NCLEX-RN | QB1 | Practice Exam #55 (50 questions)
1. Being on time, meeting deadlines and completing all scheduled duties is what virtue?
- Fidelity
- Autonomy
- Veracity
- Confidentiality
2. The nurse is reviewing the health care provider's (HCP's) prescriptions for a client admitted for premature rupture of the membranes. Gestational age of the fetus is determined to be 37 weeks. Which prescription should the nurse question?
- Monitor fetal heart rate continuously,
- Monitor maternal vital signs frequently.
- Perform a vaginal examination every shift.
- Administer an antibiotic per HCP prescription and per agency protocol
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3. Kubler-Ross's five successive stages of death and dying are:
- Anger, bargaining, denial, depression, acceptance
- Denial, anger, depression, bargaining, acceptance
- Denial, anger, bargaining, depression acceptance
- Bargaining, denial, anger, depression, acceptance
4. The normal range of pH in arterial blood is:
- 7.15-7.20
- 7.25-7.30
- 7.35-7.45
- 7.50-7.55
5. Nurse Ron is assessing a client admitted with second- and third-degree burns on the face, arms, and chest. Which finding indicates a potential problem?
- Partial pressure of arterial oxygen (PaO2) value of 80 mm Hg.
- Urine output of 20 ml/hour.
- White pulmonary secretions.
- Rectal temperature of 100.6° F (38° C).
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6. A client with schizophrenia tells the nurse, "My intestines are rotted from the worms chewing on them? This statement indicates a:
- delusion of persecution.
- delusion of grandeur.
- somatic delusion.
- jealous delusion.
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7. Infertility can be attributed to male causes such as the following EXCEPT:
- Cryptorchidism
- Orchitis
- Sperm count of about 20 million per milliliter
- Premature ejaculation
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8. Following abdominal surgery, a child has a nasogastric tube connected to suction. Several hours after surgery, the child tells the nurse that he is nauseated and then vomits approximately 200 ml of fluid. Which of these actions should the nurse take first?
- Notify the physician
- Check if the nasogastric tube can be irrigated
- Discontinue the section attached to the nasogastric tube
- Auscultate for bowel sounds
9. Situation: In a disaster there must be a chain of command in place that defines the roles of each member of the response team. Within the health care group there are pre-assigned roles based on education, experience and training on disastenQ. A guideline that is utilized in determining priorities is to assess the status of the following, EXCEPT?
- perfusion
- locomotion
- respiration
- mentation
10. Situation: Michelle, 36 weeks gestation visits the hospital because the suspects that her bag of water was ruptured.Q. While the nurse is assessing Michelle, she states that her bag of water ruptured few minutes ago. Which of the following should the nurse do first?
- Check the status of the fetal heart rate
- Turn the client to her right side
- Test the leaking fluid with nitrazine paper
- Perform a sterile vaginal examination
11. In evaluating the effect of nitroglycerin, Nurse Arthur should know that it reduces preload and relieves angina by:
- Increasing contractility and slowing heart rate.
- Increasing AV conduction and heart rate.
- Decreasing contractility and oxygen consumption.
- Decreasing venous return through vasodilation.
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12. When a client states that her "water broke," which of the following actions would be inappropriate for the nurse to do?
- Observing the pooling of straw-colored fluid.
- Checking vaginal discharge with nitrazine paper.
- Conducting a bedside ultrasound for an amniotic fluid index.
- Observing for flakes of vernix in the vaginal discharge.
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13. On a visit to the clinic, a client reports the onset of early symptoms of rheumatoid arthritis. Which of the following would be the nurse most likely to asses:
- Limited motion of joints
- Deformed joints of the hands
- Early morning stiffness
- Rheumatoid nodules
14. The nurse in the psychiatric ward informed the male client that he will be attending the 9:00 AM group therapy sessions. The client tells the nurse that he must wash his hands from 9:00 to 9:30 AM each day and therefore he cannot attend. Which concept does the nursing staff need to keep in mind in planning nursing intervention for this client?
- Depression underlines ritualistic behavior.
- Fear and tensions are often expressed in disguised form through symbolic processes.
- Ritualistic behavior makes others uncomfortable.
- Unmet needs are discharged through ritualistic behavior.
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15. Situation: Respiration is one of the most important vital sign. This is usually the first Vital sign to be assessed more than anything for it is easily altered by the patient's consciousness. The nurse should be aware of the different changes and alteration in respiration.Q. The respiratory center is found in the:
- Pons
- Hypothalamus
- Medulla
- Lungs
16. A child with type 1 diabetes mellitus is brought to the emergency department by the mother, who states that the child has been complaining of abdominal pain and has been lethargic. Diabetic ketoacidosis is diagnosed. Anticipating the plan of care, the nurse prepares to administer which type of intravenous (IV) infusion?
- Potassium infusion
- NPH insulin infusion
- 5% dextrose infusion
- Normal saline infusion
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17. The first postparturn should be done when:
- After 48 hours
- After 24 hours
- After 3 days
- Within 24 hours.
18. The nurse is assessing the client recently returned from surgery. The nurse is aware that the best way to assess pain is to:
- Take the blood pressure pulse and temperature.
- Ask the client to rate his pain on a scale of 0-5.
- Watch the client facial expression.
- Ask the client if he is in pain.
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19. How would you define a word, “acrocyanosis?
- cyanosis of hands and feet.
- transient mottling when infant is exposed to the temperature.
- fine, downy hair
- thin, white mucus
20. The sputum of a client remains positive for the tubercle bacillus even though the client has been taking Laniazid (isoniazid). The nurse recognizes that the client should have a negative sputum culture within:
- Two weeks
- Six weeks
- Eight weeks
- 12 weeks
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21. Situation: You were on duty at the medical ward when Zeny came in for admission for tiredness, cold intolerance, constipation, and weight gain. Upon examination, the doctor's diagnosis was hypothyroidism.Q. Your independent nursing care for hypothyroidism includes:
- administer sedative round the clock
- administer thyroid hormone replacement
- providing a cool, quiet, and comfortable environment
- encourage to drink 6-8 glasses of water
22. Situation: The abuse of dangerous drug is a serious public health concern that nurses need to address.Q. A drug dependent utilizes this defense mechanism and enables him to forget shame and pain.
- repression
- rationalization
- projection
- sublimation
23. A new mother tells the nurse that she is getting a new microwave so that her husband can help prepare the babys feedings. The nurse should:
- Explain that a microwave should never be used to warm the babys bottles.
- Tell the mother that microwaving is the best way to prevent bacteria in the formula.
- Tell the mother to shake the bottle vigorously for one minute after warming in the microwave.
- Instruct the parents to always leave the top of the bottle open while microwaving so heat can escape.
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24. A client has just been admitted to the nursing unit following thyroidectomy. Which assessment is the priority for this client?
- Hypoglycemia
- Level of hoarseness
- Respiratory distress
- Edema at the surgical site
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25. The patient present to the hospital voicing a concern about being exposed to HEP A (HAV) 1 week upon questioning the nurse finds the patient purchased food from a person recently diagnosed with HEP A, Nurse would be most correct when instruct the patient
- The incubation period is 3-5 wks
- HAV is spread by seual contact
- HAV is spread by blood contact
- The incubation period is 2-6 wks
26. Which clinical manifestation indicates that the burned client is moving into the fluid remobilization phase of recovery?
- Increased urine output decreased urine specific gravity
- Increased peripheral edema, decreased blood pressure
- Decreased peripheral pulses, slow capillary refill
- Decreased serum sodium level, increased hematocrit
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27. Situation: Two children were brought to you. One with chest indrawing and the other had diarrhea. The following questions apply:Oxytocin is administered to Rita to augment labor What are the first symptoms of water intoxication to observe for during this procedure?
- headache and vomiting
- a swollen tender tongue
- a high choking voice
- abdominal bleeding and pain
28. Which of the following signs and symptoms that require immediate attention and may indicate most serious complications during pregnancy?
- Severe abdominal pain or fluid discharge from the vagina.
- Excessive saliva, "bumps around the areolae, and increased vaginal mucus.
- Fatigue, nausea, and urinary frequency at anytime during pregnancy.
- Ankle edema, enlarging varicosities, and heartburn.
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29. 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.A clinic nurse reviews the record of an infant seen in the clinic. The nurse notes that a diagnosis of esophageal atresia with tracheoesophageal fistula (TEF) is suspected. The nurse expects to note which most likely sign of this condition documented in the record?
- Severe projectile vomiting
- Coughing at night time
- Choking with feedings
- Incessant crying
30. A client is brought to the emergency department in an unresponsive state, and a diagnosis of hyperosmolar hyperglycemic syndrome is made. The nurse would immediately prepare to initiate which anticipated health care provider's prescription?
- Endotracheal intubation
- 100 units of NPH insulin
- Intravenous infusion of normal saline
- Intravenous infusion of sodium bicarbonate
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31. A nurse is assessing the peripheral circulation of patient's extremities. The chart indicates the patient has edema in both lower extremities. Which of the following assessment techniques would the nurse MOST likely use to assess for this?
- Inspection and auscultation
- Inspection and palpation
- Palpation and percussion
- Percussion and auscultation
32. When reviewing the admission assessment, the nurse notes that a client was admitted to the mental health unit involuntarily. Based on this type of admission, the nurse should provide which intervention for this client?
- Monitor closely for harm to self or others.
- Assist in completing an application for admission.
- Supply the client with written information about his or her mental illness.
- Provide an opportunity for the family to discuss why they felt the admission was needed.
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33. The orthopedic nurse should be particularly alert for a fat embolus in which of the following clients having the greatest risk for this complication after a fracture?
- A 50-year-old with a fractured fibula
- A 20-year-old female with a wrist fracture
- A 21-year-old male with a fractured femur
- An 8-year-old with a fractured arm
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34. The nurse is caring for a client following enucleation and notes the presence of bright red drainage on the dressing. Which action should the nurse take at this time?
- Document the finding.
- Continue to monitor the drainage.
- Notify the health care provider (HCP).
- Mark the drainage on the dressing and monitor for any increase in bleeding.
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35. SITUATION: John Smith was diagnosed with Acute Close Angle Glaucoma. He is being seen by Nurse JetQ. The Nurse notices that Mr. Smith cannot anymore determine RED from BLUE. The nurse knew that which part of the eye is affected by this change?
- IRIS
- PUPIL
- RODS [RETINA]
- CONES [RETINA]
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36. Situation: The nurse is performing health education activities for Jane Segovial a 30 years old Dentist with Insulin dependent diabetes Mellitus.Q. Upon the assessment of HbAIC of Mrs. Segovia. The nurse has been informed of a 9 % HbAI C result. In this case, she will teach the patient to:
- Avoid infection
- Take adequate food and nutrition
- Prevent hypoglycaemia
- Prevent and recognize hypoglycaemia
37. Nurse Lucy is planning to give preoperative teaching to a client who will be undergoing rhinoplasty. Which of the following should be included?
- Results of the surgery will be immediately noticeable postoperatively
- Normal saline nose drops will need to be administered preoperatively
- After surgery nasal packing will be in place 8 to 10 days
- Aspirin containing medications should not be taken 14 days before surgery
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38. The nurse questions a doctors order of Morphine sulfate 50 mg, IM for a client with pancreatitis. Which role best fit that statement?
- Change agent
- Client advocate
- Case manager
- Collaborator
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39. The nurse is caring for a 30-year-old male admitted with a stab wound. While in the emergency room a chest tube is inserted. Which of the following explains the primary rationale for insertion of chest tubes?
- The tube will allow for equalization of the lung expansion.
- Chest tubes serve as a method of draining blood and serous fluid and assist in reinflating the lungs.
- Chest tubes relieve pain associated with a collapsed lung.
- Chest tubes assist with cardiac function by stabilizing lung expansion.
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40. Respiratory depression is a potentially life-threatening adverse effect of
- Opioids
- Anticoagulants
- Immuno modulators
- Non-steriodials (NSAIDS)
41. A client is admitted to the hospital following a burn injury to the left hand and arm. The client's burn is described as white and leathery with no blisters. Which degree of severity is this burn?
- first-degree burn
- third-degree burn
- second-degree burn
- fourth-degree burn
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42. The nurse is caring for a patient diagnosed with human immune deficiency virus. Which of the following nursing diagnoses takes priority?
- Diarrhea related to medication side effects
- Risk for infection related to inadequate immune system
- Imbalanced nutrition relate to decreased appetite
- Impaired tissue integrity related to cachexia and malnourishment
43. A client has rectal cancer and is scheduled for an abdominal perineal resection. What should be the priority nursing care during the post-op period?
- Teaching how to irrigate the ileostomy
- Stopping electrolyte loss in the incisional area
- Encouraging a high-fiber diet
- Facilitating perineal wound drainage
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44. The nurse implements a teaching plan for a pregnant client who is newly diagnosed with gestational diabetes mellitus. Which statement made by the client indicates a need for further teaching?
- "I should stay on the diabetic diet."
- "I should perform glucose monitoring at home."
- "I should avoid exercise because of the negative effects on insulin production."
- "I should be aware of any infections and report signs of infection immediately to my health care provider (HCP)"
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45. Situation: Margie has been diagnosed with Bipolar I disorder The client demonstrates extreme psychomotor agitation, flight of ideas, loud talking and elated mood.Q. Which of the following is true about manic reaction?
- It is an expression of destructive impulse
- A means of coping with frustrations and disappointments
- A means of ignoring reality
- An attempt to ward of feelings of underlying depression
46. A priority nursing diagnosis for a client admitted to the hospital with a diagnosis of diabetes insipidus is:
- Sleep pattern deprivation related nocturia
- Activity intolerance r/t muscle weakness
- Fluid volume excess r/t intake greater that output
- Risk for impaired skin integrity r/t generalized edema
47. After cardiac surgery, a clients blood pressure measures 126/80 mm Hg. Nurse Katrina determines that mean arterial pressure (MAP) is which of the following?
- 46 mm Hg
- 80 mm Hg
- 95 mm Hg
- 90 mm Hg
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48. Leprosy can be transmitted through
- Blood
- Sex
- Semen
- Prolonged skin to skin contact
49. Which of the following is TRUE in Rh incompatibility?
- The condition can occur if the mother is Rh(+) and the fetus is Rh(-)
- Every pregnancy of an Rh(-) mother will result to erythroblastosis fetalis
- On the first pregnancy of the Rh(-) mother, the fetus will not be affected
- RhoGam is given only during the first pregnancy to prevent incompatibility
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50. A nurse is caring for a child with a very low platelet count related to chemotherapy. The nurse should monitor this child’s urine for the presence of which constituent?
- Protein
- Glucose
- Erythrocytes
- Lymphocytes
NCLEX-RN | QB1 | Practice Exam #55 (50 questions)