NCLEX-RN | QB1 | Practice Exam #54 (50 questions)
1. A patient with a spinal cord injury states, "I have no control over my situation, 1 can't do anything for myself". This patient is exhibiting:
- Powerlessness
- Delusions
- Suicidal ideation
- Resignation
2. The 84-year-old male has returned from the recovery room following a total hip repair. He complains of pain and is medicated with morphine sulfate and promethazine. Which medication should be kept available for the client being treated with opioid analgesics?
- Naloxone (Narcan)
- Ketorolac (Toradol)
- Acetylsalicylic acid (aspirin)
- Atropine sulfate (Atropine)
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3. The nurse is doing bowel and bladder retraining for the client with paraplegia. Which of the following is not a factor for the nurse to consider?
- Diet pattern
- Mobility
- Fluid intake
- Sexual function
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4. The client presented with complaints of body weakness, dizziness and chest pain. Upon careful assessment, the nurse suspects Angina Pectoris. Which of the following statements made by the client can confirm this?
- I suddenly felt a pain on my chest which radiates to my back and arms.
- I suddenly felt a sharp pain on my lower abdomen.
- The pain does not subside even if I rest.
- The pain goes all the way down to my stomach.
5. The nurse is assessing the client with a total knee replacement two hours post-operative. Which information requires notification of the doctor?
- Scant bleeding on the dressing
- Low-grade temperature
- Hemoglobin of 7gm
- The urinary output has been 120ml during the last hour
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6. Infants should be restrained in a car seat in a semi-reclined position facing the rear of the car until they weigh:
- 10 pounds
- 15 pounds
- 20 pounds
- 25 pounds
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7. A hospitalized patient eats 20% of the meal and states being too tired to eat more. What should the nurse do?
- Offer to feed the patient after short rest period.
- Encourage the patient to finish the fluids.
- Remove the meal tray and allow the patient to rest.
- Encourage the patient to finish the protein portion of the meal.
8. Mr. Liberatore, age 76, is admitted to your unit. He has a past medical history of hypertension, DM, hyperlipidemia. Recently he has had several episodes where he stops talking mid sentence and stares into space. Today the episode lasted for 15 minutes. The admission diagnosis is impending CVA.Q. You explain to Julie and her mother that migraine headaches are caused by:
- an allergic response triggered by stress
- dilation of cerebral arteries
- persistent contraction of the muscles of the head, neck and face
- increased intracranial pressure
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9. Situation: Michelle is a 6 year old preschooler. She was reported by her sister to have measles but she was at home because of fever, upper respiratory problem and white sports in her mouth.Source of infection of measles is secretion of nose and throat of infection person. Filterable of measles is transmitted by:
- Water supply
- Droplet
- Food ingestion
- Sexual contact
10. 25/50 A patient is admitted to the hospital with klebsiella pneumoniae. During the initial intravenous dose of Amikin (amikacin sulfate), the patient develops severe respiratory distress. This is most likely:
- A side effect
- An indication of drug tolerance
- A drug allergy
- A toxic effect
11. The ideal site for vitamin K injection in the newborn is:
- Right upper arm
- Left upper arm
- Either right or left buttocks
- Middle third of the thigh
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12. The nurse is evaluating the patient with end stage chronic obstructive pulmonary disease (COPD).The patient has not achieved any of the goals in the plan of care.The spouse reports concerns about the patients mood and increased dependency. What action should the nurse take FIRST?
- Continue the care plan for 1 more month
- Refer the patient to psychiatric services
- Collaborate with the patient and spouse to revise the care plan
- Revise the care plan based on the spouse's input
13. You explain to a breastfeeding mother that breast milk is sufficient for all of the baby's nutrient needs only up to:
- 3 months
- 6 months
- 1 year
- 2 years
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14. The public health nurse is the supervisor of rural health midwives. Which of the following is a supervisory function of the pubic health nurse?
- Referring cases or patients to the midwife
- Providing technical guidance to the midwife
- Proving nursing care to cases referred by the midwife
- Formulating and implementing training programs for midwives
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15. One staff nurse is assigned to a group of 5 patients for the 12-hour shift. The nurse is responsible for the overall planning, giving and evaluating care during the entire shift. After the shift, same responsibility will be endorsed to the next nurse in charge. This describes nursing care delivered via the:
- Primary nursing method.
- Case method.
- Functional method.
- Team method.
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16. Situation: Nurses hold a variety of roles when providing care to a perioperative patient.Q. Which of the following role would be the responsibility of the scrub nurse?
- Assess the readiness of the client prior to surgery
- Ensure that the airway is adequate
- Account for the number of sponges, needles, supplies, used during the surgical procedure.
- Evaluate the type of anesthesia appropriate for the surgical client
17. A male client seeks medical evaluation for fatigue, night sweats, and a 20-lb weight loss in 6 weeks. To confirm that the client has been infected with the human immunodeficiency virus (HIV), the nurse expects the physician to order:
- E-rosette immunofluorescence
- quantification of T-lymphocytes.
- enzyme-linked immunosorbent assay (ELISA).
- Western blot test with ELISA.
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18. According to them. Well-being is a subjective perception of BALANCE, HARMONY and VITALITY
- Leavell and Clark
- Peterson and Zderad
- Benner and Wruber
- Leddy and Pepper
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19. Which finding is associated with Tay Sachs disease?
- Pallor of the conjunctiva
- Cherry-red spots on the macula
- Blue-tinged sclera
- White flecks in the iris
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20. Situation: You are fortunate to be chosen as part of the research team in the hospital. A review of the following IMPORTANT nursing concepts was made.Q. Which of the following communicate the results of the research to the readers. They facilitate the description of the data.
- Hypothesis
- Statistics
- Research Problem
- Tables and Graphs
21. This period ended when Pastor Fliedner, build Kaiserswerth Institute for the training of Deaconesses
- Educative period
- Apprentice period
- Dark period
- Contemporary period
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22. Situation: Agnes, a client with Leukemia is in the clinic for her routine check up.Q. The most appropriate diagnostic examination for Agnes is:
- RBC Exam
- WBC Count
- Complete Blood Count
- Bone Marrow Aspiration
23. Meryl, age 19, is highly dependent on her parents and fears leaving home to go away to college. Shortly before the semester starts, she complains that her legs are paralyzed and is rushed to the emergency department. When physical examination rules out a physical cause for her paralysis, the physician admits her to the psychiatric unit where she is diagnosed with conversion disorder. Meryl asks the nurse, “Why has this happened to me?" What is the nurse's best response?
- "You've developed this paralysis so you can stay with your parents. You must deal with this conflict if you want to walk again.”
- "It must be awful not to be able to move your legs. You may feel better if you realize the problem is psychological, not physical."
- "Your problem is real but there is no physical basis for it. We II work on what is going on in your life to find out why it's happened"
- "It isn't uncommon for someone with your personality to develop a conversion disorder during times of stress."
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24. Situation: Mrs. Ethel Agustin 50 y/o, teacher is affected with myasthenia gravis. Q. As her nurse, you have be cautious about administration of medication, if she is undermedicated this can cause:
- Emotional crisis
- Cholinergic crisis
- Menopausal crisis
- Myasthenia crisis
25. A client with a diagnosis of anorexia nervosa, who is in a state of starvation, is in a 2-bed room. A newly admitted client will be assigned to this clients room. Which client would be the best choice as a roommate for the client with anorexia nervosa?
- A client with pneumonia
- A client undergoing diagnostic tests
- A client who thrives on managing others
- A client who could benefit from the clients assistance at mealtime
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26. Nurse Kate is aware that one of the following classes of medication protect the ischemic myocardium by blocking catecholamines and sympathetic nerve stimulation is:
- Beta-adrenergic blockers
- Calcium channel blocker
- Nitrates
- Narcotics
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27. Ms. Betty Lynch, age 29, holes that she has recently developed a skin problem and makes an appointment to be seen in a clinic specializing diagnosis of psoriasis is made by the physician. When examining Mr. Lynch's skin for areas of psoriasis, the nurse should look for:
- Weeping lesions on the trunk of the body
- Patches of redness covered with silvery scales
- Areas of redness surrounded by crusts
- A rash characterized by raised, pus-filled lesions
28. The nurse is caring for a client in the emergency department who has been diagnosed with Bell's palsy. The client has been taking acetaminophen, and acetaminophen overdose is suspected. Which antidote should the nurse prepare for administration if prescribed?
- Pentostatin
- Auranofin
- Fludarabine
- Acetylcysteine
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29. A client is admitted to the postanesthesia care unit after an abdominal hysterectomy. Which assessment should the nurse report to the health care provider immediately?
- Apical pulse of 90
- Decreased urinary output
- Increased drainage from the nasogastric tube
- Serosanguineous drainage on the perineal pad 1 hour after surgery
30. The nurse notes the patient care assistant looking through the personal items of the client with cancer Which action should be taken by the registered nurse?
- Notify the police department as a robbery.
- Report this behavior to the charge nurse.
- Monitor the situation and note whether any items are missing.
- Ignore the situation until items are reported missing.
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31. The nurse administered a dose of morphine sulfate, as prescribed to a patient who is in the post-anesthesia care unit (PACU). The patient appears to be resting comfortably; the respiratory rate is 8 and the 02 saturation on 2L of oxygen via nasal cannula is 86%. The nurse should IMMEDIETLY administer.
- Flumazenil (Romazicon)
- Midazolam (Versed)
- Naloxone (Narcan)
- Ondansetron (Zofran)
32. An observation consistent with complete-airway obstruction is:
- Loud crowing when attempting to speak
- Inability to cough
- Gradual
- Wheezes on auscultation
33. Situation: Still in your self-managed Child Health Nursing Clinic, your encounter these cases pertaining to the CARE OF CHILDREN WITH PULMONARY AFFECTIONS.Q. Which of the following is the principal focus on the CARI program of the Department of Health?
- Enhancement of health team capabilities
- Teach mothers how to detect signs and where to refer
- Mortality reduction through early detection
- Teach other community health workers how to assess patients
34. A client is undergoing fluid replacement after being burned on 20% of her body 12 hours ago. The nursing assessment reveals a blood pressure of 90/50mm Hg, a pulse rate of 110 beats/minute, and a urine output of 20 mL over the past hour. The nurse reports the findings to the health care provider (HCP) and anticipates which prescription?
- Transfusing 1 unit of packed red blood cells
- Administering a diuretic to increase urine output
- Increasing the amount of intravenous (IV) lactated Ringer's solution administered per hour
- Changing the IV lactated Ringer's solution to one that contains 5% dextrose in water
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35. In immunity school entrants with BCG, you not obliged to secure parental consent This is because of which legal document?
- PD 996
- RA 7864
- Presidential Proclamation No. 6
- Presidential Proclamation No. 46
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36. The ambulance team calls the emergency department that they are going to bring a client who sustained burns in a house fire. While waiting for the ambulance, the nurse will anticipate emergency care to include assessment for:
- Gas exchange impairment.
- Hypoglycemia.
- Hyperthermia.
- Fluid volume excess.
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37. Situation: Radiation therapy is another modality of cancer management. With emphasis on multidisciplinary management you have important responsibilities as a nurse. Q. Immediately following the radiation teletherapy, Albert is:
- Considered radioactive fro 24 hours
- Given a complete bath
- Placed on isolation for 6 hours
- Free from Radiation
38. A community health nurse visits a patient who has suffered a stroke. The patient's spouse explains to the nurse that the patient chokes on foods at times. Which of the following referral ordered would the nurse anticipate needing for this patient?
- Speech therapist
- Dietician
- Physician therapist
- Neurologist
39. The postpartum nurse is providing instructions to a client after birth of a healthy newborn. Which time frame should the nurse relay to the client regarding the return of bowel function?
- 3 days postpartum
- 7 days postpartum
- On the day of birth
- Within 2 weeks postpartum
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40. The nurse is conducting an admission assessment of a client with vitamin B12 deficiency. Which finding reinforces the diagnosis of B12 deficiency?
- Enlarged spleen
- Elevated blood pressure
- Bradycardia
- Beefy tongue
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41. Situation: Nanette was rushed to the hospital due to burns. Witnesses told the emergency team that Nanette fell asleep while she is holding her cigarette thus, burning the bed sheets and herself. 2nd and 3rd degree burns are on the face, neck, anterior and posterior trunk as well as the anterior of the left leg and the whole right arm was burned. First degree burns are located on the anterior portion of the right leg and the anterior portion of the right and left arm. Nanette is a 110 lbs female client.Q. Which electrolyte disturbance is the most lethal in client with burn?
- Hyponatremia
- Hypercalcemia
- Hyperkalemia
- Hypokalemia
42. The toddler is admitted with a cardiac anomaly. The nurse is aware that the infant with a ventricular septal defect will:
- Tire easily
- Grow normally
- Need more calories
- Be more susceptible to viral infections
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43. The nurse is assessing a client who had a colon resection two days ago. The client states I feel like my stitches have burst loosed Upon further assessment dehiscence of the wound is noted. Which action should the nurse take?
- Immediately place the client in the prone position.
- Apply a sterile saline-moistened dressing to the wound.
- Administer atropine to decrease abdominal secretions.
- Wrap the abdomen with an ACE bandage.
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44. Which of the following statements refer to the vision of the hospital?
- The Holy Spirit Medical Center is a trendsetter in tertiary health care in the next five year
- The officers and staff of The Holy Spirit Medical Center believe in the unique nature of the human person
- All the nurses shall undergo continuing competency training program.
- The Holy Spirit Medical Center aims to provide a patient-centered care in a total healing environment.
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45. Which of the following findings would be expected in the infant with biliary atresia?
- Rapid weight gain and hepatomegaly
- Dark stools and poor weight gain
- Abdominal distention and poor weight gain
- Abdominal distention and rapid weight gain
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46. The client is taking rifampin 600mg po daily to treat his tuberculosis. Which action by the nurse indicates understanding of the medication?
- Telling the client that the medication will need to be taken with juice
- Telling the client that the medication will change the color of the urine
- Telling the client to take the medication before going to bed at night
- Telling the client to take the medication if night sweats occur
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47. In palpating the client's abdomen, Which of the following is the best position for the client to assume?
- Dorsal recumbent
- Side lying
- Supine
- Lithotomy
48. A patient with no known allergies is to receive penicillin every 6 hours. When administering the medication, the nurse observes a fine rash on the patient's skin. The most appropriate nursing action would be to:
- Withhold the moderation and notify the physician
- Administer the medication and notify the physician
- Administer the medication with an antihistamine
- Apply corn starch soaks to the rash
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49. The client Is scheduled for a Tensilon test to check for Myasthenia Gravis. Which medication should be kept available during the test?
- Atropine sulfate
- Furosemide
- Prostigmin
- Promethazine
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50. This is the distinctive individual qualities that differentiate a person to another
- Philosophy
- Personality
- Charm
- Character
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NCLEX-RN | QB1 | Practice Exam #54 (50 questions)