NCLEX-RN | QB1 | Practice Exam #42 (50 questions)
1. When the nurse changes the client's dressing which nursing action is correct:
- The nurse removes the solid dressing with sterile gloves.
- The nurse frees the tape by pulling it away from the incision..
- The nurse encloses the solid dressing within a latex gloves.
- The nurse cleans the wound in circles toward the incision.
2. The nurse is creating a plan of care for a client scheduled for surgery. The nurse should include which activity in the nursing care plan for the client on the day of surgery?
- Avoid oral hygiene and rinsing with mouthwash.
- Verify that the client has not eaten for the last 24 hours.
- Have the client void immediately before going into surgery.
- Report immediately any slight increase in blood pressure or pulse.
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3. Situation: As a nurse, you should be aware and prepared of the different roles you play. Q. As a nurse, you can help improve the effectiveness of communication among healthcare givers
- Use of reminders of what to do
- Using standardized list of abbreviations, acronyms, and symbols
- One-on-one oral endorsement
- Text messaging and e-mail
4. Beth a public health nurse takes an active role in community participation. What is the primary goal of community organizing?
- To educate the people regarding community health problems
- To mobilize the people to resolve community health problems
- To maximize the community's resources in dealing with health problems
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5. A client with tuberculosis has a prescription for Myambutol (ethambutol HCI). The nurse should tell the client to notify the doctor immediately if he notices:
- Gastric distress
- Changes in hearing
- Red discoloration of body fluids
- Changes in color vision
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6. Situation: Mastery of research design determination is essential in passing the Nurse Licensure Examination.Q. Diane is to conduct a study about the relationship of The number of family members in the household and the electricity bill. Which of the following is best research design suited for this study? 1.Descriptive 2.Exploratory 3.Explanatory 4.Correlational 5.Comparatives 6.Experimental
- 1,4
- 2,5
- 3,6
- 1,5
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7. The degree of patients abdominal distension may be determined by:
- Auscultation
- Palpation
- Inspection
- Percussion
8. Situation: The question with regards to the OPERATING ROOM.Q. Another worthy study is the compliance to the principles of aseptic technique among the sterile OR team. Who does NOT belong to the sterile OR team?
- scrub nurse
- assistant surgeon
- x-ray technician
- surgeon
9. Situation: Team efforts is best demonstrated in the OR. Q. In the OR, the nursing tandem for every surgery is:
- Instrument technician and circulating nurse
- Nurse anesthetist, nurse assistant, and instrument technician
- Scrub nurse and nurse anesthetist
- Scrub and circulating nurses
10. A newborn with narcotic abstinence syndrome is admitted to the nursery. Nursing care of the newborn should include:
- Teaching the mother to provide tactile stimulation
- Wrapping the newborn snugly in a blanket
- Placing the newborn in the infant seat
- Initiating an early infant-stimulation program
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11. The nurse should understand that one dose of which of the following vaccinations is recommended for this patient before the age of 65 years:
- Varicella
- Influenza
- Hepatitis B
- Pneumococcal
12. When instructions should be included in the discharge teaching plan for a client after thyroidectomy for Grave's disease?
- Keep an accurate record of intake and output.
- Use nasal desmopressin acetate DDAVP.
- Be sure to get regulate follow-up care.
- Be sure to exercise to improve cardiovascular fitness.
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13. Nurse Aida has seen her patient, Roger for the first time. She establish a contract about the frequency of meeting and introduce to Roger the expected termination. She started taking baseline assessment and set interventions and outcomes. On what phase of NPR Does Nurse Aida and Roger belong?
- Pre Orientation
- Orientation
- Working
- Termination
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14. Situation: Sterilization is the process of removing ALL living microorganism. To be free of ALL living microorganism is sterility.Q. It is important that before a nurse prepares the material to be sterilized. A chemical indicator strip should be placed above the package, preferably, Muslin sheet What is the color of the striped produced after autoclaving?
- Black
- Blue
- Gray
- Purple
15. Ms. Valencia is responsible to the number of personnel reporting to her This principle refers to:
- Span of control
- Unity of command
- Carrot and stick principle
- Esprit d' corps
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16. Grace, believes that her relationship with God is broken. She tried to go to church to ask forgiveness everyday to remedy her feelings. What kind of spiritual distress is Grace experiencing?
- Spiritual Pain
- Spiritual Alienation
- Spiritual Guilt
- Spiritual Despair
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17. A patient report difficulty sleeping through the night since the death of spouse 6 months ago which of the following is an appropriate LONG term goal?
- Feeling well rested each morning
- Not feeling tired each afternoon
- Taking brief nap in the middle of the day
- Using sleep aid on a nightly basis
18. Situation: Mrs. Ethel Agustin 50 y/o, teacher is affected with myasthenia gravis. Q. If you are extra careful and by chance you give over medication, this would lead to:
- Cholinergic crisis
- Menopausal crisis
- Emotional crisis
- Myasthenia crisis
19. A nurse working in an infertility clinic should include which of the following in her discussions with the couple?
- Adoption as an alternative to infertility treatments.
- The legal controversy surrounding artificial insemination.
- The need to seek marriage counseling before undergoing infertility treatments.
- Statistics regarding the number of couples who never learn why they are infertile.
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20. After performing an initial abdominal assessment on a client with nausea and vomiting, the nurse should expect to note which finding?
- Waves of loud gurgles auscultated in all 4 quadrants
- Low-pitched swishing auscultated in 1 or 2 quadrants
- Relatively high-pitched clicks or gurgles auscultated in all 4 quadrants
- Very high-pitched, loud rushes auscultated especially in 1 or 2 quadrants
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21. A patient with an unnecessary gait and a history of falls has a care plan intervention that includes keeping the walker in reach and pathway free of obstacle. On evaluation after 1 week, the patient has had no falls, but the gait remains unsteady. The nurse should:
- Continue the plan of care as written
- Allow the patient to replace the walker with a cane
- Allow the patient to ambulate short distance without the walker
- Have the patient practice stepping over small objects
22. The nurse is performing a breast exam on a client when she discovers a mass. Which characteristic of the mass would best indicate a reason for concern?
- Tender to the touch
- Regular shape
- Moves easily
- Firm to the touch
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23. The community nurse is teaching the group of mothers about the cervical mucus method of natural family planning. Which characteristics are typical of the cervical mucus during the "fertile" period of the menstrual cycle?
- Absence of ferning.
- Thin, clear, good spinnbarkeit.
- Thick, cloudy.
- Yellow and sticky.
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24. Dyspnea is defined as:
- Pallor
- Absence of breathing
- Cyanosis
- Difficult respiration
25. Situation: For more than a month now, Cecilia is persistently feeling restless, worried and feeling as if something dreadful is going to happen. She fears being alone in places and situations where she thinks that no one might come to rescue her just in case something happens to her.Q. Cecilia has a lot of irrational thoughts: The goal of therapy is to modify her:
- communication
- cognition
- observation
- perception
26. Nurse Bea should instruct the male client with an ileostomy to report immediately which of the following symptom?
- Absence of drainage from the ileostomy for 6 or more hours
- Passage of liquid stool in the stoma
- Occasional presence of undigested food
- A temperature of 37.6 °C
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27. Which of the following should the nurse teach the client about the signs of digitalis toxicity?
- Increased appetite
- Elevated blood pressure
- Skin rash over the chest and back
- Visual disturbances such as seeing yellow spots
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28. In palpating the client's breast, which of the following position is necessary for the patient to assume before the start of the procedure?
- Supine
- Dorsal recumbent
- Sitting
- Lithotomy
29. A nurse is caring for a patient who is 6 hours post left lobectomy. On assessment the nurse observes that the patient has become very restless and the nail beds are blue, the vital signs reveal tachycardia, tachypnea and blood pressure is rising. Which of the following complication is MOST likely?
- Pneumonia
- Hypoxia
- Postoperative bleeding
- Broncho pleural fistula
30. Situation: Mrs. Ethel Agustin 50 y/o, teacher is affected with myasthenia gravis. Q. The drug of choice for her condition is:
- Prostigmine
- Morphine
- Codeine
- Prednisone
31. The nurse understands that Hodgkin's disease is suspected when a client presents with a painless, swollen lymph node. Hodgkin's disease typically affects people in which age group?
- Children (ages 6-12 years)
- Teenagers (ages 13-20 years)
- Young adults (ages 21-40 years)
- Older adults (ages 41-50 years)
32. While the nurse is administering a large volume enema, the patient complains of cramping. The nurse should:
- Increase the flow rate
- Lower the fluid container
- Elevate the head of the bed
- Gently massage the abdomen
33. The municipality assigned to you has a population of about 20/000. Estimate the number of 1-4 year old children who be given Retinol capsule 200.000 every 6 months.
- 1500
- 2000
- 1800
- 2300
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34. The nurse is teaching a client with chronic bronchitis about breathing exercises. Which of the following should the nurse include in the teaching?
- Make inhalation longer than exhalation.
- Exhale through an open mouth.
- Use diaphragmatic breathing.
- Use chest breathing.
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35. One of the expectations is for nurses to join professional association primarily because of
- Promotes advancement and professional growth among its members
- Works for raising funds for nurse's benefit
- Facilitate and establishes acquaintances
- Assist them and securing jobs abroad
36. A male client with inflammatory bowel disease undergoes an ileostomy. On the first day after surgery, Nurse Oliver notes that the clients stoma appears dusky. How should the nurse interpret this finding?
- Blood supply to the stoma has been interrupted.
- This is a normal finding 1 day after surgery.
- An intestinal obstruction has occurred.
- The ostomy bag should be adjusted.
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37. Situation: John Mark is a 21 year old male client who was rushed following an automobile accident He is very anxious, dyspneic and in severe paimQ. The nurse notices that John's chest tube was dislodged from the chest. The most appropriate nursing intervention is to:
- Notify the physician
- Cover the insertion site with petrolatum gauze
- Immersed the tube into a bottle of sterile water
- Clamp the tube
38. A patient who is 4 days postoperative after a total hip replacement surgery, is obese and has not been able to ambulate since the surgery. The patient is now diaphoretic, has chills, and complains of pain in the thigh. There is tenderness over the anteromedial surface of the thigh. The MOST likely cause is.
- Wound infection
- Deep vein thrombosis (DVT)
- Pulmonary edema
- Dehydration
39. The nurse is assessing the casted extremity of a client. The nurse assesses for which of the following signs and symptoms indicative of infection?
- Coolness and pallor of the extremity
- Presence of a "hot spot" on the cast
- Diminished distal pulse
- Dependent edema
40. Acticoat (silver nitrate) dressings are applied to the legs of a client with deep partial thickness burns. The nurse should:
- Change the dressings once per shift.
- Moisten the dressing with sterile water.
- Change the dressings only when they become soiled.
- Moisten the dressing with normal saline.
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41. A nurse is suctioning fluids from a client via a tracheostomy tube. When suctioning, the nurse must limit the suctioning to a maximum of:
- 10 seconds
- 5 seconds
- 30 seconds
- 1 minute
42. The nurse caring for a child who sustained a burn injury plans care based on which pediatric considerations associated with this injury? Select all that apply. 1.Scarring is less severe in a child than in an adult. 2.A delay in growth may occur after a burn injury. 3.An immature immune system presents an increased risk of infection for infants and young children. 4.Fluid resuscitation is unnecessary unless the burned area is more than 25% of the total body surface area. 5.The lower proportion of body fluid to body mass in a child increases the risk of cardiovascular problems. 6.Infants and young children are at increased risk for protein and calorie deficiency because they have smaller muscle mass and less body fat than adults.
- 2,3,6
- 3,5,6
- 1,2,4,5
- 1,3,4,6
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43. Situation: Nursing informatics is a way of using information technology; computers and the internet in the improvement of nursing care. The first nursing informatics conference was held during 1977. Q. A textbook publisher wants to store large amount of data in a computer format that cannot be changed by other people. Which of the following would best serve this purpose?
- CD ROM
- Floppy disk
- RAM
- Network
44. Situation: Radiation therapy is another modality of cancer management With emphasis on multidisciplinary management you have important responsibilities as a nurse. Q. Albert is admitted with a radiation induced thrombocytopenia. As a nurse you should observe the following symptoms:
- Petechiae, ecchymosis, epistaxis
- Weakness, easy fatigability, pallor
- Headache, dizziness, blurred vision
- Severe sore throat, bacteremia, hepatomegaly
45. Constipation is:
- Fewer than 5 bowel movement per week.
- Fewer than three bowel movement per week.
- Passage of liquid feces and increased frequency of defecation.
- air or gas in GI tract
46. A client is being admitted with syndrome of inappropriate diuretic hormone. Which does the nurse expect to observe?
- Muscle weakness
- Tachycardia
- Polyuria
- Hostility
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47. An 83 year-old woman lives in a long term care facility. During the past two weeks, she has suffered two fails that resulted in minor injuries and now complains of pain in the left shoulder. On auscultation, bowel sounds are diminished in all four quadrants. On palpation, she has tenderness and guarding over the upper left quadrant and complain of a feeling of fullness. What could be the most likely underlying cause of the finding?
- Constipation
- Liver distention
- Splenic rupture
- Intestinal obstruction
48. To help prevent resident falls, the nurse aide should:
- always raise siderails when any resident is in his/her bed.
- leave residents' beds at the lowest level when care is complete.
- encourage residents to wear larger-sized, loose-fitting clothing.
- remind residents who use call lights that they need to wait patiently for staff
49. A client with acute alcohol intoxication is being treated for hypomagnesemia. During assessment of the client the nurse would expect to find:
- Bradycardia
- Negative Chvosteks sign
- Hypertension
- Positive Trousseaus sign
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50. Situation: Prevention of Dengue is an important nursing responsibility and controlling it's spread is priority once outbreak has been observed.The community health nurses primary concern in the immediate control of hemorrhage among patients with dengue is:
- Advising low fiber and non-fat diet
- Providing warmth through light weight covers
- Observing closely the patient for vital signs leading to shock
- Keeping the patient at rest.
NCLEX-RN | QB1 | Practice Exam #42 (50 questions)