NCLEX-RN | QB1 | Practice Exam #29 (50 questions)
1. Situation: You are assigned to take care of a group of patients across the lifespan.You are the nurse assigned to work with a child with acute glomerulonephritis. By following the prescribed treatment regimen, the child experiences a remission. You are now checking to make sure the child does not have a relapse. Which finding most lead you to the conclusion that a relapse is happening?
- Elevated temperature, cough, sore throat, changing complete blood count (CBC) with differential count
- A urine dipstick measurement of 2+ proteinuria or more for 3 days or the child found to have 3-4+ proteinuria plus edema.
- The urine dipstick showing glucose in the urine for 3 days, extreme thirst, increase in urine output and a moon face.
- A temperature of 37.8 degrees (100 degrees F) flank pain, burning frequency, urgency on voiding and cloudy urine.
2. While performing physical assessment of a 12 month-oldf the nurse s that the infant's anterior fontanel is still slightly open. Which of the following is the nurse's most appropriate action?
- Notify the physician immediately because there is a problem.
- Perform an intensive neurological examination.
- Perform an intensive developmental examination.
- Do nothing because this is a normal finding for the age.
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3. While caring for a child with aventriculoperitoneal shuntrevision, the nurse find the patient lying with the head and feet flexed back The nurse should call for help and prepare for a(n):
- Spinal tap
- Shunt culture
- Electrocardiogram
- Ventricular tap
4. A client who is unconscious needs frequent mouth care. When performing a mouth care, the best position of a client is:
- Fowler's position
- Side lying
- Supine
- Trendelenburg
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5. A client with anorexia nervosa is a member of a predischarge support group. The client verbalizes that she would like to buy some new clothes, but her finances are limited. Group members have brought some used clothes to the client to replace the client's old clothes. The client believes that the new clothes are much too tight and has reduced her calorie intake to 800 calories daily. How should the nurse evaluate this behavior?
- Normal behavior
- Evidence of the client's disturbed body image
- Regression as the client is moving toward the community
- Indicative of the client's ambivalence about hospital discharge
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6. The nurse inspects the color of the drainage from a nasogastric tube on a postoperative client approximately 24 hours after gastric surgery. Which finding indicates the need to notify the health care provider (HCP)?
- Dark red drainage
- Dark brown drainage
- Green-tinged drainage
- Light yellowish-brown drainage
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7. Which of the following would lead the nurse to suspect that a client with a fracture of the right femur may be developing a fat embolus?
- Acute respiratory distress syndrome
- Migraine like headaches
- Numbness in the right leg
- Muscle spasms in the right thigh
8. The nurse is doing an admission assessment on a client with a history of duodenal ulcer To determine whether the problem is currently active, the nurse should assess the client for which sign(s)/ symptom(s) of duodenal ulcer?
- Weightloss
- Nausea and vomiting
- Pain relieved by food intake
- Pain radiating down the right arm
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9. When John has been given paracetamol, his fever was brought down dramatically from 40 degrees Celsius to 36.7 degrees in a matter of 10 minutes. The nurse would assess this event as:
- The goal of reducing john's fever has been met with full satisfaction of the outcome criteria
- The desired goal has been partially met
- The goal is not completely met
- The goal has been met but not with the desired outcome criteria
10. The nurse is assessing a client with epididymitis. The nurse anticipates which findings on physical examination?
- Fever, diarrhea, groin pain, and ecchymosis
- Nausea, painful scrotal edema, and ecchymosis
- Fever, nausea, vomiting, and painful scrotal edema
- Diarrhea, groin pain, testicular torsion, and scrotal edema
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11. To minimize a toddler from scratching and picking at healing skin graft, the nurse should utilize:
- Mild sedatives
- Hand mittens
- Punishment for picking
- Distractions
12. Nurse Ron enters a clients room, the client says, "They're crawling on my sheets! Get them off my bed!" Which of the following assessment is the most accurate?
- The client is experiencing aphasia
- The client is experiencing dysarthria
- The client is experiencing a flight of ideas
- The client is experiencing visual hallucination
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13. A 28 yr-old female nurse is seen in the employee health department for mild itching and rash of both hands. Which of the following could be causing this reaction?
- possible medication allergies
- current life stressors she may be experiencing
- chemicals she may be using and use of latex gloves
- recent changes made in laundry detergent or bath soap.
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14. A nurse completes discharge instruction for patient who was admitted 5 days ago with pneumonia. Which statement by the patient would alert the nurse that more discharge teaching is needed?
- I need to gradually increase my activities
- I will not need the influenza or pneumonia vaccine
- I may experience fatigue and weakness for a prolonged time
- I need to have another chest x-ray in 4-6 weeks
15. A client arrives in the emergency room with a possible fractured femur The nurse should anticipate an order for:
- Trendelenburg position
- Ice to the entire extremity
- Bucks traction
- An abduction pillow
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16. Intravenous (IV) fluids have been infusing at 100 mL/hour via a central line catheter in the right internal jugular for approximately 24 hours to increase urine output and maintain the clients blood pressure. Upon entering the clients room, the nurse s that the client is breathing rapidly and coughing. For which additional signs of a complication should the nurse assess based on the previously known data?
- Excessive bleeding
- Crackles in the lungs
- Incompatibility of the infusion
- Chest pain radiating to the left arm
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17. A client admitted with a pheochromocytoma returns from the operating room after adrenalectomy. The nurse should carefully assess this client for:
- Hypokalemia
- Hyperglycemia
- Marked Na and water intake
- Marked fluctuations in BP
18. The nurse is caring for a client, a Vietnam veteran, who exhibits signs and symptoms of posttraumatic stress disorder Signs and symptoms of posttraumatic stress disorder include:
- hyper alertness and sleep disturbances.
- memory loss of traumatic event and somatic distress.
- feelings of hostility and violent behavior.
- sudden behavioral changes and anorexia.
19. A nurse is caring for child who is post-tonsillectomy and adenoidectomy. The nurse should plane to assess which of the following complications?
- Pulmonary hypertension
- Hemorrhage
- Hearing loss
- Corpulmonale
20. The clinic nurse reads the results of a tuberculin skin test (TST) on a 3-year-old child. The results indicate an area of induration measuring 10 mm. The nurse should interpret these results as which finding?
- Positive
- Negative
- Inconclusive
- Definitive and requiring a repeat test
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21. Situation: You are working as a Pediatric Nurse in your own Child Health Nursing Clinic, the following cases pertain to ASSESSMENT AND CARE OF THE NEWBORN AT RISK conditions.Q. Why are small-for-gestational-age newborns at risks for difficulty maintaining body temperature?
- They do not have as many fat stores as other infant's
- They are more active than usual so throw off covers
- Their skin is more susceptible to conduction of cold
- They are preterm so are born relatively small in size
22. Based on the assessment, you classified a 3-month old infant with the chief complaint of diarrhea in the category of SOME DEHYDRATION. Based on the IMCI management guidelines, which of the following will you do?
- Bring the infant to the nearest facility where IV fluids can be given
- Supervise the mother in giving 200 to 400 ml of Oresol in 4 hours
- Give the infant's mother instructions on home management
- Keep the infant in your health center for close observation
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23. The police arrive at the emergency department with a client who has lacerated both wrists. Which is the initial nursing action?
- Administer an antianxiety agent.
- Assess and treat the wound sites.
- Secure and record a detailed history.
- Encourage and assist the client to ventilate feelings.
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24. Which of the following toys should the nurse recommend for a 5-month-old?
- A big red balloon
- A teddy bear with button eyes
- A push-pull wooden truck
- A colorful busy box
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25. The client is taking TOFRANIL. The nurse should cioseiy monitor the patient for:
- Hypertension
- Hypothermia
- Increase Intra Ocular Pressure
- Increase Intra Cranial Pressure
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26. SITUATION : John Smith was diagnosed with Acute Close Angle Glaucoma. He is being seen by Nurse Mia. Nurse Mia knows that Aqueous Humor is produce where?
- In the sub arachnoid space of the meninges
- In the Lateral ventricles
- In the Choroids
- In the Ciliary Body
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27. The primary respiratory center:
- Medulla oblongata
- Pons
- Carotid bodies
- Aortic bodies
28. Situation: Vincent, age 26, who is caught in me raging conflict between his mother and his wife, complains of pains in his right leg that has progressed to the point of paralysis. After orthopedic consultation has shown no pathology, he is referred for a psychiatric consultation and is found to have a conversion disorder.Q. Which behavior is Vincent most likely to manifest?
- Demonstrate a spread of paralysis to other body parts
- Require continuous psychiatric treatment to maintain individual functioning
- Recover the use of the affected leg but under stress, again develop similar symptoms
- Follow a rather unpredictable emotional course I the future, depending on exposure to stress
29. When planning a class on pregnancy, the nurse should include symptoms of pregnancy that must be reported immediately, such as:
- Leg cramps
- Vision disturbance
- Swelling of the legs
- Constipation
30. Which type of family-nurse contact will provide you with the best opportunity to observe family dynamics?
- Clinic consultation
- Group conferences
- Home visit
- Written communication
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31. Situation: Team efforts is best demonstrated in the OR. Q.If you are the nurse in charge for scheduling surgical cases, what important information do you need to ask the surgeon?
- Who is your internist?
- Who is your assistant and anesthesiologist and what is your preferred time and type of surgery?
- Who are your anesthesiologist, internist and assistant?
- Who is your anesthesiologist?
32. The doctor has ordered neurological checks every 30 minutes for a client injured in a biking accident. Which finding indicates that the clients condition is satisfactory?
- A score of 13 on the Glascow coma scale
- The presence of dolls eye movement
- The absence of deep tendon reflexes
- Decerebrate posturing
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33. Situation: Marie is 5 and 1/2 years old and described by the mother as bedwetting at nightQ. During your conference, the parent inquires how to motivate Marie to be dry in the morning. Your response which is an immediate intervention would be:
- Give a star each time she wakes up dry and every set of five stars, give a prize
- Tokens make her materialistic at an early age. Give praise and hugs occasionally
- What does your child want that you can give every time he/she wakes up dray in the morning
- Promise him/her a long awaited vacation after school is over.
34. The home health nurse visits a client with a diagnosis of type 1 diabetes mellitus. The client relates a history of vomiting and diarrhea and tells the nurse that no food has been consumed for the last 24 hours. Which additional statement by the client indicates a need for further teaching?
- "I need to stop my insulin."
- "I need to increase my fluid intake."
- "I need to monitor my blood glucose every 3 to 4 hours."
- "I need to call the health care provider (HCP) because of these symptoms"
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35. The nurse is teaching a client who has iron deficiency anemia about foods she should include in the diet The nurse determines that the client understands the dietary modifications if which items are selected from the menu?
- Nutsandmilk
- Coffee and tea
- Cooked rolled oats and fish
- Oranges and dark green leafy vegetables
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36. Edward, a 66 year old client with slight memory impairment and poor concentration, is diagnosed with primary degenerative dementia of the Alzheimer's type. Early signs of this dementia include subtle personality changes and withdrawal from social interactions. To assess for progression to the middle stage of Alzheimer's disease, the nurse should observe the client for:
- Occasional irritable outbursts.
- Impaired communication.
- Lack of spontaneity.
- Inability to perform self-care activities.
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37. A health care provider prescribes regular insulin, 8 units/hour by continuous intravenous (IV) infusion. The pharmacy prepares the medication and then delivers an IV bag labeled 100 units of regular insulin in 100 mL normal saline (NS). An infusion pump must be used to administer the medication. The nurse sets the infusion pump at how many milliliters per hour to deliver 8 units/hour?
- 10 mL/hour.
- 3 mL/hour.
- 5 mL/hour.
- 8 mL/hour.
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38. Situation: Children have a special fascination with the workings of the digestive system. To fully understand the digestive processes. Nurse Lavigna must be knowledgeable of the anatomy and physiology of the gastrointestinal system.Q. Once food has been placed in the mouth, both mechanical and chemical digestions begin. The six activities of the digestive process are:
- ingestion, mastication, digestion, deglutition, absorption, egestion
- ingestion, mastication, deglutition, digestion, absorption, egestion
- deglutition, ingestion, mastication, egestion, absorption, defecation
- ingestion, digestion, mastication, deglutition, absorption, defecation
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39. Situation: Mr. Santos, 50, is to undergo cystoscopy due to multiple problems like scantly urination, hematuria, and dysuria.Q. After cystoscopy, Mr. Santos asked you to explain why there is no incision of any kind. What do you tell him?
- Cystoscopy is direct visualization and examination by urologist
- Cystoscopy is done by x-ray visualization of the urinary tract
- Cystoscopy is done by using lasers on the urinary tract
- Cystoscopy is an endoscopic procedure of the urinary tract
40. As a nurse manager, which of the following best describes this function?
- Initiate modification on client's lifestyle
- Protect client's right
- Coordinates the activities of other members of the health team in managing patient care
- Provide in service education programs, Use accurate nursing audit, formulate philosophy and vision of the institution
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41. Nurse Perry is evaluating the renal function of a male client. After documenting urine volume and characteristics, Nurse Perry assesses which signs as the best indicator of renal function.
- Blood pressure
- Consciousness
- Distension of the bladder
- Pulse rate
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42. The hormone responsible for the maturation of the graafian follicle is:
- Follicle stimulating hormone
- Progesterone
- Estrogen
- Luteinizing hormone
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43. Among the following statements, which should be given the HIGHEST priority?
- Client is in extreme pain
- Client's blood pressure is 60/40
- Client's temperature is 40C
- Client is cyanotic
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44. Which response by the nurse would best assist the chemically impaired client to deal with issues of guilt?
- "Addiction usually causes people to feel guilty. Don't worry, it is a typical response due to your drinking behavior.”
- "What have you done that you feel most guilty about and what steps can you begin to take to help you lessen this guilt?"
- "Don't focus on your guilty feelings. These feelings will only lead you to drinking and taking drugs."
- "You've caused a great deal of pain to your family and close friends, so it will take time to undo all the things you've done."
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45. Acupressure was started same 5.000 years ago by:
- Germans
- Filipinos
- Chinese
- Americans
46. The nurse is caring for a newborn with a suspected diagnosis of imperforate anus. The nurse monitors the infant, knowing that which is a clinical mani- festation associated with this disorder?
- Bile-stained fecal emesis
- The passage of currant jelly-like stools
- Failure to pass meconium stool in the first 24 hours after birth
- Sausage-shaped mass palpated in the upper right abdominal quadrant
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47. The physician ordered tetracycline PO qid to a child client who weights 20kg. The recommended PO tetracycline dose is 25-50 mg/kg/day. What is the maximum single dose that can be safely administered to this child?
- 500 mg
- 250 mg
- 125 mg
- 1g
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48. All of the following can cause tachycardia except:
- Fever
- Exercise
- Sympathetic nervous system stimulation
- Parasympathetic nervous system stimulation
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49. Which of the following substances has abnormal values early in the course of multiple myeloma (MM)?
- Immunoglobulins
- Platelets
- Red blood cells
- White blood cells
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50. A nurse evaluates a patient for signs of rebleeding from ruptured intracranial aneurysm that required surgical ligation. The highest risk for aneurysm rebleed is within:
- 6 hours
- 24 hours
- 48 hours
- 72 hours
NCLEX-RN | QB1 | Practice Exam #29 (50 questions)