NCLEX-RN | QB1 | Practice Exam #30 (50 questions)
1. How many ml of liquid soap is recommended for handwashing procedure?
- 1-2 ml
- 2-3 ml
- 2-4 ml
- 5-10 ml
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2. SITUATION : John Smith was diagnosed with Acute Close Angle Glaucoma. He is being seen by Nurse JetQ. The doctor orders timolol [timoptic]. Nurse jet knows that the action of this drug is
- Reduce production of CSF
- Reduce production of Aquesous Humor
- Constrict the pupil
- Relaxes the Ciliary muscle
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3. SITUATION: Mr. Ramos was barbecuing outdoors when the gas tank exploded. He sustained second degree and third degree burns of the anterior portion of BOTH arms, the upper half of his anterior trunk and the anterior and posterior portions of his left lower extremity.The nurse is administering the prescribed IVF. When she evaluated the patient, she suspected fluid overload because of which finding?
- Dark and scanty urine output
- Moist rates
- Bradycardia and hypotension
- Facial flushing and twitching
4. Which of the following difficulties are frequently found in families with a member who has bulimia nervosa?
- Mental Illness
- Multiple losses
- Chronic anxiety
- Substance abuse
5. The visiting nurse observes that the older male client is confined by his daughter-in-law to his room. When the nurse suggests that he walk to the den and join the family, he says, "I'm in everyone's way; my daughter-in-law needs me to stay here." Which is the most important action for the nurse to take?
- Say to the daughter-in-law, "Confining your father-in-law to his room is inhumane."
- Suggest to the client and daughter-in-law that they consider a nursing home for the client.
- Say nothing, because it is best for the nurse to remain neutral and wait to be asked for help.
- Suggest appropriate resources to the client and daughter-in-law, such as respite care and a senior citizens center.
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6. The nurse is teaching parents of an infant about introduction of solid food to their baby. What is the first food they can add to the diet?
- Vegetables
- Cereal
- Fruit
- Meats
7. The nurse is assessing a client with delayed wound healing. Which of the following risk factors is most important in this situation?
- Glucose level of 120
- History of myocardial infarction
- Long term steroid usage
- Diet high in carbohydrates
8. The nurse assesses the vital signs of a client, 4 hours' postpartum that are as follows: BP 90/60; temperature 100.4°F; pulse 100 weak, thready; R 20 per minute. Which of the following shouldthe nurse do first?
- Report the temperature to the physician
- Recheck the blood pressure with another cuff
- Assess the uterus for firmness and position
- Determine the amount of lochia
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9. A patient comes to the emergency department with extreme dyspnea, orthopnea,anxiety and complains of feeling panicky. The patient is coughing up white frothy sputum and is cyanotic with profuse perspiration. Inspiratory and expiratory wheezing and bubbling sounds are auscultated. The patient is diagnosed with acute pulmonary edema. What should the nurse do FIRST?
- Identify precipitating factors and underlying conditions
- Administer morphine(Duramorph) to reduce anxiety
- Assess oxygen saturation rate
- Administer digoxin(Lanoxin) to decrease fluid backing up into the lungs
10. Situation: Nurse Macarena is a Family Planning and Infertility Nurse Specialist and currently attends to FAMILY PLANNING CLIENTS AND INFERTILE COUPLES. The following conditions pertain to meeting the nursing needs of this particular population group. Which among the following is the primary focus of prevention of cancer?
- Elimination of conditions causing cancer
- Diagnosis and treatment
- Treatment at early stage
- Early detection
11. Situation: The physician has ordered 3 units of whole blood to be transfused to Wally following a repair of a dissecting aneurysm of the aorta.Q. As Wally's nurse, what will you do AFTER the transfusion has started?
- add the total amount of blood to be transfused to the intake and output
- discontinue the primary IV of Dextrose 5% Water
- check the vital signs every 15 minutes
- stay with Wally for 15 minutes to for any possible BT reactions
12. Joy has entered the chemical dependency unit for treatment of alcohol dependency. Which of the following clients possession will the nurse most likely place in a locked area?
- Toothpaste
- Shampoo
- Antiseptic wash
- Moisturizer
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13. During the first several hours after a cardiac catheterization, it would be most essential for nurse Cherry to:
- Elevate clients bed at 45°
- Instruct the client to cough and deep breathe every 2 hours
- Frequently monitor client's apical pulse and blood pressure
- Monitor clients temperature every hour
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14. Situation: Rudy was diagnosed to have chronic renal failure. Hemodialysis is ordered that an A-V shunt was surgically created.Q. A renal failure patient was ordered for creatinine clearance. As the nurse you will collect:
- 48 hour urine specimen
- first morning urine
- 24 hour urine specimen
- random urine specimen
15. The nurse must help the client with pemphigus vulgaris deal with the resulting:
- Infertility
- Paralysis
- Skin lesions
- Impaired digestion
16. When delivering the baby's head the nurse supports the mother's perineum to prevent tear. This technique is called:
- Marmet's technique
- Ritgen's technique
- Duncan maneuver
- Schultze maneuver
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17. A home care nurse visits a patient who is wheelchair bound due to recent motor vehicle accident The patient has been sitting in the wheel chair for extended periods of time which resulted in the development of a stage pressure sore on the right buttocks. What is the BEST nursing intervention?
- Instruct caretaker to change the patient's position every 2 hours
- Apply hydrogel to the stage I pressure sore every 8 hours
- Refer the patient to wound care specialist for debridement
- Encourage the patient to consume an increased amount of calcium
18. A 23-year-old patient with a recent history of encephalitis is admitted to the medical unit with new onset generalized tonic-clonic seizures. Which nursing activities included in the patient's care will be best to delegate to an LPN/LVN whom you are supervising? (Choose all that apply).
- Document the onset time, nature of seizure activity, and postictal behaviors for all seizures.
- Administer phenytoin (Dilantin) 200 mg PO daily.
- Teach patient about the need for good oral hygiene.
- Develop a discharge plan, including physician visits and referral to the Epilepsy Foundation.
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19. A patient who has been admitted to the medical unit with new-onset angina also has a diagnosis of Alzheimer's disease. Her husband tells you that he rarely gets a good night's sleep because he needs to be sure she does not wander during the night. He insists on checking each of the medications you give her to be sure they are the same as the ones she takes at home. Based on this information, which nursing diagnosis is most appropriate for this patient?
- Decreased Cardiac Output related to poor myocardial contractility
- Caregiver Role Strain related to continuous need for providing care
- Ineffective Therapeutic Regimen Management related to poor patient memory
- Risk for Falls related to patient wandering behavior during the night
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20. Situation: During surgical operation, it is inevitable to utilize sutures. The nurse should know the basic principles in suturing as well as knowledge in selecting sutures and caring for clients with sutures. Q. If the suture is removed to soon, the nurse knows that it could lead to failed healing of the wound as well as infection. If the suture is removed too late, which of the following can occur?
- Itching
- Swelling
- Scarring
- Pain
21. The parents of a child recently diagnosed with cerebral palsy ask the nurse about the limitations of the disorder The nurse responds by explaining that the limitations occur as a result of which pathophysiological process?
- An infectious disease of the central nervous system
- An inflammation of the brain as a result of a viral illness
- A chronic disability characterized by impaired muscle movement and posture
- A congenital condition that results in moderate to severe intellectual disabilities
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22. A female patient pregnant 9 months, came to the emergency with bleeding and clot discharge with blood, what is the diagnosis?
- Placenta Pravia
- Abrubito
- Bleeding
- None of the above.
23. In assisted reproductive technology (ART), there is a need to stimulate the ovaries to produce more than one mature ovA. The drug commonly used for this purpose is:
- Bromocriptine
- Clomiphene
- Provera
- Estrogen
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24. Which of the following instructions should be included in the teaching for the client with rheumatoid arthritis?
- Avoid exercise because it fatigues the joints.
- Take prescribed anti-inflammatory medications with meals.
- Alternate hot and cold packs to affected joints.
- Avoid weight-bearing activity.
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25. The doctor has prescribed Cortone (cortisone) for a client with systemic lupus erythematosis. Which instruction should be given to the client?
- Take the medication 30 minutes before eating.
- Report changes in appetite and weight.
- Wear sunglasses to prevent cataracts.
- Schedule a time to take the influenza vaccine.
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26. Which nursing action is essential prior to initiating a new prescription for 500 mL of fat emulsion (lipids) to infuse at 50 mL/hour?
- Ensure that the client does not have diabetes.
- Determine whether the client has an allergy to eggs.
- Add regular insulin to the fat emulsion, using aseptic technique.
- Contact the health care provider (HCP) to have a central Sine inserted for fat emulsion infusion.
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27. Situation: Burn is cause by transfer of heat source to the body, it can be thermal, electrical radiation or chemical.Q. Which of the following can be fatal complication of upper airway burns?
- stress ulcers
- hemorrhage
- shock
- laryngeal spasm and swelling
28. The client sustains a contusion of the eyeball following a traumatic injury with a blunt object Which intervention should be initiated immediately?
- Apply ice to the affected eye.
- Irrigate the eye with cool water.
- Notify the health care provider (HCP).
- Accompany the client to the emergency department.
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29. Mr. Snyder is admitted to your unit with a brain tumor. The type of tumor he has is currently unknown. You begin to think about the way brain tumors are classified.Q. Whether Mr Snyder's tumor is benign or malignant, it will eventually cause increased intracranial pressure. Signs and symptoms of increasing intracranial pressure may include ail of the following except:
- headache, nausea, and vomiting
- papilledema, dizziness, mental status changes
- obvious motor deficits
- increased pulse rate, drop in blood pressure
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30. SITUATION: Marvin, A male patient diagnosed with colon cancer was newly put in colostomy.Q. The nurse should insert the colostomy tube for irrigation at approximately:
- 1-2 inches
- 3-4 inches
- 6-8 inches
- 12-18 inches
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31. A physician has ordered gavage feeding every 4 hours for a 12-week-old infant with failure to thrive. In order to know how far to insert the feeding tube. The nurse should measure the distance from:
- The infant's mouth to the xiphoid process of the sternum
- The tip of the infant's nose to the ear and then to the umbilicus
- The infant's mouth to the ear and then to the umbilicus
- The tip of the infant's nose to the ear and then to the xiphoid process of the sternum
32. A 59-years old patient with lung cancer and metastases to the bone Is in the hospital for pain management. The patient rates the pain 10 on a scale of 0(no pain) to 10 (severe pain). The BEST goal for the nurse diagnosis of alteration is comfort is that the patient will:
- Show no objective signs of pain
- Not complain of pain
- State pain is at a tolerable level
- State that all pain is relieved
33. The nurse is planning to teach a client with gastroesophageal reflux disease (GERD) about substances to avoid. Which items should the nurse include on this list? Select all that apply. 1.Coffee. 2.Chocolate. 3.Peppermint. 4.Nonfat milk. 5.Fried chicken. 6.Scrambled eggs.
- 1,2,3,5
- 1,2,3
- 3,4,5
- 2,3,4
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34. Situation: Colorectal cancer can affect old and younger people. Surgical procedures and other modes of treatment are done to ensure quality of life. You are assigned in the Cancer institute to care of patients with this type of cancer.Q. Symptoms associated with cancer of the colon include:
- constipation, ascites and mucus in the stool
- diarrhea, heartburn and eructation
- blood in the stools, anemia and pencil-shaped stools
- anorexia, hematemesis, and increased peristalsis
35. A 22 year old client suffered from his first tonic-clonic seizure. Upon awakening the client asks the nurse, "What caused me to have a seizure? Which of the following would the nurse include in the primary cause of tonic clonic seizures in adults more the 20 years?
- Electrolyte imbalance
- Head trauma
- Epilepsy
- Congenital defect
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36. Situation: Two children were brought to you. One with chest indrawing and the other had diarrhea. The following questions apply:Which of the following treatment should NOT be considered if the child has severe dengue hemorrhagic fever?
- use plan C if there is bleeding from the nose or gums
- give ORS if there is skin petechiae, persistent vomiting, and positive tourniquet test
- give aspirin
- prevent low blood sugar
37. Which of the following heart muscle diseases is unrelated to other cardiovascular disease?
- Cardiomyopathy
- Coronary artery disease
- Myocardial infarction
- Pericardial Effusion
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38. A client with a right lobectomy is being transported from the intensive care unit to a medical unit The nurse understands that the clients chest drainage system:
- Can be disconnected from suction if the chest tube is clamped
- Can be disconnected from suction but the chest tube should remain unclamped
- Must remain connected by means of a portable suction
- Must be kept even with the clients shoulders during the transport
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39. A patient with severe diverticulitis had surgery for placement of colostomy. The patient is upset, crying and will not look at the colostomy. Which of the following would be the HIGHEST priority nursing diagnosis at this time?
- Knowledge deficit, colostomy care
- Distorted body image
- Self-care deficit, toileting
- Alteration in comfort
40. He thinks of an appropriate theoretical framework. Whose theory addresses the four modes of adaptation?
- Martha Rogers
- Sr. Callista Roy
- Florence Nightingale
- Jean Watson
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41. The nurse is caring for a client after a motor vehicle accident The client has a fractured tibia and bone is d protruding through the skin. Which action is of priority?
- Provide manual traction above and below the leg.
- Cover the bone area with a sterile dressing
- Apply an ACE bandage around the entire lower limb.
- Place the client in the prone position.
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42. Following hypophysectomy, patients require extensive teaching regarding this major alteration in their lifestyle
- Abnormal distribution of body hair
- Lifetime dependency on hormone replacement
- The need to drink many fluids to replace those lost
- The need to undergo repeat surgical procedures
43. Situation: Joanna Marie, a 40 year old client was diagnosed with breast cancer.Q, After Modified radical mastectomy, which assessment finding indicates that Joanna is experiencing a complication related to surgery?
- Sanguineous drainage in the Jackson Pratt drain
- Pain at the incision site
- Complaints of decreased sensation in the operative site
- Arm edema on the operative arm
44. Situation: Nursing care for the elderly.Q. The frequent use of the older client's name by the nurse is MOST effective in alleviating which of the following responses to old age?
- Loneliness
- Suspicion
- Grief
- Confusion
45. Situation: In the hospital, you are aware that we are helped by the .use of a variety of equipment/devices to enhance quality patient care delivery; Q. Before bedtime, you want to ensure Kyle's safety in 'bed. You will do which of the following:
- Put the lights on
- Put the side rails up
- Test the call system
- Lock the doors
46. Upon assessment the nurse found the following: fundus at 2 fingerbreadths above the umbilicus, last menstrual period (LMP) 5 months ago, fetal heart beat (FHB) not appreciated. Which of the following is the most possible diagnosis of this condition?
- Hydatidiform mole
- Missed abortion
- Pelvic inflammatory disease
- Ectopic pregnancy
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47. Drug therapy with thioridazine (Mellaril) shouldn't exceed a daily dose of 800 mg to prevent which adverse reaction?
- Hypertension
- Respiratory arrest
- Tourette syndrome
- Retinal pigmentation
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48. The nurse performing an admission assessment on a 2-year-old child who has been diagnosed with nephrotic syndrome s that which most common characteristic is associated with this syndrome?
- Hypertension
- Generalized edema
- Increased urinary output
- Frank, bright red blood in the urine
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49. A patient is scheduled for a pneumonectomy in the morning. Which of the following diagnosis is the MOST likely indication for this type of surgery?
- Lung carcinoma
- Pulmonary tuberculosis
- Benign pulmonary nodule
- Mediastinal shift
50. A pediatric client is admitted to the hospital for treatment of diarrhea caused by an infection with salmonella. Which of the following most likely contributed to the child illness?
- Brushing the family dog
- Playing with a turtle
- Taking a pony ride
- Feeding the family cat
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NCLEX-RN | QB1 | Practice Exam #30 (50 questions)