NCLEX-RN | QB1 | Practice Exam #39 (50 questions)
1. An adult client is found to be unresponsive on morning rounds. After checking for responsiveness and calling for help, the next action that should be taken by the nurse is to:
- check the carotid pulse
- deliver 5 abdominal thrusts
- give 2 rescue breaths
- ensure an open airway
2. Herbert, a 45 year old construction engineer is brought to the hospital unconscious after falling from a 2-story building. When assessing the client, the nurse would be most concerned if the assessment revealed:
- Reactive pupils
- A depressed fontanel
- Bleeding from ears
- An elevated temperature
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3. The nurse is teaching a patient who has just diagnosed with bacterial conjunctivitis, The nurse should that the MOST effective way to transmission of this to other people is by:
- Putting on clean gloves before cleansing the eye
- Taking medication as prescribe
- Wearing a gauze eye patch
- Performing hand hygiene
4. The purpose of increasing urine acidity through dietary means is to:
- Decrease burning sensations
- Change the urine's color
- Change the urine's concentration
- Inhibit the growth of microorganisms
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5. A home health nurse is preparing to administer a subcutaneous injection of heparin.When site on the abdomen, the nurse will choose a site:
- More than 6 inches from the umbilicus
- More than 2 inches from the umbilicus
- As close as possible to the umbilicus
6. The mother of an 8-year-old child being treated for right lower lobe pneumonia at home calls the clinic nurse. The mother tells the nurse that the child complains of discomfort on the right side and that ibuprofen is not effective. Which instruction should the nurse provide to the mother?
- Increase the dose of ibuprofen.
- Increase the frequency of ibuprofen.
- Encourage the child to lie on the left side.
- Encourage the child to lie on the right side.
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7. The nurse is assessing a six-year-old following a tonsillectomy. Which one of the following signs is an early indication of hemorrhage?
- Drooling of bright red secretions
- Pulse rate of 90
- Vomiting of dark brown liquid
- Infrequent swallowing while sleeping
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8. The nurse is assessing the neurovascular status of a client who returned to the surgical nursing unit 4 hours ago after undergoing aortoiliac bypass graft. The affected leg is warm, and the nurse notes redness and edema.The pedal pulse is palpable and unchanged from admission. How should the nurse correctly interpret the client's neurovascular status?
- The neurovascular status is normal because of increased blood flow through the leg.
- The neurovascular status is moderately impaired, and the surgeon should be called.
- The neurovascular status is slightly deteriorating and should be monitored for another hour.
- The neurovascular status is adequate from an arterial approach, but venous complications are arising.
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9. A child with croup is placed in a cool high-humidity tent connected to room air The primary purpose of the high-humidity tent is to:
- Prevent insensible water loss
- Provide a moist environment with oxygen at 30%
- Prevent dehydration and reduce fever
- Liquefy secretions and relieve laryngeal spasm
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10. During postprandial monitoring, a client with bulimia nervosa tells the nurse, "You can sit with me, but you're just wasting your time. After you sat with me yesterday, I was still able to purge. Today, my goal is to do it twice." What is the nurse's best response?
- "I trust you not to purge.”
- "How are you purging and when do you do it?"
- "Don't worry. I won't allow you to purge today."
- "I know it's important for you to feel in control, but I’ll monitor you for 90 minutes after you eat."
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11. An infant arrives in the emergency department not breathing and does have a pulse. When starting cardio pulmonary resuscitation (CPR), where is the correct place to assess for a pulse in this patient?
- Carotid
- Radial
- Brachial
- Temporal
12. Situation: Nanette was rushed to the hospital due to burns. Witnesses told the emergency team that Nanette fell asleep while she is holding her cigarette thus, burning the bed sheets and herself. 2nd and 3rd degree burns are on the face, neck, anterior and posterior trunk as well as the anterior of the left leg and the whole right arm was burned. First degree burns are located on the anterior portion of the right leg and the anterior portion of the right and left arm. Nanette is a 110 lbs female client.Q. The priority consideration for Nanette during the early phase of burn is:
- Pain
- Body Image
- Fluid status
- Infection of the wound
13. During the immediate postoperative period, a patient reveals an oxygen saturation level of 91%. The nurse should:
- Position the patient on the left side
- Administer supplemental oxygen
- Continue to provide supportive care
- Lower the temperature of the room
14. A client is admitted to the labor and delivery unit The nurse performs a vaginal exam and determines that the clients cervix is 5cm dilated with 75% effacement Based on the nurses assessment the client is in which phase of labor?
- Active
- Latent
- Transition
- Early
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15. Which of the following is true about caring for a resident who wears a hearing aid?
- Apply hairspray after the hearing aid is in place.
- Remove the hearing aid before showering.
- Clean the earmold and battery case with water daily; drying completely.
- Replace batteries weekly.
16. While caring for a patient with potassium deficiency, the nurse should expect that the patient may exhibit:
- Dysrhythmias
- Oliguria
- Diminished deep-tendon reflexes
- Hypertension
17. A nurse is assigned to care for a patient with a diagnosis of thrombotic stroke. The nurse knows that this type of stroke is most likely caused by:
- Blockage of large vessels as a result of atherosclerosis
- Emboli produced from valvular heart disease
- Decreased cerebral blood flow due to circulatory failure
- A temporary disruption in oxygenation of the brain
18. What of the following has propriety to check before start giving patient blood transfusion
- Blood group
- Name
- Expiry date
- None of the above.
19. When caring for the a client with a pneumothorax, who has a chest tube in place, nurse Kate should plan to:
- Administer cough suppressants at appropriate intervals as ordered
- Empty and measure the drainage in the collection chamber each shift
- Apply clamps below the insertion site when ever getting the client out of bed
- Encourage coughing, deep breathing, and range of motion to the arm on the affected side
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20. The nurse has conducted preoperative teaching for a client scheduled for surgery in 1 week. The client has a history of arthritis and has been taking acetylsalicylic acid. The nurse determines that the client needs additional teaching if the client makes which statement?
- "Aspirin can cause bleeding after surgery."
- "Aspirin can cause my ability to clot blood to be abnormal"
- "I need to continue to take the aspirin until the day of surgery."
- "I need to check with my health care provider about the need to stop the aspirin before the scheduled surgery."
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21. A client is being discharged to home after application of a plaster leg cast Which statement indicates that the client understands proper care of the cast?
- "I need to avoid getting the cast wet."
- "I need to cover the casted leg with warm blankets."
- "I need to use my fingertips to lift and move my leg"
- "I need to use something like a padded coat hanger end to scratch under the cast if it itches."
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22. A pediatric client with burns to the hands and arms has dressing changes with Sulfamylon (mafenide acetate) cream. The nurse is aware that the medication:
- Will cause dark staining of the surrounding skin
- Produces a cooling sensation when applied
- Can alter the function of the thyroid
- Produces a burning sensation when applied
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23. Physician ordered. Paracetamol tablet ss. What does ss means?
- without
- with
- one half
- With one half dose
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24. A 48 year old male client is brought to the psychiatric emergency room after attempting to jump off a bridge. The client's wife states that he lost his job several months ago and has been unable to find another job. The primary nursing intervention at this time would be to assess for:
- A past history of depression
- Current plans to commit suicide
- The presence of marital difficulties
- Feelings of excessive failure
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25. The nurse is instructing a hospitalized client with a diagnosis of emphysema about measures that will enhance the effectiveness of breathing during dyspneic periods. Which position should the nurse instruct the client to assume?
- Sitting up in bed
- Side-lying in bed
- Sitting in a recliner chair
- Sitting up and leaning on an over bed table
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26. Which one of the following diets include only water, tea, coffee, clear juice:
- Clear liquid diet
- Full liquid diet
- Soft diet
- Diabetic diet
27. Maureen is admitted with a diagnosis of ectopic pregnancy. Which of the following would you anticipate?
- Bed rest
- Immediate surgery
- Enema
- NPO
28. Situation: IBD is a common inflammatory functional bowel disorder also known as spastic bowel, functional colitis and mucous colitis.Q. How about ulcerative colitis, which of the following factors is believed to cause it?
- Acidic diet
- Altered immunity
- Chronic constipation
- Emotional stress
29. A woman in her third trimester complains of severe heartburn. What is appropriate teaching by the nurse to help the woman alleviate these symptoms?
- Drink small amounts of liquids frequently
- Eat the evening meal just before retiring
- Take sodium bicarbonate after each meal
- Sleep with head propped on several pillows
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30. Situation: Mr Sean is admitted to the hospital with a bowel obstruction. He complained of colicky pain and inability to pass stool.Q. Four hours postoperatively, Mr. Sean complains of guarding and rigidity of the abdomen. Nurse Leonard's initial intervention is:
- assess for signs of peritonitis
- call the physician
- administer pain medication
- ignore the client
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31. A client who's at high risk for suicide needs close supervision. To best ensure the client's safety, the nurse should:
- check the client frequently at irregular intervals throughout the night.
- assure the client that the nurse will hold in confidence anything the client says.
- repeatedly discuss previous suicide attempts with the client.
- disregard decreased communication by the client because this is common in suicidal clients.
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32. Some of the task of adolescent years include the following, except
- developing a personal Identity
- advising independence from patients
- developing relationship with peers
- unlimited expression of sexual drives
33. The fundamental concepts in Psychiatric nursing is seeing the patient as a whole organism with distinct personality. The nurse should:
- Respect the patient's moral values
- Avoid labeling the patient as psychiatric entity
- Understand the patient's family background
- Uphold the patients right to make decisions
34. In a woman who is not breastfeeding, menstruation usually occurs after how many weeks?
- 2-4 weeks
- 6-8 weeks
- 6 months
- 12 months
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35. The primary cause of anemia in a client with chronic renal failure is:
- Poor iron absorption
- Destruction of red blood cells
- Lack of intrinsic factor
- Insufficient erythropoietin
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36. The nurse is caring for a patient with Parkinson's disease. Which of the following is an expected outcome related to the nursing diagnosis of constipation related to diminished motor function, inactivity and medications?
- The patient will use a laxative every other day
- The patient will have a soft bowel movement daily
- The patient will report minimal pain with bowel movements
- The patient will limit the intake of complex carbohydrates
37. A 35-years-old female has an inherited gene mutation for achondroplasia, anautosomal dominate genetic disorder Her husband does not have gene mutation. In planning genetic counseling for this patient, the nurse would be MOST correct in including which of the following statements regarding the risk of their children inherited the genetic mutation?
- Each child has a 50% chance of inheriting the gene mutation
- Female children have 50% chance of inheriting the gene mutation
- Male children will not inherited the gene mutation
- All female children will inherit the gene mutation.
38. Situation: Mang Jose, 39 year old farmer, unmarried, had been confined in the National Center for Mental Health for three years with a diagnosis of schizophrenia. A relevant nursing diagnosis for clients with auditory hallucination is:
- Sensory perceptual alteration
- Altered thought process
- Impaired social interaction
- Impaired verbal communications
39. Nurse Arnold knows that the following changes in respiratory functioning during pregnancy is considered normal:
- Increased expiratory volume
- Decreased inspiratory capacity
- Decreased oxygen consumption
- Increased tidal volume
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40. The nurse in the neonatal care unit is supervising the actions of a certified nursing assistant in giving care to the newborns. The nursing assistant mistakenly gives a formula feeding to a newborn that is on water feeding only. The nurse is responsible for the mistake of the nursing assistant:
- Always, as a representative of the institution.
- Always, because nurses who supervise less-trained individuals are responsible for their mistakes.
- If the nurse failed to determine whether the nursing assistant was competent to take care of the client.
- Only if the nurse agreed that the newborn could be fed formula.
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41. The physician prescribes meperidine (Demerol), 75 mg IM. every 4 hours as needed, to control a client's postoperative pain. The package insert is "Meperidine, 100 mg/mL" How many milliliters of meperidine should the client receive?
- 0.75
- 0.6
- 0.5
- 0.25
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42. A health care provider's prescription reads to administer an intravenous (IV) dose of 400,000 units of penicillin G benzathine. The label on the 10-mL ampule sent from the pharmacy reads penicillin G benzathine, 300,000 units/mL The nurse prepares how much medication to administer the correct dose? Find your answer using 1 decimal place.
- 1.6 mL
- 0.3 mL
- 0.9 mL
- 1.3mL
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43. A client with a fractured leg is exhibiting shortness of breath pain upon deep breathing and hemoptysis. What do these clinical manifestations indicate to the nurse?
- Congestive heart failure
- Pulmonary embolus
- Adult respiratory distress syndrome
- Tension pneumothorax
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44. A 45-year-old patient is in a lower body cast following a motor vehicle accident. In order to minimize muscle strength loss while in the cast, the nurse will instruct the patient in the performance of:
- Isometric exercises
- Passive range of motion exercises
- Active-assistive range of motion exercises
- Resistive range of motion exercises
45. Which client should be assigned to the nursing assistant?
- The 18-year-old with a fracture to two cervical vertebrae
- The infant with meningitis with a temperature of 101° F
- The elderly client with a thyroidectomy four days ago
- The client with a thoracotomy two days ago
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46. Who conceptualized health as integration of parts and subparts of an individual?
- Newman
- Neuman
- Watson
- Rogers
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47. 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 he room
- Sign the form and tell surgeon that the patient doesn't understand the procedure.
48. Situation : If a child with diarrhea registers one sign in the pink row and one in the yellow; row in the IMCI Chart. Q. We can classify the patient as:
- moderate dehydration
- some dehydration
- no dehydration
- severe dehydration
49. A child is admitted to the pediatric ward with fever, lethargy, joint pain and abdominal pain for several weeks. The patient has a history of recurrent respiratory and ear infections. Physical findings include wide spread ecchymosis, generalized lymph adenopathy, hepato splenomegaly, and pallor. Lab work show a low hemoglobin level, low RBC count, low hematocrit, and low platelets. The nurse should expect the bone marrow stain to show a:
- Large number of lymphoblasts and lymphocytes
- Low number of lymphoblasts and large number oflymphocytes
- Low number of lymphoblasts and lymphocytes
- Large number of lymphoblasts and low number of lymphocytes
50. The appropriate needle gauge for intradermal injection is:
- 20G
- 22G
- 25G
- 26G
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NCLEX-RN | QB1 | Practice Exam #39 (50 questions)