QB1 | Practice Exam #52 -> answers with explanation - Free NCLEX Exam Practice

NCLEX-RN | QB1 | Practice Exam #52 (50 questions)

 

1. SITUATION: Marvin, A male patient diagnosed with colon cancer was newly put in colostomy.Q. The nurse plans to teach Marvin about colostomy irrigation. As the nurse prepares the materials needed, which of the following item indicates that the nurse needs further instruction?

• Plain NSS / Normal Saline
• K-Y Jelly
• Tap water
• Irrigation sleeve

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2. A client with a history of medication noncompliance is receiving outpatient treatment for chronic undifferentiated schizophrenia. The physician is most likely to prescribe which medication for this client?

• chlorpromazine (Thorazine)
• imipramine (Tofranil)
• lithium carbonate (Lithane)
• fluphenazine decanoate (Prolixin Decanoate)

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3. Which of the following would be the priority nursing diagnosis for the adult client with acute leukemia?

• Oral mucous membrane altered related to chemo-therapy
• Risk for injury related to thrombocytopenia
• Fatigue related to the disease process
• Interrupted family processes related to life-threatening illness of a family member

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4. Situation: Arnold, age 67, has had successfully treated depressive disease for more than 10 years. Lately he has been developing a plan of action. Arnold is admitted to hospital for reassessment.Q. Which assessment would best aid the nurse in evaluating Arnold's potential for suicide?

• Ask him about plans for the future
• Ask other clients about suicide while in a group
• Ask the family if he had ever attempted suicide
• Ask him if suicide was ever or is now being considered

5. The nurse is caring for a client with heart failure. On assessment, the nurse notes that the client is dyspneic, and crackles are audible on auscultation. What additional manifestations would the nurse expect to note in this client if excess fluid volume is present?

• Weight loss and dry skin
• Flat neck and hand veins and decreased urinary output
• An increase in blood pressure and increased respirations
• Weakness and decreased central venous pressure (CVP)

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6. Which of the following is NOT an enzyme secreted by the small intestine?

• Sucrase
• Enterokinase
• Amylase
• Enterokinace

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7. 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.Dina, 17 years old, asks you how a tubal ligation prevents pregnancy. Which would be the best answer?

• Prostaglandins released from the cut fallopian tubes can kill sperm
• Sperm can not enter the uterus because the cervical entrance is blocked.
• Sperm can no longer reach the ova, because the fallopian tubes are blocked
• The ovary no longer releases ova as there is nowhere for them to go.

8. The occurrence of chronic illness is greatest in:

• Older adult
• Adolescents
• Young children
• Middle-aged adults

9. The nurse is teaching circumcision care to the mother of a newborn. Which statement indicates that the mother needs further teaching?

• I will apply a petroleum gauze to the area with each diaper change.
• I will clean the area carefully with each diaper change.
• I can place a heat lamp to the area to speed up the healing process.
• I should carefully observe the area for signs of infection.

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10. All of the following are common signs and symptoms of phlebitis except:

• Pain or discomfort at the IV insertion site
• Edema and warmth at the IV insertion site
• A red streak exiting the IV insertion site
• Frank bleeding at the insertion site

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11. Situation: Stacy is diagnosed with acute lymphoid leukemia (ALL) and beginning chemotherapy.Q. Stacy's mother states to the nurse that it is hard to see Stacy with no hair. The best response for the nurse is:

• "Stacy looks very nice wearing a hat".
• "You should not worry about her hair, just be glad that she is alive”.
• "Yes it is upsetting. But try to cover up your feelings when you are with her or else she may be upset".
• "This is only temporary; Stacy will re-grow new hair in 3-6 months, but may be different in texture".

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12. Nurse Lourdes is teaching a client recovering from addisonian crisis about the need to take fludrocortisone acetate and hydrocortisone at home. Which statement by the client indicates an understanding of the instructions?

• "I'll take my hydrocortisone in the late afternoon, before dinner."
• "I'll take all of my hydrocortisone in the morning, right after I wake up.”
• I'll take two-thirds of the dose when I wake up and one-third in the late afternoon.
• "I'll take the entire dose at bedtime”

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13. Nurse Betty is assigned to the following clients. The client that the nurse would see first after endorsement?

• A 34 year-old postoperative appendectomy client of five hours who is complaining of pain.
• A 44 year-old myocardial infarction (Ml) client who is complaining of nausea.
• A 26 year-old client admitted for dehydration whose intravenous (IV) has infiltrated.
• A 63 year-old postoperative abdominal hysterectomy client of three days whose incisional dressing is saturated with serosanguinous fluid.

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14. A nurse is assessing a 5-month-old infant The parents1 state that the infant is irritable, crying excessively, vomiting formula (not projectile), arching, and stiffening. Based on this assessment, what diagnosis should the nurse anticipate?

• Esophageal astresia withtracheoesophageal fistula
• Gastroesophageal reflux
• Hirschsprung's disease
• Celiac disease

15. As per of a neurological assessment, which of the following is as; score on the Glasgow coma scale?

• Eye opening to pain, no verbalization
• Confused, obey commands
• Localized pain, abnormal extension
• Eye opening to speech confused

16. Situation: The nurse is performing health education activities for Jane Segovial a 30 years old Dentist with Insulin dependent diabetes Mellitus.Q. Jane was brought at the emergency room after four month because she fainted in her clinic. The nurse should monitor which of the following test to evaluate the overall therapeutic compliance of a diabetic patient?

• Glycosylated Hemoglobin
• Fasting blood glucose
• Ketone Sevels
• Urine glucose level

17. Situation: Rene is a 3 y/o boy brought to the health center for fever and cough. You noted grayish pinpoint dots located at the buccal mucosa. A maculopapular rash was noted on his face.Q. What is the exanthem of measles?

• Maculopapular rash
• Pseudomembrane
• Forchheimer's spot
• Koplik's spot

18. Situation: The nurse engages the client in a. nurse-patient interaction.Q. The client says, "I want to tell you something but can you promise that you will keep this, a secret?" A therapeutic response of the nurse is:

• "Yes, our interaction is confidential provided the information you tell me is not detrimental to your safety."
• "Of course yes, this is just between you and me. Promise!"
• "Yes, it is my principle to uphold my client's rights"
• "Yes, you have the right to invoke confidentiality of our interaction.”

19. He described the development of faith. He suggested that faith is a spiritual dimension that gives meaning to a persons life. Faith according to him, is a relational phenomenon.

• Giligan
• Westerhoff
• Fowler
• Freud

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20. The parents are anxious after the doctor tells that their child needs surgery. The assess parents1 ability to cope with this anxiety, which of the following questions should the nurse ask

• "Did you know that feeling anxious about your child's surgery is normal?"
• "Can you wait until after surgery to begin to cope with being anxious?"
• "How do you think feeling of anxiety will affect your child?"
• "What has helped you when you felt anxious in the past?"

21. The nurse is teaching the mother of an six-month-old with eczema. Which instruction should be included in the nurses teaching?

• Dress the infant warmly to prevent undue chilling.
• Cut the infants fingernails and toenails regularly.
• Use bubble bath instead of soap for bathing the infant.
• Wash the infants clothes with mild detergent and fabric softener.

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22. A patient with measles (rubella) is on airborne precautions, which of the following Precautions techniques would be ESSENTIAL to implement for non-immune person entering the room?

• Gloves
• Gowns
• Face shields
• Masks

23. The nurse caring for a client who is taking an aminoglycoside should monitor the client for which adverse effects of the medication? Select all that apply. 1.Seizures. 2.Ototoxicity. 3.Renal toxicity. 4.Dysrhythmias. 5.Hepatotoxicity

• 2,3,4
• 1,2,3
• 2,3,5
• 1,3,5

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24. Which of the following postpartal clients is at greatest risk for hemorrhage?

• A gravida 1 para 1 with an uncomplicated delivery of a 7-pound infant
• A gravida 1 para 0 with a history of polycystic ovarian disease
• A gravida 3 para 3 with a history of low birth weight infants
• A gravida 4 para 3 with a Caesarean section

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25. For her, Nursing is a theoretical system of knowledge that prescribes a process of analysis and action related to care of the ill person

• King
• Henderson
• Leininger
• Roy

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26. A patient with severe diverticulitis had surgery for placement of colostomy. The patient is upset, crying and will not look at the colostomy. Which of the following would be the HIGHEST priority nursing diagnosis at this time?

• Knowledge deficit, colostomy care
• Distorted body image
• Self-care deficit, toileting
• Alteration in comfort

27. A patient has been assessed and found to have severe dysphagia and will need long-term nutritional support, which one of the following types of feeding would MOST likely to be beneficial for this patient?

• Gastrostomy
• Patenteral
• Nasogastric
• Nasoduodenal

28. Malou with schizophrenia tells Nurse Melinda, "My intestines are rotted from worms chewing on them? This statement indicates a:

• Jealous delusion
• Somatic delusion
• Delusion of grandeur
• Delusion of persecution

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29. 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. The nurse's therapeutic response to Mang Carlos' daughter is:

• "You have indeed made a sound decision, Your father needs professional care which you cannot provide at home."
• "Why are you feeling guilty bringing him here?”
• "I know that his has been a difficult time for you. You seemed troubled about bringing him here"
• "You have done well everything for your father, Do not be upset. We will take care of him."

30. Situation: Mr. Reynaldo Layag executive officer, was brought to the hospital because of chest pain. Diagnosis of angina was established.Q. Nitroglycerin S.L. is prescribed for Mr. Layag's anginal pain. When teaching how to use nitroglycerine, the nurse tells him to place 1 tablet under the tongue when pain occurs and to repeat the dose in 5 minutes if pain persist. The nurse should tell Mr. Layag to:

• Place two tablets under the tongue when the intense pain occurs
• Swallow 1 tablet and place 1 tablet under the tongue when pain is intense
• Place 1 tablet under the tongue 3 minutes before activity and repeat the dose in 5 minutes if pain occurs
• Place 1 tablet under the tongue when pain occurs and use an additional tablet after the attack to prevent reoccurrence

31. A full term client is in labor Nurse Betty is aware that the fetal heart rate would be:

• 80 to 100 beats/minute
• 100 to 120 beats/minute
• 120 to 160 beats/minute
• 160 to 180 beats/minute

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32. What can you expect from Marianne, who is currently at the ONSET stage of fever?

• Hot flushed skin
• Increase thirst
• Convulsion
• Pale.cold skin

33. During the process of cocaine withdrawal, the physician orders which of the following:

• Haloperidol (Haldol)
• Imipramine (Tofranil)
• Benztropine (Cogentin)
• Diazepam (Valium)

34. The nurse is assessing a newborn in the well-baby nursery. Which finding should alert the nurse to the possibility of a cardiac anomaly?

• Diminished femoral pulses
• Harlequins sign
• Circumoral pallor
• Acrocyanosis

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35. The maximum transfusion time for a unit of packed red blood cells (RBCs) is:

• 6 hours
• 4 hours
• 3 hours
• 2 hours

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36. A client is admitted with multiple pressure ulcers. When developing the client's diet plan, the nurse should include:

• Fresh orange slices
• Steamed broccoli
• Ice cream
• Ground beef patties

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37. Mrs. Hogan, a 43-year-old woman, is admitted to your unit for cholecystectomy.Q. Mrs. Hogan returns to your clinical unit following discharge from the recovery room. Her vital signs are stable and her family is with her. Postoperative leg exercises should be initiated:

• after the physician writes the order
• after the family leaves
• if Mrs. Hogan will not be ambulated early
• stat

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38. You are creating a teaching plan for a patient with newly diagnosed migraine headaches. Which key items should be included in the teaching plan? (Choose all that apply). A)Avoid foods that contain tyramine, such as alcohol and aged cheese. B)Avoid drugs such as Tagamet, nitroglycerin and Nifedipine. C)Abortive therapy is aimed at eliminating the pain during the aura. D)A potential side effect of medications is rebound headache. E)Complementary therapies such as relaxation may be helpful. F)Continue taking estrogen as prescribed by your physician.

• A, B, C, D, E & F
• A, B, C, D & E
• B, C, D, E & F
• A, C, D, E & F

39. A topical corticosteroid is prescribed by the health care provider for a child with atopic dermatitis (eczema). Which instruction should the nurse give the parent about applying the cream?

• Apply the cream over the entire body.
• Apply a thick layer of cream to affected areas only
• Avoid cleansing the area before application of the cream.
• Apply a thin layer of cream and rub it into the area thoroughly.

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40. Which domains of learning is responsible for making John and Marsha understand the different kinds of family planning methods?

• Cognitive
• Affective
• Psychomotor
• Motivative

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41. Ryan has undergone subtotal gastrectomy. The nurse should expect that nasogastric tube drainage will be what color for about 12 to 24 hours after surgery?

• Bile green
• Bright red
• Cloudy white
• Dark brown

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42. Situation: Mr. Roberto was long diagnosed with chronic renal failure. You are his nurse and the following question assesses your knowledge in the different fluid and electrolyte imbalances that are associated with chronic renal failure.Q. Which of the following is an appropriate instruction for Mr. Roberto?

• Follow a high potassium diet
• Strictly follow the hemodialysis schedule
• Use salt substitute instead of the normal table salt
• Use alcohol on the skin to clean it due to integumentary changes

43. Situation: Mr. Roberto was long diagnosed with chronic renal failure. You are his nurse and the following question assesses your knowledge in the different fluid and electrolyte imbalances that are associated with chronic renal failure.Q. Mr. Roberto Complains of tingling in the finger and twitching of the muscles. This is caused by:

• Acidosis
• Potassium retention
• Calcium Depletion
• Sodium chloride depletion

44. Situation: Human development is one of the important concepts that a nurse should learn to be able to deal appropriately with their clients of different developmental stages.A nurse is teaching a class about the reproductive system. She explains that fertilization most often takes place in the:

• Ovary
• Fallopian tubes
• Uterus
• vagina

45. What would be the most important nursing intervention in caring for the client's residual limb during the first 24 hrs after amputation of the left leg?

• Keeping the residual limb flat on the bed
• Abducting the residual limb on a scheduled basis
• Applying traction to the residual limb
• Elevating the residual limb on a pillow

46. A client admitted to the hospital with a suspected diagnosis of acute pancreatitis is being assessed by the nurse. Which assessment findings would be consistent with acute pancreatitis? Select all that apply. 1.Diarrhea. 2.Black, tarry stools. 3.Hyperactive bowel sounds. 4.Gray-blue color at the flank. 5.Abdominal guarding and tenderness. 6.Left upper quadrant pain with radiation to the back

• 1,2,3,4
• 4,5,6
• 1,2,3,4,5
• 2,3,5

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47. The nursing care plan for a toddler diagnosed with Kawasaki Disease (mucocutaneous lymph node syndrome) should be based on the high risk for development of which problem?

• Chronic vessel plaque formation
• Pulmonary embolism
• Occlusions at the vessel bifurcations
• Coronary artery aneurysms

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48. The client has elected to have epidural anesthesia to relieve labor pain. If the client experiences hypotension the nurse would:

• Place her in Trendelenburg position.
• Decrease the rate of IV infusion.
• Administer oxygen per nasal cannula.
• Increase the rate of the IV infusion.

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49. A home care nurse visits a patient with diabetes. The patient cast three well balanced meals sweet dessert and exercises 30 minutes a day twice a week. Also, the patient is complaint with taking hypoglycemia medications Blood glucose level ranges from 150-200 mg/ di. The nurse sets a goal of eliminating sweet desserts and increasing the frequency of exercises to 3 times a week. This week, the patient exercised 3 times for 30 minutes and ate dessert only after dinner. The glucose ranges from 100-150 mg/dl. The nurse evaluate that

• The goal will not be met
• Progression is being made towards the goal
• The goal is met
• The goal is inappropriate

50. A patient is 3 week postoperative left below the knee amputation. Which of the following is an expected outcome for this patient?

• Verbalize relief of incisional pain, has intense phantom sensation
• Participates in care plan, express concern about independence
• Full passive range of motion, requires assistance with transfers
• Low grade temperature, dressing reinforced every hour

 

NCLEX-RN | QB1 | Practice Exam #52 (50 questions)