NCLEX-RN | QB1 | Practice Exam #45 (50 questions)
1. The client Is admitted to the unit after a cholescystectomy. Montgomery straps are utilized with this client. The nurse is aware that Montgomery straps are utilized on this client because:
- The client is at risk for evisceration.
- The client will require frequent dressing changes.
- The straps provide support for drains that are inserted into the incision.
- No sutures or clips are used to secure the incision.
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2. Situation: Nursing care for the elderly.Q. An elderly who has lots of regrets, unhappy and miserable is experiencing:
- Crisis
- Despair
- Loss
- Ambivalence
3. This is the single most important procedure that prevents cross contamination and infection
- Handwashing
- Cleaning
- Disinfecting
- Sterilizing
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4. The nurse is conducted a community-based educational program about Diabetes mellitus. Which of the following statements by a participant would indicate correct understanding of the teaching?
- Lantus insulin can be mixed with other insulin
- It is necessary to wipe off the top the insulin vial with alcohol to prevent infection
- Insulin will changed color after opening
- Needles can be placed in a hard plastic container with a tightly secure lid
5. To evaluate a woman's understanding about the use of diaphragm for family planning, Nurse Trish asks her to explain how she will use the appliance. Which response indicates a need for further health teaching?
- "I should check the diaphragm carefully for holes every time I use it"
- "I may need a different size of diaphragm if I gain or lose weight more than 20 pounds"
- 'The diaphragm must be left in place for at least 6 hours after intercourse"
- “I really need to use the diaphragm and jelly most during the middle of my menstrual cycle".
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6. Situation: Mr Santos, 50, is to undergo cystoscopy due to multiple problems like scantly urination, hematuria, and dysuria. Q. Within 24-48 hours post cystoscopy, it is normal to observe one of the following:
- Pink-tinged urine
- Distended bladder
- Signs of infection
- Prolonged hematuria
7. Lomotil has been prescribed to treat a client's diarrhea. The nurse should teach the client to report which of the following common side effects?
- Urinary retention
- Diaphoresis
- Hypotension
- Lethargy
8. When the nurse performs a neurologic assessment on Anne Jones, her pupils are dilated and don't respond to light.
- glaucoma
- damage to the third cranial nerve
- damage to the lumbar spine
- Bell's palsy
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9. A child recently diagnosed with sickle cell anemia is being prepared for discharge. Which of the following statement by one of the parents would require ADDITIONAL teaching by the nurse?
- High altitudes can be beneficial
- Blood transfusion may be necessary in the future
- Strenuous physical activity should be avoided
- Increased fluid intake minimize pain
10. The nurse calculates the amount of an antibiotic for injection to be given to an infant The amount of medication to be administered is 1.25mL The nurse should:
- Divide the amount into two injections and administer in each vastus lateralis muscle.
- Give the medication in one injection in the dorsogluteal muscle.
- Divide the amount in two injections and give one in the ventrogluteal muscle and one in the vastus lateralis muscle.
- Give the medication in one injection in the ventrogluteal muscle.
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11. A temporary colostomy is performed on the client with colon cancer. The nurse is aware that the proximal end of a double barrel colostomy:
- Is the opening on the clients left side
- Is the opening on the distal end on the clients left side
- Is the opening on the clients right side
- Is the opening on the distal right side
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12. To effectively teach men the importance of testicular self-examination, the nurse should know that testicular carcinoma:
- Rarely metastasizes
- Has a high incidence of early metastasis
- Cannot be detected by laboratory tests
- Must first be biopsied to confirm the diagnosis
13. These are data that are monitored by using graphic charts or graphs that indicated the progression or fluctuation of client s Temperature and Blood pressure.
- Progress notes
- Kardex
- Flow chart
- Flow sheet
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14. Which of the following complications associated with tracheostomy tube?
- Increased cardiac output
- Acute respiratory distress syndrome (ARDS)
- Increased blood pressure
- Damage to laryngeal nerves
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15. With a fetus in the left-anterior breech presentation, the nurse would expect the fetal heart rate would be most audible in which of the following areas?
- In the lower-left maternal abdominal quadrant
- Above the maternal umbilicus and to the right of midline
- In the lower-right maternal abdominal quadrant
- Above the maternal umbilicus and to the left of midline
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16. A preoperative patient has a large volume cleansing enema ordered. In order to facilitate the flow of the solution into the rectum and colon, the nurse should position the patient in the:
- Supine position with legs flexed to chest
- Right lateral position with left sharply flexed
- Supine position with legs spread
- Left lateral position with right leg sharply flexed
17. The nurse is preparing to start an IV infusion before the administration of a unit of packed red blood cells, what fluid will the nurse select to maintain the infusion before hanging the unit of blood?
- D5W
- D5W/0.45 NaCl
- LR solution
- .9% Na Cl
18. Mrs. Johanson's physician has prescribed tetracycline 500 mg po q6h. While assessing Mrs. Johanson's nursing history for allergies, the nurse notes that Mrs. Johanson's is also taking oral contraceptives. What is the most appropriate initial nursing intervention?
- Administer the dose of tetracycline.
- Notify the physician that Mrs. Johanson is taking oral contraceptives.
- Tell Mrs. Johanson, she should stop taking oral contraceptives since they are inactivated by tetracycline.
- Tell Mrs. Johanson, to use another form of birth control for at least two months.
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19. Which of the following statement by a client with prolonged vomiting indicates the initial onset of hypokalemia?
- My arm feels so weak
- 1 felt my heart beat just right now
- My face muscle is twitching
- Nurse, help! My legs are cramping
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20. Tim is admitted with a diagnosis of delusions of grandeur. The nurse is aware that this diagnosis reflects a belief that one is:
- Highly important or famous.
- Being persecuted
- Connected to events unrelated to oneself
- Responsible for the evil in the world.
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21. The nurse is aware that the following terms used to describe reduced cardiac output and perfusion impairment due to ineffective pumping of the heart is:
- Anaphylactic shock
- Cardiogenic shock
- Distributive shock
- Myocardial infarction (Ml)
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22. When developing a plan of care for a client newly diagnosed with gestational diabetes, which of the following instructions would be the priority?
- Dietary intake
- Medication
- Exercise
- Glucose monitoring
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23. A patient is admitted for pain management due to lung cancer with metastasis of the bone. With a nursing diagnosis of alteration in comfort, the nurse would anticipate the best shot term goal for this patient would be to:
- Not complain of pain
- Appear comfortable and sleep well
- Verbalize that pain is relived
- Verbalize that pain is tolerated
24. The physician has prescribed Synthroid (levothyroxine) for a client with myxedema. Which statement indicates that the client understands the nurses teaching regarding the medication?
- I will take the medication each morning after breakfast.
- I will check my heart rate before taking the medication.
- I will report visual disturbances to my doctor.
- I will stop the medication if I develop gastric upset.
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25. A week after kidney transplantation, a client develops a temperature of 101 °F (38.3 °C), the blood pressure is elevated, and there is tenderness over the transplanted kidney. The serum creatinine is rising and urine output is decreased. The x-ray indicates that the transplanted kidney is enlarged. Based on these assessment findings, the nurse anticipates which treatment?
- Antibiotic therapy
- Peritoneal dialysis
- Removal of the transplanted kidney
- Increased immunosuppression therapy
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26. 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.Pain in geriatric clients require careful assessment because they:
- experienced reduce sensory perception
- have increased sensory perception
- are expected to experience chronic pain
- have a increased pain sensitivity
27. The nurse is teaching the client about his prescribed prednisone. Which statement, if made by the client, indicates that further teaching is necessary?
- "I can take aspirin or my antihistamine if I need it"
- "I need to take the medication every day at the same time.”
- "I need to avoid coffee, tea, cola, and chocolate in my diet"
- "If I gain more than 5 pounds (2.25 kg) a week, I will call my health care provider (HCP)”
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28. A patient recently underwent joint replacement surgery, which of the following nursing diagnosis takes PRIORITY?
- Risk for peripheral neurovascular dysfunction
- Deficient knowledge on appropriate activity precaution
- Impaired physical mobility
- Sexual dysfunction related to pain
29. Situation: Nurses hold a variety of roles when providing care to a perioperative patien. Q. It is the responsibility of the pre-op nurse to do skin prep for patients undergoing surgery. If hair at the operative site is not shaved, what should be done to make suturing easy and lessen chance of incision infection?
- Draped
- Pulled
- Clipped
- Shampooed
30. To prevent xerophthalmia, young children are given Retinol capsule every 6 months. What is the dose given to preschoolers?
- 10, 000 IU
- 20, 000 IU
- 100, 000 IU
- 200, 000 IU
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31. In the morning shift, the nurse is making rounds in the nursing care units. The nurse enters in a client's room and notes that the client's tube has become disconnected from the Pleurovac. What would be the initial nursing action?
- Apply pressure directly over the incision site.
- Clamp the chest tube near the incision site.
- Clamp the chest tube closer to the drainage system.
- Reconnect the chest tube to the Pleurovac.
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32. Nurse Jannah teaches an elderly client with right-sided weakness how to use cane. Which of the following behaviors, if demonstrated by the client to the nurse, indicates that the teaching was effective?
- The client holds the cane with his right hand, moves the can forward followed by the right leg, and then moves the left leg.
- The client holds the cane with his right hand, moves the cane forward followed by his left leg, and then moves the right leg.
- The client holds the cane with his left hand, moves the cane forward followed by the right leg, and then moves the left leg.
- The client holds the cane with his left hand, moves the cane forward followed by his left leg, and then moves the right leg.
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33. The nurse is caring for an older client in a long-term care facility. Which action contributes to encouraging autonomy in the client?
- Planning meals
- Decorating the room
- Scheduling haircut appointments
- Allowing the client to choose social activities
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34. A client with pneumonia is receiving supplemental oxygen, 2 L/min via nasal cannula. The clients history includes chronic obstructive pulmonary disease (COPD) and coronary artery disease. Because of these findings, the nurse closely monitors the oxygen flow and the clients respiratory status. Which complication may arise if the client receives a high oxygen concentration?
- Apnea
- Anginal pain
- Respiratory alkalosis
- Metabolic acidosis
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35. The nurse in a health care clinic is instructing a pregnant client how to perform "kick counts." Which statement by the client indicates a need for further instruction?
- "I will record the number of movements or kicks."
- "I need to lie flat on my back to perform the procedure.”
- "If I count fewer than 10 kicks in a 2-hour period, I should count the kicks again over the next 2 hours"
- "I should place my hands on the largest part of my abdomen and concentrate on the fetal movements to count the kicks”
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36. Which assessment finding is most consistent with early alcohol withdrawal?
- Heart rate of 120 to 140 beats/minute
- Heart rate of 50 to 60 beats/minute
- Blood pressure of 100/70 mm Hg
- Blood pressure of 140/80 mm Hg
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37. A client is brought to the emergency room by the police. He is combative and yells I have to get out of here. They are trying to kill me. Which assessment is most likely correct in relation to this statement?
- The client is experiencing an auditory hallucination.
- The client is experiencing paranoid delusions.
- The client is intoxicated.
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38. When teaching a group of adolescents about variations in the length of the menstrual cycle, the nurse understands that the underlying mechanism is due to variations in which of the following phases?
- Menstrual phase
- Proliferative phase
- Secretory phase
- Ischemic phase
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39. Danny who is diagnosed with bipolar disorder and acute mania, states the nurse, "Where is my daughter? I love Louis Rain, rain go away. Dogs eat dirt.” The nurse interprets these statements as indicating which of the following?
- Echolalia
- Neologism
- Clang associations
- Flight of ideas
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40. A pregnant woman had just received her 4th dose of tetanus toxoid. Subsequently her baby will have protection against tetanus for how long?
- 1 year
- 3 years
- 10 years
- Lifetime
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41. A marathon runner experiences a sudden onset of sharp pain in calf immediately after a workout The nurse in the clinic notes mild swelling of the calf and tenderness to touch. Which of the following would the nurse suspect the patient is experiencing?
- Bursitis
- Tendonitis
- Plantar fascitis
- Joint dislocation
42. A patient with end-stage cardiomyopathy and angina pectoris to the office complaining of frequent chest pain and severe dyspnea. With a nursing diagnosed of alteration in comfort, what is the BEST long term goal for this patients?
- Perform all activities of daily living without complaints of chest pain or shortness of breath
- Verbalize and employ strategies to decrease pain and increase coronary blood flow
- Take pain medications around the check and use supplement oxygen at all times
- Understand the disease process and accept the limitation that it places on his lifestyle
43. A client is admitted to the substance abuse unit for alcohol detoxification. Which of the following medications is the nurse most likely to administer to reduce the symptoms of alcohol withdrawal?
- naloxone (Narcan)
- haloperidol (Haldol)
- magnesium sulfate
- chlordiazepoxide (Librium)
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44. A client has Gastroesophageal Reflux Disease (GERD). The nurse should teach the client that after every meals, the client should...
- Rest in sitting position
- Take a short walk
- Drink plenty of water
- Lie down at least 30 minutes
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45. The nurse is caring for patient with deep vein thrombosis (DVT). The patient's heparin sodium infusion has been discontinued and the patient is receiving prescribed warfarin sodium (Coumadin). The nurse should advise the patient that which of the following needs to be continued?
- Daily complete blood count (CBC)
- Laboratory tests for partial thromboplastin time (PTT)
- Strict bed rest
- Wearing elasticized support stockings
46. The client is diagnosed with multiple myloma. The doctor has ordered cyclophosphamide (Cytoxan). Which instruction should be given to the client?
- Walk about a mile a day to prevent calcium loss
- Increase the fiber in your diet
- Report nausea to the doctor immediately
- Drink at least eight large glasses of water a day
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47. The mother of a 3-year-old child arrives at a clinic and tells the nurse that the child has been scratching the skin continuously and has developed a rash. The nurse assesses the child and suspects the presence of scabies. The nurse bases this suspicion on which finding noted on assessment of the child's skin?
- Fine grayish red lines
- Purple-colored lesions
- Thick, honey-colored crusts
- Clusters of fluid-filled vesicles
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48. Situation: As a Nurse, you have specific responsibilities as professional. You have to demonstrate specific competencies.Q. The essential components of professional nursing practice are all the following EXCEPT:
- Culture
- Care
- Cure
- Coordination
49. What would be the long-term goal for a child with asthma?
- Quickly reverse airflow obstruction
- Correct hypoxemia
- Deliver humidified oxygen via nasal cannula
- Develop a home and school management plan
50. A 25 years-old male patient suffered a spinal cord injury at the T-4 level and is being cared for in hospital. The nurse enters the patient's room and finds the patient sitting upright and looking anxious and restless. He complains of sudden headache and nausea. Sweat forms on his forehead yet his feet are cool to touch Blood pressure:150/100 mmhg. Heart rate: 55/min. Respiratory rate:28/min. Temperature:37.1C. What nursing intervention is initially most appropriate?
- Assess for a full bladder
- Lower the head of the bed 30 degrees
- Loosen clothing and bed sheets
- Apply heating pad to lower extremities
NCLEX-RN | QB1 | Practice Exam #45 (50 questions)