NCLEX-RN | QB1 | Practice Exam #31 (50 questions)

 

1. The nurse, caring for a group of adult clients on an acute care medical-surgical nursing unit, determines that which clients would be the most likely candidates for parenteral nutrition (PN)? Select all that apply 1.A client with extensive burns 2.A client with cancer who is septic 3.A client who has had an open cholecystectomy. 4.A client with severe exacerbation of Crohn's disease 5.A client with persistent nausea and vomiting from chemotherapy

• 1,2,3,4
• 1,2,4,5
• 2,3,4,5
• 1,2,3,5

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2. Nurse Wilma recognizes that failure of a newborn to make the appropriate adaptation to extrauterine life would be indicated by:

• flexed extremities
• Cyanotic lips and face
• A heart rate of 130 beats per minute
• A respiratory rate of 40 breath per minute

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3. 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 doctor uses Parkland/Baxter formula in computing the amount of fluid needed for Nanette's resuscitation. You would expect that the doctor will order how many milliliters of IV fluids?

• 6 liters during the first 8 hours, 3 liters on the next 8 hours and another 3 liters on another 8 hours.
• 12 liters during the first 8 hours and another 12 liters on the succeeding 16 hours
• 8 liters during the first 8 hours, 4 liters on the next 8 hours and another 8 liters on another 8 hours
• 10 liters during the first 8 hours and another 10 liters on the succeeding 16 hours

4. In what position should the nurse place Mr. Rumsey while continuing with his assessment and care?

• Prone
• Supine extended
• On his back with his legs elevated
• On his side with his neck

5. Situation: Mang Cardo, Age 72, is a widower with moderate Alzheimer's disease. Was brought to the home for the Aged by his married daughter. On admission, she says to the nurse, "i never thought this would happen to us. I really feel guilty about bringing him here, I can't bear to part with him."Q. To guide the nurse in planning activities for Mang Carlos, The nurse should prioritize soliciting which information?

• Support system from the significant others
• Coping mechanism
• Routine activities at home
• The extent of memory impairment

6. A Patient complains of severe menstrual cramping. Bleeding is not UN usually heavy and the patient has no uterine disorders. Which of the following interventions should the nurse anticipate the doctor will order promote comfort?

• Acetaminophen (Tylenol)
• Strict bed rest
• Heating pad to the back of neck
• Ibuprofen (Motrin)

7. SITUATION: Wide knowledge about the human ear, it's parts and it's functions will help a nurse assess and analyze changes in the adult client's health.Q. The physician orders the following for the client with Menieres disease. Which of the following should the nurse question?

• Dipenhydramine [Benadryl]
• Atropine sulfate
• Out of bed activities and ambulation
• Diazepam [Valium]

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8. Situation: As a nurse researcher you must have a very good understanding of the common terms of concept used in research.Q. The use of another persons ideas or wordings giving appropriate credit results from inaccurate attribution of materials to its sources. Which of the following is referred to when another persons idea is inappropriate credited as one's own?

• Plagiarism
• Quotation
• Assumption
• Paraphrase

9. While providing care to a hospitalized child with third-degree burns over 20% of the body, the child rapidly becomes disoriented. The nurse knows this is an indicator of:

• Septic shock
• Separation anxiety
• Dehydration
• Depression

10. The nurse is assessing a client in the fourth stage of labor and notes that the fundus is firm, but that bleeding is excessive. Which should be the initial nursing action?

• Record the findings.
• Massage the fundus.
• Notify the health care provider (HCP).
• Place the client in Trendelenburg's position.

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11. Situation: Clients with Bipolar disorder receives a very high nursing attention due to the increasing rate of suicide related to illness.Q. A professional artist is admitted to the psychiatric unit for treatment of bipolar disorder. During the last 2 weeks, the client has created 154 paintings, slept only 2 to 3 hours every 2 days, and lost 18 lb. (8.2 kg). Based on Maslow's hierarchy of needs, what should the nurse provide this client with first?

• Help with re-establishing a normal sleep pattern.
• Experiences that build self-esteem.
• Art materials and equipment.
• The opportunity to explore family dynamics

12. The charge nurse is making assignments for the day. After accepting the assignment to a client with leukemia the nurse tells the charge nurse that her child has chickenpox. Which initial action should the charge nurse take?

• Change the nurses assignment to another client.
• Explain to the nurse that there is no risk to the client.
• Ask the nurse if the chickenpox have scabbed.
• Ask the nurse if she has ever had the chickenpox.

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13. A patient presents to the doctor's office 2-weeks status post-right-sided mastectomy. The nurse needs to measure the blood pressure. Which would be the BEST site?

• Above the left brachial artery
• Right popliteal artery
• Above the right brachialartery
• Left popliteal artery

14. A client diagnosed with schizophrenia is shouting and banging on the door leading to the outside, saying, "I need to go to an appointment" What is the appropriate nursing intervention?

• Tell the client that he cannot bang on the door.
• Ignore this behavior
• Escort the client going back into the room.
• Ask the client to move away from the door.

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15. Which of the following is not true about the human needs?

• Certain needs are common to all people
• Needs should be followed exactly in accordance with their hierarchy
• Needs are stimulated by internal factors
• Needs are stimulated by external factors

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16. Situation: - The nurse engages the client in a. nurse-patient interaction.Q. Rapport has been established in the nurse-client interaction time. I am committed to have this time available for us while you are at the hospital and ends after your discharge."

• "The best time to talk is during the nurse-client interaction time. I am committed to have this time available for us while you are at the hospital and ends after your discharge."
• "Yes, if you keep it confidential, this is part of privileged communication."
• "I am committed for your care."
• "I am sorry, though I would want to, it is against hospital policy."

17. Kristine is scheduled for a bronchoscopy. When teaching Kristine what to expect afterward, the nurse's highest priority of information would be:

• Food and fluids will be withheld for at least 2 hours.
• Warm saline gargles will be done q2h.
• Coughing and deep-breathing exercises will be done q2h
• Only ice chips and cold liquids will be allowed initially.

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18. The nurse is administering a cleansing enema to a client with a fecal impaction. Before administering the enema, the nurse should place the client in which position?

• Left Sims' position
• Right Sims' position
• On the left side of the body, with the head of the bed elevated 45 degrees
• On the right side of the body, with the head of the bed elevated 45 degrees

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19. After a hearing restoration operation a patient has no signs of complications and soon recovers which of the following is an expected outcome 5 days after the hearing restoration surgery?

• Regain full hearing
• Minimal facial nerve paralysis
• Minimal urinary incontinence
• Ambulate without difficulty

20. Situation: "Group Approach" in Nursing.Q. Membership dropout generally occurs in group therapy after a member:

• Accomplishes his goal in joining the group
• Discovers that his feelings are shared by the group members
• Experiences feelings of frustration in the group
• Discusses personal concerns with group members

21. Situation: Mrs. Andres brought his son, Juanito, age 3 to the Pediatric clinic. She noticed that her son is not speaking and tend to repeat everything she says. The mother also told the nurse that Juanito prefers to be alone, will cry when someone will come near him and tend to rock himself from morning till he will fell asleep.Q. According to Freud, Juanito is at what psychosexual stage?

• Anal
• Oral
• Phallic
• Latency

22. The drug usually given parentally to enhance uterine contraction is:

• Terbutalline
• Pitocin
• Magnesium sulfate
• Lidocaine

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23. A newborn who has an asymmetrical Moro reflex response should be further assessed for which of the following?

• Talipes equinovarus
• Fractured clavicle
• Congenital hypothyroidism
• Increased intracranial pressure

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24. A woman undergoing radiation therapy developed redness and burning of the skin around the best. This is best classified as what type of disease?

• Neoplastic
• Traumatic
• Nosocomial
• Iatrogenic

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25. The nurse is caring for a diabetic child whose 11 a.m. blood glucose monitoring check is 302 mg/dL The physician orders the following coverage scheduled 50 to 200 mg/dL-2 units of Humulin R201 to 250 mg/dL-4 units of Humuiin R251 to 300 mg/dL-6 units of Humulin R301 to 350 mg/dL-8 units of Humulin R 351 to 399 mg/dL-10 units of Humulin R Over 400 mg/dL-call the physician. According to the coverage schedule; how many unites you would give your patient:

• 4 units
• 6 units
• 8 units
• 10 units

26. Which one of the following is NOT a function of the Upper airway?

• For clearance mechanism such as coughing
• Transport gases to the lower airways
• Warming, Filtration and Humidification of inspired air
• Protect the lower airway from foreign mater

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27. Situation: The body has regulatory mechanism to maintain the needed electrolytes. However there are conditions/surgical interventions that could compromise life. You have to understand how management of these conditions are done.Q. If there is an accidental injury to the parathyroid gland during a thyroidectomy which of the following might Leda develops postoperative?

• Cardiac arrest
• Dyspnea
• Respiratory failure
• Tetany

28. Which of the following reacts to viruses and bacteria by increasing in number?

• Antigens
• Antibodies
• Rh factors
• Platelets

29. A patient receives a blood transfusion for severe anemia after surgery. While evaluating the patient the nurse finds that the patient's oral temperature has began to rise from 98.20F (36.80F) to 101.00F(38.30C). What should the nurse do?

• Give the patient an anti-pyretic medication and continue the transfusion as ordered
• Discontinue the intravenous line and restart in another site
• Stop the transfusion, keep the vein open with normal saline, and notify the doctor immediately
• Use a blood cooling device to cool the blood as it infuses

30. A child and his family were exposed to Mycobacterium tuberculosis about 2 months ago, to confirm the presence or absence of an infection, it is most important for all family members to have a:

• chest x-ray
• blood culture
• sputum culture
• PPD intradermal test

31. A client with AIDS asks the nurse why he cannot have a pitcher of water left at his bedside. The nurse should tell the client that:

• It would be best for him to drink ice water.
• He should drink several glasses of juice instead.
• It makes it easier to keep a record of his intake.
• He should drink only freshly run water.

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32. While suctioning a client's laryngectomy tube, the nurse insert the catheter:

• About 1-2 inches
• As the client exhales
• Until resistance is met, then withdraw it 1-2 cm
• Until the client begins coughing

33. While reading the progress notes on a client with cancer the nurse notes a TNM classification of T1 N1 MO. What does this classification indicate?

• The tumor is in situ no regional lymph nodes are involved and there is no metastasis.
• No evidence of primary tumor exists lymph nodes cant be assessed and metastasis cant be assessed.
• The tumor is extended with regional lymph node involvement and distant metastasis.
• The tumor is extended and regional lymph nodes are involved but there is no metastasis.

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34. Shoes with low, broad heels, plus a good posture will prevent which prenatal discomfort?

• Backache
• Vertigo
• Leg cramps
• Nausea

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35. Which of the following should the nurse do when applying gloves prior to a surgical procedure?

• Slipping gloved hand with all fingers when picking up the second glove
• Grasping the first glove by inserting four fingers, with thumbs up underneath the cuff
• Putting the gloves into the dominant hand first
• Adjust only the fitting of the gloves after both gloves are on

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36. The nurse is caring for a 2 year-old who is being treated with chelation therapy, calcium disodium edetate, for lead poisoning. The nurse should be alert for which of the following side effects?

• Neurotoxicity
• Hepatomegaly
• Nephrotoxicity
• Ototoxicity

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37. A patient is being followed in the clinic for hypertension, adult onset diabetes, and obesity. The patient is apathetic about learning nutritional guide lines to reach the goals of weight loss and consumption of a healthy diet. The patient admitted to eating "whatever is put in front of me". Which of the following actions would the nurse take?

• Collaborate with the patient to set goals
• Add a nursing diagnosis of non-compliance
• Refer for Psychiatric screening for depression
• Discuss nutritional interventions with the spouse

38. The physician has made a diagnosis of shaken child^ syndrome for a 13-month-old who was brought to the emergency room after a reported fall from his highchair. Which finding supports the diagnosis of shaken childsl syndrome?

• Fracture of the clavicle
• Periorbital bruising
• Retinal hemorrhages
• Fracture of the humerus

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39. He discusses the goal of the department Which of the following statements is a goal?

• Increase the patient satisfaction rate
• Eliminate the incidence of delayed administration of medications
• Establish rapport with patients.
• Reduce response time to two minutes.

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40. Situation: In the OR, there are safety protocols that should be followed. The OR nurse should be well versed with ail these to safeguard the safety and quality of patient delivery outcome.Q. OR nurses should be aware that maintaining the client's safety is the overall goal of nursing care during the intraoperative phase. As the circulating nurse, you make certain that throughout the procedure:

• the surgeon greets his client before induction of anesthesia
• the surgeon and anesthesiologist are in tandem
• strap made of strong non-abrasive materials are fastened securely around the joints of the knees and ankles and around the 2 hands around an arm board.
• Client is monitored throughout the surgery by the assistant anaesthesiologist

41. A client who is human immunodeficiency virus (HlV)-positive has had a tuberculin skin test (TST). The nurse notes a 7-mm area of induration at the site of the skin test and interprets the result as which finding?

• Positive
• Negative
• Inconclusive
• Need for repeat testing

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42. Mr. Duffy is admitted to the CCU with a diagnosis of R/O Ml. He presented in the ER with a typical description of pain associated with an Ml, and is now cold and clammy, pale and dyspneic. He has an IV of D5W running, and is complaining of chest pain. Oxygen therapy has not been started, and he is not on the monitor. He is frightened. Q. The coronary arteries furnish blood supply to the myocardium. Which of the following is a true statement relative to the coronary circulation?

• the right and left coronary arteries are the first of many branches off the ascending aorta
• blood enters the right and left coronary arteries during systole only
• the right coronary artery forms almost a complete circle around the heart, yet supplies only the right ventricle
• the left coronary artery has two main branches, the left anterior descending and left circumflex: both supply the left ventricle

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43. Which of the following is the best guarantee that the patient's priority needs are met?

• Checking with the relative of the patient
• Preparing a nursing care plan in collaboration with the patient
• Consulting with the physician
• Coordinating with other members of the team

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44. Hypertension is defined as persistent blood pressure levels in which the systolic and diastolic above

• 110/60 mmHg
• 130/80 mmHg
• 120/70 mmHg
• 140/90 mmHg

45. A client having a colonoscopy is medicated with Versed (midazolam). The nurse recognizes that the client:

• Will be able to remember the procedure within 2-3 hours
• Will not be able to remember having the procedure done
• Will be able to remember the procedure within 2-3 days
• Will not be able to remember what occurred before the procedure

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46. Postoperative thyroidectomy nursing care includes which measures?

• Have the client speak every 5-10 mins if hoarseness is present
• Provide a low calcium diet to prevent hypercalcemia
• Check the dressing all the back of the neck for bleeding
• Apply a soft cervical collar to restrict neck movement

47. A client with Hodgkins lymphoma is receiving Platinol (cisplatin). To help prevent nephrotoxicity the nurse should:

• Slow the infusion rate.
• Make sure the client is well hydrated.
• Record the intake and output every shift.
• Tell the client to report ringing in the ears.

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48. While caring for a client with infective endocarditis, the nurse must be alert for signs of pulmonary embolism. Which of the following assessment findings suggests this complication?

• Positive Homan's sign
• Fever and chills
• Dyspnea and cough
• Sensory impairment

49. When the duodenal enzyme sucrase acts on SUCROSE, which 2 monosaccharides are formed?

• Galactose + Galactose
• Glucose + Fructose
• Glucose + Galactose
• Fructose + Fructose

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50. A client has clear fluid leaking from the nose following a basilar skull fracture. Which finding would alert the nurse that cerebrospinal fluid is present?

• Fluid is clear and tests negative for glucose.
• Fluid is grossly bloody in appearance and has a pH of 6.
• Fluid clumps together on the dressing and has a pH of 7.
• Fluid separates into concentric rings and tests positive for glucose.

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NCLEX-RN | QB1 | Practice Exam #31 (50 questions)