NCLEX-RN | QB3 | Practice Exam #49 (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 providing discharge teaching for a client taking dissulfiram (Antabuse). The nurse should instruct the client to avoid eating:

• Peanuts dates raisins
• Figs chocolate eggplant
• Pickles salad with vinaigrette dressing beef
• Milk cottage cheese ice cream

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2. Situation: Ensuring safety is one of your most important responsibilities. You will need to provide instructions and information to your clients to prevent complications. Q. Randy has chest tubes attached to a pleural drainage system. When caring for him you should:

• empty the drainage system at the end of the shift
• clamp the chest tube when auctioning
• palpate the surrounding areas for crepitus
• change the dressing daily using aseptic techniques

3. To maintain Bryants traction the nurse must make certain that the childs:

• Hips are resting on the bed with the legs suspended at a right angle to the bed
• Hips are slightly elevated above the bed and the legs are suspended at a right angle to the bed
• Hips are elevated above the level of the body on a pillow and the legs are suspended parallel to the bed
• Hips and legs are flat on the bed with the traction positioned at the foot of the bed

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4. A client who has been hospitalized after experiencing a heart attack will most likely receive a diet consisting of:

• Low fat, high protein, and carbohydrates
• Low fat low sodium, and high carbohydrates
• Low fat, low sodium, and low carbohydrates
• None of above.

5. A 5-year-old is admitted to the unit following a tonsillectomy. Which of the following would indicate a complication of the surgery?

• Decreased appetite
• A low-grade fever
• Chest congestion
• Constant swallowing

6. A nurse assessing a 16-month-old child observes bruises scattered over the body that are at different stage of healing. The child also has poor and diaper rash. The goal of treatment for this child is to:

• Ensure the physical and emotional safety of the child
• Remove the child from the parents
• Admonish the parents of the child
• Ensure that the child stays with the biological parents

7. Nurse Nikki knows that laboratory results supports the diagnosis of systemic lupus erythematosus (SLE) is:

• Elevated serum complement level
• Thrombocytosis, elevated sedimentation rate
• Pancytopenia, elevated antinuclear antibody (ANA) titer
• Leukocytosis, elevated blood urea nitrogen (BUN) and creatinine levels

8. When teaching umbilical cord care for Jennifer a new mother, the nurse Jenny would include which information?

• Apply peroxide to the cord with each diaper change
• Cover the cord with petroleum jelly after bathing
• Keep the cord dry and open to air
• Wash the cord with soap and water each day during a tub bath.

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9. A client with schizophrenia has been started on medication therapy with clozapine. The nurse should assess the results of which laboratory study to monitor for adverse effects from this medication?

• Platelet count
• Blood glucose level
• Liver function studies
• White blood cell count

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10. Third postpartum visit must be done by public health nurse:

• Within 24 hours after delivery
• After 2-4 weeks
• Within 1 week
• After 2 months

11. The nurse is providing postprocedure care for a client who underwent percutaneous lithotripsy. In this procedure, an ultrasonic probe inserted through a nephrostomy tube into the renal pelvis generates ultra-high-frequency sound waves to shatter renal calculi. The nurse should instruct the client to:

• limit oral fluid intake for 1 to 2 weeks
• report the presence of fine, sand-like particles through the nephrostomy tube.
• Notify the physician about cloudy or foul smelling urine
• Report bright pink urine within 24 hours after the procedure

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12. The nurse applies a commercially made hot moist pack, called a hydrocollator, to the clients lower back. To reduce the potential for a thermal injury the nurse should plan to:

• Wrap the pack in several thick towels
• Rub skin lotion over the back area
• Place a pillow between hint and the back
• Position the client on rubber ring

13. A community health nurse is assessing client's urine using the Acetic Acid solution. Which of the following, if done by a nurse, indicates lack of correct knowledge with the procedure?

• The nurse added the Urine as the 2/3 part of the solution
• The nurse heats the test tube after adding 1/3 part acetic acid
• The nurse heats the test tube after adding 2/3 part of Urine
• The nurse determines abnormal result if she noticed that the test tube becomes cloudy

14. The nurse is to apply a dressing to a stage II pressure ulcer. Which of the following dressing is best?

• Dry gauze dressing
• wet gauze dressing
• wet to dry dressing
• moisture vapor permeable dressing

15. The client is admitted to the postpartum unit with an order to continue the infusion of Pitocin. The nurse is aware that Pitocin is working if the fundus is:

• Deviated to the left.
• Firm and in the midline.
• Boggy.
• Two finger breadths below the umbilicus.

16. Situation: Dennis 40 y/o married man, an electrical engineer was admitted with the diagnosis of paranoid disorders. He has became suspicious and distrustful 2 months before admission. Upon admission, he kept on saying, "my wife has been planning to kill me." Q. The nurse confirms that Dennis is manifesting auditory hallucination. The appropriate nursing diagnosis she identifies is:

• Sensory perceptual alteration
• Self esteem disturbance
• Ineffective individual coping
• Defensive coping

17. SITUATION: Mr. Francisco, 70 years old, suddenly could not lift his spoons nor speak at breakfast. He was rushed to the hospital unconscious. His diagnosis was CVA. Q. Which of the following is the most important assessment during the acute stage of an unconscious patient like Mr. Francisco?

• Level of awareness and response to pain
• Papillary reflexes and response to sensory stimuli
• Coherence and sense of hearing
• Patency of airway and adequacy of respiration

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18. A client is participating in a therapy group and focuses on viewing ail team members as equally important in helping the clients to meet their goals. The nurse is implementing which therapeutic approach?

• Milieu therapy
• Interpersonal therapy
• Behavior modification
• Support group therapy

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19. The nurse is inserting a nasogastric tube in an adult client. During the procedure, the client begins to cough and has difficulty breathing. What is the most appropriate action?

• Insert the tube quickly.
• Notify the health care provider immediately.
• Pull back on the tube and wait until the respiratory distress subsides.
• Remove the tube and reinsert it when the respiratory distress subsides.

20. A patient is recently diagnosed with Herpes Zoster. The nurse establishing the care plan would MOST likely assign the highest priority to which of the following nursing diagnosis?

• Anxiety
• Social Isolation
• Peripheral neurovascular dysfunction
• Acute pain

21. What is the most common symptom in a client with abdominal aortic aneurysm?

• Abdominal pain
• Diaphoresis
• Headache
• Upper back pain

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22. Which of the following best define pulse deficit?

• The difference between the apical and radial pulse rates.
• The difference between the systole and diastole values.
• The difference between the brachial and radial pulse rates.
• The difference between the temporal and femoral pulse rates.

23. Joy's stream of consciousness is occupied exclusively with thoughts of her father's death. Nurse Ronald should plan to help Joy through this stage of grieving, which is known as:

• Shock and disbelief
• Developing awareness
• Resolving the loss
• Restitution

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24. Which purposes of placental functioning should the nurse include in a prenatal class? Select all that apply. 1.It cushions and protects the baby. 2.It maintains the temperature of the baby. 3.It is the way the baby gets food and oxygen. 4.It prevents all antibodies and viruses from passing to the baby. 5.It provides an exchange of nutrients and waste products between the mother and developing fetus.

• 1,2,5
• 2,3,4
• 1,2,3,4,5
• 3,5

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25. Shelly with manic episodes is taking lithium. Which electrolyte level should the nurse check before administering this medication?

• Calcium
• Sodium
• Chloride
• Potassium

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26. The nurse is assisting a client with diverticulitis to select appropriate foods. Which food should be avoided?

• Bran
• Fresh peach
• Tomatoes
• Dinner roll

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27. Situation: Human development is one of the important concepts that a nurse should learn to be able to deal appropriately with their clients of different developmental stages. Which statement best describes when fertilization occurs?

• When the spermatozoon passes into the ovum and the nuclei fuse into a single cell.
• When the ovum is discharged from the ovary near the fimbriated end of the fallopian tube.
• When the embryo attaches to the uterine wall.
• When the sperm and ova undergo developmental changes resulting in a reduction in the number of chromosomes.

28. 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. What type of research it this?

• Correlational
• Descriptive
• Experimental
• Quasrexperimental

29. The nurse assisted with the birth of a newborn. Which nursing action is most effective in preventing heat loss by evaporation?

• Warming the crib pad
• Closing the doors to the room
• Drying the infant with a warm blanket
• Turning on the overhead radiant warmer

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30. Situation: Elvira is a 26 year old woman you admit to a birthing room. She's been having contractions 45 seconds long and 3 minutes apart for the last 6 hours. She tells you she wants to have her baby "naturally" without any analgesia or anesthesia. Her husband is in the Army and assigned overseas, so he is not with her. Although her sister lives only two blocks from the hospital, Elvira doesn't want her called. She asks if she can talk to her mother on the telephone instead. Elvira is having long and hard uterine contractions. What length of contraction would you report as abnormal?

• Any length over 30 seconds
• A contraction over 70 seconds in length.
• A contraction that peaks at 20 seconds.
• A contraction shorter than 60 seconds.

31. When caring for a patient with new sigmoid colostomy, the nurse knows that the stoma may be expected to decrease in size from up to:

• One months
• Two months
• Six months
• One year

32. Whitney verbalizes that she is anxious that the diagnostic test might reveal laryngeal cancer. Which of the following is the most appropriate nursing intervention?

• Tell the client not to worry until the results are in
• Ask the client to express feelings and concern
• Reassure the client everything will be alright
• Advice the client to divert his attention by watching television and reading newspapers

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33. Toxicity from which of the following medications may cause a client to see a green-yellow halo around lights?

• Digoxin
• Furosemide (Lasix)
• Metoprolol (Lopressor)
• Enalapril (Vasotec)

34. The nurse is suspected of charting medication administration that he did not give. The nurse can be charged with:

• Fraud
• Malpractice
• Negligence
• Tort

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35. Situation: Nursing informatics is a way of using information technology, computers and the internet in the improvement of nursing care. The first nursing informatics conference was held during 1977. Q. One advantage of a computerized recording system is that:

• The nursing diagnoses for a client's data can be accurately determined
• Cost of confinement will be reduced
• Information concerning the client can be easily updated
• The number of people to take care of the client will be reduced

36. When providing postoperative care for the child with a cleft palate, the nurse should position the child in which of the following positions?

• Supine
• Prone
• In an infant seat
• On the side

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37. A client in labor has an order for Demerol (meperidine) 75 mg. IM to be administered 10 minutes before delivery. The nurse should:

• The nurse should question the order
• Question the order.
• Give the medication IM during the delivery to prevent pain from the episiotomy.
• Give the medication as ordered.

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38. Which test should be added to the yearly physical of a patient who has recently turned 50 years old?

• Culture and sensitivity
• Fecal occult blood
• Routine urine analysis test
• Angiography studies

39. A nurse is assigned to care for a patient with a diagnosis of thrombotic stroke. The nurse knows that this type of stroke is most likely caused by:

• Blockage of large vessels as a result of atherosclerosis
• Emboli produced from valvular heart disease
• Decreased cerebral blood flow due to circulatory failure
• A temporary disruption in oxygenation of the brain

40. A patient is diagnosed with peptic ulcer. What would be the long term goal for this patient?

• Patient remains free of signs and symptoms of gastrointestinal bleeding
• Patient maintains lifestyle alterations to prevent recurrence of ulcer
• Patient expresses decreased pain level
• Patient performs activities of daily living without difficulty

41. In the investigation of an epidemic, you compare the present frequency of the disease with the usual frequency at this time of the year in this community. This is done during which stage of the investigation?

• Establishing the epidemic
• Testing the hypothesis
• Formulation of the hypothesis
• Appraisal of facts

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42. During the assessment phase of a preoperative interview, the patient reports feeling nervous. The patient conveys to the nurse that a parent died in surgery due to malignant hyperthermia. To whom would this information be MOST pertinent?

• Post-anesthesia care unit(PACU) nurse
• Scrub nurse
• Anesthesia team
• Charge nurse

43. Which outcome criteria would be appropriate for a child diagnosed with oppositional defiant disorder?

• Accept responsibility for own behaviors.
• Be able to verbalize own needs and assert rights.
• Set firm and consistent limits with the client.
• Allow the child to establish his own limits and boundaries.

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44. Ricardo, was diagnosed with type I diabetes. The nurse is aware that acute hypoglycemia also can develop in the client who is diagnosed with:

• Liver disease
• Hypertension
• Type 2 diabetes
• Hyperthyroidism

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45. A hospitalized client is started on phenelzine for the treatment of depression. The nurse should instruct the client that which foods are acceptable to consume while taking this medication? Select all that apply. 1.Figs 2.Yogurt 3.Crackers 4.Aged cheese 5.Tossed salad 6.Oatmeal raisin cookies

• 1,2,3
• 3,5
• 2,4,6
• 1,3,5,6

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46. The nurse is caring for a patient diagnosed with human immune deficiency virus. Which of the following nursing diagnoses takes priority?

• Diarrhea related to medication side effects
• Risk for infection related to inadequate immune system
• Imbalanced nutrition relate to decreased appetite
• Impaired tissue integrity related to cachexia and malnourishment

47. A patient is who is prepared for hip surgery has an order for external pneumatic compression devices. The nurse teaches the patient that pneumatic compression can help prevent:

• Upper respiratory infection
• Decreased breath sounds
• Deep vein thrombosis
• Bleeding at the surgical site

48. A patient with dementia is being treated for dehydration. The patient is confused and has been immobile for the past month. Currently, the patient is incontinent and unable to feed self. The nursing care plan should include

• Coughing and deep breathing every 30 minutes
• Positioning and turning every 2 hours
• Range of motion exercise to all extremities every hour
• Ambulates at least 20 steps every shift

49. The abbreviation for micro drop is?

• μgtt
• gtt
• mdr
• mgts

50. Situation: Nurses hold a variety of roles when providing care to a perioperative patient. Q. It is the responsibility of the pre-op, nurse to do skin prep for patients undergoing surgery. If hair at the operative site is not shaved, what should be done to make suturing easy and lessen chance of incision infection?

• Draped
• Pulled
• Clipped
• Shampooed

 

NCLEX-RN | QB3 | Practice Exam #49 (50 questions)