NCLEX-RN | QB1 | Practice Exam #51 (50 questions)
1. Ronny told Blake, "Do you think I'm crazy?" Blake responded, "Do you think you're crazy?" Blake uses what example of therapeutic communication?
- Reflecting
- Restating
- Exploring
- Seeking clarification
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2. The community nurse is aware that the biological used in Expanded Program on Immunization (EPI) should NOT be stored in the freezer?
- DPT
- Oral polio vaccine
- Measles vaccine
- MMR
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3. SITUATION: Mr Roxas, an obese 35 year old MS Professor is admitted due to pain in his weight bearing joint. The diagnosis was Osteoarthritis.Q. As a nurse, you instructed Mr. Roxas how to use a cane. Mr. Roxas has a weakness on his right leg due to self immobilization and guarding. You plan to teach Mr. Roxas to hold the cane
- On his left hand, because his right side is weak
- On his left hand, because of reciprocal motion.
- On his right hand, to support the right leg.
- On his right hand, because only his right leg is weak.
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4. Situation: You are the nurse in the Out-Patient-Department and during your shift you encountered multiple children's condition. The following questions apply.Q. A child with visible severe wasting or severe palmar pallor may be classified as:
- moderate malnutrition/anemia
- severe malnutrition/anemia
- not very tow weight no anemia
- anemia/very low weight
5. A resident who has stress incontinence
- will have an indwelling urinary catheter.
- should wear an incontinent brief at night.
- may leak urine when laughing or coughing.
- needs toileting every 1-2 hours throughout the day.
6. Nurse Tina is caring for a client with delirium and states that 'look at the spiders on the wall1'. What should the nurse respond to the client?
- 'You're having hallucination, there are no spiders in this room at all"
- "I can see the spiders on the wall, but they are not going to hurt you"
- "Would you like me to kill the spiders"
- "I know you are frightened, but I do not see spiders on the wall"
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7. A client with diabetic neuropathy reports a burning, electrical-type in the lower extremities that is not responding to NSAIDs. You anticipate that the physician will order which adjuvant medication for this type of pain?
- Amitriptyline (Elavil)
- Corticosteroids
- Methylphenidate (Ritalin)
- Lorazepam (Ativan)
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8. A patient present to the clinic voicing a concern above being exposed to hepatitis A (HA V) one week ago. Upon questioning, the nurse finds the patient purchased for from a person recently diagnosed with HAV. The number would be MOST correct when instructing the patient
- The incubation period is 3 to 5 weeks
- HA V is spread by sexual transmission
- HA V is spread by blood contact
- The incubation period is 2 to 5 months
9. A patient presents to the office for a physical assessment The patient is found to be healthy and fit but occasionally drinks alcohol and has unprotected sex. What is the BEST nursing diagnosis?
- Health-seeking behavior
- knowledge deficit, high risk behavior
- Low self esteem
- Altered thought process
10. The nurse teaches a client newly diagnosed with type 1 diabetes about storing Humulin N insulin. Which statement indicates to the nurse that the client understood the discharge teaching?
- "I should keep the insulin in the cabinet during the day only”
- "I know I have to keep my insulin in the refrigerator at all times."
- I can store the open insulin bottle in the kitchen cabinet for 1 month.
- "The best place for my insulin is on the window sill, but in the cupboard is just as good."
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11. A client with anorexia nervosa describes herself as "a whale." However, the nurse's assessment reveals that the client is 5' 8" (1.7 m) tall and weighs only 90 lb (40.8 kg). Considering the client's unrealistic body image, which intervention should be included in the plan of care?
- Asking the client to compare her figure with magazine photographs of women her age
- Assigning the client to group therapy in which participants provide realistic feedback about her weight
- Confronting the client about her actual appearance during one-on-one sessions, scheduled during each shift
- Telling the client of the nurse's concern for her health and desire to help her make decisions to keep her healthy
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12. A patient is being prepared for a right breast biopsy under general anesthesia. The patient asks the nurse about the surgical scar and possible postoperative complications. Which of the following actions would be appropriate for the nurse to take?
- Review the post operative risks with the patient
- Notify surgeon about the patient's questions
- Complete the patient's preoperative check list
- Show the patient photos of breast surgical scars
13. A 59-years old patient with lung cancer and metastasis to the bone is in the hospital for pain management. The patient rates the pain 10 on a scale of 0(no pain) to 10 (severe pain). The BEST goal for the nurse diagnosis of alteration is comfort is that the patient will:
- Show no objective signs of pain
- Not complain of pain
- State pain is at a tolerable level
- State that all pain is relieved
14. Situation: During surgical operation, it is inevitable to utilize sutures. The nurse should know the basic principles in suturing as well as knowledge in selecting sutures and caring for clients with sutures.Q. Another alternative "suture" for skin closure is the use of ____
- Staple
- Therapeutic glue
- Absorbent dressing
- Invisible suture
15. The nursing instructor asks a nursing student to identify the priorities of care for an assigned client. Which statement indicates that the student correctly identifies the priority client needs?
- Actual or life-threatening concerns
- Completing care in a reasonable time frame
- Time constraints related to the clients needs
- Obtaining needed supplies to care for the client
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16. Which of the following would the nurse use as the best method to assess for the development of deep vein thrombosis in a client with a spinal cord injury?
- Homan's sign
- Pain
- Tenderness
- Leg girth
17. Which statement correctly describes suctioning through an endotracheal tube
- The catheter is inserted into the endotracheal tube; intermittent suction is applied until no further secretions are retrieved; the catheter is then withdrawn.
- The catheter is inserted through the nose, and the upper airway is suctioned; the catheter is then removed from the upper airway and inserted into the endotracheal tube to suction the lower airway
- With suction applied, the catheter is inserted into the endotracheal tube; when resistance is met, the catheter is slowly withdrawn
- The catheter is inserted into the endotracheal tube to a point of resistance, and intermittent suction is applied during withdrawal.
18. The client is admitted with chronic obstructive pulmonary disease. Blood gases reveal pH 7.36 CO2 45 O2 84 bicarb 28. The nurse would assess the client to be in:
- Uncompensated acidosis
- Compensated alkalosis
- Compensated respiratory acidosis
- Uncompensated metabolic acidosis
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19. Anthony is very hostile toward one of the staff for no apparent reason. He is manifesting:
- Splitting
- Transference
- Countertransference
- Resistance
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20. A client tells the nurse that she takes St Johns wort (hypericum perforatum) three times a day for mild depression. The nurse should tell the client that:
- St. John wort seldom relieves depression.
- She should avoid eating aged cheese.
- Skin reactions increase with the use of sunscreen.
- The herbal is safe to use with other antidepressants.
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21. When assessing a child with a cleft palate, the nurse is aware that the child is at risk for more frequent episodes of otitis media due to whichof the following?
- Lowered resistance from malnutrition
- Ineffective functioning of the Eustachian tubes
- Plugging of the Eustachian tubes with food particles
- Associated congenital defects of the middle ear.
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22. An infant on the pediatric unit suddenly starts to have generalized seizure activity. Which of these actions should the nurse take first?
- Insert a padded tongue blade into the infant's mouth.
- Test the infant's pupillary response to light at least twice during the seizure.
- Suction the infant's oropharynx several times during the seizure.
- Note the duration of the infant's seizure.
23. The nurse is monitoring a client who was diagnosed with type 1 diabetes mellitus and is being treated with NPH and regular insulin. Which manifestations would alert the nurse to the presence of a possible hypoglycemic reaction? Select all that apply. 1.Tremors. 2.Anorexia. 3.Irritability. 4.Nervousness. 5.Hot, dry skin. 6.Muscle cramps
- 1,2,3
- 1,3,4
- 2,4,5
- 1,2,4,6
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24. A diagnosis of Hodgkin's disease is suspected in a 12-year-old child. Several diagnostic studies are performed to determine the presence of this disease. Which diagnostic test result will confirm the diagnosis of Hodgkin's disease?
- Elevated vanillylmandelic acid urinary levels
- The presence of blast cells in the bone marrow
- The presence of Epstein-Barr virus in the blood
- The presence of Reed-Sternberg cells in the lymph nodes
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25. The nurse is preparing to care for a client who has returned to the nursing unit following cardiac catheterization performed through the femoral vessel. The nurse checks the health care provider's (HCP's) prescription and plans to allow which client position or activity following the procedure?
- Bed rest in high Fowler's position
- Bed rest with bathroom privileges only
- Bed rest with head elevation at 60 degrees
- Bed rest with head elevation no greater than 30 degrees
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26. 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 a plan 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
27. A nurse admits a 3 week-old infant to the special care nursery with a diagnosis of bronchopulmonary dysplasia. As the nurse reviews the birth history, which data would be most consistent with this diagnosis?
- Gestational age assessment suggested growth retardation
- Meconium was cleared from the airway at delivery
- Phototherapy was used to treat Rh incompatibility
- The infant received mechanical ventilation for 2 weeks
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28. A male client who is experiencing disordered thinking about food being poisoned is admitted to the mental health unit. The nurse uses which communication technique to encourage the client to eat dinner?
- Focusing on self-disclosure of own food preference
- Using open ended question and silence
- Offering opinion about the need to eat
- Verbalizing reasons that the client may not choose to eat
29. Following ocular surgery the nurse establishes care interventions to include orienting the patients to new changes in environment and supervising the Patients ability to feed themselves and perform self-care activities. Which of the following nursing diagnosis do these activities support?
- Activity intolerance
- Impaired environmental interpretation syndrome
- Disturbed sensoryperception
- Risk for autonomicdysreflexia
30. The nurse is planning to administer hydrochlorothiazide to a client The nurse should monitor for which adverse effects related to the administration of this medication?
- Hypouricemia, hyperkalemia
- Increased risk of osteoporosis
- Hypokalemia, hyperglycemia, sulfa allergy
- Hyperkalemia, hypoglycemia, penicillin allergy
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31. When administering albuterol to a child with asthma, the nurse should observe for sign of what major side effect to this medication?
- Tachycardia
- Renal failure
- Apnea Blurred vision
- None of the above.
32. The registered nurse is making assignments for the day. Which client should not be assigned to the pregnant nurse?
- The client receiving linear accelerator radiation therapy for lung cancer
- The client with a radium implant for cervical cancer
- The client who has just been administered soluble brachytherapy for thyroid cancer
- The client who returned from an intravenous pyelogram
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33. After surgery and insertion of a total joint prosthesis, a client develops severe sudden pain and an inability to move the extremity. The nurse interprets these findings as indicating which of the foilowing?
- A developing infection
- Bleeding in the operative site
- Joint dislocation
- Glue seepage into soft tissue
34. Situation: Melamine contamination in milk has brought world wide crisis both in the milk production sector as well as the health and economy. Being aware of the current events is one quality that a nurse should possess to prove that nursing is a dynamic profession that will adapt depending on the patient's needs.Q. What kind of renal failure from melamine poisoning cause?
- Chronic Prerenal
- Acute, Postrenal
- Chronic, Intrarenal
- Acute, Prerenal
35. When a client is admitted to an inpatient mental health unit with the diagnosis of anorexia nervosa, a cognitive behavioral approach is used as part of the treatment plan. The nurse plans care based on which purpose of this approach?
- Providing a supportive environment
- Examining intrapsychic conflicts and past issues
- Emphasizing social interaction with clients who withdraw
- Helping the client to examine dysfunctional thoughts and beliefs
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36. SITUATION : Mr Francisco, 70 years old, suddenly could not lift his spoons nor speak at breakfast. He was rushed to the hospital unconscious. His diagnosis was CVA.Q. One of the complications of prolonged bed rest is decubitus ulcer Which of the following can best prevent its occurrence?
- Massage reddened areas with lotion or oils
- Turn frequently every 2 hours
- Use special water mattress
- Keep skin clean and dry
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37. Angel was diagnosed as having Dengue fever. You will say that there is slow capillary refill when the color of the nail bed that you pressed does not return within how many seconds?
- 3 seconds
- 6 seconds
- 9 seconds
- 10 seconds
38. Centralized organizations have some advantages. Which of the following statements are TRUE? 1.Highly cost-effective. 2.Makes management easier. 3.Reflects the interest of the worker. 4.Allows quick decisions or actions.
- 1&2
- 2&4
- 2,3&4
- 1,2&4
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39. A client with psychotic depression is receiving Haldol (haloperidol). Which one of the following adverse effects is associated with the use of haloperidol?
- Akathisia
- Cataracts
- Diaphoresis
- Polyuria
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40. After taking an overdose of phenobarbital (Barbita), Mario is admitted to the emergency department. Dr Trinidad prescribes activated charcoal (Charcocaps) to be administered by mouth immediately. Before administering the dose, the nurse verifies the dosage ordered. What is the usual minimum dose of activated charcoal?
- 5 g mixed in 250 ml of water
- 15 g mixed in 500 mi of water
- 30 g mixed in 250 ml of water
- 60 g mixed in 500 ml of water
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41. 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.Being a community health nurse, you have the responsibility of participating in protecting the health of people. Consider this situation: Vendors selling bread with their bare hands. They receive money with these hands. You do not see them washing their hands. What should you say/do?
- "Miss, may I get the bread myself because you have not washed your hands"
- "Miss, it is better to use a pick up forceps/ bread tong"
- "Miss, your hands are dirty. Wash your hands first before getting the bread"
- All of these
42. A client who has been hospitalized with disorganized type schizophrenia for 8 years can't complete activities of daily living (ADLs) without staff direction and assistance. The nurse formulates a nursing diagnosis of Self-care deficient: Dressing/grooming related to inability to function without assistance. What is an appropriate goal for this client?
- "Client will be able to complete ADLs independently within 1 month."
- "Client will be able to complete ADLs with only verbal encouragement within 1 month."
- "Client will be able to complete ADLs with assistance in organizing grooming items and clothing within 1 month."
- "Client will be able to complete ADLs with complete assistance within 1 month.”
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43. Situation: Joint Commission on Accreditation of Hospital Organization (JCAHO) patient safety goals and requirements include the care and efficient use of technology in the OR arid elsewhere in the healthcare facility.Q. You identified a potential risk of pre and postoperative clients. To reduce the risk of patient harm resulting from fall, you can implement the following EXCEPT:
- Assess potential risk of fail associated with the patient's the following EXCEPT: medication regimen
- Take action to address any identified risks through Incident Report (IR)
- Allow client to walk with relative to the OF?
- Assess and periodically reassess individual client's risk for falling
44. Which of the following is the primary predisposing factor related to mastitis?
- Epidemic infection from nosocomial sources localizing in the lactiferous glands and ducts
- Endemic infection occurring randomly and localizing in the periglandular connective tissue
- Temporary urinary retention due to decreased perception of the urge to avoid
- Breast injury caused by overdistention, stasis, and cracking of the nipples
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45. Situation: In the hospital, you are aware that we are helped by the .use of a variety of equipment/devices to enhance quality patient care delivery. Q. Kyle's room is fully mechanized. What do you teach the watcher and Kyle to alert the nurse for help?
- How to lock side rails
- Number of the telephone operator
- Call system
- Remote control
46. Situation: After abdominal surgery, the circulating and scrub nurses have critical responsibility about sponge and instrument countQ. Which of the following are 2 interventions of the surgical team when an instrument was confirmed missing?
- MRI and Incidence report
- CT Scan, MRI, Incidence Report
- X-ray and Incidence Report
- CT scan and Incidence Report
47. Which of the following instructions should be included in the nurses teaching regarding oral contraceptives?
- Weight gain should be reported to the physician.
- An alternate method of birth control is needed when taking antibiotics.
- If the client misses one or more pills two pills should be taken per day for one week.
- Changes in the menstrual flow should be reported to the physician.
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48. A male client arriving in the emergency department is receiving cardiopulmonary resuscitation from paramedics who are giving ventilations through an endotracheal (ET) tube that they placed in the clients home. During a pause in compressions, the cardiac monitor shows narrow QRS complexes and a heart rate of beats/minute with a palpable pulse. Which of the following actions should the nurse take first?
- Start an I.V. line and administer amiodarone (Cardarone), 300 mg I.V over 10 minutes.
- Check endotracheal tube placement.
- Obtain an arterial blood gas (ABG) sample.
- Administer atropine, 1 mg I.V
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49. The nurse is teaching a patient who was just diagnosed with narcolepsy. The nurse should teach the patient that which of the following typically INCREASES the level of fatigue?
- Taking brief naps
- Participating in an exercise program
- Eating large meals
- Working in a cool environment
50. A diabetic client receives a combination of regular and NPH insulin at 0700 hours. The nurse teaches the client to be alert for signs of hypoglycemia at
- 1200 and 1300 hours
- 1100 and 1700 hours
- 1000 and 2200 hours
- 0300 and 1100 hours
NCLEX-RN | QB1 | Practice Exam #51 (50 questions)