NCLEX-RN | QB1 | Practice Exam #44 (50 questions)
1. A nurse should teach a patient who is taking chlorpromazine (Thorazine) to avoid:
- Exposure to the sun
- Swimming in a chlorinated pool
- Drinking fluids high in sodium
- Eating foods such as chocolate and aged cheese
2. The nurse prepares a list of home care instructions for the parents of a child who has a plaster cast applied to the left forearm. Which instructions should be included on the list? Select all that apply. 1.Use the fingertips to lift the cast while it is drying. 2.Keep small toys and sharp objects away from the cast. 3.Use a padded ruler or another padded object to scratch the skin under the cast if it itches. 4.Place a heating pad on the lower end of the cast and over the fingers if the fingers feel cold. 5.Elevate the extremity on pillows for the first 24 to 48 hours after casting to prevent swelling. 6.Contact the health care provider (HCP) if the child complains of numbness or tingling in the extremity.
- 1,2,3,4
- 2,4,6
- 1,3,5,6
- 2,5,6
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3. A client is brought to the emergency department by emergency medical services (EMS) after being hit by a car. The name of the client is unknown, and the client has sustained a severe head injury and multiple fractures and is unconscious. An emergency craniotomy is required. Regarding informed consent for the surgical procedure, which is the best action?
- Obtain a court order for the surgical procedure.
- Ask the EMS team to sign the informed consent.
- Transport the victim to the operating room for surgery.
- Call the police to identify the client and locate the family.
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4. The nurse is reviewing a treatment plan with the parents of a newborn with hypospadias. Which statement by the parents indicates their understanding of the plan?
- "Caution should be used when straddling the infant on a hip"
- "Vital signs should be taken daily to check for bladder infection."
- "Catheterization will be necessary when the infant does not void"
- "Circumcision has been delayed to save tissue for surgical repair"
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5. 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
6. Situation: Vincent, age 26, who is caught in me raging conflict between his mother and his wife, complains of pains in his right leg that has progressed to the point of paralysis. After orthopedic consultation has shown no pathology, he is referred for a psychiatric consultation and is found to have a conversion disorder.Q. Which intervention would be most therapeutic for the nurse to make?
- Encourage him to try to walk
- Tell him there is nothing wrong
- Avoid focusing on his physical symptoms
- Help him follow through with the physical therapy plan
7. Nurse Cristina is caring for a client who experiences false sensory perceptions with no basis in reality. These perceptions are known as:
- Delusions
- Hallucinations
- Loose associations
- Neologisms
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8. Situation: Mrs. Pichay is admitted to your ward. The MD ordered "Prepared for thoracentesis this pm to remove excess air from the pleural cavity". Q. Which of the following nursing responsibility is essential in Mrs. Pichay who will undergo thoracentesis?
- Support and reassure client during the procedure
- Ensure that informed consent has been signed
- Determine if client has allergic reaction to local anesthesia
- Ascertain if chest x-rays and other tests have been prescribed and completed
9. A newly admitted female client was diagnosed with deep vein thrombosis. Which nursing diagnosis should receive the highest priority?
- Ineffective peripheral tissue perfusion related to venous congestion.
- Risk for injury related to edema.
- Excess fluid volume related to peripheral vascular disease.
- Impaired gas exchange related to increased blood flow.
10. The nurse is preparing to discharge a client with a long history of polio. The nurse should tell the client that:
- Taking a hot bath will decrease stiffness and spasticity.
- A schedule of strenuous exercise will improve muscle strength.
- Rest periods should be scheduled throughout the day.
- Visual disturbances can be corrected with prescription glasses.
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11. A child with cystic fibrosis exacerbation presents to the emergency room. Which nursing diagnosis takes FIRST? Priority in planning for intervention?
- Imbalanced nutrition related to increased metabolic requirements because of malabsorption
- Deficient knowledge regarding prevention of cystic fibrosis exacerbation
- Impaired gas exchange related to airway obstruction due to mucous
- Interrupted familyn processes related to hospitalization
12. A health care provider prescribes 1000 mL of normal saline 0.9% to infuse over 8 hours. The drop factor is 15 drops (gtt)/1 mL. The nurse sets the flow rate at how many drops per minute? Find your answer to the nearest whole number.
- 34 drops per minute.
- 31 drops per minute.
- 41 drops per minute.
- 25 drops per minute.
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13. A 25 year old male is admitted to a mental health facility because of inappropriate behavior The client has been hearing voices, responding to imaginary companions and withdrawing to his room for several days at a time. Nurse Monette understands that the withdrawal is a defense against the clients fear of:
- Phobia
- Powerlessness
- Punishment
- Rejection
14. Andy is not yet fluent in French, but he works in Quebec where majority speaks French. He is starting to learn the language of the people. What type of adaptation is Andy experiencing?
- Biologic/Physiologic adaptive mode
- Psychologic adaptive mode
- Sociocultural adaptive mode
- Technological adaptive mode
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15. A 50 year-old male presents to the medical office 3 weeks after cardiac surgery with complaints of a feeling of weakness, difficulty breathing, and joint pains. Upon examination the nurse finds a fever and a friction rub on auscultation of the chest. The nurse recognizes that the MOST likely surgical complication is:
- Neuropsychological dysfunction
- Postpericardiotomy syndrome
- Cardiac tamponade
- Phrenic nerve damage
16. The nurse employed in a long-term care facility is planning assignments for the clients on a nursing unit The nurse needs to assign four clients and has a licensed practical (vocational) nurse and 3 unlicensed assistive personnel (UAPs) on a nursing team. Which client would the nurse most appropriately assign to the licensed practical (vocational) nurse?
- A client who requires a bed bath
- An older client requiring frequent ambulation
- A client who requires hourly vital sign measurements
- A client requiring abdominal wound irrigations and dressing changes every 3 hours
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17. Joey plans to revisit the organizational chart of the department He plans to create a new position of a Patient Educator who has a coordinating relationship with the head nurse in the unit. Which of the following will likely depict this organizational relationship?
- Box
- Solid line
- Broken line
- Dotted line
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18. One (1) tsp is equals to how many drops?
- 15
- 60
- 10
- 30
19. The nurse is inserting an intravenous (IV) line into a client's vein. After the initial stick, the nurse would continue to advance the catheter in which situation?
- The catheter advances easily.
- The vein is distended under the needle.
- The client does not complain of discomfort.
- Blood return shows in the backflash chamber of the catheter.
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20. Which of the following goal take PRIORITY when recovering from general anesthesia in post anesthesia care unit (PACU)?
- Thermoregulation
- Plastic skin turgor
- Patent airway
- Patient voids freely
21. Sally Baker, a 40-year-old woman, is admitted to the hospital with an established diagnosis of mitral stenosis. She is scheduled for surgery to repair her mitral valve. Q. Which of the following operative procedures of the thorax is paired with the correct definition?
- Pneumonectomy: removal of the entire lung
- Wedge resection: removal of one or more lobes of a lung
- Decortication: removal of the ribs or sections of ribs
- Thoracoplasty: removal of fibrous membrane that develops over visceral pleura as a result of emphysema
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22. A 68 year-old woman is receiving parenteral nutrition at home. The district nurse visits the woman and notes that she has gained one kilogram of weight since a health provider had visited one week ago. There is pitting edema of 2+ of the lower extremities. The patient is alert, active and oriented.Which nursing diagnosis is most appropriate?
- Non-compliance
- Impaired gas exchange
- Imbalanced nutrition
- Fluid volume overload
23. When caring for a female client who is being treated for hyperthyroidism, it is important to:
- Provide extra blankets and clothing to keep the client warm.
- Monitor the client for signs of restlessness, sweating, and excessive weight loss during thyroid replacement therapy.
- Balance the client's periods of activity and rest.
- Encourage the client to be active to prevent constipation.
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24. 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.The school nurse notices a child who is wearing old, dirty poor-fitting clothes is always hungry has no lunch money and is always tired. When the nurse asks the boy his tiredness, he talks of playing outside until midnight The nurse will suspect that this child is:
- Being raised by a parent of low intelligence quotient (IQ)
- An orphan
- A victim of child neglect
- The victim of poverty
25. Which of the following characteristics will distinguish a postmature neonate at birth?
- Plenty of lanugo and vernix caseosa
- Lanugo mainly on the shoulders and vernix in the skin folds
- Pinkish skin with good turgor
- Almost leather-like, dry, cracked skin, negligible vernix caseosa
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26. The nurse performs a routine assessment of newborn boy who was born 30 minutes before. One testicle is descended and the urinary meatus opens on the underside of the ventral shaft. Based on the findings, which additional body part should be examined carefully?
- Anus
- Buttocks
- Umbilicus
- Groin
27. Situation: Mr. Roberto's condition continues to worsen and the doctor suggested Kidney Transplantation.Q. Which of the following is the rationale why Azathioprine (Imuran), Prednisone or Cyclosporine (Sandimmune) is given in a client that has undergone Kidney Transplantation?
- To enhance the immune system preventing rejection
- To suppress the immune system preventing rejection
- To enhance kidney function
- To protect the newly transplanted kidney from invading pathogens
28. Situation: There are other important basic knowledge in the performance of our task as Community Health Nurse in relation to IMMUNIZATION these include: Q. The correct temperature to store vaccines in a refrigerator is:
- between -4 deg C and +8 deg C
- between +2 deg C and +8 deg C
- between -8 deg C and 0 deg C
- between -8 deg C and +8 deg C
29. A client has been diagnosed as having bladder cancer, and a cystectomy and an ileal conduit are scheduled. Preoperatively, the nurse plans to:
- Limit fluid intake for 24 hours
- Teach muscle tightening exercises
- Teach the procedure for irrigation of the stoma
- Provide cleansing enemas and laxatives as ordered
30. Situation: Milo, a 16-year-old male, has been diagnosed to have AIDS. He worked as entertainer in a cruise ship. Causative organism in AIDS is one of the following:
- Fungus
- Bacteria
- retrovirus
- Parasites
31. A 4-year-old child is admitted to the hospital for abdominal pain. The mother reports that the child has been pale and excessively tired and is bruising easily. On physical examination, lymphadenopathy and hepatosplenomegaly are noted. Diagnostic studies are being performed because acute lymphocytic leukemia is suspected. The nurse determines that which laboratory result confirms the diagnosis?
- Lumbar puncture showing no blast cells
- Bone marrow biopsy showing blast cells
- Platelet count of 350,000 mm3 (350A109/L)
- White blood cell count 4500 mm3 (4.5A109/L)
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32. The physician ordered Phenylephrine (Neo-Synephrine) nasal spray to a 13-year-old client. The nurse caring to the client provides instructions that the nasal spray must be used exactly as directed to prevent the development of:
- Increased nasal congestion.
- Nasal polyps.
- Bleeding tendencies.
- Tinnitus and diplopia.
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33. Nurse Becky is caring for client who begins to experience seizure while in bed. Which action should the nurse implement to prevent aspiration?
- Position the client on the side with head flexed forward
- Elevate the head
- Use tongue depressor between teeth
- Loosen restrictive clothing
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34. A client is discharged following hospitalization for congestive heart failure. The nurse teaching the family suggests they encourage the client to rest frequently in which of the following positions?
- High Fowler's
- Supine
- Left lateral
- Low Fowler's
35. Situation: Nurses hold a variety of roles when providing care to a perioperative patient. Q. As a perioperative nurse, how can you best meet the safety need of the client after administering preoperative narcotic?
- Put side rails up and ask the client not to get out of bed
- Send the client to OR with the family
- Allow client to get up to go to the comfort room
- Obtain consent form
36. Which instruction by the nurse should be included in the teaching plan for an infertile woman who has been shown to have a 28-day biphasic menstrual cycle?
- Douche with a cider vinegar solution immediately before having intercourse.
- Schedule intercourse every day from day 8 to day 14 of the menstrual cycle.
- Be placed on folliicle-stimulating hormone therapy by the fertility specialist.
- Assess the basal body temperature pattern for at least 6 more months.
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37. Mr. Duffy is admitted to the CCU with a diagnosis of R/O Ml. He presented in the ER with a typical description of pain associated with an Mi, and is now cold and clammy, pale and dyspneic. He has an IV of D5W running, and is complaining of chest pain. Oxygen therapy has not been started, and he is not on the monitor. He is frightened.Q. You did the initial assessment on Mr. Kaplan when he came to your unit What classical signs and symptoms did you note?
- fruity-smelling breath.
- Weakness, anorexia, pruritus
- Polyuria, polydipsia, polyphagia
- Ruddy complexion
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38. Mrs. Hogan, a 43-year-old woman, is admitted to your unit for cholecystectomy.Q. An esophageal obturator airway (EOA):
- Can be inserted by any person trained in ACLS.
- Requires visualization of the trachea before insertion.
- Never causes regurgitation.
- Should not be used with a conscious person, pediatric patients, or patients who have swallowed caustic substances.
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39. The physician has ordered a low-potassium diet for a client with acute glomerulonephritis. Which snack is suitable for the client with potassium restrictions?
- Raisins
- Orange
- Banana
- Apple
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40. Katrina, a newly admitted is extremely hostile toward a staff member she has just met, without apparent reason. According to Freudian theory the nurse should suspect that the client is experiencing which of the following phenomena?
- Intellectualization
- Transference
- Triangulation
- Splitting
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41. Situation: As a nurse you are expected to participate in initiating or participating in the conduct of research studies to improve nursing practice. You have to be updated on the latest trends and issues affecting profession and the best practices arrived at by the profession. Q. You are shown a Likert Scaie that will be used in evaluating your performance in the clinical area. Which of the following questions will you not use in critiquing the Likert Scale?
- Are the techniques to complete and score the scale provided?
- Are the reliability and validity information on the scale described?
- If the Likert Scale is to be used for a study, was the development process described?
- Is the instrument clearly described?
42. Situation: Pharmacological treatment was not effective for Johnny's hyperthyroidism and now he is scheduled for Thyroidectomy.Q. As a nurse, you know that intact skin as an effective barrier to most microorganisms. Therefore, items that come in contact with the intact skin or mucous membranes should be:
- Clean
- Sterile
- Alcoholized
43. Situation: Elderly clients usually produce unusual signs when it comes to different diseases. The aging process is a complicated process and the nurse should understand that it is an inevitable fact and she must be prepared to care for the growing elderly population.Q. Cardiac ischemia in an older patient usually produces:
- ST-T wave changes
- Very high creatinine kinase level
- Chest pain radiating to the left arm
- Acute confusion
44. In the Bartholomew's rule of 4, when the level of the fundus is midway between the umbilicus and xyphoid process the estimated age of gestation (AOG) is:
- 5th month
- 6th month
- 7th month
- 8th month
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45. Contact precautions are initiated for a client with a health care-associated (nosocomial) infection caused by methicillin-resistant Staphylococcus aureus. The nurse prepares to provide colostomy care and should obtain which protective items to perform this procedure?
- Gloves and gown
- Gloves and goggles
- Gloves, gown, and shoe protectors
- Gloves, gown, goggles, and a mask or faceshield
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46. Which of the following is among an ideal way of collecting a urine specimen for culture and sensitivity?
- Use a clean container
- Discard the first flow of urine to ensure that the urine is not contaminated
- Collect around 30-50 ml of urine
- Add preservatives, refrigerate the specimen or add ice according to the agency's protocol
47. The nurse is caring for a client with peripheral vascular disease. To correctly assess the oxygen saturation level the monitor may be placed on the:
- Hip
- Ankle
- Earlobe
- Chin
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48. Gentian Violet is used for:
- Wound
- Umbilical infections
- Ear infections
- Burn
49. A client with a history of depression is treated with Parnate (tranylcypromine) an MAO inhibitor. Ingestion of foods containing tyramine while taking an MAO inhibitor can result in:
- Extreme elevations in blood pressure
- Rapidly rising temperature
- Abnormal movement and muscle spasms
- Damage to the eighth cranial nerve
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50. A client is admitted to the emergency room after falling down a flight of stairs. Initial assessment reveals a large bump on the front of the head and a two-inch laceration above the right eye. Which finding is consistent with injury to the frontal lobe?
- Complaints of blindness
- Decreased respiratory rate and depth
- Failure to recognize touch
- Inability to identify sweet taste
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NCLEX-RN | QB1 | Practice Exam #44 (50 questions)