispers, "Now just leave. I told you to stay home. There isn't enough work here for both of us!" What is the nurse's best initial response?

• "When people are under stress, they may see things or hear things that others don't. Is that what just happened?"
• "I'm having a difficult time hearing you. Please look at me when you talk.”
• "There is no one else in the room. What are you doing?"
• "Who are you talking to? Are you hallucinating?"

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11. The nurse is assessing a client with an altered level of consciousness. One of the first signs of altered level of consciousness is:

• Inability to perform motor activities
• Complaints of double vision
• Restlessness
• Unequal pupil size

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12. The nurse is using drawing, puppetry, and other forms of play therapy while treating a terminally ill, school-age child. The purpose of these techniques is to help the child:

• internalize his feelings about death and dying.
• accept responsibility for his situation.
• express feelings that he can't articulate.
• have a good time while he's in the hospital.

13. A physician has ordered gavage feeding every 4 hours for a 12-week-old infant with failure to thrive. In order to know how far to insert the feeding tube. The nurse should measure the distance from:

• The infant's mouth to the xiphoid process of the sternum
• The tip of the infant's nose to the ear and then to the umbilicus
• The infant's mouth to the ear and then to the umbilicus
• The tip of the infant's nose to the ear and then to the xiphoid process of the sternum

14. In inspecting the abdomen, which of the following is NOT DONE?

• Ask the client to void first
• Knees and legs are straighten to relax the abdomen
• The best position in assessing the abdomen is Dorsal recumbent
• The knees and legs are externally rotated

15. On review of the client's record, the nurse notes that the admission was voluntary. Based on this information, the nurse plans care anticipating which client behavior?

• Fearfulness regarding treatment measures
• Anger and aggressiveness directed toward others
• An understanding of the pathology and symptoms of the diagnosis
• A wiilingness to participate in the planning of the care and treatment plan

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16. Ms. Valencia prepares the process standards. Which of the following is NOT a process standard?

• Initial assessment shall be done to all patients within twenty four hours upon admission.
• Informed consent shall be secured prior to any invasive procedure
• Patients' reports 95% satisfaction rate prior to discharge from the hospital.
• Patient education about their illness and treatment shall be provided for all patients and their families.

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17. The nurse is caring for full-term newborn who was delivered vaginally 5 minute s ago. The infant's APGAR Score was 8 at one minute and 10 at 5minutes. Which of the following has the highest priority?

• Maintaining the infant in the supine position
• Assessing the infant's red reflex
• Preventing heat loss from the infant
• Administering humidified oxygen to the infant

18. In a toddler, which of the following injuries is most likely the result of child abuse?

• A hematoma on the occipital region of the head
• A 1-inch forehead laceration
• Several small, dime-sized circular burns on the child's back
• A small isolated bruise on the right lower extremity

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19. A five-year-old child is hospitalized for correction of congenital hip dysplasia. During the assessment of the child the nurse can expect to find the presence of:

• Scarf sign
• Harlequin sign
• Cullens sign
• Trendelenburg sign

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20. In group therapy, a client who has used I.V. heroin every day for the past 14 years says, "I don't have a drug problem. I can quit whenever 1 want. I’ve done it before." Which defense mechanism is the client using?

• Denial
• Obsession
• Compensation
• Rationalization

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21. The client with a pacemaker should be taught to:

• Report ankle edema
• Check his blood pressure daily
• Refrain from using a microwave oven
• Monitor his pulse rate

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22. Mr. Liberatore, age 76, is admitted to your unit He has a past medical history of hypertension, DM, hyperlipidemia. Recently he has had several episodes where he stops talking mid sentence and stares into space. Today the episode lasted for 15 minutes. The admission diagnosis is impending CVA. Q. You explain to Julie and her mother that migraine headaches are caused by:

• an allergic response triggered by stress
• dilation of cerebral arteries
• persistent contraction of the muscles of the head, neck and face
• increased intracranial pressure

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23. During surgery requiring general anesthesia, the patient heart's stops and acarotid pulse is not palpated. How many compressions per minute should be administered?

• 50
• 60
• 80
• 100

24. Which of the following actions by a community health nurse is most appropriate when noting multiple bruises and burns on the posterior trunk of an 18-month-old child during a home visit?

• Report the child's condition to Protective Services immediately.
• Schedule a follow-up visit to check for more bruises.
• Notify the child's physician immediately.
• Don nothing because this is a normal finding in a toddler.

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25. The client with depression has been hospitalized for 3 days on the psychiatric unit. This is the second hospitalization during the past year. The physician orders a different drug, tranylcypromine sulfate (Parnate), when the client does not respond positively to a tricyclic antidepressant. Which of the following reactions should the client be cautioned about if her diet includes foods containing tryaminetyramine?

• Heart block.
• Grand mal seizure.
• Respiratory arrest.
• Hypertensive crisis.

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26. A pregnant client with a history of alcohol addiction is scheduled for a nonstress test. The nonstress test:

• Determines the lung maturity of the fetus
• Measures the activity of the fetus
• Shows the effect of contractions on the fetal heart rate
• Measures the neurological well-being of the fetus

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27. The doctor has told the resident that his cancer is growing and that he is dying. When the resident tells the nurse aide that there is a mistake, the nurse aide should

• understand that denial is a normal reaction.
• remind the resident the doctor would not lie.
• suggest the resident ask for more tests.
• ask if the resident is afraid of dying.

28. Situation: After an abdominal surgery, the circulating and scrub nurses have critical responsibility about sponge and Instrument count. Q. Another alternative "suture" for skin closure is the use of:

• Staple
• Therapeutic glue
• Absorbent dressing
• invisible suture

29. During surgery the pt has the following intake and output: IV fluid 650 cc ,1V antibiotic 50 cc f 1 unit of packed red blood cells 350 cc, nasogastric output 120, estimated blood loss 80 cc, and urine in the folyes catheter 240 cc. What is the patients total intake?

• 650 cc
• 700 cc
• 900 cc
• 1050 cc

30. The nurse is watching the cardiac monitor, and a client's rhythm suddenly changes. There are no P waves; instead, there are fibrillatory waves before each QRScomplex. How should the nurse correctly interpret the client's heart rhythm?

• Atrial fibrillation
• Sinus tachycardia
• Ventricular fibrillation
• Ventricular tachycardia

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31. Situation: Camila, 25 years old, was reported to be gradually withdrawing and isolating herself from friends and family members. She became neglectful of her personal hygiene. She was observed to be talking irrelevantly and incoherently. She was diagnosed as schizophrenia Q. Camila's indifference toward the environment is a compensatory behavior to overcome:

• Guilt feelings
• Ambivalence
• Narcissistic behavior
• Insecurity feelings

32. Situation: With the improvement in life expectancies and the emphasis in the quality of life it is important to provide quality care to our older patients. There are frequently encountered situations and issues relevant to the older, patients. Q. The older patient is at higher risk for in inconvenience because of:

• dilated urethra
• increased glomerular filtration rate
• diuretic use
• decreased bladder capacity

33. For a male client with dysthymic disorder, which of the following approaches would the nurse expect to implement?

• Psychotherapeutic approach
• Psychoanalysis
• Antidepressant therapy
• ECT

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34. Situation: Vincent, age 26, who is caught in me raging conflict between his mother and his wife, complains of pains in his right leg that has progressed to the point of paralysis. After orthopedic consultation has shown no pathology, he is referred for a psychiatric consultation and is found to have a conversion disorder. Q. The nurse understands which of the following concepts about Vincent's conversion disorder?

• It is an unconscious method for him to cope with the present situation
• It is usually necessary for him to cope with the present situation
• It is reversible and will subside if he is helped to focus on other things
• It will probably be solved when he learns to deal with ongoing family conflicts

35. The nurse on the 311 shift is assessing the chart of a client with an abdominal aneurysm scheduled for surgery in the morning and finds that the consent form has been signed but the client is unclear about the surgery and possible complications. Which is the most appropriate action?

• Call the surgeon and ask him or her to see the client to clarify the information.
• Explain the procedure and complications to the client.
• Check in the physicians progress notes to see if understanding has been documented.
• Check with the clients family to see if they understand the procedure fully.

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36. The stage of dying as identified by Dr. Elizabeth Kubler-Ross occurs in what order?

• Anger, depression, bargaining, denial, acceptance
• Bargaining, denial, Anger, acceptance, depression
• Denial, Anger, bargaining, depression, acceptance
• Depression, denial, Anger, bargaining, acceptance

37. Which finding might be seen in baby James a neonate suspected of having an infection?

• Flushed cheeks
• Increased temperature
• Decreased temperature
• Increased activity level

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38. The home health nurse is visiting a client with an exacerbation of rheumatoid arthritis. To prevent deformities of the knee joints the nurse should:

• Tell the client to walk without bending the knees.
• Encourage movement within the limits of pain.
• Instruct the client to sit only in a recliner.
• Tell the client to remain in bed as long as the joints are painful.

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39. What is the most important characteristic of a nurse patient relationship?

• It is growth facilitating
• Based on mutual understanding
• Fosters hope and confidence
• Involves primarily emotional bond

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40. While caring for a terminally ill preschool-aged child whose death is eminent , the child asks the nurse “ Am I going to die11? The best nursing response is:

• I'm not sure what is wrong with you. but I hope not
• Don't worry when you die. you will be the angels
• We all die someday, but you are not going to die today or tomorrow
• I can't talk to you about that, you will have to ask your doctor

41. Which statement about an individual with a personality disorder is true?

• Psychotic behavior is common during acute episodes
• Prognosis for recovery is good with therapeutic intervention
• The individual typically remains in the mainstream of society, although he has problems in social and occupational roles
• The individual usually seeks treatment willingly for symptoms that are personally distressful.

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42. A client with cholelithiasis experience discomfort after ingesting fatty foods because.

• Fatty foods are hard to digest
• Bile flow into the intestine is obstructed
• The liver is manufacturing inadequate bile
• There is inadequate closure of the Ampulla of Vater

43. A client has developed hepatitis A after eating contaminated oysters. The nurse assesses the client for which expected assessment finding?

• Malaise
• Dark stools
• Weight gain
• Left upper quadrant discomfort

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44. Situation: Survey and Statistics are important part of research that is necessary to explain the characteristics of the population. Q. In the value: 87,85,88,92,90: What is the mean?

• 88.2
• 88.4
• 87
• 90

45. A child presents to the emergency department with difficulty breathing. The child’sParents report that child has a history of bronchial asthma and has recently had an Upper respiratory tract infection (URI). Upon auscultation, the nurse decreased Breath sounds in the left-lower lung field. The nurse should NEXT assess the child's:

• Oral temperature
• O2 saturation
• Apical pulse
• Level of comfort

46. A patient sustained multiple musculoskeletal trauma after a motor vehicle collision and is now in skeletal traction awaiting surgery. The nurse observes that the patient has developed a large area of fl at, Pin point purple-colored areas on the thorax. Which of the following actions would be appropriate for the nurse to take?

• Discontinue the opioid that is being administered
• Place an extra blanket on the patient
• Release the weights on the patient's skeletal traction
• Administer diphenhydramine(Benadryl) prescribed p.r.n allergic reaction

47. A client with acute pancreatitis is experiencing severe abdominal pain. Which of the following orders should be questioned by the nurse?

• Meperidine l00mg IM m 4 hours PRN pain
• Mylanta 30 ccs m 4 hours via NG
• Cimetadine 300mg PO m.i.d.
• Morphine 8mg IM m 4 hours PRN pain

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48. The client experiencing 7th cranial nerve (facial Nerve) damage will most likely report which of the following symptoms?

• Bell's palsy
• Vertigo
• Impaired vision
• Headache

49. A 58-year-old male client tells the office nurse that his wife does not let him change his colostomy bag himself. Which response by the nurse indicates as understanding of the situation?

• Your wife's need to help you is a reality you should accept
• Do you think your wife might benefit from counseling?
• You feel you need privacy when changing your colostomy?
• Have you discussed the situation with your doctor?

50. When nurse Hazel considers a clients placement on the continuum of anxiety, a key in determining the degree of anxiety being experienced is the clients:

• Perceptual field
• Delusional system
• Memory state
• Creativity level

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NCLEX-RN | QB3 | Practice Exam #43 (50 questions)