NCLEX-RN | QB3 | Practice Exam #45 (50 questions)

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

1. Situation: The Gastrointestinal System is responsible for taking in and processing nutrients for all parts of the body, any problem can quickly affect other body systems and, if not adequately treated, can affect overall health, growth, and development. The following questions are about gastrointestinal disorders in a child. A home care nurse provides instructions to the mother of an infant with cleft palate regarding feeding. Which statement if made by the mother indicates a need for further instructions?

• "I will use a nipple with a small hole to prevent choking.'
• "I will stimulate sucking by rubbing the nipple on the lower lip."
• "I will allow the infant time to swallow."
• "I will allow the infant to rest frequently to provide time for swallowing what has been placed in the mouth.”

2. The nurse noticed that the signed consent form has an error. The form states, "Amputation of the right leg" instead of the left leg that is to be amputated. The nurse has administered already the preoperative medications. What should the nurse do?

• Call the physician to reschedule the surgery.
• Call the nearest relative to come in to sign a new form
• Cross out the error and initial the form.
• Have the client sign another form.

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3. Refers to conditions that increases vulnerability of individual or group to illness or accident

• Predisposing factor
• Etiology
• Risk factor
• Modifiable Risks

4. They are the first ones to suggest a four (4) step nursing process called APIE or assessment, planning, implementation, and evaluation. 1. Yura 2. Walsh 3. Roy 4. Knowles

• 1,2
• 1,3
• 3,4
• 2,3

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5. Nurse John is aware that the therapy that has the highest success rate for people with phobias would be:

• Psychotherapy aimed at rearranging maladaptive thought process
• Psychoanalytical exploration of repressed conflicts of an earlier development phase
• Systematic desensitization using relaxation technique
• Insight therapy to determine the origin of the anxiety and fear

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6. A nonstress test is performed on a client who is pregnant, and the results of the test indicate non-reactive findings. The health care provider prescribes a contraction stress test, and the results are documented as negative. How should the nurse document this finding?

• A normal test result
• An abnormal test result
• A high risk for fetal demise
• The need for a cesarean section

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7. Situation: Please respond as a professional nurse in the other health situations through the following question. After a vaginal examination, the nurse determines that the client's fetus is in an occiput posterior position. The nurse would anticipate that the client will have:

• A precipitous birth
• Intense back pain
• Frequent leg cramps
• Nausea and vomiting

8. The nurse is reviewing the laboratory results for a client with cirrhosis and notes that the ammonia level is 85 mcg/dL (51 mcmol/L). Which dietary selection does the nurse suggest to the client?

• Roast pork
• Cheese omelet
• Pasta with sauce
• Tuna fish sandwich

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9. A client with a history of cocaine addiction is admitted to the coronary care unit for evaluation of substernal chest pain. The electrocardiogram (ECG) shows a 1-mm ST- segment elevation the anteroseptal leads and T-wave inversion in leads V3 to V5. Considering the client's history of drug abuse, the nurse expects the physician to prescribe:

• lidocaine (Xylocaine).
• procainamide (Pronestyl).
• nitroglycerin (Nitro-Bid IV).
• epinephrine

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10. In some hip surgeries, Fentanyl analgesia is given. What is your nursing priority care in such a case?

• Instruct client to observe strict bed rest
• Check for epidural catheter drainage
• Administer analgesia through epidural catheter as prescribed
• Assess respiratory rate carefully

11. The most effective treatment modality for persons if anti social PD is

• hypnotherapy
• gestalt therapy
• behavior therapy
• crisis intervention

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12. The nurse has administered an intravenous infusion of Cyclophosphamide to a 43 year-old patient with breast cancer. The nurse formulates a care plan with the nursing problem of risk for infection related to leucopenia secondary to chemotherapy. The patient is discharged home following treatment Which findings should the patient report immediately?

• Dyspnea
• Tachycardia
• Sore throat
• Discoloration of urine

13. Which of the following best describes preterm labor?

• Labor that begins after 20 weeks gestation and before 37 weeks gestation
• Labor that begins after 15 weeks gestation and before 37 weeks gestation
• Labor that begins after 24 weeks gestation and before 28 weeks gestation
• Labor that begins after 28 weeks gestation and before 40 weeks gestation

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14. The nurse is caring for a patient with chest tubes connected to close suction. The nurse should make sure that which of the following remains readily available at the patients bed side?

• A sterile towel
• Petroleum gauze
• Normal saline solution
• Sterile gloves

15. Marielle, 17 years old was sexually attacked while on her way home from school. She is brought to the hospital by her mother. Rape is an example of which type of crisis:

• Situational
• Adventitious
• Developmental
• Internal

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16. By the end of which of the following would the nurse most commonly expect a child's birth weight to triple?

• 4 months
• 7 months
• 9 months
• 12 months

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17. The client with preeclampsia is admitted to the unit with an order for magnesium sulfate IV. Which action by the nurse indicates a lack of understanding of magnesium sulfate?

• The nurse places a sign over the bed not to check blood pressures in the left arm.
• The nurse obtains an IV controller
• The nurse inserts a Foley catheter.
• The nurse darkens the room.

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18. Situation: As a beginner in research, you are aware that sampling is an essential element of the research process. Q. Which of the following sampling methods allows the use of any group of research subject?

• Purposive
• Convenience
• Snow-ball
• Quota

19. A nurse is reviewing the laboratory report of a client with a tentative diagnosis of kidney failure. What mechanism does the nurse expect to be maintained when ammonia is excreted by healthy kidneys?

• Osmotic pressure of the blood
• Acid-base balance of the body
• Low bacterial levels in the urine
• Normal red blood cell production

20. The client with preeclampsia is admitted to the unit with an order for magnesium sulfate. Which action by the nurse indicates the understanding of magnesium toxicity?

• The nurse performs a vaginal exam every 30 minutes.
• The nurse places a padded tongue blade at the bedside.
• The nurse inserts a Foley catheter.
• The nurse darkens the room.

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21. Nurse Tony stresses the need for all the employees to follow orders and instructions from him and not from anyone else. Which of the following principles does he refer to?

• Scalar chain
• Discipline
• Unity of command
• Order

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22. A client with depression has been hospitalized for treatment after taking a leave of absence from work. The client's employer expects the client to return to work following inpatient treatment. The client tells the nurse, "I'm no good. I'm a failure". According to cognitive theory, these statements reflect:

• Learned behavior
• Punitive superego and decreased self-esteem
• Faulty thought processes that govern behavior
• Evidence of difficult relationships in the work environment

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23. To differentiate as a female, the hormonal stimulation of the embryo that must occur involves which of the following?

• Increase in maternal estrogen secretion
• Decrease in maternal androgen secretion
• Secretion of androgen by the fetal gonad
• Secretion of estrogen by the fetal gonad

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24. When teaching the parents of neonate with spina bifida techniques to promote bladder emptying, the nurse reviews a technique in which firm, gentle pressure is applied to the abdomen press towards the symphysis pubis. This method is known as:

• Crede's
• Intermittent
• Foley
• Prophylactic

25. A full-term male has hypospadias. Which statement describes hypospadias?

• The urethral opening is absent
• The urethra opens on the top side of the penis
• The urethral opening is enlarged
• The urethra opens on the under side of the penis

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26. Situation: Marie is 5 1/2 years old and described by the mother as bedwetting at night. Q. A therapeutic verbal approach that communicates strong disapproval is:

• "You are supposed to get up and go in the toilet when you feel you have to go and did not. The next time you bed wet, I’ll tell your friends and hand your sheets out the window for them to see."
• "You are supposed to get up and go in the toilet when you feel you have to go and you did not. I expect you to from now on without fail."
• "If you bed wet, you will change your bed linen and wash the sheets."
• "If you don't make an effort to control your bedwetting, I'd be upset and disappointed."

27. Situation: Danny, 6 years old was admitted due to increasing frequency of bowel movements, abdominal cramps and distension. Q. What is the immediate home care management for diarrhea?

• Milk
• Imodium
• Water
• Oresol

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28. A client is scheduled for NGT Feeding. Checking the residual volume, you determined that he has 40 cc residual from the last feeding. You reinstill the 40 cc of residual volume and added the 250 cc of feeding ordered by the doctor. You then instill 60 cc of water to clear the lumen and the tube. How much will you put in the client's chart as input?

• 250 cc
• 290 cc
• 310 cc
• 350 cc

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29. Tony with agoraphobia has been symptom-free for 4 months. Classic signs and symptoms of phobia include:

• Severe anxiety and fear
• Withdrawal and failure to distinguish reality from fantasy
• Depression and weight loss
• Insomnia and inability to concentrate

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30. An elderly patient had surgery two days for an intestinal obstruction. Vital signs at 10 am are temperature 37.5C (99.5 F), heart rate 86, respiratory rate 16 blood pressure level 132/72 mm Hg, pain level of 4 on a scale of 0 to 10. The abdominal dressing is dry and intact. The nasal gastric tube to low intermittent suction. The patient is on strict input and output every two hours. At 12.20 pm, the patient complains abdominal pain, upon assessment the vital signs are temperature 37.5 C, heart rate 98, respiration rate 24, blood pressure level 146/ 88 mm Hg, pain level is 8 out of 10. The patient abdomen is distended and rigid, the dressing remains dry and intact. The nurse should first:

• Reposition the patient on the right side
• Irrigate the nasal gastric tube to check patency
• Medicate the patient for pain as ordered
• Increase the suction on his nasal gastric tube to high intermittent suction

31. Nurse Jon assesses vital signs on a client undergone epidural anesthesia. Which of the following would the nurse assess next?

• Headache
• Bladder distension
• Dizziness
• Ability to move legs

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32. The physician has ordered Activase (alteplase) for a client admitted with a myocardial infarction. The desired effect of Activase is:

• Prevention of congestive heart failure
• Stabilization of the clot
• Increased tissue oxygenation
• Destruction of the clot

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33. Situation: Organ donation is a new form of treatment that provides multiple complication such as rejection. Q. Organ donation to save life was initially with the first transplant done by:

• Dr. Christian Barnard of the Union of South Africa
• Dr. Christian Bale of the U.S.A.
• Dr Christian Barnard of Soviet Union
• Dr Christian Barnard of U.K.

34. The nurse is providing an orientation regarding case management to the nursing students. Which characteristics should the nurse include in the discussion in understanding case management?

• Main objective is a written plan that combines discipline-specific processes used to measure outcomes of care.
• Main purpose is to identify expected client, family and staff performance against the timeline for clients with the same diagnosis.
• Main focus is comprehensive coordination of client care, avoid unnecessary duplication of services, improve resource utilization and decrease cost.
• Primary goal is to understand why predicted outcomes have not been met and the correction of identified problems.

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35. Nurse Cathy learns that some leaders are transactional leaders. Which of the following does NOT characterize a transactional leader?

• Focuses on management tasks
• Is a caretaker
• Uses trade-offs to meet goals
• Inspires others with vision

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36. A new parent expresses concern to the nurse regarding sudden infant death syndrome (SIDS). She asks the nurse how to position her new infant for sleep. In which position should the nurse tell the parent to place the infant?

• Side or prone
• Back or prone
• Stomach with the face turned
• Back rather than on the stomach

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37. What is the most common problem in TUBE FEEDING?

• Diarrhea
• Infection
• Hyperglycemia
• Vomiting

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38. A client is diagnosed with bleeding from the upper gastrointestinal system. The nurse would expect the clients stools to be:

• Brown
• Black
• Clay colored
• Green

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39. Nurse Ron is caring for a male client taking an anticoagulant. The nurse should teach the client to:

• Report incidents of diarrhea.
• Avoid foods high in vitamin K
• Use a straight razor when shaving.
• Take aspirin to pain relief.

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40. The nurse is assessing a patient with a history of a seizure disorder. While checking the patients vital signs, the patient develops rhythmic, jerking movements of the arms and legs. The nurse should IMMEDIATELY place the patient in which of the following positions?

• Pron
• Supine
• Semi-fowler's
• Lateral

41. The nurse is caring for a client with a severe burn who is scheduled for an autograft to be placed on the lower extremity. The nurse creates a postoperative plan of care for the client and should include which intervention in the plan?

• Maintain the client in a prone position.
• Elevate and immobilize the grafted extremity.
• Maintain the grafted extremity in a flat position.
• Keep the grafted extremity covered with a blanket.

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42. Nurse Michelle hears the alarm sound on the telemetry monitor. The nurse quickly looks at the monitor and notes that a client is in a ventricular tachycardia. The nurse rushes to the client's room. Upon reaching the client's bedside, the nurse would take which action first?

• Prepare for cardioversion
• Prepare to defibrillate the client
• Call a code
• Check the client's level of consciousness

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43. A patient comes to the emergency department with extreme dyspnea, orthopnea, anxiety and complains of feeling panicky. The patient is coughing up white frothy sputum and is cyanotic with profuse perspiration. Inspiratory and expiratory wheezing and bubbling sounds are auscultated. The patient is diagnosed with acute pulmonary edema. What should the nurse do FIRST?

• Identify precipitating factors and underlying conditions
• Administer morphine(Dura morph) to reduce anxiety
• Assess oxygen saturation rate
• Administer digoxin(Lanoxin) to decrease fluid backing up into the lungs

44. Situation: Nurse Macarena is a Family Planning and Infertility Nurse Specialist and currently attends to FAMILY PLANNING CLIENTS AND INFERTILE COUPLES. The following conditions pertain to meeting the nursing needs of this particular population group. Who among the following are recipients of the secondary level of care for cancer cases?

• Those under early case detection
• Those under post case treatment
• Those scheduled for surgery
• Those undergoing treatment

45. Situation: Jerome, a 37 years old man, was admitted to the hospital with periodic episode of manic behavior alternating with me depression. Diagnosis: Bipolar I disorder Q. Nursing care plan for a hyperactive patient like Jerome, should give priority to:

• Discourage him from manipulating the staff
• Prevent him from assaulting other patients
• Protect him against suicidal attempts
• Provide adequate food and fluid intake

46. Nurse Oliver must apply an elastic bandage to a client's ankle and calf. He should apply the bandage beginning at the client's:

• Knee
• Ankle
• Lower thigh
• Foot

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47. Situation: Basic knowledge on Intravenous solutions is necessary for care of clients with problems with fluids and electrolytes. Q. You know that the hallmark of nursing accountability is the:

• Accurate documentation and reporting
• Admitting your mistakes
• Filing an incidence report
• Reporting a medication error

48. A nurse is preparing the client's morning NPH insulin dose and notices a clumpy precipitate inside the insulin vial. The nurse should:

• draw up and administer the dose
• shake the vial in an attempt to disperse the clumps
• draw the dose from a new vial
• warm the bottle under running water to dissolve the clump

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49. Which client is at greatest risk for complications following abdominal surgery?

• A 68-year-old obese client with non-insulin-dependent diabetes
• A 27-year-old client with a recent history of urinary tract infections
• A 16-year-old client who smokes a half-pack of cigarettes per day
• A 40-year-old client who exercises regularly with no history of medical conditions

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50. The nurse evaluates the ability of a hepatitis B-positive mother to provide safe bottle­ feeding to her newborn during postpartum hospitalization. Which maternal action best exemplifies the mother's knowledge of potential disease transmission to the newborn?

• The mother requests that the window be closed before feeding.
• The mother holds the newborn properly during feeding and burping.
• The mother tests the temperature of the formula before initiating feeding.
• The mother washes and dries her hands before and after self-care of the perineum and asks for a pair of gloves before feeding.

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NCLEX-RN | QB3 | Practice Exam #45 (50 questions)