NCLEX-RN | QB3 | Practice Exam #56 (50 questions)
All 50 questions are randomized each time you take the test, and do not appear in the same order.
1. Situation: One important toot a community health nurse uses in the conduct of his/her activities is the CHN Bag. Which of the following BEST DESCRIBES the use of this vital facility for our practice? What is the rationale in the use of bag technique during home visit?
- It helps render effective nursing care to clients or other members of the family
- It saves time and effort of the nurse in the performance of nursing procedures
- It should minimize or prevent the spread of infection from individuals to families
- It should not overshadow concerns for the patient
2. A client who's taking antipsychotic medication develops a very high temperature, severe muscle rigidity, tachycardia, and rapid deterioration in mental status. The nurse suspects what complication of antipsychotic therapy?
- Agranulocytosis
- Extrapyramidal effects
- Anticholinergic effects
- Neuroleptic malignant syndrome (NMS)
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3. Later that day, he bought his son ice cream and food. What defense mechanism is Mr. Poncho unconsciously doing?
- Restitution
- Conversion
- Redoing
- Reaction formation
4. A client arriving at the emergency department has experienced frostbite to the right hand. Which finding would the nurse note on assessment of the client's hand?
- A pink, edematous hand
- Fiery red skin with edema in the nail beds
- Black fingertips surrounded by an erythematous rash
- A white color to the skin, which is insensitive to touch
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5. According to the hypothetical graph of urinary output versus time of intravenous (IV) administration, at what hour of IV administration dose the urinary output attain the desired output of 30 ml/hr.:
- 2 hours
- 4 hours
- 6 hours
- 8 hours
6. 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. Mr. & Mrs. Bond brought their son in the hospital for check up. The child has failure to thrive and was diagnosed with pyloric stenosis. Which among the following statements are the characteristic manifestations of pyloric stenosis?
- Vomiting in the early morning
- Bile containing vomitus immediately after meal
- sausage shaped mass in the abdomen
- Projectile vomiting with no bile content
7. A client has been notified that because of fallopian tube obstruction, her best option for becoming pregnant is through in vitro fertilization. The client asks the nurse about the procedure. Which of the following responses is correct?
- "During the stimulation phase of the procedure, the physician will make sure that only one egg reaches maturation.”
- "Preimplantation genetic diagnosis will be performed on your partner's sperm to make sure that the sperm are normal.”
- "After ovarian stimulation, you will be artificially inseminated with your partner's sperm."
- "Any extra embryos will be preserved for you if you wish to conceive again in the future.”
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8. A newborn was delivered pre-term weighing 2700 grams with. Apgar scores of 4 and 6, respectively. When the mother had presented to the Obstetrical Triage Unit, she was already 7 centimeters dilated and fully effaced. Her due date was unknown as she had no parental care. The infant showed signs of fetal distress and was finally delivered by Cesarean section. At birth a large, thin, membranous sac was protruding from the umbilical base. What is the priority nursing intervention at birth?
- Maintain cardio respiratory stability
- Protect the herniated viscera
- Manage fluid intake and output
- Establish vascular access
9. During surgery requiring general anesthesia, the patient's heart stops and a carotid pulse is not palpated. How many compressions per minute should be administered?
- 50
- 60
- 80
- 100
10. The client is scheduled to have an intravenous cholangiogram. Before the procedure the nurse should assess the patient for:
- Shellfish allergies
- Reactions to blood transfusions
- Gallbladder disease
- Egg allergies
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11. The nurse is assessing a newborn who was born to a mother who is addicted to drugs. Which findings should the nurse expect to note during the assessment of this newborn? Select all that apply. 1. Lethargy 2. Sleepiness 3. Irritability 4. Constant crying 5. Difficult to comfort 6. Cuddles when being held
- 1,2,4
- 3,4,5
- 1,2,3,4
- 2,3,5
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12. The diet that is appropriate in normal pregnancy should be high in:
- Protein, minerals and vitamins
- Carbohydrates and vitamins
- Proteins, carbohydrates and fats
- Fats and minerals
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13. Situation: The OR is divided in three zones to control traffic flow and contamination. Q. Nursing intervention for a patient on low dose IV insulin therapy includes the following EXCEPT:
- Elevation of serum ketones to monitor ketosis
- Vital signs including BP
- Estimate serum potassium
- Elevation of blood glucose levels
14. Meperidine has been prescribed for a client to treat pain. Which side and adverse effects should the nurse monitor for? Select all that apply. 1. Diarrhea 2. Tremors 3. Drowsiness 4. Hypotension 5. Urinary frequency 6. Increased respiratory rate
- 1,2,3,4,5,6
- 2,3,4
- 1,2,3
- 1,4,6
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15. When asking the parents about the onset of problems in young client with the diagnosis of schizophrenia, Nurse Linda would expect that they would relate the clients difficulties began in:
- Early childhood
- Late childhood
- Adolescence
- Puberty
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16. Practices that promote health through personal cleanliness is called:
- General appearance.
- Self-image.
- Insomnia.
- Hygiene.
17. Situation: In the OR, there are safety protocols that should be followed. The OR nurse should be well versed with all these to safeguard the safety and quality of patient delivery outcome. Q. Which of the following should be given highest priority when receiving patient in the OR?
- Assess level of consciousness
- Verify patient identification and informed consent
- Assess vital signs
- Check for jewelry, gown, manicure, and dentures
18. A client is admitted to the hospital with a suspected diagnosis of Hodgkin's disease. Which assessment finding would the nurse expect to note specifically in the client?
- Fatigue
- Weakness
- Weight gain
- Enlarged lymph nodes
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19. Amy, a pregnant mother from a sectarian group strictly adheres to a. vegetarian diet. The vitamin supplement the nurse recommend is:
- Vit.C
- Vit. B12
- Vit. D
- Vit. A
20. Birth Control Methods and Infertility: In basal body temperature (BBT) technique, the sign that ovulation has occurred is an elevation of body temperature by:
- 1.0-1.4 degrees centigrade
- 0.2-0.4 degrees centigrade
- 2.0-4.0 degrees centigrade
- 1.0-4.0 degrees centigrade
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21. A pain scale is used to assess the degree of pain. The client rates the pain as an 8 on a scale of 10 before medication and a 7 on a scale of 10 after being medicated. Nurse Glenda determines that the:
- Client has a low pain tolerance
- Medication is not adequately effective
- Medication has sufficiently decreased the pain level
- Client needs more education about the use of the pain scale
22. Cystic fibrosis is an exocrine disorder that affects several systems of the body. The earliest sign associated with a diagnosis of cystic fibrosis is:
- Steatorrhea
- Frequent respiratory infections
- Increased sweating
- Meconium ileus
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23. Which of the following is not a late sign and symptoms of leprosy?
- Paralysis
- Contractures
- Madarosis
- Gynecomastia
24. In which phase of nursing process the nurse collect data about the client:
- Diagnosis.
- Assessment.
- Implementation.
- Evaluation.
25. 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. The episodes Mr. Liberatore has been experiencing are probably:
- small cerebral hemorrhages
- TIA's or transient ischemic attacks
- Secondary to hypoglycemia
- Secondary to hyperglycemia
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26. In evaluating the appropriateness of various exercises enjoyed by a patient with osteoporosis, the nurse would recommend:
- Walking
- Bowling
- Sit-ups
- Golf
27. The nurse is caring for a patient scheduled for left arm amputation due to bone carcinoma. Adequate assessment and management of preoperative pain will result in:
- Decreased phantom limb sensation
- Increased range of motion after surgery
- Decreased depression after surgery
- Decreased likelihood of cancer recurrence
28. Initial interventions for Marco with acute anxiety include all except which of the following?
- Touching the client in an attempt to comfort him
- Approaching the client in calm, confident manner
- Encouraging the client to verbalize feelings and concerns
- Providing the client with a safe, quiet and private place
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29. During the early postoperative period, a client who has undergone a cataract extraction complains of nausea and severe eye pain over the operative site. What should be the initial nursing action?
- Call the health care provider (HCP).
- Reassure the client that this is normal.
- Turn the client onto his or her operative side.
- Administer the prescribed pain medication and antiemetic.
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30. To describe the sex composition of the population, which demographic tool may be used?
- Sex ratio
- Sex proportion
- Population pyramid
- Any of these maybe used
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31. Which of the following statement is not true about stress?
- It is a nervous energy
- It is an essential aspect of existence
- It has been always a part of human experience
- It is something each person has to cope
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32. A patient is scheduled for an abdominal aneurysm repair. This is what type of surgical intervention?
- Diagnostic
- Transplant
- Curative
- Palliative
33. The nurse shows a patient advocate role when:
- defend the patients right
- refer patient for other services she needs
- work with significant others
- intercedes in behalf of the patient.
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34. To monitor clients registered in long-term regimens, such as the Multi-Drug Therapy, which component will be most useful?
- Tally report
- Output report
- Target/client list
- Individual health record
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35. Situation: In the OR, there are safety protocols that should be followed. The OR nurse should be well versed with all these to safeguard the safety and quality to patient delivery outcome. Q. Which of the following should be given highest priority when receiving patient in the OR?
- Assess level of consciousness
- Verify patient identification and informed consent
- Assess vital signs
- Check for jewelry, gown, manicure and dentures
36. Situation: A "disaster" is a large-scaie emergency—even a small emergency left unmanaged may turn into a disaster. Disaster preparedness is crucial and is everybody's business. There are agencies that are in charge of ensuring prompt response. Comprehensive Emergency Management (CEM) is an integrated approach to the management of emergency program and activities for all four emergency phases (mitigation, preparedness, response, and recovery), for all type of emergencies and disasters (natural, man-made, and attack) and for all levels of government and the private sector. Q. Which of the four phases of emergency management is defined as "sustained action that reduces or eliminates long-term risk to people and properly from natural hazards and the effect"?
- Recovery
- Mitigation
- Response
- Preparedness
37. Which of the following is the MOST important discharge planning instruction for a patient with mononucleosis?
- Avoid activities that may increase injury to the spleen
- Avoid crowded areas to prevent the spread of infection
- Consume vitamin K rich food to decrease the risk of bleeding
- Take an antibiotics a prescribed to treat infection
38. A client with severe back pain and hematuria is found to have hydronephrosis due to urolithiasis. The nurse anticipates which treatment will be done to relieve the obstruction? Select all that apply. 1. Peritoneal dialysis 2. Analysis of the urinary stone 3. Intravenous opioid analgesics 4. insertion of a nephrostomy tube 5. Placement of a ureteral stent with ureteroscopy
- 2,3,5
- 4,5
- 1,2,3
- 2,3,4,5
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39. Situation Carlo, 16 years old, comes to the ER with acute asthmatic attack RR is 46/min and he appears to be in acute respiratory distress. Q. Which of the following nursing actions should be initiated first?
- Promote emotional support
- Administer oxygen at 6L/min
- Suction the client every 30 min
- Administer bronchodilator by nebulizer
40. Nurse Randy is planning to administer oral medication to a 3 year old child. Nurse Randy is aware that the best way to proceed is by:
- "Would you like to drink your medicine?"
- "If you take your medicine now, 111 give you lollipop"
- "See the other boy took his medicine? Now it's your turn "
- "Here's your medicine. Would you like a mango or orange juice?"
41. When discussing normal infant growth and development with parents, which of the following toys would the nurse suggest as most appropriate for an 8-month-old?
- Push-pull toys
- Rattle
- Large blocks
- Mobile
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42. A 62 yr-old client diagnosed with pyelonephritis and possible septicemia has had five urinary tract infections over the past two years. She's fatigued from lack of sleep; urinates frequently, even during the night; and has lost weight recently. Test reveal the following: sodium level 152 mEq/L, osmolarity 340 mOsm/L, glucose level 125 mg/dl, and potassium level 3.8 mEq/L. which of the following nursing diagnoses is most appropriate for this client?
- Deficient fluid volume related to inability to conserve water
- Imbalanced nutrition: less than body requirements related to hypermetabolic state
- Deficient fluid volume related to osmotic diuresis induced by hypernatremia
- Imbalanced nutrition: less than body requirements related to catabolic effects of insulin deficiency
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43. The nurse employed in a hospital is waiting to receive a report from the laboratory via the facsimile (fax) machine. The fax machine activates and the nurse expects the report, but instead receives a sexually oriented photograph. Which is the most appropriate initial nursing action?
- Call the police.
- Cut up the photograph and throw it away.
- Call the nursing supervisor and report the incident.
- Call the laboratory and ask for the name of the individual who sent the photograph.
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44. Nurse Patricia is reconstituting a powdered medication in a vial. After adding the solution to the powder, she nurse should:
- Do nothing.
- Invert the vial and let it stand for 3 to 5 minutes.
- Shake the vial vigorously.
- Roll the vial gently between the palms.
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45. An experienced traveling nurse has been assigned to work in the ED; however, this is the nurse's first week on the job. Which area of the ED is the most appropriate assignment for the nurse?
- Trauma team
- Triage
- Ambulatory or fast track clinic
- Pediatric medicine team
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46. A client is prescribed nicotinic acid for hyperlipidemia and the nurse provides instructions to the client about the medication. Which statement by the client indicates an understanding of the instructions?
- "It is not necessary to avoid the use of alcohol."
- "The medication should be taken with meals to decrease flushing”
- "Clay-colored stools are a common side effect and should not be of concern"
- "Ibuprofen IB taken 30 minutes before the nicotinic acid should decrease the flushing."
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47. A diabetic multigravida is scheduled for an amniocentesis at 32 weeks gestation to determine the L/S ratio and phosphatidyl glycerol level. The L/S ratio is 1:1 and the presence of phosphatidylglycerol is noted. The nurses assessment of this data is:
- The infant is at low risk for congenital anomalies.
- The infant is at high risk for intrauterine growth retardation.
- The infant is at high risk for respiratory distress syndrome.
- The infant is at high risk for birth trauma.
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48. Which client outcome would best indicate successful treatment for a client with an antisocial personality disorder?
- The client exhibits charming behavior when around authority figures
- The client has decreased episodes of impulsive behaviors
- The client makes statements of self-satisfaction
- The client's statements indicate no remorse for behaviors
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49. A community health nurse assesses a 68-year-old patient who lives in a group home. The patient reports decreased appetite after transferring to the group home because the food tastes too bland. What type of data is the nurse collecting from the above information?
- Analytical
- Derived
- Objective
- Subjective
50. The nurse is evaluating the developmental level of a 2-year-old. Which does the nurse expect to observe in this child?
- Uses a fork to eat
- Uses a cup to drink
- Pours own milk into a cup
- Uses a knife for cutting food
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