NCLEX-RN | QB1 | Practice Exam #41 (50 questions)
1. Which dietary guidelines are important for nurse Oliver to implement in caring for the client with burns?
- Provide high-fiber, high-fat diet
- Provide high-protein, high-carbohydrate diet.
- Monitor intake to prevent weight gain.
- Provide ice chips or water intake.
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2. The physician orders a maintenance dose of 5,000 units of subcutaneous heparin (an anticoagulant) daily. Nursing responsibilities for Mrs. Mitchell now include:
- Reviewing daily activated partial thromboplastin time (APTT) and prothrombin time.
- Reporting an APTT above 45 seconds to the physician
- Assessing the patient for signs and symptoms of frank and occult bleeding
- All of the above
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3. Baby Tina a 3 month old infant just had a cleft lip and palate repair. What should the nurse do to prevent trauma to operative site?
- Avoid touching the suture line, even when cleaning.
- Place the baby in prone position.
- Give the baby a pacifier.
- Place the infant's arms in soft elbow restraints.
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4. The burned client newly arrived from an accident scene is prescribed to receive 4 mg of morphine sulfate by IV push. What is the most important reason to administer the opioid analgesic to this client by the intravenous route?
- The medication will be effective more quickly than if given intramuscular
- It is less likely to interfere with the client's breathing and oxygenation.
- The danger of an overdose during fluid remobiliization is reduced.
- The client delayed gastric emptying.
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5. Situation: One important toot a community health nurse uses in the conduct of his/her activities is the CHN Bag. Which of the following BEST DESCRIBES the use of this vital facility for our practice? Which among the following is important in the use of the bag technique during home visit?
- Arrangement of the bag's contents must be convenient to the nurse
- The bag should contain all necessary supplies and equipment ready for use
- Be sure to thoroughly clean your bag especially when exposed to communicable disease cases
- Minimize if not totally prevent the spread of infection
6. A patient who has kaposi's sarcoma has all of the following nursing diagnoses. To which one should the nurse give priority?
- Altered thought processes related to lesions
- Altered with maintenance related to non compliance
- Defensive coping related to loss of boundaries
- Hopelessness, related to inability to control disease process
7. Which is the best way to disseminate information to the public?
- Newspaper
- School bulletins
- Community bill boards
- Radio and Television
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8. Which of the following signs should the nurse expect in a client with known amphetamine overdose?
- Hypotension
- Tachycardia
- Hot dry skin
- Constricted pupils
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9. Upon arrival to the nursery erythromycin eyedrops are applied to the newborns eyes. The nurse understands that the medication will:
- Make the eyes less sensitive to light
- Help prevent neonatal blindness
- Strengthen the muscles of the eyes
- Improve accommodation to near objects
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10. 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 large number of neural tube defects may be prevented if a pregnant woman includes which supplement in her diet?
- Vit. A
- Vit. E
- Vit. D
- Vit. B9
11. A patient has a 6-year history of inflammatory bowel disease that is resistant to medical therapy. The patient can BEST decreased the like hood of the disease progressing to:
- Consuming only elemental foods
- Stopping smoking
- Using effective birth control
- Avoiding over heating
12. A client with borderline personality disorder is admitted to the psychiatric unit. Initial nursing assessment reveals that the clients wrists are scratched from a recent suicide attempt. Based on this finding, the nurse should formulate a nursing diagnosis of:
- Ineffective individual coping related to feelings of guilt
- Situational low self-esteem related to feelings of loss of control.
- Risk for violence: Self-directed related to impulsive mutilating acts.
- Risk for violence: Directed toward others related to verbal threats.
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13. A home health nurse has several elderly clients in her case load. Which of the following clients is most likely to be a victim of elder abuse?
- A 76-year-old female with Alzheimers dementia
- A 70-year-old male with diabetes mellitus
- A 64-year-old female with a hip replacement
- A 72-year-old male with Parkinsons disease
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14. Situation: Leo lives in the squatter area. He goes to nearby school. He helps his mother gather molasses after school. One day, he was absent because of fever, malaise, anorexia and abdominal discomfortQ. What is the average incubation period of Hepatitis A?
- 30 days
- 60 days
- 50 days
- 14 days
15. The nurse is assign ed to care for an elderly patient with a low-exudates stage III
- Hydrogel
- Hydrocolloid
- Polyurethane
- Polyurethane foam
16. The physician has ordered intubation and mechanical ventilation for a client with periods of apnea following a closed head injury. Arterial blood gases reveal a pH of 7.47 PCO2 of 28 and HCO3 of 23. These findings indicate that the client has:
- Respiratory acidosis
- Respiratory alkalosis
- Metabolic acidosis
- Metabolic alkalosis
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17. SITUATION: Alfred, a 40 year old construction worker developed cough, night sweats and fever He was brought to the nursing unit for diagnostic studies. He told the nurse he did not receive a BCG vaccine during childhood.Q. Direct sputum examination and Chest X-ray of TB symptomatic is in what level of prevention?
- Primary
- Secondary
- Tertiary
- Quarterly
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18. To assess the adequacy of food intake, which of the following assessment parameters is best used?
- Food likes and dislikes
- Regularity of meal times
- 3 day diet recall
- Eating style and habits
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19. The nurse is preparing to discontinue a client's nasogastric tube. The client is positioned properly, and the tube has been flushed with 15 mL of air to clear secretions. Before removing the tube, the nurse should make which statement to the client?
- 'Take a deep breath when I tell you. and hold it while I remove the tube"
- 'Take a deep breath when I tell you. and bear down while I remove the tube"
- 'Take a deep breath when I tell you. and slowly exhale while I remove the tube."
- 'Take a deep breath when I tell you. and breathe normally while I remove the tube."
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20. Situation: Burn is cause by transfer of heat source to the body, it can be thermal, electrical radiation or chemical.Q. A burn that is said to be "WEEPING" is classified as:
- Superficial partial thickness burn
- Deep partial thickness burn
- Full thickness burn
- Deep full thickness burn
21. What clinical manifestation should alert the nurse to possible carbon monoxide poisoning in a client who experienced a burn injury during a house fire?
- Pulse oximetry reading of 80%
- Expiratory stridor and nasal flaring
- Cherry red color to the mucous membranes
- Presence of carbonaceous particles in the sputum
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22. Parents of a 6 month-old breast fed baby ask the nurse about increasing the baby's diet Which of the following should be added first?
- Cereal
- Eggs
- Meat
- Juice
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23. 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. In the recent technological innovations, which of the following describe researches that are made to improve and make human life easier?
- Pure research
- Applied research
- Basic research
- Experimental research
24. Situation: Carbon Monoxide poisoning is said to be the 2nd leading cause of poison death. It is said to be the leading cause of inhalation poisoning. Mr. Edgardo was rushed to the hospital after being unconscious inside an enclosed parking lot Carbon monoxide poisoning is suspected.Q. Initially, in patient with suspected inhalation poisoning, the most important intervention at the scene of poisoning is:
- Assess the patient's airway breathing and circulation
- Conduct a head to toe physical assessment
- Administer oxygen and loosen the client's clothing
- Carry the client on the fresh air immediately opening ail windows and doors if this is enclosed
25. Which of the following interventions is important for a Cely experiencing with paranoid personality disorder taking olanzapine (Zyprexa)?
- Explain effects of serotonin syndrome
- Teach the client to watch for extrapyramidal adverse reaction
- Explain that the drug is less effective if the client smokes
- Discuss the need to report paradoxical effects such as euphoria
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26. The nurse on oncology is caring for a client with a white blood count of 600. During evening visitation a visitor brings a potted plant What action should the nurse take?
- Allow the client to keep the plant.
- Place the plant by the window.
- Water the plant for the client.
- Tell the family members to take the plant home.
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27. Situation: Clients with Bipolar disorder receives a very high nursing attention due to the increasing rate of suicide related to illness.Q. A client with a diagnosis of major depression, recurrent with psychotic features is admitted to the mental health unit. To create a safe environment for the client, the nurse most importantly devises a plan of care that deals specifically with the clients:
- Disturbed thought process
- Self Care Deficit
- Imbalanced Nutrition
- Deficient Knowledge
28. The nurse is caring for a client in the late stages of amyotrophic lateral sclerosis (ALS). Which finding would the nurse expect?
- confusion
- loss of half of visual field
- shallow respirations
- tonic-clonic seizures
29. Mrs. Hogan, a 43-year-old woman, is admitted to your unit for cholecystectomy. Q. When giving bag-valve mask ventilations:
- Rapid and forceful ventilations are desirable so that adequate ventilation will be assured
- Effective ventilations can always be given by one person.
- Cricoid pressure may prevent gastric inflation during ventilations.
- Tidal volumes will always be larger than when giving mouth to pocket mask ventilations.
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30. A child present to the emergency department with complaint of chest pain on exertion, shortness of breath, and dizziness. Upon examination the nurse notes palpitation and a systolic ejection murmur at the right upper sterna border. Skin color is normal. The nurse suspect.
- Aortic stenosis
- Aortic regurgitation
- Mitral stenosis
- Mitral valve prolapse
31. A client with end-stage renal failure receives hemodialysis via an arteriovenous fistula (AV) placed in the right arm. When caring for the client the nurse should:
- Take the blood pressure in the right arm above the AV fistula.
- Flush the AV fistula with IV normal saline to keep it patent.
- Auscultate the AV fistula for the presence of a bruit.
- Perform needed venopunctures distal to the AV fistula.
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32. Situation: The abuse of dangerous drug is a serious public health concern that nurses need to address. Q. This drug produces mirthfulness, fantasies, flight of ideas, loss of train of thought, distortion of size, distance and time, and "bloodshot eyes", due to dilated pupils.
- Opiates
- LSD
- Marijuana
- Heroin
33. The nurse is assisting a health care provider with the removal of a chest tube. The nurse should instruct the client to take which action?
- Stay very still.
- Exhale very quickly.
- Inhale and exhale quickly.
- Perform the Valsalva maneuver.
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34. A client is being admitted to the hospital for treatment of acute cellulitis of the lower left leg. During the admission assessment, the nurse expects to note which finding?
- An inflammation of the epidermis only
- A skin infection of the dermis and underlying hypodermis
- An acute superficial infection of the dermis and lymphatics
- An epidermal and lymphatic infection caused by Staphylococcus
35. Baby Jenny who is small-for-gestation is at increased risk during the transitional period for which complication?
- Anemia probably due to chronic fetal hypoxia
- Hyperthermia due to decreased glycogen stores
- Hyperglycemia due to decreased glycogen stores
- Polycythemia probably due to chronic fetal hypoxia
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36. An Asian American client is experiencing a fever. The nurse plans care so that the client can self-treat the disorder using which method?
- Prayer
- Magnetic therapy
- Foods considered to be yin
- Foods considered to be yang
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37. Situation: Mental Retardation is an increasingly common childhood disorder that impairs learning.Q. An important principle for the nurse to follow in interacting with retarded children is:
- seen that if the child appears contented, his needs are being met
- provide an environment appropriate to their development task as scheduled
- treat the child according to his chronological age
- treat the child according to his developmental level
38. Antibiotics are prescribed for a child with otitis media who underwent a myringotomy with insertion of tympanostomy tubes. The nurse provides discharge instructions to the parents regarding the administration of the antibiotics. Which statement, if made by the parents, indicates understanding of the instructions provided?
- "Administer the antibiotics until they are gone.”
- "Administer the antibiotics if the child has a fever”
- "Administer the antibiotics until the child feels better."
- "Begin to taper the antibiotics after 3 days of a full course.”
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39. When the nurse palpates the suprapubic area of the mother and found that the presenting part is still movable, the right term for this observation that the fetus is:
- Engaged
- Descended
- Floating
- Internal Rotation
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40. An adolescent client is diagnosed with conjunctivitis, and the nurse provides information to the client about the use of contact lenses. Which client statement indicates the need for further information?
- "I should obtain new contact lenses.”
- "I should not wear my contact lenses ”
- "My old contact lenses should be discarded"
- "My contact lenses can be worn if they are cleaned as directed”
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41. Situation: IBD is a common inflammatory functional bowel disorder also known as spastic bowel, functional colitis and mucous colitis. Q. Which of the following alimentary canal is the most common location for Chron's disease?
- Descending colon
- Jejunum
- Sigmoid Colon
- Terminal Ileum
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42. Situation: Mariah is a 31 year old lawyer who has been married for 6 months. She is now pregnant. She consults you for guidance. At 5 months gestation, which of the following fetal development would probably be expected:
- Fetal development are felt by Mariah
- Vernix caseosa covers the entire body
- Viable if delivered within this period
- Braxton Hicks contractions are observed
43. A surgeon instructs a nurse to serve as a witness to an elderly patient's informed consent for surgery. During the explanations to the patient, it becomes clear that the patient is confused and does not understand the procedure, but reluctantly sign the consent form. The nurse should:
- Sign the form as a witness, making a nation that the patient did not appear to understand
- Not sign the form as a witness and notify the nurse supervisor
- Not sign the form and answer the patient's questions after the surgeon leaves the room
- Sign the form and tell surgeon that the patient doesn't understand the procedure
44. Which of the following types of medications can be administered via gastrostomy tube?
- Any oral medications
- Capsules whole contents are dissolve in water
- Enteric-coated tablets that are thoroughly dissolved in water
- Most tablets designed for oral use, except for extended-duration compounds
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45. Which information should be reported to the state Board of Nursing?
- The facility fails to provide literature in both Spanish and English.
- The narcotic count has been incorrect on the unit for the past three days.
- The client fails to receive an itemized account of his bills and services received during his hospital stay.
- The nursing assistant assigned to the client with hepatitis fails to feed the client and give the bath.
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46. A patient is 90-minutes post-abdominal hysterectomy and complains of pain in the post anesthesia care unit (PACU). The nurse administers the prescribed dose unit intravenous morphine. Five minutes later, the patient is difficult to arouse, with the following vital signs. What should the nurse do NEXT? Respiratory rate : 6/min Saturation : 86% on room air
- Document the efficacy of analgesic therapy
- Administer naloxone (Narcan)
- Place in supine position
- Check the surgical site for bleeding
47. A nurse giving post-operative discharge instructs a patient who had abdominal surgery, when teaching the patient about wound healing all of the following are the true EXCEPT:
- Wound may feel tightly or itchy as healing occurs
- Scabs promote infection of the new skin underneath them
- Numbness or a slight pulling sensation is normal
- Wound should not have any drainage
48. A client receiving Vancocin (vancomycin) has a serum level of 20mcg/mL. The nurse knows that the therapeutic range for vancomycin is:
- 5-10mcg/mL
- 10-25mcg/mL
- 25-40mcg/mL
- 40-60mcg/mL
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49. During prenatal consultation, a client asked you if she can have her delivery at home. After history taking and physical examination, you advised her against a home delivery. Which of the following findings disqualifies her for a home delivery?
- Her OB score is G5P3
- She has some palmar pallor
- Her blood pressure is 130/80
- Her baby is in cephalic presentation
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50. A nurse has taught a client taking a xanthine bronchodilator about beverages to avoid. The nurse determines that the client understands the information if the client chooses which of the following beverages from the dietary menu?
- chocolate milk
- cranberry juice
- coffee
- cola
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NCLEX-RN | QB1 | Practice Exam #41 (50 questions)