NCLEX-RN | QB1 | Practice Exam #59 (50 questions)
1. Situation: Blood transfusion was ordered for Andre after an episode of severe bleeding.Q. Before administering the transfusion, The nurse must start an IV infusion of which of the following?
- Sterile water
- NSS
- D5W
- D5LR
2. The client arrives in the emergency department after a motor vehicle accident Nursing assessment findings include BP 80/34 pulse rate 120 and respirations 20. Which is the clients most appropriate priority nursing diagnosis?
- Alteration in cerebral tissue perfusion
- Fluid volume deficit
- Ineffective airway clearance
- Alteration in sensory perception
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3. Maureen in her third trimester arrives at the emergency room with painless vaginal bleeding. Which of the following conditions is suspected?
- Placenta previa
- Abruptio placentae
- Premature labor
- Sexually transmitted disease
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4. During the conversation with the nurse, a victim of physical abuse says, "Let me try to explain why I stay with my husband? Which of the following reasons would the client be LEAST likely to mention?
- Tm responsible for keeping my family together"
- "When it's not too bad, the abuse adds spice to our relationship"
- "I love my husband"
- 'Tm not sure I could get a job that pays even minimum wage"
5. A patient is admitted to the emergency department with a sucking, chest wound has diminished breath sounds or auscultation. Which of the following interventions would the nurse perform FIRST?
- Monitor O2 saturation and arterial blood gas (ABG)levels
- Apply Petroleum Gauze to wound
- Prepare the patient for emergency thoracentesis
- Position the patient in an upright position.
6. 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 An electrocardiogram Conform atrial fibrillation, right ventricular hypertrophy and deviation towards the rightWhat was the most likely origin of the disorder?
- Hypertension
- Rheumatic fever
- Atherosclerosis
- Genetic predisposition
7. A client is being admitted to the substance abuse unit for alcohol detoxification. As part of the intake interview, the nurse asks him when he had his last alcoholic drink. He says that he had his last drink 6 hours before admission. Based on this response, the nurse should expect early withdrawal symptoms to:
- not occur at all because the time period for their occurrence has passed.
- begin anytime within the next 1 to 2 days.
- begin within 2 to 7 days.
- begin after 7 days.
8. A pregnant client with severe preeclampsia is receiving IV magnesium sulfate. What should the nurse keep at the bedside to prepare for the possibility of magnesium sulfate toxicity?
- Oxygen
- Naloxone
- Calcium gluconate
- Suction equipment
9. You are caring for a patient with a recurrent glioblastoma who is receiving dexamethasone (Decadron) 4 mg IV every 6 hours to relieve symptoms of right arm weakness and headache. Which assessment information concerns you the most?
- The patient does not recognize family members.
- The blood glucose level is 234 mg/dL
- The patient complains of a continued headache.
- The daily weight has increased 1 kg.
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10. A client had a 1000-mL bag of 5% dextrose in 0.9% sodium chloride hung at 1500. The nurse making rounds at 1545 finds that the client is complaining of a pounding headache and is dyspneic, experiencing chills, and apprehensive, with an increased pulse rate. The intravenous (IV) bag has 400 mL remaining. The nurse should take which action first?
- Slow the IV infusion.
- Sit the client up in bed.
- Remove the IV catheter.
- Call the health care provider (HCP).
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11. Initially The nurse identifies which of the ff: Nursing diagnosis:
- self centred disturbance
- impaired social interaction
- sensory perceptual alteration
- altered thought process
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12. A patient is admitted to the hospital with a cerebrovascular accident, accident, right hemiplegia, and expressive aphasia. With a nursing diagnosis of impaired verbal communication, what is the BEST term goal for this patient?
- Learn to speak clearly within 30 days
- Communicate effectively within one week
- Have all needs anticipated by staff daily
- Make basic needs known daily
13. Which of the following is the primary antidote for Tylenol poisoning?
- Narcan
- Digoxin
- Acetylcysteine
- Flumazenil
14. Situation: Mariah is a 31 year old lawyer who has been married for 6 moths. She is now pregnant.She consults you for guidance.She worries about her small breast, thinking that she probably will incapable to breastfeed her baby. Which of the following responses of the nurse is correct?
- "The size of your breast will not affect your lactation."
- 'You can switch to bottle feeding."
- 'You can try to have exercise to increase the size of your breast.”
- "Manual expression of milk is possible."
15. The major sign of iron deficiency anemia is pallor. What part is best examined for pallor?
- Palms
- Nailbeds
- Around the lips
- Lower conjunctival sac
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16. Following lumbar surgery a patient has a 4 millimeter (mm) surgical incision. The incision is clean and the edges are well appropriate. This type of tissue healing is classified as which of the following?
- Primary intention
- Secondary intention
- Tertiary intention
- Superficial epidermal
17. A client taking Dilantin (phenytoin) for tonic-clonic seizures is preparing for discharge. Which information should be included in the clients discharge care plan?
- The medication can cause dental staining.
- The client will need to avoid a high-carbohydrate diet.
- The client will need a regularly scheduled blood work.
- The medication can cause problems with drowsiness.
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18. A client experiencing disturbed thought processes believes that his food is being poisoned. Which communication technique should the nurse use to encourage the client to eat?
- Using open-ended questions and silence
- Sharing personal preference regarding food choices
- Documenting reasons why the client does not want to eat
- Offering opinions about the necessity of adequate nutrition
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19. In assessing a client's suicide potential, which statement by the client would give the nurse the HIGHEST cause for concern?
- my thoughts of hurting myself are scary to me
- I'd like to go to sleep and not wake up
- I've thought about taking pills and alcohol till I pass out
- I'd like to be free from all these worries
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20. A physician orders an intravenous fluid of DSNS at 100cc/hr This is an example of which of the solution?
- Hypotonic
- Isotonic
- Hypertonic
- Hyper alimentation
21. A nursing assistant interrupts the performance of a ritual by a client with obsessive-compulsive disorder. What is the most likely client reaction?
- Anxiety
- Hostility
- Aggression
- Withdrawal
22. What is the host of schistosoma japonlcum?
- Mosquitoes
- Rats
- Snails
- Dogs
23. When Nurse Clarence respects the client's self-disclosure, this is a gauge for the nurses':
- Respectfulness
- Loyalty
- Trustworthiness
- Professionalism
24. A client tells the nurse that people from Mars are going to invade the earth. Which response by the nurse would be most therapeutic?
- "That must be frightening to you. Can you tell me how you feel about it?"
- "There are no people living on Mars."
- "What do you mean when you say they're going to invade the earth?"
- "I know you believe the earth is going to be invaded, but I don't believe that"
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25. A home care nurse visits an elderly patient who had a surgical repair for fracture. The patient is taking opioid analgesics. Today, the patient complaints of decreased appetite and absence of a bowel movement for four days. Which of the following can be inferred?
- Constipation related to use of opioids
- Decreased appetite due to depression
- Constipation due to acute pain
- Decreased appetite due to use of opioid
26. Situation: Agnes, a client with Leukemia is in the clinic for her routine check up.Q. What should you encourage her to use in order to maintain her oral hygiene?
- Use regular toothbrush
- Gargle with mouthwash only
- Use cotton pledget only
- Use soft toothbrush
27. The nurse is providing instructions to a client and the family regarding home care after right eye cataract removal. Which statement by the client would indicate an understanding of the instructions?
- "I should sleep on my left side"
- "I should sleep on my right side."
- "I should sleep with my head flat"
- "I should not wear my glasses at any time."
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28. Which of the following factors are major components of a client's general background drug history?
- Allergies and socioeconomic status
- Urine output and allergies
- Gastric reflex and age
- Bowel habits and allergies
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29. The mother of a nine-year-old with asthma has brought an electric CD player for her son to listen to while he is receiving oxygen therapy The nurse should:
- Explain that he does not need the added stimulation.
- Allow the player but ask him to wear earphones.
- Tell the mother that he cannot have items from home.
- Ask the mother to bring a battery-operated CD instead.
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30. Situation: A "disaster" is a large-scale 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. You are a community health nurse collaborating with the Red Cross and working with disaster relief following a typhoon which flooded and devastated the whole province. Finding safe housing for survivors, organizing support for the family, organizing counseling debriefing sessions and securing physical care are the services you are involved with. To which type of prevention are these activities included.
- Tertiary prevention
- Primary prevention
- Aggregate care prevention
- Secondary prevention
31. The first thing that a nurse must ensure when the baby's head comes out is
- The cord is intact
- No part of the cord is encircling the baby's neck
- The cord is still attached to the placenta
- The cord is still pulsating
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32. Situation: Joanna Marie, a 40 year old client was diagnosed with breast cancer.Q. Joanna is taking Adriamycin together with tamoxifen. You know that Adriamycin works by:
- Inhibiting DNA Synthesis
- Preventing Folic acid synthesis
- Changing the osmotic gradient of the cell
- Increase cell wall permeability
33. Situation: You are working as a Pediatric Nurse in your own Child Health Nursing Clinic, the following cases pertain to ASSESSMENT AND CARE OF THE NEWBORN AT RISK conditions.Baby John develops hyperbilirubinemia. What is a method used to treat hype
- when a girl has a geographic tongue
- when a boy has a possible inguinal hernia
- when a child has symptoms of epiglottitis
- when children are under 5 years of age
34. Its seeds are taken 2 hours after supper to expel round worms, which can cause ascariasis;
- Akapulko
- Bayabas
- Niyug-niyogan
- Bawang
35. Mr Snyder is admitted to your unit with a brain tumor The type of tumor he has is currently unknown. You begin to think about the way brain tumors are classified.Q. Glioma is an intracranial tumor Which of the following statements about gliomas do you know to be false?
- 50% of all intracranial tumors are gliomas
- gliomas are usually benign
- they grow rapidly and often cannot be totally excised from the surrounding tissue
- most glioma victims die within a year after diagnosis
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36. A client is brought to the psychiatric clinic by family members, who tell the admitting nurse that the client repeatedly drives while intoxicated despite their pleas to stop. During an interview with the nurse, which statement by the client most strongly supports a diagnosis of psychoactive substance abuse?
- "I'm not addicted to alcohol. In fact, I can drink more than I used to without being affected.”
- "I only spend half of my paycheck at the bar."
- "I just drink to relax after work."
- "I know I've been arrested three times for drinking and driving, but the police are just trying to hassle me."
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37. Which nursing diagnosis is most appropriate for a client with anorexia nervosa who expresses feelings of guilt about not meeting family expectations?
- Disturbed body image
- Defensive coping
- Powerlessness
- Anxiety
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38. The uterus returns to the pelvic cavity in which of the following time frames?
- 7th to 9th day postpartum.
- 2 weeks postpartum.
- End of 6th week postpartum.
- When the lochia changes to alba.
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39. Mike is admitted to a psychiatric unit with a diagnosis of undifferentiated schizophrenia. Which of the following defense mechanisms is probably used by Mike?
- Projection
- Rationalization
- Regression
- Repression
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40. In Integrated Management of Childhood Illness, severe conditions generally require urgent referral to a hospital. Which of the following severe conditions DOES NOT always require urgent referral to a hospital?
- Mastoiditis
- Severe dehydration
- Severe pneumonia
- Severe febrile disease
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41. When the method of wound healing is one in which wound edges are not surgically approximated and integumentary continuity is restored by granulations, the wound healing is termed
- Second intention healing
- Primary intention healing
- Third intention healing
- First intention healing
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42. Which of the following should the nurse use to provide support to Mn Heywood's spine?
- A sheepskin pad
- An air mattress
- A bed board
- A foam square
43. Situation: J.E, is an 18-year old freshman admitted to the ICU following a motor vehicle accident in which he sustained multiple trauma including a ruptured spleen, myocardial contusion, fractured pelvis, and fractured right femur. He had a mild contusion, but is alert and oriented. His vital signs BP 120/80, pulse 84, respirations 12, and temperature 99 F orally.Q. Appropriate nursing interventions for J.E. would be
- Skin care and position q2h and prn; maintain alignment of extremities; respiratory exercises
- Skin care/bathe daily; passive leg exercises daily; respiratory therapy for intermittent positive pressure breathing therapy
- Skin care and position q2h; teach use of overhead trapeze; respiratory exercises, and intermittent positive pressure breathing q2h
- Skin care q2h; teach use of overhead trapeze; respiratory exercises; use pressure relief devices
44. The nurse is reviewing true and false labor signs with a multiparous client The nurse determines that the client understands the signs of true labor if she makes which statement?
- "I won't be in labor until my baby drops."
- "My contractions will be felt in my abdominal area”
- "My contractions will not be as painful if I walk around."
- "My contractions will increase in duration and intensity"
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45. Nurse Rachel teaches a client who has been recently diagnosed with hepatitis A about untoward signs and symptoms related to Hepatitis that may develop. The one that should be reported immediately to the physician is:
- Restlessness
- Yellow urine
- Nausea
- Clay-colored stools
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46. Situation: Developing countries such as the Philippines suffer from high infant and child mortality rates. Thus, as a management to the existing problem, the WHO and UNICEF launched the IMCLThe following are treatments for acute ear infections:
- Dry the ear by wicking
- Give antibiotics for 5 days
- Follow up in 5 days
- A and C only
47. A Patient with tuberculosis can transmit the disease to another individual Through:
- Air droplets
- Physical contact
- Hand to mouth exchange
- Blood and body fluids
48. A client is diagnosed with scleroderma. Which intervention should the nurse anticipate to be prescribed?
- Maintain bed rest as much as possible.
- Administer corticosteroids as prescribed for inflammation.
- Advise the client to remain supine for 1 to 2 hours after meals.
- Keep the room temperature warm during the day and cool at night.
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49. A female client tells nurse Nikki that she has been working hard for the last 3 months to control her type 2 diabetes mellitus with diet and exercise. To determine the effectiveness of the clients efforts, the nurse should check:
- urine glucose level.
- fasting blood glucose level.
- serum fructosamine level.
- glycosylated hemoglobin level.
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50. A client has sustained a closed fracture and has just had a cast applied to the affected arm. The client is complaining of intense pain. The nurse elevates the limb, applies an ice bag, and administers an analgesic, with little relief. Which problem may be causing this pain?
- Infection under the cast
- The anxiety of the client
- Impaired tissue perfusion
- The recent occurrence of the fracture
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NCLEX-RN | QB1 | Practice Exam #59 (50 questions)