NCLEX-RN | QB1 | Practice Exam #33 (50 questions)
1. An infant who weighs 9 kg (19.8 lbs) requires 900ml of fluids per day for maintenance fluids. The inf ant typically consumes 120ml during each feeding. The infant must have how many feedings per day to meet the fluid maintenance needs?
- 4
- 8
- 10
- 12
2. The nurse is caring for an infant following a cleft lip repair. While comforting the infant the nurse should avoid:
- Holding the infant
- Offering a pacifier
- Providing a mobile
- Offering sterile water
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3. The following are correct statements about false labor EXCEPT:
- The pain is irregular in intensity and frequency.
- The duration of contraction progressively lengthens over time
- There is no vaginal bloody discharge
- The cervix is still closed
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4. Situation: The nurse is performing health education activities for Jane Segovia, a 30 years old Dentist with Insulin dependent diabetes Mellitus.Q. Jane has been scheduled to have a FBS taken in the morning. The nurse tells Jane to eat or drink after midnight Prior to taking the blood specimen, the nurse noticed that Jane is holding a bottle of distilled water. The nurse asked Jane if she drink any, and she said yes. Which of the following is the best nursing action?
- Administer syrup of ipecac to remove the distilled water from the stomach.
- Suction the stomach content using NGT prior to specimen collection
- Advice to physician to reschedule to diagnostic examination next day
- Continue as usual and have the FBS analysis performed and specimen be taken.
5. Before adding potassium to an infants LV. line, Nurse Ron must be sure to assess whether this infant has:
- Stable blood pressure
- Patent fontanelles
- Moro's reflex
- Voided
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6. A client with HELLP syndrome is admitted to the labor and delivery unit for observation. The nurse knows that the client will have elevated:
- Serum glucose levels
- Liver enzymes
- Pancreatic enzymes
- Plasma protein levels
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7. Situation: Among common conditions found in children especially among poor communities are ear infection/problems. The following questions apply. Q. An ear discharge that has been present for more than 14 days can be classified as:
- mastoiditis
- chronic ear infection
- acute ear infection
- complicated ear infection
8. When planning the care for a young adult client diagnosed with anorexia nervosa which of these concerns should the nurse determine to be the priority for long term mobility?
- digestive problems
- amenorrhea
- Electrolyte imbalance
- blood disorders
9. A patient with pneumonia experiences ineffective airway clearance related to the presence of thick secretions secondary to infection. Oxygen saturation is 89% on room air Which of the following nursing interventions takes priority?
- Deliver oxygen with humidity
- Encourage fluid intake
- Assist patient into position of comfort
- Inspect sputum for odor and color
10. He opts to use a self-report method. Which of the following is NOT TRUE about this method?
- Most direct means of gathering information
- Versatile in terms of content coverage
- Most accurate and valid method of data gathering
- Yields information that would be difficult to gather by another method
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11. Which type of fluid should the nurse expect to prepare and administer as fluid resuscitation during the emergent phase of burn recovery?
- Colloids
- Crystalloids
- Fresh-frozen plasma
- Packed red blood cells
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12. A nurse educates a patient about the use of incentive spirometry to prevent atlectasis after a surgery. The nurse is performing what step of the nursing process?
- Diagnosis
- Assessment
- Implementation
- Evaluation
13. Another name for a stone in the urinary tract is:
- Calix
- Calculus
- Calcemia
- Calcitonin
14. The client is newly diagnosed with juvenile onset diabetes. Which of the following nursing diagnoses is a priority?
- Anxiety
- Pain
- Knowledge deficit
- Altered thought process
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15. The community health nurse Is instructing a group of young female clients about breast self examination. The nurse should instruct the clients to perform the examination at which time?
- At the onset of menstruation
- Every month during ovulation
- Weekly at the same time of day
- 1 week after menstruation begins
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16. Situation: Mrs. Cruz was admitted in the Medical Floor due to pyrosis, dyspepsia and difficulty of swallowing.Q. Mrs. Cruz body mass index (BMI) is 25. You can categorized her as:
- normal
- overweight
- underweight
- obese
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17. A client is admitted to the emergency department with chest pain that is consistent with myocardial infarction based on elevated troponin levels. Heart sounds are normal and vital signs are noted on the clients chart The nurse should alert the health care provider because these changes are most consistent with which complication? Refer to chart
- Cardiogenic shock
- Cardiac tamponade
- Pulmonary embolism
- Dissecting thoracic aortic aneurysm
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18. Which contraindication should the nurse assess for prior to giving a child immunization?
- Depressed immune system
- Mild cold symptoms
- Chronic asthma
- Allergy to eggs
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19. The nurse is taking the blood pressure of the obese client If the blood pressure cuff is too small the results will be:
- A false elevation
- A false low reading
- A blood pressure reading that is correct
- A subnormal finding
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20. An 82 year-old patient has Parkinson's disease. During the assessment, the nurse would expect which of the following actions to produce the MOST tremor activity of the hands?
- Eating with a fork
- Resting hands in lap
- Standing with hands loose at sides
- Rolling a small pill between the fingers
21. Situation: Health education and Health Promotion is an important part of nursing responsibility in the community. Immunization is a form of health promotion that aims at preventing the common childhood illnesses.After TT3 vaccination a mother is said to be protected to tetanus by around?
- 0.8
- 0.85
- 0.99
- 0.9
22. Diarrhea is best described by its:
- Amount
- Consistency
- Frequency
- Odor
23. Nicolas is experiencing hallucinations tells the nurse, "The voices are telling me I'm no good? The client asks if the nurse hears the voices. The most appropriate response by the nurse would be:
- "It is the voice of your conscience, which only you can control?
- "No, I do not hear your voices, but I believe you can hear them".
- "The voices are coming from within you and only you can hear them?
- "Oh, the voices are a symptom of your illness; don't pay any attention to them?
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24. A 4-year-old child diagnosed with leukemia is hospitalized for chemotherapy. The child is fearful of the hospitalization. Which nursing intervention should be implemented to alleviate the child's fears?
- Encourage the child's parents to stay with the child.
- Encourage play with other children of the same age.
- Advise the family to visit only during the scheduled visiting hours.
- Provide a private room, allowing the child to bring favorite toys from home.
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25. What structure of the body is responsible for the production of follicle-stimulating hormone (FSH)?
- hypothalamus
- thymus
- kidney
- anterior pituitary gland
26. The nurse has just administered the first dose of omalizumab to a client Which statement by the client would alert the nurse that the client may be experiencing a life-threatening effect?
- "I have a severe headache?
- "My feet are quite swollen?
- "I am nauseated and may vomit?
- "My lips and tongue are swollen"
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27. Situation: As a Community Health Nurse relating with people in different communities, and in the implementation of health programs and projects you experience vividly as well the varying forms of leadership and management from the Barangay Level to the Local Government/Municipal City Level. The following statements can correctly be made about an effective and efficient community or even agency managerial-leader. A.Considers the achievement and advancement of the organization she/he represents as well as his people. B.Considers the recognition of individual efforts toward the realization of organizational goals as well as the welfare of his people. C.Considers the welfare of the organization above all other consideration by higher administration. D.Considers its own recognition by higher administration for purposes of promotion and prestige
- Only C and D are correct
- A, C and D are correct
- B, C, and D are correct
- Only A and B are correct
28. Situation: Nette, a nurse palpates the abdomen of Mrs. Medina, a primigravida. She is unsure of the date of her last menstrual period. Leopold's Maneuver is done. The obstetrician told mat she appears to be 20 weeks pregnant. Q. If Mrs. Medina comes to you for check-up on June 2, her EDO is June 11, what do you expect during assessment?
- Fundic ht 2 fingers below xyphoid process, engaged
- Cervix close, uneffaced, FH-midway between the umbilicus and symphysis pubis
- Cervix open, fundic ht. 2 fingers below xyphoid process, floating
- Fundal height at least at the level of the xyphoid process, engaged
29. Nurse Len is teaching a group of women to perform BSE. The nurse should explain that the purpose of performing the examination is to discover:
- Cancerous lumps
- Areas of thickness or fullness
- Changes from previous examinations.
- Fibrocystic masses
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30. Nurse Ronald could evaluate that the staffs approach to setting limits for a demanding, angry client was effective if the client:
- Apologizes for disrupting the unit's routine when something is needed
- Understands the reason why frequent calls to the staff were made
- No longer calls the nursing staff for assistance
- Discuss concerns regarding the emotional condition that required hospitalizations
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31. The physician has prescribed Cognex (tacrine) for a client with dementia. The nurse should monitor the client for adverse reactions which include:
- Hypoglycemia
- Jaundice
- Urinary retention
- Tinnitus
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32. An old patient with history of risk to fall down use walker as assistant the pt use diuretic medicine and the pt use to go to the bathroom more often in the night what the nurse should do for pt to ensure safety:
- hold diuretic
- keep bathroom light open
- Commode a bathroom beside the patient.
- keeps the way to the bathroom clear of any obstacles
33. The emergency department has shortage of staff The nurse manager informs the staff nurse in the critical care unit that she has to float to the emergency department. What should the staff nurse expect under these conditions?
- The float staff nurse will be informed of the situation before the shift begins.
- The staff nurse will be able to negotiate the assignments in the emergency department.
- Cross training will be available for the staff nurse.
- Client assignments will be equally divided among the nurses.
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34. Situation: Nurse Joanna works as an OB-Gyn Nurse and attends to several HIGH- RISK PREGNANCIES: Particularly women with preexisting or newly acquired illness. The following conditions apply, Q. Bernadette is a 22-year old woman. Which condition would make her more prone than others to developing a Candida infection during pregnancy?
- Her husband plays golf 6 days a week
- She was over 35 when she became pregnant
- She usually drinks tomato juice for breakfast
- She has developed gestational diabetes
35. Situation : A patient was admitted in the Medical Floor at St. Luke's Hospital. He was asymptomatic. The doctor suspects diverticulosis.Q. Which of the following tests should be administered to client with diverticulosis?
- Proctoscopy
- Barium enema
- Barium swallow
- Gastroscopy
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36. Situation: You were on duty at the medical ward when Zeny came in for admission for tiredness, cold intolerance, constipation, and weight gain. Upon examination, the doctor's diagnosis was hypothyroidism.Q. Your appropriate nursing diagnosis for Zeny who is suffering from hypothyroidism would probably include which of the following?
- Activity intolerance related to tiredness associated with disorder
- Risk to injury related to incomplete eyelid closure
- Imbalance nutrition related to hypermetabolism
- Deficient fluid volume related to diarrhea
37. When the blood pressure is 140 / 100 mmHg, the pulse pressure is:
- 40 mmHg
- 142 mmHg
- 100 mmHg
- 242 mmHg
38. Nurse Anne is caring for a client who has been treated long term with antipsychotic medication. During the assessment, Nurse Anne checks the client for tardive dyskinesia. If tardive dyskinesia is present, Nurse Anne would most likely observe:
- Abnormal movements and involuntary movements of the mouth, tongue, and face.
- Abnormal breathing through the nostrils accompanied by a "thrill."
- Severe headache, flushing, tremors, and ataxia.
- Severe hypertension, migraine headache.
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39. A client with hypertension has been told to maintain a diet low in sodium. The nurse who is teaching this client about foods that are allowed should include which food item in a list provided to the client?
- Tomato soup
- Boiled shrimp
- Instant oatmeal
- Summer squash
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40. The nurse administered a dose of morphine sulfate as prescribed to a patient who is in the post anesthesia care unit (PACU). The patient appears to be resting comfortably, the respiratory rate is 8 and the O2saturation is 21 oxygen via cannula is 86%. The nurse should IMMEDIATELY administer:
- Flumazenil (Romazicon)
- Medazolum (versed)
- Naloxone (Narcan)
- Ondansetron (Zofran)
41. SITUATION: Mr. Francisco, 70 years old, suddenly could not lift his spoons nor speak at breakfast. He was rushed to the hospital unconscious. His diagnosis was CVA. Q. If Mr. Francisco's Right side is weak, What should be the most accurate analysis by the nurse?
- Expressive aphasia is prominent on clients with right sided weakness
- The affected lobe in the patient is the Right lobe
- The client will have problems in judging distance and proprioception
- Clients orientation to time and space will be much affected
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42. Which of the following is the MOST common type of cardiomyopathy in children and is treated with medications such as digoxin (Lanoxin) and warfarin (Coumadin)?
- Hypertrophic
- Dilated
- Restrictive
- Diastolic
43. The nurse is monitoring a 3-year-old child for signs and symptoms of increased intracranial pressure (1CP) after a craniotomy. The nurse plans to monitor for which early sign or symptom of increased ICP?
- Vomiting
- Bulging anterior fontanel
- Increasing head circumference
- Complaints of a frontal headache
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44. A client is wearing a continuous cardiac monitor, which begins to sound its alarm. The nurse sees no electrocardiographic complexes on the screen. Which is the priority nursing action?
- Call the health care provider.
- Call a code.
- Check the client's status and lead placement.
- Press the recorder button on the electrocardiogram console.
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45. Situation: As a nurse you need to anticipate the occurrence of complications of stroke so that life threatening situations can be prevented. Q. Ivy, age 40, was admitted to the hospital with a severe headache, stiff neck and photophobia. She was diagnosed with a subarachnoid hemorrhage secondary to ruptured aneurysm. While waiting for surgery, you can provide a therapeutic by doing which of the following?
- honoring her request for a television
- placing her bed near the window
- dimming the light in her room
- allowing the family unrestricted visiting privileges
46. The nurse is caring for a client who has a history of aplastic anemia. Which of the following data from the nursing history indicates that the anemia is not being managed effectively?
- Pallor of skin and mucous membranes
- Heart rate of 68 bpm, bounding pulse
- Blood pressure of 146/90 mm Hg
- Poor skin turgor
47. 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 mal absorption
- Deficient knowledge regarding prevention of cystic fibrosis exacerbation
- Impaired gas exchange related to airway obstruction due to mucous
- Interrupted family processes related to hospitalization
48. Morphine 8 mg IM has been ordered for a client The ampule label reads 15 mg/mL. How many milliliters will the nurse give?
- 0.45 mL
- 0.53 mL
- 0.66 mL
- 0.75 mL
49. According to a standard staging classification of Hodgkin's disease, which of the following criteria reflects stage II?
- Involvement of extralymphatic organs or tissues
- Involvement of single lymph node region or structure
- Involvement of two or more lymph node regions or structures.
- Involvement of lymph node regions or structures on both sides of the diaphragm.
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50. The physician orders DS 500 cc with KC110 mEq/liter at 30 cc/hr. The nurse in-charge is going to hang a 500 cc bag. KCI is supplied 20 mEq/10 cc. How many cc's of KC1 will be added to the IV solution?
- 0.5 cc
- 2 cc
- 1.5 cc
- 2.5 cc
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NCLEX-RN | QB1 | Practice Exam #33 (50 questions)