NCLEX-RN | QB1 | Practice Exam #47 (50 questions)
1. Discharge planning for hospitalized patient begins:
- When the treating Dr gives discharge order
- When all of the specific needs of the patient have been identified
- When the patient begins to ask about his discharge plans
- From the first day of admission
2. A preterm neonate is receiving oxygen by an overhead hood. During the time the infant is under the hood, it would be appropriate for nurse Gian to:
- Hydrate the infant q15 min
- Put a hat on the infant's head
- Keep the oxygen concentration consistent
- Remove the infant q15 min for stimulation
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3. A nurse is caring for a client who had a closed reduction of a fractured right wrist followed by the application of a fiberglass cast 12 hours ago. Which finding requires the nurse's immediate attention?
- Capillary refill of fingers on right hand is 3 seconds
- Skin warm to touch and normally colored
- Client reports prickling sensation in the right hand
- Slight swelling of fingers of right hand
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4. A 30 year-old married man presents to the clinic with complaints of feeling sad for the past three months. He is unable to maintain a regular sleep routine, has lost his appetite and has difficulty concentrating. He is prescribed a medication which prevents the reuptake of specific neurotransmitters that could contribute to his mental health problem. Which side effects would be most important for the nurse to advise the patient of?
- Polyuria
- Photophobia
- Fluid retention
- Sexual dysfunction
5. A patient hospitalized with tuberculosis (TB) has a productive cough and hemoptysis. Which of the following types of isolation room would be the best choice for the patient?
- Reverse isolation
- Standard isolation
- Positive-pressure
- Negative-pressure
6. A patient with chronic obstructive pulmonary disease complains of a frequent cough , bilateral wheezing is auscultated in the lung fields . The nurse administer albuterol nebulizer treatment, as ordered and educates the patient on way to decrease exacerbation. Which of the following actions indicate that the patient understands the instruction?
- The patient reduces number of cigarettes smoked per day
- The patient requested a pneumococcal vaccination
- The patient increases sodium and potassium intake
- The patent exercises whenever experiencing shortness of breath
7. The RN is making assignments for the morning staff. Which client should be cared for by the RN?
- A client with hemianopsia
- A client with asterixis
- A client with akathesia
- A client with hemoptysis
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8. A client with a solar burn of the chest, back, face, and arms is seen in urgent care. The nurse's primary concern should be:
- fluid resuscitation
- infection
- body image
- pain management
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9. SITUATION: MARK Lester had been diagnosed with Stage 1 bronchogenic cancer He had undergone lobectomy on the left lower lung, A two-bottle drainage system is inserted,The patient is placed on bed post-operatively in what position?
- Prone
- Trendelenburg
- Right side
- Left side
10. A home care nurse visits an elderly patient who had a surgical repair for fracture. The patient is taking opioid analgesics. Today, the patient complaints of decreased appetite and absence of a bowel movement for four days. Which of the following can be inferred?
- Constipation related to use of opioids
- Decreased appetite due to depression
- Constipation due to acute pain
- Decreased appetite due to use of opioid
11. The nurse assesses the health condition of the female client The client tells the nurse that she discovered a lump in the breast last year and hesitated to seek medical advice. The nurse understands that, women who tend to delay seeking medical advice after discovering the disease are displaying what common defense mechanism?
- Intellectualization.
- Suppression.
- Repression.
- Denial
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12. The nurse is assisting a client undergoing induction of labor at 41 weeks of gestation. The client's contractions are moderate and occurring every 2 to 3 minutes, with a duration of 60 seconds. An internal fetal heart rate monitor is in place. The baseline fetal heart rate has been 120 to 122 beats/minute for the past hour. What is the priority nursing action?
- Notify the health care provider.
- Discontinue the infusion of oxytocin.
- Place oxygen on at 8 to 10 L/minute via face mask.
- Contact the client's primary support person(s) if not currently present.
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13. Stephanie is a new Staff Educator of a private tertiary hospital She conducts orientation among new staff nurses in her department. Joseph, one of the new staff nurses, wants to understand the channel of communication, span of control and lines of communication. Which of the following will provide this information?
- Organizational structure
- Policy
- Job description
- Manual of procedures
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14. Situation: Colorectal cancer can affect old and younger people. Surgical procedures and other modes of treatment are done to ensure quality of life. You are assigned in the Cancer institute to care of patients with this type of cancer.Q. The following are risk factors for colorectal cancer, EXCEPT:
- inflammatory bowels
- high fat high fiver diet
- smoking
- genetic factors-familial adenomatous polyposis
15. Auranofin (Ridaura) is prescribed for a client with rheumatoid arthritis, and the nurse monitors the client for signs of an adverse effect related to the medication. Which of the following indicates an adverse effect?
- nausea
- diarrhea
- anorexia
- proteinuria
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16. A client elects to have epidural anesthesia to relieve the discomfort of labor Following the initiation of epidural anesthesia the nurse should give priority to:
- Checking for cervical dilation
- Placing the client in a supine position
- Checking the clients blood pressure
- Obtaining a fetal heart rate
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17. 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, As a professional, a nurse can do research for varied reason except:
- Professional advancement through research participation
- To validate results of new nursing modalities
- For financial gains
- To improve nursing care
18. A male client complains of vertigo. Nurse Bea anticipates that the client may have a problem with which portion of the ear?
- Tymphanic membranes
- Inner ear
- Auricle
- External ear
19. The nurse should anticipate that hemorrhage related to uterine atony may occur postpartally if this condition was present during the delivery:
- Excessive analgesia was given to the mother
- Placental delivery occurred within thirty minutes after the baby was born
- An episiotomy had to be done to facilitate delivery of the head
- The labor and delivery lasted for 12 hours
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20. Ms. Valencia develops the standards to be followed. Among the following standards, which is considered as a structure standard?
- The patients verbalized satisfaction of the nursing care received
- Rotation of duty will be done every four weeks for all patient care personnel.
- All patients shall have their weights taken recorded
- Patients shall answer the evaluation form before discharge
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21. This is the amount of heat required to raise the temperature of 1 kg water to 1 degree Celsius
- Calorie
- Joules
- Metabolism
- Basal metabolic rate
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22. Situation: Graciela 1 and 1/2 year old is admitted the hospital from the emergency room with a fracture of the left femur due to a Tall down a flight of stairs. Graciela is placed oh Bryant's traction.Q. Part of discharge plan is for the nurse to give instructions about the care of Graciela's cast to the mother. Which of these statements indicate that the mother understood an important aspect of case care?
- I will use white shoe polish to keep the cast neat
- I will place plastic sheeting around the perineal area of the cast
- I will use cool water to wash the cast
- I will reinforce cracked areas on the cast with adhesive tape
23. A nurse visits a patient who is 37-weeks pregnant and asking for information about breast feeding versus feeding prepared infant formula. A beneficial reason to breast feed includes:
- Readily available and economical
- Keeps a baby full longer
- Larger curds than cow's milk and therefore is easier to digest
- Encourage greater deposits of subcutaneous fat in an infant
24. Refers to the pressure when the ventricles are at rest
- Diastole
- Systole
- Preload
- Pulse pressure
25. Situation: The patients chart is a legal documentation the is admissible in the court In working with the client, The protection of the information on the chart and patient's privacy is one of the priority. You are caring for Ana, a 12 year old grade 6 pupil from manila and is one of the daughters of Maria, A 38 year old mother of 12.Q. Who cannot access the client's chart?
- Maria
- The patient
- Member of the health care team
- The nurse from the nearby hospital
26. The nurse is caring for a client with schizophrenia who experiences auditory hallucinations. The client appears to be listening to someone who isn't visible. He gestures, shouts angrily, and stops shouting in mid-sentence. Which nursing intervention is the most appropriate?
- Approach the client and touch him to get his attention.
- Encourage the client to go to his room where he'll experience fewer distractions.
- Acknowledge that the client is hearing voices but make it clear that the nurse doesn't hear these voices.
- Ask the client to describe what the voices are saying.
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27. A male client is being transferred to the nursing unit for admission after receiving a radium implant for bladder cancer. The nurse in-charge would take which priority action in the care of this client?
- Place client on reverse isolation.
- Admit the client into a private room.
- Encourage the client to take frequent rest periods.
- Encourage family and friends to visit.
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28. Which of the following statement clearly defines therapeutic communication?
- Therapeutic communication is an interaction process which is primarily directed by the nurse
- It conveys feeling of warmth, acceptance and empathy from the nurse to a patient in relaxed atmosphere
- Therapeutic communication is a reciprocal interaction based on trust and aimed at identifying patient needs and developing mutual goals
- Therapeutic communication is an assessment component of the nursing process
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29. Situation: Two children were brought to you. One with chest indrawing and the other had diarrhea. The following questions apply: Ms. Jordan, RN, believes that a patient should be treated as individual. This ethical principle that the patient referred to:
- beneficence
- nonmaleficence
- respect for person
- autonomy
30. The most frequent causes of death among clients with AIDS are opportunistic diseases. Which of the following opportunistic infections is characterized by tonsilllopharyngitis?
- Respiratory candidiasis
- Infectious mononucleosis
- Cytomegalovirus disease
- Pneumocystis carinii pneumonia
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31. Nurse Irma saw Roger and told Nurse Aida “Oh look at that psychotic patient" Nurse Aida should intervene and correct Nurse Irma because her statement shows that she is lacking?
- Positive regard
- Comfortable sense of self
- Self awareness
- Empathy
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32. A client has many irrational thoughts. The goal of therapy is to change her:
- Personality
- Communication
- Behavior
- Cognition
33. Which biological used in EPI is stored in the freezer?
- Tetanus toxoid
- Measles vaccine
- Hepatitis B vaccine
- DPT
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34. The nurse in a birthing room is monitoring a client with dysfunctional labor for signs of fetal or maternal compromise.Which assessment finding should alert the nurse to a compromise?
- Maternal fatigue
- Coordinated uterine contractions
- Progressive changes in the cervix
- Persistent nonreassuring fetal heart rate
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35. In an industrial accident, client who weighs 155 lb (70.3 kg) sustained fuli-thickness burns over 40% of his body. He's in the burn unit receiving fluid resuscitation. Which observation shows that the fluid resuscitation is benefiting the client?
- A urine output consistently above 100 ml/hour
- A weight gain of 4 lb (1.8 kg) in 24 hours.
- Body temperature readings all within normal limits
- An electrocardiogram (ECG) showing no arrhythmias.
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36. A client is receiving captopril (Capoten) for heart failure. The nurse should notify the physician that the medication therapy is ineffective if an assessment reveals:
- A skin rash.
- Peripheral edema.
- A dry cough.
- Postural hypotension.
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37. A parent brings her 4-month-old infant to a wellbaby clinic for immunizations. The child is up to date with the immunization schedule. The nurse should prepare to administer which immunizations to this infant?
- Varicella, hepatitis B vaccine (HepB)
- Diphtheria, tetanus, acellular pertussis (DTaP); measles, mumps, rubel a (MMR); inactivated poliovirus vaccine (IPV)
- MMR, Haemophilus influenzae type b (Hib), DTaP
- DTaP Hib, IPV, pneumococcal vaccine (PCV), rotavirus vaccine (RV)
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38. Situation: Understanding different models of care is a necessary part of the nurse patient relationship.Q. The most advantageous therapy for a preschool age child with a history of physical and sexual abuse would be:
- Play
- Psychoanalysis
- Group
- Family
39. 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 sensory perception
- Risk for autonomic dysreflexia
40. A 22-year-old client is diagnosed with dependent personality disorder. Which behavior is most likely evidence of ineffective individual coping?
- Inability to make choices and decisions without advice
- Showing interest only in solitary activities
- Avoiding developing relationships
- Recurrent self-destructive behavior with history of depression
41. Celeste who used heroin during her pregnancy delivers a neonate. When assessing the neonate, the nurse Lynnette expects to find:
- Lethargy 2 days after birth.
- Irritability and poor sucking.
- A flattened nose, small eyes, and thin lips.
- Congenital defects such as limb anomalies.
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42. Dr. Garcia writes the following order for the client who has been recently admitted “Digoxin J 25 mg P.O. once daily." To prevent a dosage error, how should the nurse document this order onto the medication administration record?
- "Digoxin .1250 mg PO. once daily"
- "Digoxin 0.1250 mg PO. once daily"
- "Digoxin 0.125 mg PO. once daily"
- "Digoxin .125 mg PO. once daily"
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43. The nurse is preparing discharge instructions for a client receiving baclofen. Which instruction should be included in the teaching plan?
- Restrict fluid intake.
- Avoid the use of alcohol.
- Stop the medication if diarrhea occurs.
- Notify the health care provider (HCP) if fatigue occurs.
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44. A client with a head injury is being monitored for increased intracranial pressure (ICP). His biood pressure is 90/60 mmHG and the ICP is 18 mm Hg; therefore his cerebral perfusion pressure (CPP) is:
- 52 mm Hg
- 88 mm Hg
- 48 mm Hg
- 68 mm Hg
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45. A client has been diagnosed with glomerulonephritis complains of thirst The nurse should offer:
- Juice
- Ginger ale
- Milk shake
- Hard candy
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46. Intra-uterine device prevents pregnancy by the ff. mechanism EXCEPT
- Endometrium inflames
- Fundus contracts to expel uterine contents
- Copper embedded in the IUD can kill the sperms
- Sperms will be barred from entering the fallopian tubes
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47. Situation: The nurse engages the client in a. nurse-patient interaction. When the nurse respects the clients self-disclosure, this is a gauge for the nurse's:
- trustworthiness
- loyalty
- integrity
- professionalism
48. Imelda is in the recovery stage after the incident As a nurse, you know that the diet that will be prescribed to Miss Imelda is:
- Low calorie, High protein with Vitamin A and C rich foods
- High protein, High calorie with Vitamin A and C rich foods
- High calorie, Low protein with Vitamin A and C rich foods
- Low calorie, Low protein with Vitamin A and C rich foods
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49. This is considered as the most important aspect of handwashing
- Time
- Friction
- Water
- Soap
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50. A client asks the nurse about the gamete intrafallopian transfer (GIFT) procedure. Which of the following responses would be appropriate for the nurse to make?
- Fertilization takes place in the woman's body.
- Zygotes are placed in the fallopian tubes.
- Donor sperm are placed in a medium with donor eggs.
- A surrogate carries the infertile woman's fetus.
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NCLEX-RN | QB1 | Practice Exam #47 (50 questions)