NCLEX-RN | QB3 | Practice Exam #55 (50 questions)

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

 

1. Mrs. Hogan, a 43-year-old woman, is admitted to your unit for cholecystectomy. Q. Mrs. Hogan is scheduled for surgery 2 days later and is to be given atropine 0.3 mg IM and Demerol 50 mg IM one hour preoperatively. Which nursing actions follow the giving of the pre-op medication?

• have her void soon after receiving the medication
• allow her family to be with her before the medication takes effect
• bring her valuables to the nursing station
• reinforce pre-op teaching

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2. According to the goals of Reproductive health, all are true, EXCEPT:

• Every pregnancy should be Intended
• Every birth be healthy
• Every woman should be given a condom to protect herself from pregnancy and other STDs
• Every sex should be free or coercion and infection

3. A clinic nurse prepares a teaching plan for a client receiving an antineoplastic medication. When implementing the plan, the nurse should make which statement to the client?

• "You can take aspirin as needed for headache.”
• "You can drink beverages containing alcohol in moderate amounts each evening"
• "You need to consult with the health care provider (HCP) before receiving immunizations."
• "It is fine to receive a flu vaccine at the local health fair without HCP approval because the flu is so contagious."

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4. A 36-year-old patient with a history of seizures and medication compliance of phenytoin (Dilantin) and carbamazepine (Tegretol) is brought to the ED by the MS personnel for repetitive seizure activity that started 45 minutes prior to arrival You anticipate that the physician will order which drug for status epilepticus?

• PO phenytoin and carbamazepine
• IV lorazepam (Ativan)
• IV carbamazepine
• IV magnesium sulfate

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5. The nurse is teaching the parents of an infant with osteogenesis imperfecta. The nurse should explain the need for:

• Additional calcium in the infants diet
• Careful handling to prevent fractures
• Providing extra sensorimotor stimulation
• Frequent testing of visual function

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6. A client was admitted to the psychiatric unit after complaining to her friends and family that neighbors have bugged her home in order to hear all of her business. She remains aloof from other clients, paces the floor and believes that the hospital is a house of torture. Nursing interventions for the client should appropriately focus on efforts to

• Convince the client that the hospital staff is trying to help
• Help the client to enter into group recreational activities
• Provide interactions to help the client learn to trust staff
• Arrange the environment to limit the client's contact with other clients

7. A nurse is caring for a child with spasmodic croup. Which clinical finding alerts the nurse that immediate nursing intervention is required?

• Irritability
• Hoarseness
• Barking cough
• Rapid respirations

8. A client who has glaucoma is to have miotic eyedrops instilled in both eyes. The nurse knows that the purpose of the medication is to:

• Anesthetize the cornea
• Dilate the pupils
• Constrict the pupils
• Paralyze the muscles of accommodation

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9. Situation: Salome, 80 year old widow, has been observed to be irritable, demanding and speaking louder than usual. She would prefer to be alone and take her meals by herself, minimized receiving visitors al home and no longer bothers to answer telephone calls because of deterioration of her hearing. ‘She was brought by her daughter to, the Geriatic clinic for assessment and treatment Q. The nurse will assist Salome and her daughter to plan a goal which is:

• adjust to the loss of sensory and .perceptual function
• participate in conversation and other social situations
• accept the steady loss of hearing that occurs with aging
• increase her self-esteem to maintain her authoritative role

10. The nurse is preparing to give an oral potassium supplement. The nurse should give the medication:

• Without diluting it
• With 4oz. of juice
• With water only
• On an empty stomach

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11. During the nurse's preoperative assessment, the nurse notices that the patient is extremely anxious. The patient's blood pressure is 142/92 mm Hg, heart rate is 104 per minute, and respirations are 34. The nurse should:

• Notify the anesthesiologist or surgeon
• Call the operating room and cancel the surgery.
• Go ahead and give the preoperative medicine early to help calm the patient.
• Instruct the patient on possible postoperative complications.

12. To decrease the incidence of aspiration of gastric contents in a child hospitalization with severe burns, the nurse should position the head:

• Flat except during meals
• Elevates 30-45 degrees during meals
• Elevated 15-30 degrees for12-hours after meals
• Elevated 45 degrees at all times

13. A health care provider orders daily sputum specimens to be collected from a client. When is the most appropriate time for the nurse to collect these specimens?

• After activity
• Before meals
• On awakening
• Before a respiratory treatment

14. All of the following is used Central Venous Catheter, EXCEPT:

• Clients require long term IV medication
• IV medications are irritating to peripheral veins
• Clients require short term IV medication
• Difficult to insert peripheral catheter

15. Which of the following, if done by the nurse, indicates incompetence during suctioning an unconscious client?

• Measure the length of the suction catheter to be inserted by measuring from the tip of the nose, to the earlobe, to the xiphoid process
• Use KY Jelly if suctioning nasopharyngeal secretion
• The maximum time of suctioning should not exceed 15 seconds
• Allow 30 seconds interval between suctioning

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16. Which of the following observations should the postanesthesia care unit (PACU) nurse plan to make first when the client who has had a modified radical mastectomy returns from the operating room?

• Obtaining and recording vital signs
• Observing that drainage tubes are patent and functioning
• Ensuring that the client's airway is free of obstruction
• Checking the client's dressings for drainage

17. A nurse evaluates a patient who had a modified radical mastectomy two weeks ago. Which of the following observations would indicate that the patient is progressing as expected?

• Incision intact; numbness along suture line
• Affected arm supported in sling; hand at level of the heart
• Reports cessation of intimate contact with spouse
• Indicates plan to replace wardress with loose fitting clothing

18. The term "pink puffer" refers to the female client with which of the following conditions?

• Adult respiratory distress syndrome (ARDS)
• Asthma
• Chronic obstructive bronchitis
• Emphysema

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19. 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. You are the nurse assigned to work with a child with acute glomerulonephritis. By following the prescribed treatment regimen, the child experiences a remission. You are now checking to make sure the child does not have a relapse. Which finding would most lead you to the conclusion that a relapse is happening?

• Elevated temperature, cough, sore throat, changing complete blood count (CBC) with differential
• A urine dipstick measurement of 2+ proteinuria or more for 3 days, or the child found to have 3-4+ proteinuria plus edema.
• The urine dipstick showing glucose in the urine for 3 days, extreme thirst, increase in urine output, and a moon face.
• A temperature of 37.8 degrees (100 degrees F), flank pain, burning frequency, urgency on voiding, and cloudy urine.

20. Situation: Colorectal cancer can affect old and younger people. Surgical procedures and other modes of treatment are done to ensure quality of life. You are assigned in the Cancer institute to care of patients with this type of cancer. Q. Several days prior to bowel surgery, Larry may be given sulfasuxidine and neomycin primarily to:

• promote rest of the bowel by minimizing peristalsis
• reduce the bacterial content of the colon
• empty the bowel of solid waste
• soften the stool by retaining water in the colon

21. 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. After discharge, which of these behaviors indicate a positive result of being able to overcome her phobia?

• she read a book in the public library
• she drives alone along the long expressway
• she watches television with the family in the recreation room
• she joint an art therapy group

22. Which of the following factors would have the most influence on the outcome of a crisis situation?

• Age
• Previous coping skills
• Self-esteem
• Perception of the problem

23. A client with cancer who is receiving chemotherapeutic drugs has been given injections of pegfiIgastrim (Neulasta). Which laboratory value reveals that the drug is producing the desired effect?

• Hemoglobin of 13.5g/dL
• White blood cells count of 6000/mm
• Platelet count of 300 000/mm
• Hematocrit of 39%

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24. The nurse is monitoring a client who is receiving oxytocin to induce labor. Which assessment findings should cause the nurse to immediately discontinue the oxytocin infusion? Select all that apply. 1. Fatigue 2. Drowsiness 3. Uterine hyperstimulation 4. Late decelerations of the fetal heart rate 5. Early decelerations of the fetal heart rate

• 1,4,5
• 3,4
• 2,3,4
• 1,2,3,4,5

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25. Which of the following is a desired expected outcome 24 hours postoperatively?

• Gag reflex present.
• Cerebral perfusion pressure, 68mmHg.
• Intracranial pressure, 21 mmHg.
• Decreased lacrimation.

26. A client with increased intracranial pressure is placed on mechanical ventilation with hyperventilation. The nurse knows that the purpose of the hyperventilation is to:

• Prevent the development of acute respiratory failure
• Decrease cerebral blood flow
• Increase systemic tissue perfusion
• Prevent cerebral anoxia

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27. Which of the following WBC component proliferates in cases of Anaphylaxis?

• Neutrophils
• Basophils
• Eosinophils
• Monocytes

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28. A 66 year-old woman is admitted to the hospital with a history hypertension. She present with breathing difficulties that worsen with activity and while sleeping, she is generally weak and feels that her heart misses beats and that it sometimes beats loudly. An electrocardiogram shows atrial fibrillation, right ventricular hypertrophy and deviation towards the right. Which nursing intervention is most appropriate for this patient?

• Provide a bedside commode (portable toilet)
• Place in right side lying position
• Encourage family and friends to visit
• Encourage independent hygienic activities

29. The nurse is discussing negativism with the parents of a 30 month-old child. How should the nurse tell the parents to best respond to this behavior?

• Reprimand the child and give a 15 minute "time out"
• Maintain a permissive attitude for this behavior
• Use patience and a sense of humor to deal with this behavior
• Assert authority over the child through limit setting

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30. The physician ordered, Maxitrol, Od. What does Od means?

• Both eye
• On demand
• Only one dose
• Once a day

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31. A nurse is discharging a patient after hospitalization due to myocarditis. Which of the following statements should be included in discharge teaching?

• There is usually some residual heart enlargement
• May resume previous activities as before hospitalization
• Avoid immunizations against infectious disease
• Rapidly beating heart is a common side effect of the illness and is not dangerous

32. Postpartum blues is said to be normal provided that the following characteristics are present. These are 1. Within 3-10 days only; 2. Woman exhibits the following symptoms- episodic tearfulness, fatigue, oversensitivity, poor appetite; 3. Maybe more severe symptoms in primpara

• All of the above
• 1 and 2
• 2 only
• 2 and 3

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33. A patient has just diagnosed with hypothyroidism. Which of the following instructions is correct?

• You will need to take thyroid hormone replacement therapy your Entire life
• You will need to take thyroid hormone replacement therapy until your laboratory result
• You will need to take thyroid hormone replacement therapy for about 2 months.
• You will need to take thyroid hormone replacement therapy for 1 year.

34. The nurse is setting up the physical environment for an interview with a client and plans to obtain subjective data regarding the client's health. Which interventions are appropriate? Select all that apply. 1. Set the room temperature at a comfortable level. 2. Remove distracting objects from the interviewing area. 3. Place a chair for the client across from the nurse's desk. 4. Ensure comfortable seating at eye level for the client and nurse. 5. Provide seating for the client so that the client faces a strong light. 6. Ensure that the distance between the client and nurse is at least 7 feet (2.1 meters).

• 1,2,3,4,5
• 1,2,4
• 2,3,5
• 2,4,5

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35. A month after receiving a blood transfusion an immunocompromised male patient develops fever, liver abnormalities, a rash, and diarrhea. The nurse would suspect this patient has:

• Nothing related to the blood transfusion.
• Graft-versus-host disease (GVHD).
• Myelosuppression.
• An allergic response to a recent medication.

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36. The nurse is monitoring the chest tube drainage system in a client with a chest tube. The nurse notes intermittent bubbling in the water seal chamber. Which is the most appropriate nursing action?

• Check for an air leak.
• Document the findings.
• Notify the health care provider.
• Change the chest tube drainage system.

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37. The nurse is performing an assessment on a client with pheochromocytoma. Which assessment data would indicate a potential complication associated with this disorder?

• A urinary output of 50 mL/hour
• A coagulation time of 5 minutes
• A heart rate that is 90 beats/minute and irregular
• A blood urea nitrogen level of 20 mg/dL (7.1 mmol/L)

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38. Situation: Mental Retardation is an increasingly common childhood disorder that impairs learning. Q. Which of the following is true with regards to mental retardation?

• Mental retardation is always accompanied by physical features
• Hereditary and perinatal factors do not result to mental retardation
• Mental retardation is a mental illness
• Hereditary and perinatal factors are known to result to impaired intellectual functioning

39. The nurse has instructed the client about the correct positioning of his leg and hip following hip replacement surgery. Which of the following statements indicate that the client has understood these instructions?

• I may cross my legs as long as I keep my knees extended
• I should avoid bending over to tie my shoes
• I can sit in any chair that I find comfortable
• I should avoid any unnecessary walking for about 3 months after my surgery

40. Situation: During surgical operation, it is inevitable to utilize sutures. The nurse should know the basic principles in suturing as well as knowledge in selecting sutures and caring for clients with sutures. Q. The nurse noticed that there are yellow and brown crustings around the area of the suture. Which of the following is the best cleansing medium to remove such crusting?

• Hydrogen Peroxide
• Povidone Iodine
• NSS
• Alcohol

41. The nurse must instruct a client with glaucoma to avoid taking over-the-counter medications like:

• Antihistamines.
• NSAIDs.
• Antacids.
• Salicylates.

42. What should be done in order to prevent contaminating of the environment in bed making?

• Avoid fanning soiled linens
• Strip all linens at the same time
• Finished both sides at the time
• Embrace soiled linen

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43. In traditional Chinese medicine, the yielding, negative and feminine force is termed:

• Yin
• Yang
• Chai
• Yang is the male dominating, positive and masculine force.

44. Situation: Johnny, sought consultation to the hospital before. Q. Should you check for hemorrhage, you will:

• Thyroid storm
• Check for hypotension
• Apply neck collar to prevent haemorrhage
• Observe the dressing if is soaked with blood

45. A home care nurse visits a diabetic patient who was started on insulin injections. Upon examination, the nurse observes small lumps and dents on the right upper arm where the patient has injected insulin. What is the BEST nursing intervention?

• Refer patient to dermatologist for diabetic cellulites
• Instruct the patient to rotate the sites of injection
• Refer patient to an endo for better control of glucose level
• Instruct patient to inject in the muscular area instead of a endoarea

46. A client was just admitted to the hospital to rule out a gastrointestinal (GI) bleed. The client has brought several bottles of medications prescribed by different specialists. During the admission assessment, the client states, "Lately, I have been hearing some roaring sounds in my ears, especially when I am alone." Which medication would the nurse identify as the cause of the client's complaint?

• Doxycycline
• Atropine sulfate
• Acetylsalicylic acid
• Diltiazem hydrochloride

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47. A diabetic patient comes to the office for follow-up six weeks undergoing below the knee amputation of the right leg for gangrene. The nurse observes that the patient is progressing well with the use of a prosthesis and that the skin is intact The patient reports being generally pain free but occasionally feels severe pain and itching of the right ankle. What should the nurse do?

• Notify the doctor that there appears to be nerve damage of the right leg
• Refer to pain management specialist for longterm management
• Refer to psychiatrist for evaluation since the patient has no right ankle
• Explain the phenomena of phantom pain and phantom sensation to the patient

48. Situation: You are actively practicing nurse who just finished your Graduate Studies. You earned the value of Research and would like to utilize the knowledge and skills gained in the application of research to Nursing service. The following questions apply to research. "A supposition or system of ideas that is proposed to explain a given phenomenon" best defines:

• a paradigm
• a concept
• a theory
• a conceptual framework

49. The nurse is instructing a client to perform a testicular self-examination (TSE). The nurse should provide the client with which information about the procedure?

• To examine the testicles while lying down
• That the best time for the examination is after a shower
• To gently feel the testicle with 1 finger to feel for a growth
• That TSEs should be done at least every 6 months

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50. When teaching a client with a cardiac problem, who is on a a low saturated fat diet, the nurse should stress the importance of decreasing the intake of:

• Vegetables and whole grains
• Fish and shrimp
• Nuts and beans
• Butter, lamb meats

 

NCLEX-RN | QB3 | Practice Exam #55 (50 questions)