NCLEX-RN | QB1 | Practice Exam #58 (50 questions)
1. Situation: You are assigned at the surgical ward and clients have been complaining of post pain at varying degrees. Pain as you know is very subjective.Q. Surgical pain might be minimized by which nursing action in the O.R.
- Skill of surgical team and lesser manipulation
- Appropriate preparation for the scheduled procedure
- Use of modern technology in closing the wound
- Proper positioning and draping of client.
2. A nurse is discussing sexual arousal during a preadolescent boys' sex education class. Which of the following should the nurse base her reply on when a boy asks, "What exactly happens when my body gets aroused, anyway?"
- The vas deferens thickens and expands.
- The sympathetic nerves of the penis are stimulated.
- The corpora of the penis become engorged.
- The prepuce of the penis elongates.
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3. A patient has partial-thickness burns to both legs and portions of his trunk. Which of the following LV. fluids is given first?
- Albumin
- D5W
- Lactated Ringer's solution
- 0.9% sodium chloride solution with 2 mEq of potassium per 100 ml
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4. Joe who is very depressed exhibits psychomotor retardation, a flat affect and apathy. The nurse in charge observes Joe to be in need of grooming and hygiene. Which of the following nursing actions would be most appropriate?
- Waiting until the client's family can participate in the client's care
- Asking the client if he is ready to take shower
- Explaining the importance of hygiene to the client
- Stating to the client that it's time for him to take a shower
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5. A client with schizophrenia hears a voice telling him he is evil and must die. The nurse understands that the client is experiencing:
- a delusion.
- flight of ideas.
- ideas of reference.
- a hallucination.
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6. Which of the ff: is not a characteristic of PD?
- disregard rights of others
- loss of cognitive functioning
- fails to conform to social norms
- not capable of experiencing guild or remorse for their behaviour
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7. A 56-year-old woman is currently receiving radiation therapy to the chest wall for recurrent breast cancer She calls her health care provider to report that she has pain while swallowing and burning and tightness in her chest Which of the following complications of radiation therapy is most likely responsible for her symptoms?
- Hiatal hernia
- Stomatitis
- Radiation enteritis
- Esophagitis
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8. A 55-year old client underwent cataract removal with intraocular lens implant Nurse Oliver is giving the client discharge instructions. These instructions should include which of the following?
- Avoid lifting objects weighing more than 5 lb (2.25 kg).
- Lie on your abdomen when in bed
- Keep rooms brightly lit
- Avoiding straining during bowel movement or bending at the waist.
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9. Edward, a 66 year old client with slight memory impairment and poor concentration, is diagnosed with primary degenerative dementia of the Alzheimer's type. Early signs of this dementia include subtle personality changes and withdrawal from social interactions. To assess for progression to the middle stage of Alzheimer's disease, the nurse should observe the client for:
- Occasional irritable outbursts.
- Impaired communication.
- Lack of spontaneity.
- Inability to perform self-care activities.
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10. The nurse is caring for a patient who just had a chest tube inserted due to spontaneous pneumothorax. An appropriate goal is that the patient will:
- Be free of pain with in 4hours
- Report decreased pain
- Rest quietly
- Sleep with few movements
11. The child with seizure disorder is being treated with phenytoin (Dilantin). Which of the following statements by the patients mother indicates to the nurse that the patient is experiencing a side effect of Dilantin therapy?
- She is very irritable lately.
- She sleeps quite a bit of the time.
- Her gums look too big for her teeth.
- She has gained about 10 pounds in the last six months
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12. Situation: Nurse Lorena 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.Lilia is scheduled to have a hysterosalpingogram. Which of the following instructions would you give her regarding this procedure?
- She will not be able to conceive for 3 months after the procedure
- The sonogram of the uterus will reveal any tumors present
- Many women experience mild bleeding as an after effect
- She may feel some cramping when the dye is inserted
13. Among the following signs and symptoms, which would most likely be present in a client with mitral regurgitation?
- Altered level of consciousness
- Exceptional Dyspnea
- Increase creatine phosphokinase concentration
- Chest pain
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14. 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.A client is 7 months pregnant and has just been diagnosed as having a partial placenta previa. She is stable and has minimal spotting and is being sent home. Which of these instructions to the client may indicate a need for further teaching?
- Maintain bed rest with bathroom privileges
- Avoid intercourse for three days.
- Call if contractions occur.
- Stay on left side as much as possible when lying down.
15. The nurse is assigned to care for a client with anorexia nervosa. Initially which nursing intervention is most appropriate for this client?
- Providing one-on-one supervision during meals and for 1 hour afterward
- Letting the client eat with other clients to create a normal mealtime atmosphere
- Trying to persuade the client to eat and thus restore nutritional balance
- Giving the client as much time to eat as desired
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16. An adult is hospitalized for treatment of deep electrical burns. Burn wound sepsis develops and mafenide acetate 10% (Sulfamylon) is ordered bid. While applying the Sulfamylon to the wound, it is important for the nurse to prepare the client for expected responses to the topical application, which include:
- severe burning pain for a few minutes following application.
- possible severe metabolic alkalosis with continued use.
- black discoloration of everything that comes in contact with this drug.
- chilling due to evaporation of solution from the moistened dressings.
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17. Nurse Oliver is teaching a diabetic pregnant client about nutrition and insulin needs during pregnancy. The nurse determines that the client understands dietary and insulin needs if the client states that the second half of pregnancy require:
- Decreased caloric intake
- Increased caloric intake
- Decreased Insulin
- Increase Insulin
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18. Based on Erikson's theory, the primary developmental task of the middle years is:
- to attain independence
- to achieve generativity
- to establish heterosexual relationship
- to develop a sense of personal identity
19. The nurse is caring for a full-term new born who was delivered vaginally 5 minutes ago. The infant's APGAR score was 8 at one minute and 10 at 5 minutes. Which of the following has the highest PRIORITY?
- Maintaining the infant in the supine position
- Assessing the infant's red reflex
- Preventing heat loss from the infant
- Administering humidified oxygen to the infant
20. Chemotherapeutic agents often produce a certain degree of myelosuppression including leukopeniA. Leukopenia does not present immediately but is delayed several days to weeks because:
- The patients hemoglobin and hematocrit are normal.
- Red blood cells are affected first.
- The current white cell count is not affected by chemotherapy.
- Folic acid levels are normal.
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21. An external insulin pump is prescribed for a client with diabetes mellitus. When the client asks the nurse about the functioning of the pump, the nurse bases the response on which information about the pump?
- It is timed to release programmed doses of either short-duration or NPH insulin into the bloodstream at specific intervals.
- “It continuously infuses small amounts of NPH insulin into the bloodstream while regularly monitoring blood glucose levels.
- It is surgically attached to the pancreas and infuses regular insulin into the pancreas. This releases insulin into the bloodstream.
- It administers a small continuous dose of short duration insulin subcutaneously. The client can self-administer an additional bolus dose from the pump before each meal.
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22. The charge nurse overhears the patient care assistant speaking harshly to the client with dementia. The charge nurse should:
- Change the nursing assistants assignment
- Explore the interaction with the nursing assistant
- Discuss the matter with the clients family
- Initiate a group session with the nursing assistant
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23. A1 1/2 year old child was classified as having 3rd degree of protein energy malnutrition, kwashiorkor. Which of the following signs will be most apparent in this child?
- Voracious appetite
- Wasting
- Apathy
- Edema
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24. The nurse is working with a client who despite making a heroic effort was unable to rescue a neighbor trapped in a house fire. Which client focused action should the nurse engage in during the working phase of the nurse-client relationship?
- Exploring the client's ability to function
- Exploring the client's potential for self-harm
- Inquiring about the client's perception or appraisal of why the rescue was unsuccessful
- Inquiring about and examining the client's feelings for any that may block adaptive coping
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25. A patient with iron deficiency anemia due to an insufficient iron intake needs to learn to select better food choices. The nurse works with this patient to establish apian of care and provide education on proper nutrition and good sources of iron. Besides educating the patient on a well-balanced diet the nurse would MOST likely teach the patient that good source of iron include:
- Seafood, cheese, soybean oil, and chocolate
- Animal proteins, egg yolks, dried fruits, and nuts
- Dairy products, citrus fruits,fish liver oils, and poultry
- Seafood, fruit, poultry, and tomatoes
26. A 2 1/2 year old child undergoes a ventriculoperitoneal shunt revision. Before discharge, nurse John, knowing the expected developmental behaviors for this age group, should tell the parents to call the physician if the child:
- Tries to copy all the father's mannerisms
- Talks incessantly regardless of the presence of others
- Becomes fussy when frustrated and displays a shortened attention span
- Frequently starts arguments with playmates by claiming all toys are "mine"
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27. Nurse Ron begins to teach a male client how to perform colostomy irrigations. The nurse would evaluate that the instructions were understood when the client states, "I should:
- Lie on my left side while instilling the irrigating solution."
- Keep the irrigating container less than 18 inches above the stoma"
- Instill a minimum of 1200 ml of irrigating solution to stimulate evacuation of the bowel"
- Insert the irrigating catheter deeper into the stoma if cramping occurs during the procedure"
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28. A client seeks care because she feels depressed and has gained weight To treat her atypical depression, the physician prescribes tranylcypromine sulfate (Parnate), 10 mg by mouth twice per day. When this drug is used to treat atypical depression, what is its onset of action?
- 1 to 2 days
- 3 to 5 days
- 6 to 8 days
- 10 to 14 days
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29. Which of the following conditions is linked to more than 50% of clients with abdominal aortic aneurysms?
- HPN
- PVD
- Syphilis
- DM
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30. Situation: Andrea is admitted to the ER following an assault where she was hit on the face and head. She was brought to the ER by a police woman. Emergency measures were stated.Q. tn a client with a Cheyne stokes respiration, which of the following is the most appropriate nursing diagnosis?
- Narrowing of Pulse Pressure, Cheyne stokes respiration, Tachycardia
- Ineffective breathing pattern
- Impaired gas exchange
- Activity intolerance
31. Conceptualized the BEHAVIORAL SYSTEM MODEL
- Orem
- Johnson
- Henderson
- Parse
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32. The following are nursing measures to stimulate lactation EXCEPT:
- Frequent regular breast feeding
- Breast pumping
- Breast massage
- Application of cold compress on the breast
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33. The nurse is assigned to care for an elderly patient with a low-exudates stage Hi pressure ulcer, which of the following types of dressings would the nurse MOST likely plan to use?
- Hydrogel
- Hydrocolloid c
- Polyurethane
- Polyurethane foam
34. The nurse is preparing a list of home care instructions for a client who has been hospitalized and treated for tuberculosis. Which instructions should the nurse include on the list? Select all that apply. 1.Activities should be resumed gradually. 2.Avoid contact with other individuals, except family members, for at least 6 months. 3.A sputum culture is needed every 2 to 4 weeks once medication therapy is initiated. 4.Respiratory isolation is not necessary because family members already have been exposed. 5.Cover the mouth and nose when coughing or sneezing and put used tissues in plastic bags. 6.When 1 sputum culture is negative, the client is no longer considered infectious and usually can return to former employment.
- 1,2,3,4,6
- 2,3,4,5
- 1,2,3,4,5
- 1,3,4,5
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35. A 2-years-old child in the emergency department exhibits symptoms of bacterial meningitis. Which of the following tests confirm or rule out this diagnosed?
- Magnetic resonance imaging (MRI)
- Magneto encephalogram
- Computed tomography scan(CT)
- Lumbar puncture (LP)
36. 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.Q. Which of the following studies is based on qualitative research?
- A study examining clients reactions to stress after open heart surgery
- A study measuring nutrition and weight, loss/gain in clients with cancer
- A study examining oxygen levels after endotracheal suctioning
- A study measuring differences in blood pressure before during and after a procedure
37. A client receiving thrombolytic therapy with a continuous infusion of alteplase suddenly becomes extremely anxious and complains of itching. The nurse hears stridor and notes generalized urticaria and hypotension. Which nursing action is the priority?
- Administer oxygen and protamine sulfate.
- Cut the infusion rate in half and sit the client up in bed.
- Stop the infusion and call for the Rapid Response Team (RRT).
- Administer diphenhydramine and epinephrine and continue the infusion.
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38. Views people as physiologic system and Absence of sign and symptoms equates health.
- Clinical Model
- Role performance Model
- Adaptive Model
- Eudaemonistic Model
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39. During the change of shift report the nurse states that the clients last pulse strength was a 1+. The oncoming nurse recognizes that the clients pulse was:
- Bounding
- Full
- Normal
- Weak
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40. A 54-year-old female was found unconscious on the floor of her bathroom with self- inflicted wrist lacerations. An ambulance was called and the client was taken to the emergency department When she was stable, the client was transferred to the inpatient psychiatric unit for observation and treatment with antidepressants. Now that the client is feeling better, which nursing intervention is most appropriate?
- Observing for extrapyramidal symptoms
- Beginning a therapeutic relationship
- Canceling any no-suicide contracts
- Continuing suicide precautions
41. A client tells you she has heard that glaucoma may be a hereditary problem and she is concerned about her adult children. What is the best response?
- "There is no need for concern; glaucoma is not hereditary order."
- "Screening for glaucoma should be included in an annual eye exam for everyones over 50”
- "There may be a genetic factor with glaucoma and your children over 30 y/o should be
- "Are your grandchildren complaining of any eye problems? Glaucoma generally skips a generation."
42. 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. Mr Snyder is scheduled for surgery in the morning, and you are surprised to find out that there is no order for an enema. You assess the situation and conclude that the reason for this is:
- Mr. Snyder has had some mental changes due to the tumor and would find an enema terribly traumatic
- Straining to evacuate the enema might increase the intracranial pressure
- Mr. Snyder had been on clear liquids and then was NPO for several days, so an enema is not necessary
- An oversight and you call the physician to obtain the order
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43. Situation: If a child with diarrhea registers one sign in the pink row and one in the yellow; row in the 1MCI Chart.The child with no dehydration needs home treatment. Which of the following is not included the rules for home treatment in this case:
- continue feeding the child
- give oresol every 4 hours
- know when to return to the health center
- give the child extra fluids
44. A client with pancreatic cancer has an infusion of TPN (Total Parenteral Nutrition). The doctor has ordered for sliding-scale insulin. The most likely explanation for this order is:
- Total Parenteral Nutrition leads to negative nitrogen balance and elevated glucose levels.
- Total Parenteral Nutrition cannot be managed with oral hypoglycemics.
- Total Parenteral Nutrition is a high-glucose solution that often elevates the blood glucose levels.
- Total Parenteral Nutrition leads to further pancreatic disease.
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45. Which of the following groups of newborn reflexes below are present at birth and remain unchanged through adulthood?
- Blink, cough, rooting, and gag
- Blink, cough, sneeze, gag
- Rooting, sneeze, swallowing, and cough
- Stepping, blink, cough, and sneeze
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46. Mrs. Cruz, 80 years old is diagnosed with pneumonia. Which of the following symptoms may appear first?
- Altered mental status and dehydration
- Fever and chills
- Hemoptysis and Dyspnea
- Pleuritic chest pain and cough
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47. A nurse in a newborn nursery receives a phone call to prepare for the admission of a 43- week-gestation newborn with Apgar scores of 1 and 4. In planning for the admission of this infant, the nurse's highest priority should be to:
- Connect the resuscitation bag to the oxygen outlet
- Turn on the apnea and cardiorespiratory monitors
- Set the radiant warmer control temperature at 36.5C (97.6 F)
- Set up the intravenous line with 5% dextrose in water
48. Which of the following classes of medications protects the ischemic myocardium by blocking catecholamines and sympathetic nerve stimulation?
- Beta-adrenergic blockers
- Calcium channel blockers
- Narcotics
- Nitrates
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49. The nurse has been assigned to care for a 60 year old critically ill patient with a triple-lumen central venous line. The doctor's orders include daily care of the insertion site and catheter device. The nurse creates care plane based on the nursing diagnosis, Risk for infection related to insertion of a venous cathetenWhich intervention is most likely to prevent infection?
- Re-cap access hub after drawing blood
- Maintain clean technique
- Wash hands before performing catheter care
- Clean catheter tubing with isopropyl alcohol
50. Alfred was newly diagnosed with anxiety disorder. The physician prescribed buspirone (BuSpar). The nurse is aware that the teaching instructions for newly prescribed buspirone should include which of the following?
- A warning about the drugs delayed therapeutic effect, which is from 14 to 30 days.
- A warning about the incidence of neuroleptic malignant syndrome (NMS).
- A reminder of the need to schedule blood work in 1 week to check blood levels of the drug.
- A warning that immediate sedation can occur with a resultant drop in pulse.
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NCLEX-RN | QB1 | Practice Exam #58 (50 questions)