NCLEX-RN | QB1 | Practice Exam #46 (50 questions)
1. Which of the following is TRUE in colostomy feeding?
- Hold the syringe 18 inches above the stoma and administer the feeding slowly
- Pour 30 ml of water before and after feeding administration
- Insert the ostomy feeding tube 1 inch towards the stoma
- A Pink stoma means that circulation towards the stoma is all well
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2. The physician has ordered Claforan (cefotaxime) 1g every six hours. The pharmacy sends the medication premixed in l00mL of D5W with instructions to infuse the medication over one hour. The IV set delivers 20 drops per milliliter The nurse should set the IV rate at:
- 50 drops per minute
- 33 drops per minute
- 25 drops per minute
- 12 drops per minute
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3. A client with borderline personality disorder becomes angry when he is told that today's psychotherapy session with the nurse will be delayed 30 minutes because of an emergency. When the session finally begins, the client expresses anger. Which response by the nurse would be most helpful in dealing with the client's anger?
- "If it had been your emergency, I would have made the other client wait."
- "I know it's frustrating to wait. I'm sorry this happened."
- "You had to wait. Can we talk about how this is making you feel right now?"
- "I really care about you and I'll never let this happen again."
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4. The registered nurse is preparing to insert a nasogastric tube in an adult client To determine the accurate measurement of the length of the tube to be inserted, the nurse should take which action?
- Mark the tube at 10 inches (25.5 cm).
- Mark the tube at 32 inches (81 cm).
- Place the tube at the tip of the nose and measure by extending the tube to the earlobe and then down to the xiphoid process.
- Place the tube at the tip of the nose and measure by extending the tube to the earlobe and then down to the top of the sternum.
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5. Situation: You are a nurse working in the medical ward.Q. A nurse is waiting for a report to be sent by fax. The machine activates but instead of the report, the nurse received a sexually oriented photograph. The MOST appropriate nursing action is to:
- call the nursing supervisor and report the incident
- cut the photograph and throw it away.
- call the police
- call the unit who sent it and ask for the name of person who sent the photograph
6. A two-year-old child with congestive heart failure has been receiving digoxin for one week The nurse needs to recognize that an early sign of digitalis toxicity is:
- bradypnea.
- failure to thrive.
- tachycardia.
- vomiting.
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7. The community health nurse is conducting a research study and is identifying clients in the community at risk for latex allergy. Which client population is most at risk for developing this type of allergy?
- Hairdressers
- The homeless
- Children in day care centers
- Individuals living in a group home
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8. Functional nursing has some advantages, which one is an EXCEPTION?
- Psychological and sociological needs are emphasized.
- Great control of work activities.
- Most economical way of delivering nursing services.
- Workers feel secure in dependent role
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9. The nurse is providing instructions about measures to prevent postpartum mastitis to a client who is breast-feeding her newborn. Which client statement would indicate a need for further instruction?
- "I should breast-feed every 2 to 3 hours"
- "I should change the breast pads frequently"
- "I should wash my hands well before breast-feeding"
- "I should wash my nipples daily with soap and water."
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10. The therapeutic approach in the care of Armand an autistic child include the following EXCEPT:
- Engage in diversionary activities when acting-out
- Provide an atmosphere of acceptance
- Provide safety measures
- Rearrange the environment to activate the child
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11. 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 22 year old client is at 20 weeks gestation. She asks the nurse about the development of her fetus at this stage. Which of the following developments occurs at 20 weeks gestation?
- The pancreas starts producing insulin and the kidneys produce urine.
- The fetus follows a regular schedule of turning, sleeping, sucking, and kicking.
- Swallowing reflex has been mastered, and the fetus sucks its thumb.
- Surfactant forms in the lungs.
12. Which of the following will best describe a management function?
- Writing a letter to the editor of a nursing journal.
- Negotiating labor contracts.
- Directing and evaluating nursing staff members.
- Explaining medication side effects to a client.
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13. The client delivered a nine-pound infant two days ago. An effective means of managing discomfort from an episiotomy is:
- Medicated suppository
- Taking showers
- Sitz baths
- Ice packs
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14. The sequence in examining the quadrants of the abdomen is:
- RUQ, RLQ, LUQ, LLQ
- RLQ, RUQ, LLQ, LUQ
- RUQ, RLQ, LLQ, LUQ
- RLQ, RUQ, LUQ, LLQ
15. The nurse is administering fluids intravenously as prescribed to a client who sustained superficial partial-thickness burn injuries of the back and legs. In evaluating the adequacy of fluid resuscitation, the nurse understands that which assessment would provide the most reliable indicator for determining the adequacy?
- Vital signs
- Urine output
- Mental status
- Peripheral pulses
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16. This is the study of the patterns of health and disease. Its occurrence and distribution in man, for the purpose of control and prevention of disease.
- Epidemiology
- Ecology
- Statistics
- Geography
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17. Agatha, was hacked and slashed by a psychotic man while she was crossing the railway. She suffered multiple injuries and was injected Tetanus toxoid Immunoglobulin. Agatha asked you, What immunity does TTIg provides? You best answered her by saying TTIg provides
- Natural active immunity
- Natural passive immunity
- Artificial active immunity
- Artificial passive immunity
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18. The nurse evaluates the ability of a hepatitis B-positive mother to provide safe bottle feeding to her newborn during postpartum hospitalization. Which maternal action best exemplifies the mother's knowledge of potential disease transmission to the newborn?
- The mother requests that the window be closed before feeding.
- The mother holds the newborn properly during feeding and burping.
- The mother tests the temperature of the formula before initiating feeding.
- The mother washes and dries her hands before and after self-care of the perineum and asks for a pair of gloves before feeding.
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19. The nurse is assisting a patient to ambulate in the hall The patient a history of coronary artery disease(CAD), and had coronary artery bypass graft surgery(CABG) 3 days ago, the patient reports chest pain rated 3 on a scale of 0 (no pain)to 10 (severe pain) the nurse should FIRST:
- Determine how long it has since the patient's last dose of aspirin
- Obtain a chair for the patient so sit down
- Assess the patient's radial pulse
- Ask the patient to take several slow, deep breaths
20. The nurse is has just admitted a client with severe depression. From which focus should the nurse identify a prioriy nursing diagnosis?
- Nutrition
- Elimination
- Activity
- Safety
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21. The client with a cervical fracture is placed in traction. Which type of traction will be utilized at the time of discharge?
- Russells traction
- Bucks traction
- Halo traction
- Crutchfield tong traction
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22. A male client should be taught about testicular examinations:
- when sexual activity starts
- after age 60
- after age 40
- before age 20
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23. The nurse is preparing a client with a history of command hallucinations for discharge by providing instructions on interventions for managing hallucinations and anxiety. Which statement in response to these instructions suggests to the nurse that the client has a need for additional information?
- "My medications will help my anxious feelings."
- 'I'll go to support group and talk about what I am feeling."
- "I need to get enough sleep and eat well to help prevent feeling anxious"
- "When I have command hallucinations, I'll call a friend and ask him what I should do"
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24. A child with Tetralogy of Fallot is scheduled for a modified Blalock Taussig procedure. The nurse understands that the surgery will:
- Reverse the direction of the blood flow
- Allow better blood supply to the lungs
- Relieve pressure on the ventricles
- Prevent the need for further correction
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25. A 16 year-old client is admitted to a psychiatric unit with a diagnosis of attempted suicide. The nurse is aware that the most frequent cause for suicide in adolescents is
- Progressive failure to adapt
- Feelings of anger or hostility
- Reunion wish or fantasy
- Feelings of alienation or isolation
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26. Prior to administration of an albuterol nebulizer, the nurse should help the patient assume what position?
- Sitting and leaning forward
- Feet elevated above level of heart
- High fowler's
- Standing
27. A client arrives in the emergency department with a penetrating eye injury from wood chips that occurred while cutting wood. The nurse assesses the eye and notes a piece of wood protruding from the eye. What is the initial nursing action?
- Apply an eye patch.
- Perform visual acuity tests.
- Irrigate the eye with sterile saline.
- Remove the piece of wood using a sterile eye clamp.
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28. The physician has ordered an indwelling urinary catheter inserted in a hospitalized patient, the nurse is aware that:
- The procedure requires surgical asepsis
- Lubricant not needed for catheter insertion
- Smaller catheters are used for male catheter
- Normally a clean technique is required for catheter insertion
29. The nurse is caring for a client admitted to the emergency department with diabetic ketoacidosis (DKA). In the acute phase, the nurse plans for which priority intervention?
- Correct the acidosis.
- Administer 5% dextrose intravenously.
- Apply a monitor for an electrocardiogram.
- Administer short-duration insulin intravenously.
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30. The mother of a child with cystic fibrosis tells the nurse that her child makes snoring sounds when breathing. The nurse is aware that many children with cystic fibrosis have:
- Choanal atresia
- Nasal polyps
- Septal deviations
- Enlarged adenoids
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31. A client with type 1 diabetes mellitus has been on a regimen of multiple daily injection therapy. He's being converted to continuous subcutaneous insulin therapy. While teaching the client bout continuous subcutaneous insulin therapy, the nurse would be accurate in telling him the regimen includes the use of:
- intermediate and long-acting insulins
- short and long-acting insulins
- short-acting only
- short and intermediate-acting insulins
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32. After a tonsillectomy a child begins to vomit bright red blood. The nurse should take which initial action?
- Turn the child to the side.
- Administer the prescribed antiemetic.
- Notify the health care provider (HCP).
- Maintain NPO (nothing by mouth) status.
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33. A nurse is caring a patient who had right mastectomy 2 days ago. Which of the following is the appropriate nursing goal for this type of surgery
- Acceptance of altered body image
- Avoid large crowd
- Limit right arm movement
- Perform range of motion for left arm
34. SITUATION : a 20 year old college student was rushed to the ER of PGH after he fainted during their ROTC drill. Complained of severe right iliac pain. Upon palpation of his abdomen, Ernie jerks even on slight pressure. Blood test was ordered. Diagnosis is acute appendicitis.Q. When do you think the NGT tube be removed?
- When patient requests for it
- Abdomen is soft and patient asks for water
- Abdomen is soft and flatus has been expelled
- B and C only
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35. The nurse is caring for the client following a cerebral vascular accident. Which portion of the brain is responsible for taste, smell, and hearing?
- Occipital
- Frontal
- Temporal
- Parietal
36. Situation: Consider the following hypothesis: "The Job turnover rate and job dissatisfaction levels of graduate nurses who have worked less than 2 years is higher than for those graduate nurses who have worked for more than 2 years 'Q. The type of hypothesis in this situation is classified as:
- Simple, Directional
- Simple, Non Directional
- Complex, Directional
- Complex, Research
37. SITUATION: John Lloyd, a 27 basketbail player sustained inhalation burn that required him to have tracheostomy due to massive upper airway edema.Q. Wilma, His sister and a nurse is suctioning the tracheostomy tube of John Lloyd. Which of the following, if made by Wilma indicates that she is committing an error?
- Hyperventilating John Lloyd with 100% oxygen before and after suctioning
- Instilling 3 to 5 ml normal saline to loosen up secretion
- Applying suction during catheter withdrawal
- Suction the client every hour
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38. The nurse is assessing a newborn who was born to a mother who is addicted to drugs. Which findings should the nurse expect to note during the assessment of this newborn? Select all that apply. 1.Lethargy. 2.Sleepiness. 3.Irritability. 4.Constant crying. 5.Difficult to comfort. 6.Cuddles when being held.
- 1,2,4
- 3,4,5
- 1,2,3,4
- 2,3,5
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39. The most common psychogenic disorder among elderly person is:
- Depression
- Sleep disturbances (such as bizarre dreams)
- Inability to concentrate
- Decreased appetite
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40. Charina, a college student who frequently visited the health center during the past year with multiple vague complaints of Gl symptoms before course examinations. Although physical causes have been eliminated, the student continues to express her belief that she has a serious illness. These symptoms are typically of which of the following disorders?
- Conversion disorder
- Depersonalization
- Hypochondriasis
- Somatization disorder
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41. A client comes to the emergency department while experiencing a panic attack. The nurse can best respond to a client having a panic attack by:
- staying with the client until the attack subsides.
- telling the client everything is under control.
- telling the client to lie down and rest.
- talking continually to the client by explaining what's happening.
42. The nurse is preparing a client with an axillo-popliteal bypass graft for discharge. The client should be taught to avoid
- Using a recliner to rest
- Resting in supine position
- Sitting in a straight chair
- Sleepinain right Sim’s position
43. Nurse Jenny is instilling an otic solution into an adult male client left ear. Nurse Jenny avoids doing which of the following as part of the procedure
- Pulling the auricle backward and upward
- Warming the solution to room temperature
- Pacing the tip of the dropper on the edge of ear canal
- Placing client in side lying position
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44. The nurse is monitoring a client in the immediate postpartum period for signs of hemorrhage. Which sign, if noted, would be an early sign of excessive blood loss?
- A temperature of 100.4°F(38°C)
- An increase in the pulse rate from 88 to 102 beats/minute
- A blood pressure change from 130/88 to 124/80 mm Hg
- An increase in the respiratory rate from 18 to 22 breaths/minute
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45. The blood alcohol concentration of a client admitted following a motor vehicle accident is 460mg/dL. The nurse should give priority to monitoring the client for:
- Loss of coordination
- Respiratory depression
- Visual hallucinations
- Tachycardia
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46. After a muscle biopsy nurse Willy should teach the client to:
- Change the dressing as needed
- Resume the usual diet as soon as desired
- Bathe or shower according to preference
- Expect a rise in body temperature for 48 hours
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47. An infant is ordered to recive 500 ml of D5NSS for 24 hours. The Intravenous drip is running at 60 gtts/min. How many drops per minute should the flow rate be?
- 60 gtts/min.
- 21 gtts/min
- 30 gtts/min
- 15 gtts/min
48. Nurse Tina is caring for a client with depression who has not responded to antidepressant medication. The nurse anticipates that what treatment procedure may be prescribed?
- Neuroleptic medication
- Short term seclusion
- Psychosurgery
- Electroconvulsive therapy
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49. For a client with anorexia nervosa, which goal takes the highest priority?
- The client will establish adequate daily nutritional intake.
- The client will make a contract with the nurse that sets a target weight.
- The client will identify self-perceptions about body size as unrealistic.
- The client will verbaiize the possible physiological consequences of self-starvation.
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50. An obstetrical client decides to have an epidural anesthetic to relieve pain during labor. Following administration of the anesthesia, the nurse should monitor the client for:
- Seizures
- Postural hypertension
- Respiratory depression
- Hematuria
NCLEX-RN | QB1 | Practice Exam #46 (50 questions)