NCLEX-RN | QB1 | Practice Exam #38 (50 questions)
1. After ileostomy, the nurse expects that the drainage appliance will be applied to the stoma:
- When the client is able to begin self-care procedures.
- 24 hours later, when the swelling subsided.
- In the operating room after the ileostomy procedure.
- After the ileostomy begins to function.
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2. A client is experiencing anxiety attack. The most appropriate nursing intervention should include?
- Turning on the television
- Leaving the client alone
- Staying with the client and speaking in short sentences
- Ask the client to play with other clients
3. Which of the following do not correctly correlates the increase BP of Ms. Aida, a 70 year old diabetic?
- Females, after the age 65 tends to have lower BP than males
- Disease process like Diabetes increase BP
- BP is highest in the morning, and lowest during the night
- Africans, have a greater risk of hypertension than Caucasian and Asians.
4. A client with cancer is to undergo an intravenous pyelogram. The nurse should:
- Force fluids 24 hours before the procedure.
- Ask the client to void immediately before the study.
- Hold medication that affects the central nervous system for 12 hours pre- and post-test.
- Cover the clients reproductive organs with an x-ray shield.
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5. A five-month-old infant is admitted to the ER with a temperature of 103.6A,°F and irritability. The mother states that the child has been listless for the past several hours and that he had a seizure on the way to the hospital. A lumbar puncture confirms a diagnosis of bacterial meningitis. The nurse should assess the infant for:
- Periorbital edema
- Tenseness of the anterior fontanel
- Positive Babinski reflex
- Negative scarf sign
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6. Lactulose (Chronulac) has been prescribed for a client with advanced liver disease. Which of the following assessments would the nurse use to evaluate the effectiveness of this treatment?
- An increase in appetite
- A decrease in fluid retention
- A decrease in lethargy
- A reduction in jaundice
7. When caring for a client with an internal radiation implant, the nurse should observe which principles? Select all that apply. 1.Limiting the time with the client to 1 hour per shift. 2. Keeping pregnant women out of the client's room. 3.Placing the client in a private room with a private bath. 4.Wearing a lead shield when providing direct client care. 5.Removing the dosimeter film badge when entering the client's room.
- 1,2,3
- 3,4,5
- 2,3,5
- 2,3,4
8. At which of the following times would the nurse instruct the client to take ibuprofen (Motrin), prescribed for left hip pain secondary to osteoarthritis, to minimize gastric mucosal irritation?
- At bedtime
- On arising
- Immediately after meal
- On an empty stomach
9. A home health nurse has entered a home to complete an admission assessment on a patient who has a methicillin-resistant Staphylococcus aureus (MRSA) urinary tract infection. The patient will receive intravenous anti-infective via a peripherally inserted central catheter (PICC) for 3 weeks. Which of the following actions should the nurse take FIRST?
- Shake the patient's hand
- Place the nursing supply bag on a clean, dry surface
- Obtain the patient's written consent for home health care
- Perform hand hygiene per the agency protocol
10. A nurse is caring for an infant with respiratory distress syndrome. Which of the following nursing intervention is appropriate
- Measure oxygen saturation level once a shift
- Suction frequently for 30-45 second each time
- Monitor for symptoms of hyperglycemia
- Maintain infant temperature between 36.70 & 37.80C(97& 98 F)
11. The nurse is caring for a client who has been taking a sulfonamide and should monitor for signs and symptoms of which adverse effects of the medication? Select all that apply. 1.Ototoxicity. 2.Palpitations. 3.Nephrotoxicity. 4.Bone marrow suppression. 5.Gastrointestinal (GI) effects. 6.Increased white blood cell (WBC) count
- 1,3,5,6
- 3,4,5
- 1,2,3,4
- 2,3,5
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12. How many lobes are there in the RIGHT LUNG?
- One
- Two
- Three
- Four
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13. A patient is being treated for pneumonia. Considering Maslow's hierarchy of needs, which of the following nursing diagnoses would have HIGHEST priority?
- Risk for impaired skin integrity
- Ineffective coughing.
- Disturbed sleep pattern
- Ineffective breathing pattern
14. The following are concept of health: 1.Health is a state of complete physical, mental and social wellbeing and not merely an absence of disease or infirmity. 2.Health is the ability to maintain balance. 3.Health is the ability to maintain internal milieu. 4.Health is integration of all parts and subparts of an individual
- 1,3
- 1,3,4
- 2,3,4
- 1,2,3,4
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15. Situation: Mr Gil age 86 years, has been diagnosed with Alzheimer's disease.Q. Mr. Gil will need assistance in maintaining contact with society for as long as possible. Which therapy might help him achieve this goal?
- Psychodrama
- Recreation therapy
- Occupational therapy
- Re-motivation therapy
16. Mark has multiple abrasions and a laceration to the trunk and all four extremities says, "I can't eat all this food". The food that the nurse should suggest to be eaten first should be:
- Meat loaf and coffee
- Meat loaf and strawberries
- Tomato soup and apple pie
- Tomato soup and buttered bread
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17. A newborn was delivered pre-term weighing 2700 grams with. Apgar scores of 4 and 6, respectively. When the mother had presented to the Obstetrical Triage Unit, she was already 7 centimeters dilated and fully effaced. Her due date was unknown as she had no parental care. The infant showed signs of fetal distress and was finally delivered by Cesarean section. At birth a large, thin, membranous sac was protruding from the umbilical base.What is the priority nursing intervention at birth?
- Maintain cardio respiratory stability
- Protect the herniated viscera
- Manage fluid intake and output
- Establish vascular access
18. A patient visits the clinic for a 2- week checkup after a corneal transplantation (keratoplasty). The nurse observes the patent's sclera is red and the patient complains of the eye feeling irritated. The nurse suspects the patient may have:
- Infection
- Hemorrhage
- Graft rejection
- Postoperative glaucoma
19. The term "blue bloater" refers to which of the following conditions?
- Adult respiratory distress syndrome (ARDS)
- Asthma
- Chronic obstructive bronchitis
- Emphysem
20. Prior to providing care for a hospitalized infant the nurse who focuses on preventive measures must.
- Introduce self-parent
- Perform hand hygiene
- Have a witness present
- Assess the child's developmental level
21. The client newly diagnosed with chronic kidney disease recently has begun hemodialysis. Knowing that the client is at risk for disequilibrium syndrome, the nurse should assess the client during dialysis for which associated manifestations?
- Hypertension, tachycardia, and fever
- Hypotension, bradycardia, and hypothermia
- Restlessness, irritability, and generalized weakness
- Headache, deteriorating level of consciousness, and twitching
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22. The nurse is performing an assessment of a pregnant client who is at 28 weeks of gestation. The nurse measures the fundal height in centimeters and notes that the fundal height is 30 cm. How should the nurse interpret this finding?
- The client is measuring large for gestational age.
- The client is measuring small for gestational age.
- The client is measuring normal for gestational age.
- More evidence is needed to determine size for gestational age.
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23. While working with an obese adolescent, it is important for the nurse to recognize that obesity in adolescents is most often associated with what other behavior?
- Sexual promiscuity
- Poor body image
- Dropping out of school
- Drug experimentation
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24. The best method of prevention of TB and leprosy esp. among children is:
- Taking INH for prophylaxis
- Healthy environment
- Good nutrition
- BCG immunization
25. When doing community-based teaching for latex allergies, the nurse should plan to teach the patient that:
- Food handled by people wearing latex gloves stimulates an allergies response
- Food containing nuts may trigger an allergic cross-response in people with latex allergies
- The patient should wear a face while in the hospital due to large amount of airborne latex
- Hoses used on gases pumps contain latex and should be avoided.
26. The nurse is caring for a cognitively impaired client who begins to pull at the tape securing his IV site. To lessen the likelihood of the client dislodging the IV the nurse should:
- Place tape completely around the extremity with taped ends out of the clients vision.
- Tell him that if he pulls out the IV it will have to be restarted.
- Apply clove hitch restraints to the clients hands.
- Wrap the IV site loosely with Kerlix to remove it from his site.
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27. Situation: Respiration is one of the most important vital sign. This is usually the first Vital sign to be assessed more than anything for it is easily altered by the patient's consciousness. The nurse should be aware of the different changes and alteration in respiration.Q. In a client with diabetic ketoacidosis, Kussmauls respiration is exhibited. This is evidence that there is the presence of:
- Respiratory acidosis
- Metabolic acidosis
- Respiratory alkalosis
- Metabolic alkalosis
28. Situation: Records contain those, comprehensive descriptions of patient's health conditions and needs and at the same serve as evidences of every nurse's accountability in the, caregiving process. Nursing records normally differ from institution to, institution nonetheless they follow similar patterns of meeting needs for specifics, types of information. The following pertains to documentation/records management. Q. These records show all medications and treatment provided on a repeated basis. What do you call this record?
- Nursing Health History and Assessment Worksheet
- Discharge Summary
- Nursing Kardex
- Medicine and Treatment Record
29. A man who has been in an MVA is going into shock. Before placing the client in a modified trendelenburg position, the nurse should assess the client for
- long bone fracture
- air embolus
- head injury
- thrombophlebitis
30. 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. Which is your dependent variable?
- Job dissatisfaction
- Job turnover rate
- Job dissatisfaction and job turnover rate
- Length of employment
31. When caring for a patient with an ostomy the nurse knows that extra skin protection for the peristoma) skin is MOST important for those with a(n):
- Ileostomy
- Ascending colostomy
- Transverse colostomy
- Sigmoid colostomy
32. Which finding is the best indication that a client with ineffective airway clearance needs suctioning?
- Oxygen saturation
- Respiratory rate
- Breath sounds
- Arterial blood gases
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33. The ability of the body to defend itself against scientific invading agent such as baceria, toxin, viruses and foreign body
- Hormones
- Secretion
- Immunity
- Glands
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34. The physician orders an intramuscular injection of Demerol for the postoperativepatient's pain. When preparing to draw up the medication, the nurse is careful to remove the correct vial from the narcotics cabinet It is labeled:
- simethicone.
- albuterol.
- meperidine.
- ibuprofen.
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35. An Orthodox Jewish couple is seeking infertility counseling. The woman states that her menstrual cycle is 21 days long. After testing, no physical explanation is found for the infertility. Which of the following may explain why the woman has been unable to conceive?
- Her Kosher diet is lacking in the essential nutrients needed for achieving optimal reproductive health.
- "The positions allowed Orthodox Jewish couples during intercourse hinder the process of fertilization.
- Orthodox Jewish couples are known to have a high rate of infertility because of inborn genetic diseases.
- Orthodox Jewish couples refrain from intercourse during menses and for seven days after it ends.
36. Situation: Records contain those, comprehensive descriptions of patient's health conditions and needs and at the same serve as evidences of every nurse's accountability in the, care giving process. Nursing records normally differ from institution to, institution nonetheless they follow similar patterns of meeting needs for specifics, types of information. The following pertains to documentation/records management.This flip-over card is usually kept in a portable file at the Nurses Station. It has 2-parts: the activity and treatment section and a nursing care plan section. This carries information about basic demographic data, primary medical diagnosis, current orders of the physician to be carried out by the nurse, written nursing care plan, nursing orders, scheduled tests and procedures, safety precautions in-patient care and factors related to daily living activities/ this record is used in the charge-of-shift reports or during the bedside rounds or walking rounds. What record is this?
- Discharge Summary
- Medicine and Treatment Record
- Nursing Health History and Assessment Worksheet
- Nursing Kardex
37. The home health nurse is visiting a client with Pagets disease. An important part of preventive care for the client with Pagets disease is:
- Keeping the environment free of clutter
- Advising the client to see the dentist regularly
- Encouraging the client to take the influenza vaccine
- Telling the client to take a daily multivitamin
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38. A client experiencing a great deal of stress and anxiety is being taught to use self-control therapy. Which statement by the client indicates a need for further teaching about the therapy?
- 'This form of therapy can be applied to new situations"
- "An advantage of this technique is that change is likely to last."
- "Talking to oneself is a basic component of this form of therapy"
- "This form of therapy provides a negative reinforcement when the stimulus is produced"
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39. A nurse is giving discharge planning instruction to the parents of a 1-years old child with acute otitis media. Which of the following discharge instruction take FIRST priority?
- Administer antibiotics as prescribed
- Breastfeed as long as possible
- Administer influenza vaccination
- Avoid smoking around the child
40. A client walks into the mental health clinic and states to the nurse, "I guess I can't make it without my wife. I can't even sleep without her? Which of the following responses by the nurse would be most therapeutic?
- "Things always look worse before they get better"
- "I'd say that you're not giving yourself a fair chance?
- "I'll ask the doctor for some sleeping pills for you?
- "Tell me more about what you mean when you say you can't make it without your wife"
41. The nurse must verify the clients identity before administration of medication. Which of the following is the safest way to identify the client?
- Ask the client his name
- Check the client's identification band
- State the client's name aloud and have the client repeat it
- Check the room number
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42. Vasectomy is a procedure done on a male for sterilization. The organ involved in this procedure is
- Prostate gland
- Seminal vesicle
- Testes
- Vas deferens
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43. A client with schizophrenia is receiving depot injections of Haldol Decanoate (haloperidol decanoate). The client should be told to return for his next injection in:
- One week
- Two weeks
- Four weeks
- Six weeks
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44. He likewise stresses the need for all the employees to follow orders and instructions from him and not from anyone else. Which of the following principles does he refer to?
- Scalar chain
- Discipline
- Unity of command
- Order
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45. The client is taking fluoxetine (Prozac) 20 mg at bedtime. He states that Prozac is not helping him to sleep. The nurse judges:
- That the client should take Prozac in the morning.
- That dose is too high.
- That the client's symptoms of depression seem to be getting worse.
- That the client is on the wrong medication.
46. An adolescent primigravida who is 10 weeks pregnant attends the antepartal clinic for a first check-up. To develop a teaching plan the nurse should initially assess:
- The clients knowledge of the signs of preterm labor
- The clients feelings about the pregnancy
- Whether the client was using a method of birth control
- The clients thought about future children
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47. A nurse and client are talking about the client's progress toward understanding his behavior under stress. This is typical of which phase in the therapeutic relationship?
- Pre-interaction
- Orientation
- Working
- Termination
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48. An anti hypertensive medication has been prescribed for a client with hypertension. The client tells the clinic nurse that he would like to take an herbal substance to help lower his blood pressure. The nurse should take which action?
- Advise the client to read the labels of herbal therapies closely.
- Tell the client that herbal substances are not safe and should never be used.
- Encourage the client to discuss the use of an herbal substance with the health care provider (HCP).
- Tell the client that if he takes the herbal substance he will need to have his blood pressure checked frequently.
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49. 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. Which of the following is the three (3) integrated components of the nursing informatics? 1.Nursing science. 2.Computer sciences. 3.Health science. 4.Information science
- 3,4,5
- 1,3,4
- 1,2,4
- 1,2,3
50. Tracy is receiving combination chemotherapy for treatment of metastatic carcinoma. Nurse Ruby should monitor the client for the systemic side effect of:
- Ascites
- Nystagmus
- Leukopenia
- Polycythemia
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NCLEX-RN | QB1 | Practice Exam #38 (50 questions)