NCLEX-RN | QB1 | Practice Exam #56 (50 questions)
1. A male client is admitted and diagnosed with acute pancreatitis after a holiday celebration of excessive food and alcohol Which assessment finding reflects this diagnosis?
- Blood pressure above normal range.
- Presence of crackles in both lung fields.
- Hyperactive bowel sounds
- Sudden onset of continuous epigastric and back pain.
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2. If the LMP is Jan. 30, the expected date of delivery (EDO) is
- Oct. 7
- Oct. 24
- Nov. 7
- Nov. 8
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3. At what age a child can brush her teeth without help?
- 6 years
- 7 years
- 5 years
- 8 years
4. The nurse calls security and has physical restraints applied to a client who was admitted voluntarily when the client becomes verbally abusive, demanding to be discharged from the hospital. Which represents the possible legal ramifications for the nurse associated with these interventions? Select all that apply. 1.Libel. 2.Battery. 3.Assault. 4.Slander. 5.False imprisonment
- 1,2,3
- 2,3,4
- 2,3,5
- 1,3,5
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5. A client is suffering from catatonic behaviors. Which of the following would the nurse use to determine that the medication administered PRN have been most effective?
- The client responds to verbal directions to eat
- The client initiates simple activities without direction
- The client walks with the nurse to her room
- The client is able to move all extremities occasionally
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6. Situation: Baby Philip, a full term male child, is delivered by his mother who is RH negative.Q. At the time of delivery, baby Philip's blood is typed to determine the ABO group and the presence of the RH factor. The nurse is aware that:
- The RH factor is not genetically determined
- Not all infants of RH-positive fathers are RH positive
- The RH factor of the fetus is determined by the father
- During gestation, the RH factor of the fetus may change
7. A 58 year old woman has newly diagnosed with hypothyroidism. The nurse is aware that the signs and symptoms of hypothyroidism include:
- Diarrhea
- Vomiting
- Tachycardia
- Weight gain
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8. Excessive alcohol intake is what type of risk factor?
- Genetics
- Age
- Environment
- Lifestyle
9. A client in a postpartum unit complains of sudden sharp chest pain and dyspnea. The nurse notes that the client is tachycardic and the respiratory rate is elevated. The nurse suspects a pulmonary embolism. Which should be the initial nursing action?
- Initiate an intravenous line.
- Assess the client's blood pressure.
- Prepare to administer morphine sulfate.
- Administer oxygen, 8 to 10 L/minute, by face mask.
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10. Situation: Mang Cardo, Age 72, is a widower with moderate Alzheimer's disease. Was brought to the home for the Aged by his married daughter. On admission, she says to the nurse, "I never thought this would happen to us. I really feel guilty about bringing him here, I can't bear to part with him."Q. Mang Cardo has been talking about how he got his scratch on his left arm, he told you that it was caused by a shard of glass that touches his skin accidentally. The next day, he told you that the scratch was caused by a knife he did not see that it fell from the table towards his arms. The next day, he said it was bitten by an ant and he scratched it because it was itchy. This is a symptom seen in Dementia known as:
- Confusion
- Altercation
- Aphasia
- Confabulation
11. When developing the plan of care for a client receiving haloperidol, which of the following medications would nurse Monet anticipate administering if the client developed extra pyramidal side effects?
- Olanzapine (Zyprexa)
- Paroxetine (Paxil)
- Benztropine mesylate (Cogentin)
- Lorazepam (Ativan)
12. A neonate begins to gag and turns a dusky color. What should the nurse do first?
- Calm the neonate
- Notify the physician.
- Provide oxygen via face mask as ordered
- Aspirate the neonate's nose and mouth with a bulb syringe.
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13. A client with diabetes mellitus is told that amputation of the leg is necessary to sustain life. The client is very upset and tells the nurse, "This is all my health care provider's fault I have done everything I've been asked to do!" Which nursing interpretation is best for this situation?
- An expected coping mechanism
- An ineffective defense mechanism
- A need to notify the hospital lawyer
- An expression of guilt on the part of the client
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14. 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. Why are smail-for-gestational-age newborns at risks for difficulty maintaining body temperature?
- They do not have as many fat stores as other infant's
- They are more active than usual so throw off covers
- Their skin is more susceptible to conduction of cold
- They are preterm so are born relatively small in size
15. Situation: Understanding different models of care is a necessary part of the nurse patient relationship.Q. Which of these nursing actions belong to the secondary level of preventive intervention?
- Providing mental health consultation to health care providers
- Providing emergency psychiatric services
- Being politically active in relation to mental health issues
- Providing mental health education to members of the community
16. Situation: The question with regards to the OPERATING ROOM. Q. What OR attires are worn in the semi-restricted area?
- scrub suit only
- scrub suit shoe cover, mask
- scrub suit and head cap, with or without the shoe cover
- head cap, mask, shoe cover only
17. Situation: Vincent, age 26, who is caught in me raging conflict between his mother and his wife, complains of pains in his right leg that has progressed to the point of paralysis. After orthopedic consultation has shown no pathology, he is referred for a psychiatric consultation and is found to have a conversion disorder.Q. How would the nurse expect Vincent to behave?
- Appear gently depressed
- Exhibit free floating anxiety
- Appear calm and composed
- Demonstrate anxiety when discussing symptoms
18. A client newly diagnosed with diabetes is started on Precose (acarbose). The nurse should tell the client that the medication should be taken:
- one hour before meals
- 30 minutes after meals
- With the first bite of a meal
- Daily at bedtime
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19. When a sink has hand-control faucets, the nurse aide should use
- a paper towel to turn the water on.
- a paper towel to turn the water off.
- an elbow, if possible, to turn the faucet controls on and off.
- bare hands to turn the faucet controls both on and off.
20. The nurse is monitoring a client who is taking digoxin for adverse effects. Which findings are characteristic of digoxin toxicity? Select all that apply. 1.Tremors. 2.Diarrhea. 3.Irritability. 4.Blurred vision. 5.Nausea and vomiting
- 1,2,3,4
- 1,2,3
- 3,4,5
- 2,4,5
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21. Situation: Mariah is a 31 year old lawyer who has been married for 6 moths. She is now pregnant.She consults you for guidance.You advised her to observe and record the signs of ovulation. Which of the following signs will she likely note down? 1. A 1 degree Fahrenheit rise in basal body temperature. 2.Cervical mucus becomes copious and clear. 3.One pound increase in weight. 4.Mittelschmerz
- 1,2,4
- 1,2,3
- 2,3,4
- 1,3,4
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22. The nurse is preparing a plan of care for a client, and is asking the client about religious preferences. The nurse considers the client's religious preferences as being characteristic of a Jehovah's Witness if which client statement is made?
- "I cannot have surgery."
- "I cannot have any medicine."
- "I believe the soul lives on after death."
- "I cannot have any food containing or prepared with blood"
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23. At what stage of labor and delivery does a primigravida differ mainly from a multigravida?
- Stage 1
- Stage 2
- Stage 3
- Stage 4
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24. The nurse is assigned to care for a suicidal client initially, which is the nurse's highest care priority?
- Assessing the clients home environment and relationships outside the hospital
- Exploring the nurse's own feelings about suicide
- Discussing the future with the client
- Referring the client to a clergyperson to discuss the moral implications of suicide
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25. Situation: Pharmacological treatment was not effective for Johnny's hyperthyroidism and now he is scheduled for Thyroidectomy.Q. Instruments in the surgical suite for surgery is classified as either CRITICAL, SEMI CRITICAL and NON CRITICAL, if the instrument are introduced directly into the blood stream or into any normally sterile cavity or area of the body it is classified as:
- Administer with glass only
- Semi critical
- Non critical
- Ultra critical
26. Situation: Joanna Marie, a 40 year old client was diagnosed with breast cancer. Q. Rationale for elevating the arm of Joanna post operatively is to:
- Improve coping ability
- Prevent infection
- Improve Edema
- Decrease bleeding and drainage
27. Johnny a firefighter was involved in extinguishing a house fire and is being treated to smoke inhalation. He develops severe hypoxia 48 hours after the incident, requiring intubation and mechanical ventilation. He most likely has developed which of the following conditions?
- Adult respiratory distress syndrome (ARDS)
- Atelectasis
- Bronchitis
- Pneumonia
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28. For a patient scheduled for a total pancreatectomy, the nurse would be instruct the patient that the procedure work MOST likely cause
- Pancreatic ascites
- Chronic pancreatitis
- Diabetes mellitus
- Diabetes insipidus
29. The nurse in a maternity unit is providing emotional support to a client and her significant other who are preparing to be discharged from the hospital after the birth of a dead fetus. Which statement made by the client indicates a component of the normal grieving process? "We want to attend a support group."
- "We never want to try to have a baby again."
- "We are going to try to adopt a child immediately."
- "We are okay and we are going to try to have another baby immediately."
- "We want to attend a support group."
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30. An insulin dependent diabetic patient is admitted to the hospital in ketoacidosis. Of the nursing diagnoses shown in the table which is the two with the HIGHEST priority? A. Knowledge deficit related to diabetes Mellitusi. B. Anxiety related to new diagnosis of diabetes Mellitus. C. Altered nutrition more than body requirement. D. Altered health maintenance related to elevated blood E. Altered in fluid and electrolyte balance related to ketoacidosis F. Risk for infection related to chronic disease
- A,C
- E,F
- D,E
- B,E
31. The client with a fractured tibia has been taking methocarbamol (Robaxin), when teaching the client about this drug, which of the following would the nurse include as the drug's primary effect?
- Killing of microorganisms
- Reduction in itching
- Relief of muscle spasms
- Decrease in nervousness
32. Atropine sulfate (Atropine) is indicated in all but one of the following client?
- A client with high blood
- A client with bowel obstruction
- A client with glaucoma
- A client with U.T.I
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33. A client has sustained a fractured right femur in a fall on stairs. Nurse Troy with the emergency response team assess for signs of circulatory impairment by:
- Turning the client to side lying position
- Asking the client to cough and deep breathe
- Taking the client's pedal pulse in the affected limb
- Instructing the client to wiggle the toes of the right foot
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34. A client is admitted with a blood alcohol level of 180mg/dL. The nurse recognizes that the alcohol in the client’s system should be fully metabolized within:
- 3 hours
- 5 hours
- 7 hours
- 9 hours
35. A client who is undergoing ovarian stimulation for infertility calls the infertility nurse and states, "My abdomen feels very bloated, my clothes are very tight, and my urine is very dark” Which of the following is the appropriate statement for the nurse to make at this time?
- "Please take a urine sample to the lab so they can check it for an infection." to the office to be examined today."
- "Those changes mean that you will menstruate within the next three days."
- "It is important for you to come in"
- "Abdominal bloating is an expected response to the medications."
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36. Which of the following can lead to infertility in adult males?
- German measles
- Orchitis
- Chicken pox
- Rubella
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37. An obstetrical client decides to have an epidural anesthetic to relieve pain during labor. Following administration of the anesthesia the nurse should monitor the client for:
- Seizures
- Postural hypertension
- Respiratory depression
- Hematuria
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38. A client experiences post partum hemorrhage eight hours after the birth of twins. Following administration of IV fluids and 500 ml of whole blood, her hemoglobin and hematocrit are within normal limits. She asks the nurse whether she should continue to breast feed the infants. Which of the following is based on sound rationale?
- "Nursing will help contract the uterus and reduce your risk of bleeding"
- "Breastfeeding twins will take too much energy after the hemorrhage."
- "The blood transfusion may increase the risks to you and the babies"
- "Lactation should be delayed until the "real milk" is secreted"
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39. A client with a forceful, pounding heartbeat is diagnosed with mitral valve prolapse. This client should avoid which of the following?
- high volumes of fluid intake
- aerobic exercise programs
- caffeine-containing products
- foods rich in protein
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40. Situation: After abdominal surgery, the circulating and scrub nurses have critical responsibility about sponge and instrument count. Q. The layers of the abdomen are divided into 5. Arrange the following from the first layer going to the deepest layer: 1.Fascia. 2.Muscle. 3.Peritoneum. 4.Subcutaneous fat. 5.Skin
- 5,4,3,2,1
- 5,4,2,1,3
- 5,4,1,3,2
- 5,4,1,2,3
41. A female client seeks care at an infertility clinic. Which of the following tests may the client undergo to determine what, if any, infertility problem she may have? Select all that apply. 1.Chorionic villus sampling. 2.Endometrial biopsy. 3.Hysterosalpingogram. 4.Serum progesterone assay. 5.Postcoital test.
- 1,2,3
- 2,3,4,5
- 1,2,3,4,5
- 1,2,3,4
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42. Situation: Nette, a nurse palpates the abdomen of Mrs. Medina, a primigravida. She is unsure of the date of her last menstrual period. Leopold's Maneuver is done. The obstetrician told mat she appears to be 20 weeks pregnant. Q. In her pregnancy, she experienced fatigue and drowsiness. This probably occurs because:
- of high blood pressure
- she is expressing pressure
- the fetus utilizes her glucose stores and leaves her with a Sow blood glucose
- of the rapid growth of the fetus
43. The nurse is assessing a client who has been given a diagnosis of polycythemia vera. What characteristics will the nurse anticipate finding when assessing this client?
- Increased fatigue and bleeding tendencies
- Hemoglobin below 13 mg/dl
- Headaches, dyspnea, claudication
- Back pain, ecchymosis, and joint tenderness
44. Karina a client with myasthenia gravis is to receive immunosuppressive therapy. The nurse understands that this therapy is effective because it:
- Promotes the removal of antibodies that impair the transmission of impulses
- Stimulates the production of acetylcholine at the neuromuscular junction.
- Decreases the production of autoantibodies that attack the acetylcholine receptors.
- Inhibits the breakdown of acetylcholine at the neuromuscular junction.
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45. What is the most appropriate factor in toilet training?
- age of child
- developmental readiness of the child
- available time
- maternal flexibility
46. Nurse Audrey is caring for a client who has suffered a severe cerebrovascular accident During routine assessment, the nurse notices Cheyne-Stokes respirations. Cheyne-stokes respirations are:
- A progressively deeper breaths followed by shallower breaths with apneic periods.
- Rapid, deep breathing with abrupt pauses between each breath.
- Rapid, deep breathing and irregular breathing without pauses.
- Shallow breathing with an increased respiratory rate.
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47. Situation: Please respond as a professional nurse in the other health situations through the following question.The nurse would anticipate a cesarean birth for a client who has which infection present at the onset of labor?
- Herpes simplex virus
- Human papillomavirus
- Hepatitis
- Toxoplasmosis
48. A client receiving parenteral nutrition (PN) in the home setting has a weight gain of 5 lb in 1 week The nurse should next assess the client for the presence of which condition?
- Thirst
- Polyuria
- Decreased blood pressure
- Crackles on auscultation of the lungs
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49. Situation: Team efforts is best demonstrated in the OR.Q. The breakdown in teamwork is often times a failure in:
- Electricity
- Inadequate supply
- Leg work
- Communication
50. A nurse caring for a patient with acute pulmonary edema observes that the patient's cough produces white, frothy and that the patient is extremely dyspneic. The patient has inspiratory and expiratory wheezing on auscultation of the lungs. The immediate objective of treatment is to
- Improve oxygenation
- Decrease anxiety
- Improve tissue perfusion
- Decrease risk for aspiration
NCLEX-RN | QB1 | Practice Exam #56 (50 questions)