NCLEX-RN | QB1 | Practice Exam #60 (50 questions)
1. Situation: Nurse's in ail practice areas are likely to come in contact with clients suffering from acute or chronic drug abuse.Q. The psychodynamic therapy of substance abuse is based upon the premise that drug abuse is:
- a common problem brought about by socioeconomic deprivation
- caused by multiplicity of factors
- predisposed by an inability to develop appropriate psychological resources to manage developmental stresses
- due to biochemical factors
2. Situation: Harriet, a 38 year-old schoolteacher with rheumatoid arthritis, is admitted to the hospital with severe and swelling of the joints of both hands.Q. Harriet ask the nurse why the physician is going to inject hydrocortisone into her affected joint. The nurse explains that the most important reason for doing this is to:
- Relieve pain
- Reduce inflammation
- Provide Psychotherapy
- Prevent ankylosis of the joint
3. A psychotic client reports to the evening nurse that the day nurse put something suspicious in his water with his medication. The nurse replies, "You're worried about your medication?" The nurse's communication is:
- an example of presenting reality.
- reinforcing the client's delusions.
- focusing on emotional content.
- a nontherapeutic technique called mind reading.
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4. TT2 provides how many percentage of protection against tetanus?
- 100
- 99
- 80
- 90
5. The physician ordered a blood glucose test for the neonates the nurse knows the best site to puncture is usually:
- The lateral heel.
- Anterior sole
- Fingertip
- Anterior scalp
6. A patient has an order for 100 milliliters (ml) of intravenous (IV) fluid to infuse over eight hours. The available IV tubing has a drip factor of 10 gtts/ml. Which of the following rates is correct?
- 125 ml/hour
- 125 drop/minute
- 21 drops/minute
- 21 ml/hour
7. Following infusion of a unit of packed red blood cells, the client has developed new onset of tachycardia, bounding pulses, crackles, and wheezes. Which action should the nurse implement first?
- Maintain bed rest with legs elevated.
- Place the client in high-Fowler's position.
- increase the rate of infusion of intravenous fluids.
- Consult with the health care provider (HCP) regarding initiation of oxygen therapy.
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8. A client with clotting disorder has an order to continue Lovenox (enoxaparin) injections after discharge. The nurse should teach the client that Lovenox injections should:
- Be injected into the deltoid muscle
- Be injected into the abdomen
- Aspirate after the injection
- Clear the air from the syringe before injections
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9. Nurse Christine provides health teaching for the parents of a child diagnosed with celiac disease. Nurse Christine teaches the parents to include which of the following food items in the child's diet:
- Rye toast
- Oatmeal
- White bread
- Rice
10. Situation: In your professional nursing role, it is essential to establish a meaningful nurse patient relationship.Q. A male nurse reminds the client that is already time for group activities, The client responded by yelling to the nurse "You are always telling me what to do! Just like my father!" This is an example of:
- Symbolization
- Transference
- Reaction Formation
- Counter Transference
11. Situation: Mariah is a 31 year old lawyer who has been married for 6 moths. She is now pregnantShe consults you for guidance.She reports an increase in BBT on December 16. Which hormone brings about this change in her BBT?
- Estrogen
- Progesterone
- Gonadootrophine
- Follicle Stimulating Hormone
12. There is a continuous bubbling in the water sealed drainage system with suction. And oscillation is observed. As a nurse, what should you do?
- Consider this as normal findings
- Notify the physician
- Prepare a petrolatum gauze dressing
- Check for tube leak
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13. In what psychosexual development according to Freud is temper tantrum observed?
- phallic
- oral
- anal
- latency
14. Situation: Joint Commission on Accreditation of Hospital Organization (JCAHO) patient safety goals and requirements include the care and efficient use of technology in the OR arid elsewhere in the healthcare facility. Q. JCAHO's universal protocol for surgical and invasive procedures to prevent wrong site, wrong person, and wrong procedures/surgery includes the following EXCEPT:
- Mark the operative site if possible
- Conduct pre-procedure verification process
- Take a video of the entire intra-operative procedure
- Conduct time out immediately before starting the procedure
15. A client has a diagnosis of discoid lupus erythematosus (DLE). The nurse recognizes that discoid lupus differs from systemic lupus erythematosus because it:
- Produces changes in the kidneys
- Is confined to changes in the skin
- Results in damage to the heart and lungs
- Affects both joints and muscles
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16. Stated that health is WELLNESS. A termed define by the culture or an individual.
- Roy
- Henderson
- Rogers
- King
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17. The nurse administered a dose of morphine sulfate, as prescribed to apatient who is in the post-anesthesia care unit (PACU). The patient appears to be resting comfortably; the respiratory rate is 8 and the dsaturation on 2L of oxygen via nasal cannula is 86%. The nurse should 1MMEDIETLY administer.
- Flumazenil (Romazicon)
- Midazolam (Versed)
- Naloxone (Narcan)
- None of the above
18. Situation: Nurse Dorina is going to perform an abdominal examination to Mr. Lim who was admitted due to on and off pain since yesterday.Q. Mr. Lim felt pain upon release of Nurse Dorina's hand. This can be referred as:
- referred pain
- rebound tenderness
- direct tenderness
- indirect tenderness
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19. Situation: Arnold, age 67, has had successfully treated depressive disease for more than 10 years. Lately he has been developing a plan of action. Arnold is admitted to hospital for reassessment. Arnold confides to the nurse that he has been thinking of suicide. Which of the following motivations should the nurse recognize in Arnold?
- Wishes to frighten the nurse
- Wants attention from the staff
- Feels safe and can share his feelings with the nurse
- Shows fearful of his own impulses and is seeking protection from them
20. Nurse Bea plans of assigning competent people to fill the roles designed in the hierarchy. Which process refers to this?
- Staffing
- Scheduling
- Recruitment
- Induction
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21. She plans of assigning competent people to fill the roles designed in the hierarchy. Which process refers to this?
- Staffing
- Scheduling
- Recruitment
- Induction
22. In doing a child's admission assessment, Nurse Betty should be alert to note which signs or symptoms of chronic lead poisoning?
- Irritability and seizures
- Dehydration and diarrhea
- Bradycardia and hypotension
- Petechiae and hematuria
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23. Situation: Still in your self-managed Child Health Nursing Clinic, your encounter these cases pertaining to the CARE OF CHILDREN WITH PULMONARY AFFECTIONS.Q. You were able to identify factors that lead to respiratory problems in the community where your health facility serves. Your primary role therefore in order to reduce morbidity due to pneumonia is to:
- Teach mothers how to recognize early signs and symptoms of pneumonia
- Make home visits to sick children
- Refer cases to hospitals
- Seek assistance and mobilize the BHWs to have a meeting with mothers
24. The priority of care for a client with Alzheimer's disease is:
- Help client develop coping mechanism
- Encourage to learn new hobbies and interest
- Provide him stimulating environment
- Simplify the environment to eliminate the need to make chores
25. Tertiary prevention is needed in which stage of the natural history of disease?
- Pre-pathogenesis
- Pathogenesis
- Prodromal
- Terminal
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26. A five-month-old is diagnosed with atopic dermatitis. Nursing interventions will focus on:
- Preventing infection
- Administering antipyretics
- Keeping the skin free of moisture
- Limiting oral fluid intake
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27. Which client factors should alert the nurse to potential increased complications with a burn injury?
- The client is a 26-year-old male.
- The client has had a burn injury in the past.
- The burned areas include the hands and perineum.
- The burn took place in an open field and ignited the clients clothing.
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28. A patient receives a blood transfusion for severe anemia after surgery. While evaluating the patient the nurse finds that the patient's oral temperature has began to rise from 98.20F (36.80F) to 101.00F(38.30C). What should the nurse do?
- Give the patient an anti-pyretic medication and continue the transfusion as ordered
- Discontinue the intravenousiine and restart in another site
- Stop the transfusion, keep the vein open with normal saline, and notify the doctor immediately
- Use a blood cooling device to cool the blood as it infuses
29. Tristan is on Lithium has suffered from diarrhea and vomiting. What should the nurse in- charge do first:
- Recognize this as a drug interaction
- Give the client Cogentin
- Reassure the client that these are common side effects of lithium therapy
- Hold the next dose and obtain an order for a stat serum lithium level
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30. A client arrives at the clinic complaining of fatigue, lack of energy constipation, and depression. Hypothyroidism is diagnosed, and levothyroxine is prescribed. What is an expected outcome of the medication?
- Alleviate depression
- Increase energy levels
- Increase blood glucose levels
- Achieve normal thyroid hormone levels
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31. The nurse is preparing for the admission of an infant with a diagnosis of bronchiolitis caused by respiratory syncytial virus (RSV). Which interventions should the nurse include in the plan of care? Select all that apply. 1.Place the infant in a private room. 2.Ensure that the infant's head is in a flexed position. 3.Wear a mask at all times when in contact with the infant. 4.Place the infant in a tent that delivers warm humidified air. 5.Position the infant on the side, with the head lower than the chest. 6.Ensure that nurses caring for the infant with RSV do not care for other high-risk children.
- 1,6
- 1,2,3,4,5
- 2,3,4,6
- 1,3,5,6
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32. The most appropriate time for the nurse to obtain a sputum specimen for culture is:
- Early in the morning
- After the patient eats a light breakfast
- After aerosol therapy
- After chest physiotherapy
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33. Situation: Joanna Marie, a 40 year old client was diagnosed with breast cancer.Q. Which of the following may be use to her post operatively?
- Cystoclysis bottle
- 3 way bottle system
- Jackson Pratt Drain
- Pleural drainage
34. A 59-year-old patient arrives in the emergency department diaphoretic and complains of chest pain and shortness of breath. The patients sibling states that this has happened before and it is just anxiety. Upon evaluation the physician diagnosis unstable angina and prescribes anti-anginal medications. What is the expected results of this drug therapy
- Balanced between oxygen supply and demand
- Increase in blood flow to the heart
- Reduction in oxygen demand and consumption
- Vessel relaxation
35. While caring for a client in the second stage of labor the nurse notices a pattern of early decelerations. The nurse should:
- Notify the physician immediately.
- Turn the client on her left side.
- Apply oxygen via a tight face mask.
- Document the finding on the flow sheet.
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36. The physician has ordered an MRI for a client with an orthopedic ailment An MRI should not be done if the client has:
- The need for oxygen therapy
- A history of claustrophobia
- A permanent pacemaker
- Sensory deafness
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37. Situation: John Mark is a 21 year old male client who was rushed following an automobile accident He is very anxious, dyspneic and in severe pain.Q. To ensure that the system is functioning effectively, the nurse should:
- Observe for intermittent bubbling in the water seal chamber
- Flush the chest tube with 30 to 60 ml of NSS every 4 hours
- Maintain the client in a side lying position always
- Strip the chest tube in the direction towards the client
38. Nurse Oliver is assessing a clients abdomen. Which finding should the nurse report as abnormal?
- Dullness over the liver.
- Bowel sounds occurring every 10 seconds.
- Shifting dullness over the abdomen.
- Vascular sounds heard over the renal arteries
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39. Following a full-thickness (3rd degree) burn of his left arm, a client is treated with artificial skin. The client understands postoperative care of the artificial skin when he states that during the first 7 days after the procedure, hell restrict:
- range of motion
- protein intake
- going outdoors
- fluid ingestion
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40. Situation: Ricky is a 12 year old-boy with Down's syndrome. He stands 5' V and weight 100 lbs. He is slim and walks sluggishly with a limp. He wears a neck brace as support for his neck. X - ray of cervical spine showed "subluxation of C1 in relation to C2 with cord compression." He attends a school for special education.Q. The nurse has one on one health education sessions with Ricky's mother. The mother understood that for her son to learn to cope and be independent, she should constantly provide activities for Ricky to be able to:
- socialize with people
- eventually go to school alone
- select and prepare his own food
- do activities of daily living
41. Situation: Anna is experiencing left sharp pain and occasional hematuria. She was advised to undergo IVP by her physician.Q. The presence of calculi in the urinary tract is called:
- Colelithiasis
- Nephrolithiasis
- Ureterolithiasis
- Urolithiasis
42. Situation: Records are vital tools in any institution and should be properly maintained for specific use and time.Q. Records Management and Archives Offices of the DOH is responsible for implementing its policies on record, disposal You know that your institution is covered by this policy it;
- Your hospital is considered tertiary
- Your hospital is in Metro Manila
- It obtained permit to operate from DOH
- Your hospital is Philhealth accredited
43. A nurse assists a patient with Alzheimer's disease in teeth brushing. The patient indicates warning to complete the task alone, but is unable to get the toothpaste on the toothbrush. The nurse can MUST effectively help the patient by:
- Providing privacy to complete the task
- Completing task
- Providing hand-over-hand assistance with the task
- Telling the patient to brush the teeth today
44. A 42 year-old patient is in a lower body cast following a motor vehicle accident. In order to minimize muscle strength loss while in the cast, the nurse will instruct the patient in the performance of.
- Isometric exercises
- Passive range of motion exercises
- Active-assistive range of motion exercises
- Resistive range of motion exercises
45. A client is admitted with Wernicke's encephalopathy. The nurse anticipates that the first physician's order will include:
- Administering a steroid medication, such as Decadron
- Giving thiamine 100 mg IM STAT
- Ordering an EEG
- Ordering an MRI
46. You are giving discharge instructions to a woman who has been treated for contusions and bruises sustained during an episode of domestic violence. What is your priority intervention for this patient?
- Transportation arrangements to a safe house
- Referral to a counselor
- Advice about contacting the police
- Follow-up appointment for injuries
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47. The RN on the oncology unit is preparing to mix and administer amphoteracin B (Fungizone) to a client. Which action is contraindicated for administering this drug IV?
- Mix the drug with normal saline solution.
- Administer the drug over 4-6 hours.
- Hydrate with IV fluids two hours before the infusion is scheduled to begin.
- Premedicate the client with ordered acetaminophen (Tylenol) and diphenhydramine (Benadryl).
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48. A patient with bacterial pneumonia reports increased pain during deep breathing and coughing exercises. To minimize the patient's pain, the nurse should teach the patient to.
- Take a cough suppressant prescribed PR.N at regular time intervals
- Turn onto the side before doing the respiratory exercises
- Hold a pillow tightly against the chest while coughing
- Drink warm liquids right before taking deep breaths
49. At the six-week check-up the mother asks when she can expect the baby to sleep all night The nurse should tell the mother that most infants begin to sleep all night by age:
- One month
- Two months
- 3-4 months
- 5-6 months
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50. The nurse understands that the diagnosis of oral cancer is confirmed with:
- Biopsy
- Gram Stain
- Oral culture
- Oral washings for cytology
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NCLEX-RN | QB1 | Practice Exam #60 (50 questions)