NCLEX-RN | QB3 | Practice Exam #53 (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 caring for a client admitted to the emergency room after a fall. X-rays reveal that the client has several fractured bones in the foot. Which treatment should the nurse anticipate for the fractured foot?

• Application of a short inclusive spica cast
• Stabilization with a plaster-of-Paris cast
• Surgery with Kirschner wire implantation
• A gauze dressing only

2. Patient with Asthma and on Nebulization, as nurse when do you do the Chest physiotherapy?

• During Nebulization
• Before Nebulization
• After Nebulization
• None of the above.

3. The nurse is teaching the parent of a child with celiac disease.Which of following diets should be reviewed with the parent?

• Gluten-free
• Dairy free
• Vegetarian
• Sodium-restricted

4. A client with diabetes mellitus has a glycosylated hemoglobin Ale level of 9%. On the basis of this test result, the nurse plans to teach the client about the need for which measure?

• Avoiding infection
• Taking in adequate fluids
• Preventing and recognizing hypoglycemia
• Preventing and recognizing hyperglycemia

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5. The client pulls out the chest tube and fails to report the occurrence to the nurse. When the nurse discovers the incidence he should take which initial action?

• Order a chest x-ray.
• Reinsert the tube.
• Cover the insertion site with a Vaseline gauze.
• Call the doctor.

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6. The client has an order for FeSO4 liquid. Which method of administration would be best?

• Administer the medication with milk.
• Administer the medication with a meal.
• Administer the medication with orange juice.
• Administer the medication undiluted.

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7. Which of the following statements, if made by a patient who has had a basal cell carcinoma removed, would indicate to the nurse the need for further instruction?

• "I will use sunscreen with at least a sun protection factor (SPF) of 15."
• "I will use tanning booths rather than sunbathing from now on.”
• "I will stay out of the sun between 10:00 AM and 2:00 PM"
• "I will wear a broad - brimmed heat when I am in the sun"

8. A couple comes to the family planning clinic and asks about sterilization procedures. Which question by the nurse should determine whether this method of family planning would be most appropriate?

• "Did you ever had surgery?"
• "Do you plan to have any other children?"
• "Do either of you have diabetes mellitus?"
• "Do either of you have problems with high blood pressure?"

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9. He raised the issue on giving priority to patient needs. Which of the following offers the best way for setting priority?

• Assessing nursing needs and problems
• Giving instructions on how nursing care needs are to be met
• Controlling and evaluating the delivery of nursing care
• Assigning safe nurse: patient ratio

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10. A client is admitted with a diagnosis of myxedema. An initial assessment of the client would reveal the symptoms of:

• Slow pulse rate weight loss diarrhea and cardiac failure
• Weight gain lethargy slowed speech and decreased respiratory rate
• Rapid pulse constipation and bulging eyes
• Decreased body temperature weight loss and increased respirations

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11. The client with a myocardial infarction comes to the nurses station stating that he is ready to go home because there is nothing wrong with him. Which defense mechanism is the client using?

• Rationalization
• Denial
• Projection
• Conversion reaction

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12. Which action by the healthcare worker indicates a need for further teaching?

• The nursing assistant ambulates the elderly client using a gait belt.
• The nurse wears goggles while performing a veno-puncture.
• The nurse washes his hands after changing a dressing.
• The nurse wears gloves to monitor the IV infusion rate.

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13. Nurse KC should regularly assess the clients ability to metabolize the total parenteral nutrition (TPN) solution adequately by monitoring the client for which of the following signs:

• Hyperglycemia
• Hypoglycemia
• Hypertension
• Elevate blood urea nitrogen concentration

14. Situation: Records contain those, comprehensive descriptions of patient's health conditions and needs and at the same serve as evidences of every nurse's accountability in the, caregiving process. Nursing records normally differ from institution to, institution nonetheless they follow similar patterns of meeting needs for specifics, types of information. The following pertains to documentation/records management. Q. These, are sheets/forms which provide an efficient and time saving way to record information that must be obtained repeatedly at regular and/or short intervals, of time. This does not replace the progress notes; instead this record of information on vital signs, intake and output, treatment, postoperative care, postpartum care, and diabetic regimen, etc., this is used whenever specific measurements or observations are needed to-be documented repeatedly. What is this?

• Nursing Kardex
• Graphic Flowsheets
• Discharge Summary
• Medicine and Treatment Record

15. The nurse is preparing to administer a feeding via a nasogastric tube. The nurse would perform which of the following before initiating the feeding?

• Assess for tube placement by aspirating stomach content.
• Place the patient in a left-lying position.
• Administer feeding with 50% Dextrose.
• Ensure that the feeding solution has been warmed in a microwave for two minutes.

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16. The postpartum nurse is assessing a client who delivered a healthy infant by cesarean section for signs and symptoms of superficial venous thrombosis. Which sign should the nurse note if superficial venous thrombosis were present?

• Paleness of the calf area
• Coolness of the calf area
• Enlarged, hardened veins
• Palpable dorsalis pedis pulses

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17. Situation: In the hospital, you are aware that we are helped by the use of a variety of equipment/devices to enhance quality patient care delivery; Q. You are initiate an IV line to your patient, Kyle, 5, who is febrile. What IV administration set will you prepare?

• Blood transfusion set
• Macroset
• Volumetric chamber
• Microset

18. SITUATION: John Smith was diagnosed with Acute Close Angle Glaucoma. He is being seen by Nurse Gia. Nurse Gia knows that the normal IOP is:

• 8-21 mmHg
• 2-7 mmHg
• 31-35 mmHg
• 15-30 mmHg

19. Situation: Graciela 1 year old is admitted the hospital from the emergency room with a fracture of the left femur due to a Tall down a flight of stairs. Graciela is placed oh Bryant's traction. Q. The nurse notes that the fall might also cause a possible head injury. She will be observed for signs of increased intracranial pressure which include:

• Narrowing of the pulse pressure
• Vomiting
• Periorbital edema
• A positive Kernig's sign

20. Normal Saline 0.9% solution is considered as which of the following:

• Isotonic solution
• Hypotonic solution
• Hypertonic solution
• None of the above

21. Nurse Susan administered intravenous gamma globulin to an 18 month-old child with AIDS. The parent asks why this medication is being given. What is the nurse's best response?

• "It will slow down the replication of the virus.”
• "This medication will improve your child's overall health status."
• "This medication is used to prevent bacterial infections"
• "It will increase the effectiveness of the other medications your child receives"

22. A 55-year-old male client confides in the nurse that he is concerned about his sexual function. What is the nurse's best response?

• "How often do you have sexual relations?"
• "Please share with me more about your concerns."
• 'You are still young and have nothing to be concerned about”
• 'You should not have a decline in testosterone until you are in your 80s”

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23. The baby cries and the mother notices tiny, shiny and white specks on the mouth and hard palate. The mother understood If she states:

• "it is caused by milk curd"
• "I'll use sterile gauze in removing the crusts"
• "I'll notify the dentist"
• "prevent infection"

24. Which of the following is the initial sign of hypoxemia in an adult client? 1. Tachypnea 2. Tachycardia 3. Cyanosis 4. Pallor 5. Irritability 6. Flaring of Nares

• 1,2
• 2,5
• 2,6
• 3,4

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25. Situation: The patients chart is a legal documentation the is admissible in the court In working with the client, The protection of the information on the chart and patients privacy is one of the priority. You are caring for Ana, a 12 year old grade 6 pupil from manila and is one of the daughters of Maria, A 38 year old mother of 12. Q. Who owns the patient chart?

• The patient
• The doctor in charge
• The hospital
• The government

26. Situation: A group of nursing students were discussing the normal growth and development concepts when assigned to observe the school children. Q. During the oedipal stage of growth and development, the child:

• Loves and hates (ambivalence) both parents
• Loves the parent of the same sex and the parent of the opposite sex
• Loves the parent of the opposite sex and hates the parent of the same sex
• Love the parent of the same sex and hates the parent of the opposite sex.

27. A prisoner, with a known history of alcohol abuse, has been in police custody for 48 hours. Initially, anxiety, sweating, and tremors were noted. Now, disorientation, hallucination, and hyper-reactivity are observed. The medical diagnosis is delirium tremens. What is the priority nursing diagnosis?

• Risk for Injury related to seizures
• Risk for Other-Directed Violence related to hallucinations
• Risk for Situational Low Self-esteem related to police custody
• Risk for Nutritional Deficit related to chronic alcohol abuse

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28. Situation: Carbon Monoxide poisoning is said to be the 2nd leading cause of poison death. It is said to be the leading cause of inhalation poisoning. Mr. Edgardo was rushed to the hospital after being unconscious inside an enclosed parking lot. Carbon monoxide poisoning is suspected. Q. The pulse oximetry reading of Mr. Edgardo is 100%. This suggests that:

• There is no danger of hypoxia
• There is no carbon monoxide poisoning, it should be ruled out
• This is not a reliable sign to rule out carbon monoxide poisoning, further assessment is required
• That the client has an improved chance of surviving, since the client is well oxygenated

29. A nurse schedules a patient for a surgical procedure to take place in 1 week. When would the nurse MOST likely implement surgical education?

• After admission to the hospital
• Start during this visit
• Immediately prior to anesthesia
• After the operation

30. A patient had a total abdominal hysterectomy 2days-ago and has not been out of the bed yet. The patient is complaining left leg pain and swelling. What should the nurse do FIRST?

• Gently massage the patient's leg
• Assess the patient's pain level
• Assess the patient for Homan's sign
• Instruct the patient to reflex the left knee and hip

31. After completing chemical detoxification and a 12-step program to treat crack addiction, a client is being prepared for discharge. Which remark by the client indicates a realistic view of the future?

• "I'm never going to use crack again"
• "I know what I have to do. I have to limit my crack use.”
• "I'm going to take 1 day at a time. I'm not making any promises."
• "I will substitute crack for something else"

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32. A client had a total thyroidectomy yesterday. The client is complaining of tingling around the mouth and in the fingers and toes. What would the nurses next action be?

• Obtain a crash cart.
• Check the calcium level.
• Assess the dressing for drainage.
• Assess the blood pressure for hypertension.

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33. An infertile man is being treated with Viagra (sildenafil citrate) for erectile dysfunction (ED). Which of the following is a contraindication for this medication?

• Preexisting diagnosis of herpes simplex 2.
• Nitroglycerin ingestion for angina pectoris.
• Retinal damage from type I diabetes mellitus.
• Postsurgicai care for resection of the prostate.

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34. For a client with a head injury whose neck has been stabilized, the preferred bed position is:

• Trendelenburg's
• 30-degree head elevation
• flat
• side-lying

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35. A 35-years-old female has an inherited gene mutation for achondroplasia, an autosomal dominate genetic disorder. Her husband does not have genemutation. In planning genetic counseling for this patient, the nurse would be MOST correct in including which of the following statements regarding the risk of their children inherited the genetic mutation?

• Each child has a 50% chance of inheriting the gene mutation
• Female children have 50% chance of inheriting the gene mutation
• Male children will not inherited the gene mutation
• All female children will inherit the gene mutation.

36. The nurse is providing discharge instructions to a client following gastrectomy and should instruct the client to take which measure to assist in preventing dumping syndrome?

• Ambulate following a meal.
• Eat high-carbohydrate foods.
• Limit the fluids taken with meals.
• Sit in a high Fowler's position during meals.

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37. Metformin is prescribed for a client with type 2 diabetes mellitus. What is the most common side effect that the nurse should include in the client's teaching plan?

• Weight gain
• Hypoglycemia
• Flushing and palpitations
• Gastrointestinal disturbances

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

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

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39. An elderly patient with severe degenerative joint disease comes to the clinic for routine follow up of pain management. The patient reports that over the past month, the pain has begun to increase in severity. The patient requests an increase in dosage of the pain medication. The nurse recognize that this is MOST likely due to:

• Drug addiction
• Drug tolerance
• An improvement in condition
• Lack of efficacy of the current medication

40. A 70 yr-old client with a diagnosis of left sided cerebrovascular accident is admitted to the facility. To prevent the development of diffuse osteoporosis, which of the following objectives is most appropriate?

• Maintaining protein levels.
• Maintaining vitamin levels.
• Promoting weight-bearing exercises
• Promoting range-of-motion (ROM) exercises

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41. Matilda, with hyperthyroidism is to receive Lugol's iodine solution before a subtotal thyroidectomy is performed. The nurse is aware that this medication is given to:

• Decrease the total basal metabolic rate.
• Maintain the function of the parathyroid glands.
• Block the formation of thyroxine by the thyroid gland.
• Decrease the size and vascularity of the thyroid gland.

42. The nurse is caring for a client hospitalized with bipolar disorder manic phase who is taking lithium. Which of the following snacks would be best for the client with mania?

• Potato chips
• Diet cola
• Apple
• Milkshake

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43. A depressed client verbalizes feelings of low self-esteem and self-worth typified by statements such as "I'm such a failure. I can't do anything right." How should the nurse plan to respond to the client's statement?

• Reassure the client that things will get better.
• Tell the client that this is not true and that we all have a purpose in life.
• Identify recent behaviors or accomplishments that demonstrate the client's skills.
• Remain with the client and sit in silence; this will encourage the client to verbalize feelings.

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44. During a breast examination, which finding most strongly suggests that the Luz has breast cancer?

• Slight asymmetry of the breasts.
• A fixed nodular mass with dimpling of the overlying skin
• Bloody discharge from the nipple
• Multiple firm, round, freely movable masses that change with the menstrual cycle

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45. All of the following are purpose of inflammation except

• Increase heat thereby produce abatement of phagocytosis
• Localized tissue injury by increasing capillary permeability
• Protect the issue from injury by producing pain
• Prepare for tissue repair

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46. Situation: It is common that client ask the nurse personal questions. Q. Anticipation of persona) questions is given adequate attention during which phase of the nurse patient relationship?

• Orientation phase
• Working phase
• Pre-interact ion phase
• Termination phase

47. Another name for knee-chest position is:

• Genu-dorsal
• Genu-pectoral
• Lithotomy
• Sim's

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48. The following are common causes of dysfunctional labor. Which of these can a nurse, on her own manage?

• Pelvic bone contraction
• Full bladder
• Extension rather than flexion of the head
• Cervical rigidity

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49. Situation: There are other important basic knowledge in the performance of our task as Community Health Nurse in relation to IMMUNIZATION these include: This vaccine content is derived from RNA recombinants:

• Measles
• Tetanus toxoids
• Hepatitis B vaccines
• DPT

50. A client with obsessive compulsive personality disorder annoys his co-workers with his rigid-perfectionistic attitude and his preoccupation with trivial details. An important nursing intervention for this client would be:

• Helping the client develop a plan for changing his behavior
• Contracting with him for the time he spends on a task
• Avoiding a discussion of his annoying behavior because it will only make him worse
• Encouraging him to set a time schedule and deadlines for himself

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NCLEX-RN | QB3 | Practice Exam #53 (50 questions)