NCLEX-RN | QB1 | Practice Exam #25 (50 questions)
1. 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 Mlf 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. You know that all but one of the following may eventually result in uremia. Which option is not implicated?
- glomerular disease
- uncontrolled hypertension
- renal disease secondary to drugs, toxins, infections, or radiations
- all of the above
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2. SITUATION: A 65 year old woman was admitted for Parkinson's Disease. The charge nurse is going to make an initial assessment.Q. Which of the following is a characteristic of a patient with advanced Parkinson's disease?
- Disturbed vision
- Forgetfulness
- Mask like facial expression
- Muscle atrophy
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3. The nurse is teaching the mother of an infant with galactosemia. Which information should be included in the nurses teaching?
- Check food and drug labels for the presence of lactose.
- Foods containing galactose can be gradually added.
- Future children will not be affected.
- Sources of galactose are essential for growth.
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4. The most serious adverse effect of tricyclic antidepressant (TCA) overdose is:
- Seizures.
- Hyperpyrexia.
- Metabolic acidosis.
- Cardiac arrhythmias.
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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. Initially, the nursing diagnosis would be:
- Impaired communication
- Impaired social interaction
- Altered thought process
- Altered family process
6. The nurse has admitted a client to the clinical nursing unit after undergoing a right mastectomy The nurse should plan to place the right arm in which position?
- Elevated on a pillow
- Level with the right atrium
- Dependent to the right atrium
- Elevated above shoulder level
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7. The nurse is providing care for a 10-month-old diagnosed with Wilms tumor. Most parents of infants with Wilms tumor report finding the mass when:
- The infant is diapered or bathed.
- The infant is unable to use his arms.
- The infant is unable to follow a moving object.
- The infant is unable to vocalize sounds.
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8. The nurse in the labor room is caring for a client in the active stage of the first phase of labor The nurse is assessing the fetal patterns and s a late decel- eration on the monitor strip. What is the most appropriate nursing action?
- Administer oxygen via face mask.
- Place the mother in a supine position.
- Increase the rate of the oxytocin intravenous infusion.
- Document the findings and continue to monitor the fetal patterns.
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9. On review of the clients' medical records, the nurse determines that which client is at risk for fluid volume excess?
- The client taking diuretics and has tenting of the skin
- The client with an ileostomy from a recent abdominal surgery
- The client who requires intermittent gastrointestinal suctioning
- The client with kidney disease and a 12-year history of diabetes mellitus
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10. Nurse Jen is caring for a male client with manic depression. The plan of care for a client in a manic state would include:
- Offering a high-calorie meals and strongly encouraging the client to finish all food.
- Insisting that the client remain active through the day so that he'll sleep at night.
- Allowing the client to exhibit hyperactive, demanding, manipulative behavior without setting limits.
- Listening attentively with a neutral attitude and avoiding power struggles.
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11. What stress response can you expect from a patient with blood sugar of 50 mg/dl?
- Body will try to decrease the glucose level
- There will be a halt in release of sex hormones
- Client will appear restless
- Blood pressure will increase
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12. A nursing process which involves the performance of the nursing plan care is:
- Assessment
- Nursing diagnosis
- Implementation
- Evaluation
13. The nurse is caring for an infant with a diagnosis of bladder exstrophy. To protect the exposed bladder tissue, the nurse should plan which intervention?
- Cover the bladder with petroleum jelly gauze.
- Cover the bladder with a nonadhering plastic wrap.
- Apply sterile distilled water dressings over the bladder mucosa.
- Keep the bladder tissue dry by covering it with dry sterile gauze.
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14. Situation: Harriet, a 38 year-old schoolteacher with rheumatoid arthritis, is admitted to the hospital with severe and swelling of the joints of both hands.Q. When planning nursing care for Hariet, the nurse should take into consideration the fact that:
- Inflammation of the synovial membrane will rarely occur
- Bony ankylosis of the joint is irreversible and causes immobility
- Complete immobility is desired during the acute phase of inflammation
- If the redness and swelling of a joint occur, they signify irreversible damage
15. A male adult client has undergone a lumbar puncture to obtain cerebrospinal fluid (CSF) for analysis. Which of the following values should be negative if the CSF is normal?
- Red blood cells
- White blood cells
- Insulin
- Protein
16. Mang Dagul, a 50 year old chronic smoker was brought to the E.R because of difficulty in breathing. Pleural effusion was the diagnosis and CTT was ordered. What does C.T.T Stands for?
- Chest tube thoracotomy
- Chest tube thoracostomy
- Closed tube thoracotomy
- Closed tube thoracostmy
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17. Which of the following oxygen delivery method can deliver 100% Oxygen at 15 LPM?
- Nasal Cannula
- Simple Face mask
- Non Rebreather mask
- Partial Rebreather mask
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18. A 14-year-old boy has acne and according to his parents, dominates the bathroom by using the mirror all the time.Which of the following remarks by the nurse would be least helpful in talking to the boy and his parents?
- "This is probably the only concern he has about his body. So don't worry about it or the time he spends on it."
- "Teenagers are anxious about how their peers perceive them. So they spend a lot of time grooming.”
- "A teen may develop a poor self-image when experiencing acne. Do you feel this way sometimes?"
- "You appear to be keeping your face well washed. Would you feel comfortable discussing your cleansing method?"
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19. Central venous access devices are beneficial in pediatric therapy because:
- They don't frighten children.
- Use of the arms is not restricted.
- They cannot be dislodged.
- They are difficult to see.
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20. A client who is admitted with an above-the-knee amputation tells the nurse that his foot hurts and itches. Which response by the nurse indicates understanding of phantom limb pain?
- The pain will go away in a few days.
- The pain is due to peripheral nervous system interruptions. I will get you some pain medication.
- The pain is psychological because your foot is no longer there.
- The pain and itching are due to the infection you had before the surgery.
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21. Parenteral penicillin can be administered as an:
- IM injection or an IV solution
- IV or an intradermal injection
- Intradermal or subcutaneous injection
- IM or a subcutaneous injection
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22. A patient is brought to emergency room with a severe head injury. A craniotomy is performed to evacuate a blood clot. Which of the following is a desired expected outcomes 24 hours postoperatively?
- Gag reflux present
- Cerebral perfusion pressure, 68mm Hg
- Intracranial pressure, 21mm Hg
- Decreased lacrimation
23. The nurse is caring for a client with full thickness burns to the lower half of the torso and lower extremities. During the emergent phase of injury the primary nursing diagnosis would focus on:
- Imbalanced nutrition less than body requirements related to hypermetabolic state
- Risk for infection related to altered skin integrity
- Risk for fluid volume imbalance related to intracompartmental fluid shift
- Acute pain related to burn injury
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24. Personal state in which a person feels unhealthy:
- Illness
- Disease
- Health
- Wellness
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25. In the past year, Barangay A had an average population of 1655. 46 babies were born in that year, 2 of whom died less than 4 weeks after they were born. They were 4 recorded stillbirths. What is the neonatal mortality rate?
- 27.8/1000
- 43.5/1000
- 86.9/1000
- 130.4/1000
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26. Ms. X has just been diagnosed with condylomata acuminata (genital warts). What information is appropriate to tell this client?
- This condition puts her at a higher risk for cervical cancer; therefore, she should have a Papanicolaou (Pap) smear annually.
- The most common treatment is metronidazole (Flagyl), which should eradicate the problem within 7 to 10 days.
- The potential for transmission to her sexual partner will be eliminated if condoms are used every time they have sexual intercourse.
- The human papillomavirus (HPV), which causes condylomata acuminata, can't be transmitted during oral sex.
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27. Alvin with a massive pulmonary embolism will have an arterial blood gas analysis performed to determine the extent of hypoxia. The acid-base disorder that may be present is?
- Metabolic acidosis
- Metabolic alkalosis
- Respiratory acidosis
- Respiratory alkalosis
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28. SITUATION : John Smith was diagnosed with Acute Close Angle Glaucoma. He is being seen by Nurse JetQ. Mr Smith has undergone eye angiography using an Intravenous dye and fluoroscopy. What activity is contraindicated immediately after procedure?
- Reading newsprint
- Lying down
- Watching TV
- Listening to the music
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29. The nurse observes a patient who is eating. The patient suddenly stands up, places both hands onto the neck and is unable to speak when the nurse asks if the patient can speak. The nurse observes that the patient is neither coughing not cyanotic. The nurse should IMMEDIATELY:
- Lay the patient fiat before compressing the mediastinal area
- Insert a finger into the patient's mouth to feel for any food
- Stand behind the patient while performing abdominal thrusts
- Activate the emergency call light near the patient
30. The central problem the nurse might face with a disturbed schizophrenic client is the clients:
- Suspicious feelings
- Continuous pacing
- Relationship with the family
- Concern about working with others
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31. A client with pancreatitis has been transferred to the intensive care unit. Which order would the nurse anticipate?
- Blood pressure every 15 minutes
- Insertion of a Levine tube
- Cardiac monitoring
- Dressing changes two times per day
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32. In collecting a routine specimen for fecalysis, which of the following, if done by a nurse, indicates inadequate knowledge and skills about the procedure?
- The nurse scoop the specimen specifically at the site with blood and mucus
- She took around 1 inch of specimen or a teaspoonful
- Ask the client to call her for the specimen after the client wiped off his anus with a tissue
- Ask the client to defecate in a bedpan, Secure a sterile container
33. Which Instruction should Nurse Tommy would give to a male client who is having external radiation therapy:
- Protect the irritated skin from sunlight.
- Eat 3 to 4 hours before treatment.
- Wash the skin over regularly.
- Apply lotion or oil to the irradiated area when it is red or sore.
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34. Which of the following would be the nurse's most appropriate response to a client who asks why she must have a cesarean delivery if she has a complete placenta previa?
- "You will have to ask your physician when he returns"
- "You need a cesarean to prevent hemorrhage"
- "The placenta is covering most of your cervix"
- "The placenta is covering the opening of the uterus and blocking your baby"
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35. Which of the following is a form of radiography:
- Fluoroscopy.
- Contrast medium.
- CT. Scan
- All of the above
36. A nursing diagnosis for a male client with a diagnosed multiple personality disorder is chronic low self-esteem probably related to childhood abuse. The most appropriate short term client outcome would be:
- Verbalizing the need for anxiety medications
- Recognizing each existing personality
- Engaging in object-oriented activities
- Eliminating defense mechanisms and phobia
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37. A patient with poor wound healing and poor appetite has an order to begin total parental nutrition (TPN). Waiting for the TPN solution to arrivefrom the pharmacy, the nurse shouldobtain:
- A pair of sterile gloves
- An infusion pump
- IV tubing with a micro-dripchamber
- Povidine-iodine (Beta dine)swabs
38. A client arrives in the emergency department followingan automobilecrash.The clients forehead hitthe steering wheel and a hyphema is diagnosed. The nurse should place the client in which position?
- Flat in bed
- A semi-Fowler's position
- Lateral on the affected side
- Lateral on the unaffected side
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39. Arterial ulcers are best described as ulcers that:
- Are smooth in texture
- Have irregular borders
- Are cool to touch
- Are painful to touch
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40. In preparing a female client for electroconvulsive therapy (ECT), Nurse Michelle knows that succinylcholine (Anectine) will be administered for which therapeutic effect?
- Short-acting anesthesia
- Decreased oral and respiratory secretions.
- Skeletal muscle paralysis.
- Analgesia.
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41. While giving care to a client with an internal cervical radiation implant, the nurse finds the implant in the bed. The nurse should take which initial action?
- Call the health care provider (HCP).
- Reinsert the implant into the vagina.
- Pick up the implant with gloved hands and flush it down the toilet.
- Pick up the implant with long-handled forceps and place it in a lead container.
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42. Situation: Johnny sought consultation to the hospital beforeQ. The nurse knows that Tapazole has which of the following side effect that will warrant immediate withholding of the medication?
- Colace (Docusate)
- Sore throat
- Hyperthermia
- Thrombocytosis
43. A patient is admitted to the hospital with complaints of nausea, vomiting, diarrhea, and severe abdominal pain. Which of the following would immediately alert the nurse that the patient has bleeding from the Gl tract?
- Complete blood count
- Guaiac test
- Vital signs
- Abdominal girth
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44. In developing care plan for a hospitalized 3 year old child with asthma, the nurse plans to talk calmly in an appropriate language and explains all procedures. Which of the following statements by the BEST demonstrates implementation of the approach?
- "You can use the stethoscope to listen to your heart and your doll's, and then I will listen"
- "You must not wiggle while listen to your heart. You can hold your doll"
- "The stethoscope will feel cold on your chest. You can tell your doll how cold it feels"
- "let go of your doll and place your hands on your tummy while I use the stethoscope"
45. As the client reaches 8cm dilation the nurse s a pattern on the fetal monitor that shows a drop in the fetal heart rate of 30bpm beginning at the peak of the contraction and ending at the end of the contraction. The FHR baseline is 165 tol 75bpm with variability of 0 to 2bpm. What is the most likely explanation of this pattern?
- The baby is asleep.
- The umbilical cord is compressed.
- There is a vagal response.
- There is uteroplacental insufficiency.
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46. A home health nurse visits a patient who is newly diagnosed with diabetes . The glucose level ranges from 120mg/dl to 150mg/dl while current glycosylated hemoglobin (hbA1C) level is 6.9 %. The patient is complaint with taking prescribed hypoglycemic medications and eats 3 meals a day followed by desserts sweetened with granulated sugar. The patient also exrcises 30 minutes a day 3 times a week. Which of the following educational intervention takes PRIORITY?
- Glucose monitoring
- Medications
- Dietary requirements
- Exercise regimen
47. A 45 year-old women is admitted for a surgical procedure. Local anesthetic medication, bupivacaine, and fentanyl are administered through a tiny needle placed into the subarachnoid space. The anesthetic is administered with the patient in an upright and seated position, five minutes later, the nurse records the patients vital signs: Blood pressure: 88/58 mmHg; Heart rate: 110/min; Respiratory rate: 18/min; Temperature: 38.0
- Blood pressure
- Pulse rate
- Respiratory rate
- Body temperature
48. A physician orders an intravenous fluid of DSNS at 100cc/hr. This is an example of which of the solution?
- Hypotonic
- Isotonic
- Hypertonic
- Hyper alimentation
49. Parathyroid hormone (PTH) has which effects on the kidney?
- Stimulation of calcium reabsorption and phosphate excretion
- Stimulation of phosphate reabsorption and calcium excretion
- Increased absorption of vit D and excretion of vit E
- Increased absorption of vit E and excretion of Vit D
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50. A patient with Alzheimer's disease has a fall, which results to a fracture of the right leg, after repair of the fracture the patient is discharged home with family with instructions of wound care, the family verbalizes that the patient has been doing well,which of the following instructions would the nurse give to the family?
- Instruct the family how to provide skin integrity
- Suggest to the family that if the stress is overwhelming, placement in a skilled nursing facility may be needed
- Suggest collecting the patient on a regular schedule and applying incontinence brief at all times
- Assess for the cause of incontinence and add an appropriate nursing diagnosis post and interventions
NCLEX-RN | QB1 | Practice Exam #25 (50 questions)