NCLEX-RN | QB1 | Practice Exam #24 (50 questions)
1. A patient with the deep vein thrombosis (DVT) is being treated with a low-molecular weight heparin.(LMWH). The patient reports increased pain in the affected extremely. The nurse observe the affected extremity has increased in size by 0.2 cm (0.8 inches) during the past 24 hours. Which of the following actions should the nurse take?
- Administer the next dose of LMWH before the scheduled time.
- Apply dry heal to the site
- Elevate the extremity
- Reinforce the importance of ankle circling exercises
2. When administering pancrelipase (Pancreases capsules) to child with cystic fibrosis, nurse Faith knows they should be given:
- With meals and snacks
- Every three hours while awake
- On awakening, following meals, and at bedtime
- After each bowel movement and after postural draianage
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3. Situation: Lizbeth 20 year-old college student is brought to the hospital by her mother who states that for the past week her behavior has become very strange. She has become more and more withdrawn - Diagnosis: Schizophrenia Catatonic.Q. Lizbeth keeps her eyes closed and does not answer the questions asked by the nurse or physician. The nurse know that;
- The patient can cannot hear nor understand what is being asked
- The patient is aware of what is happening around her even though she does not respond
- The patient is in regressed state and should be treated like a frightened child
- The patient is aware of what is going on around her and could respond if she wants to.
4. A newborn's failure to pass meconium within the first 24 hours after birth may indicate which of the following?
- Hirschsprung disease
- Celiac disease
- Intussusception
- Abdominal wall defect
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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. 1 really feel guilty about bringing him here, I can't bear to part with him."Q. Cardo appears to be awake and restless throughout the night, Which of the following is the medication you are expecting to be given?
- Diazepam [Valium]
- Chlorpromazine [Thorazine]
- Imipramine [Tofranil]
- Lithium [Lithane]
6. A child is treated for possible acetaminophen (Tylenol) overdose. The child is currently stable with normal vital signs. Which of the following organ function system would be MOST affected?
- Liver
- Stomach
- Lungs
- Heart
7. Louie, with burns over 35% of the body, complains of chilling. In promoting the client's comfort, the nurse should:
- Maintain room humidity below 40%
- Place top sheet on the client
- Limit the occurrence of drafts
- Keep room temperature at 80 degrees
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8. Prior to administering an enema, the nurse will assist the patient to assume what position
- Prone with pillow under knees
- Left-side with right knee flexed
- Right-side with left knee flexed
- On back with head of bed flat
9. A nurse has just received a medication order which is not legible. Which statement best reflects assertive communication?
- "I cannot give this medication as it is written. I have no idea of what you mean.”
- "Would you please clarify what you have written so I am sure I am reading it correctly?"
- "I am having difficulty reading your handwriting. It would save me time if you would be"
- "Please print in the future so I do not have to spend extra time attempting to read your writing."
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10. The nurse is caring for a client who she believes has been abusing opiates. Assessment findings in a client abusing opiates, such as morphine, include:
- dilated pupils and slurred speech.
- rapid speech and agitation.
- dilated pupils and agitation.
- euphoria and constricted pupils
11. Situation: You are going to participate in a Cancer Consciousness Week. You are assigned to take charge of the women to make them aware of cervical cancer. You reviewed its manifestations and managementQ. When a panhysterectomy is performed due to cancer of the cervix, which of the following organs are moved?
- the uterus, cervix, and one ovary
- the uterus, cervix, and two-thirds of the vagina
- the uterus, cervix, tubes and ovaries
- the uterus and cervix
12. Situation: The patient who is depressed will undergo electroconvulsive therapy.Q. Studies on biological depression support electroconvulsive therapy as a mode of treatment. The rationale is:
- ECT produces massive brain damage which destroys the specific area containing memories related to the events surrounding the development of psychotic condition
- "The treatment serves as a symbolic punishment for the client who feels guilty and worthless
- ECT relieves depression psychologically by increasing the norepinephrine level
- ECT is seen as a life-threatening experience and depressed patients mobilize all their bodily defenses to deal with this attack.
13. She surfs the internet for more information about leadership styles. She reads about shared leadership as a practice in some magnet hospitals. Which of the following describes this style of leadership?
- A Leadership behavior is generally determined by the relationship between the leader's personality and the specific situation
- Leaders believe that people are basically good and need not be closely controlled
- Leaders rely heavily on visioning and inspire members to achieve results
- Leadership is shared at the point of care
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14. Which of the following is the mission of the Department of Health?
- Health for all Filipinos
- Ensure the accessibility and quality of health
- Improve the general health status of the population
- Health in the hands of the Filipino people by the year 2020
15. Situation: There are other important basic knowledge in the performance of our task as Community Health Nurse in relation to IMMUNIZATION these include:Which of the following dose of tetanus toxoid is given to the mother to protect her infant from neonatal tetanus and likewise provide 10 years protection for the mother?
- Tetanus toxoid 3
- Tetanus toxoid 2
- Tetanus toxoid 1
- Tetanus toxoid 4
16. Because a severely depressed client has not responded to any of the antidepressant medications, the psychiatrist decides to try electroconvulsive therapy (ECT). Before the treatment the nurse should:
- Have the client speak with other clients receiving ECT
- Give the client a detailed explanation of the entire procedure
- Limit the client's intake to a light breakfast on the days of the treatment
- Provide a simple explanation of the procedure and continue to reassure the client
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17. The nurse is caring for a client following a laryngectomy. The nurse can best help the client with communication by:
- Providing a pad and pencil
- Checking on him every 30 minutes
- Telling him to use the call light
- Teaching the client simple sign language
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18. A client with acute renal failure is aware that the most serious complication of this condition is:
- Constipation
- Anemia
- Infection
- Platelet dysfunction
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19. The physician orders penicillin for a patient with streptococcal pharyngitis. The nurse administers the drug as ordered, and the patient has an allergic reaction. The nurse checks the medication order sheet and finds that the patient is allergic to penicillin. Legal responsibility for the error is:
- A only the nurse's—she should have checked the allergies before administering the medication.
- only the physician's—she gave the order, the nurse is obligated to follow it.
- only the pharmacist's—he should alert the floor to possible allergic reactions.
- the pharmacist, physician, and nurse are all liable for the mistake
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20. A six-month-old client is placed on strict bed rest following a hernia repair. Which toy is best suited to the client?
- Colorful crib mobile
- Hand-held electronic games
- Cars in a plastic container
- 30-piece jigsaw puzzle
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21. A nurse is caring for a client who has a tracheostomy and temperature of 39° C. which intervention will most likely lower the clients arterial blood oxygen saturation?
- Endotracheal suctioning
- Encouragement of coughing
- Use of cooling blanket
- Incentive spirometry
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22. An instrument used for auscultation is:
- Percussion-hammer
- Audiometer
- Stethoscope
- Sphygmomanometer
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23. A client experiencing alcohol withdrawal is upset about going through detoxification. Which of the following goals is a priority?
- The client will commit to a drug-free lifestyle.
- The client will work with the nurse to remain safe.
- The client will drink plenty of fluids daily.
- The client will make a personal inventory of strengths
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24. A client with a stroke and malnutrition has been placed on Total Parenteral Nutrition (TPN). The nurse s air entering the client via the central line. Which initial action is most appropriate?
- Notify the physician.
- Elevate the head of the bed.
- Place the client in the left lateral decubitus position.
- Stop the TPN and hang D5 1/2 NS.
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25. Situation: The nurse is often met with the following situations when clients become angry and hostile. Q.A patient grabs a chair and about to throw it. The nurse best responds saying:
- "Stop! Put that chair down"
- "Don't be silly"
- "Stop, the security will be here in a minute."
- "Calm down"
26. After a motor vehicle accident, Armand an 22-year-old client is admitted with a pneumothorax. The surgeon inserts a chest tube and attaches it to a chest drainage system. Bubbling soon appears in the water seal chamber. Which of the following is the most likely cause of the bubbling?
- Air leak
- Inadequate suction
- Adequate suction
- Kinked chest tube
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27. A health care provider prescribes 1 unit of packed red blood cells to infuse over 4 hours. The unit of blood contains 250 mL. The drop factor is 10 drops (gtt)/1 mL. The nurse prepares to set the flow rate at how many drops per minute?
- 12 drops per minute.
- 15 drops per minute.
- 10 drops per minute.
- 20 drops per minute.
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28. Nurse Gio plans a long term care for parents of children with sickle-cell anemia, which includes periodic group conferences. Some of the discussions should be directed towards:
- Finding special school facilities for the child
- Making plans for moving to a more therapeutic climate
- Choosing a means of birth control to avoid future pregnancies
- Airing their feelings regarding the transmission of the disease to the child
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29. Which of the following skills is the most significant one learned during the schoolage period?
- Collecting
- Ordering
- Reading
- Sorting
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30. Which of the following assessment findings in a client with leukemia would indicate that the cancer has invaded the brain?
- Headache and vomiting.
- Restlessness and tachycardia
- Hypervigilant and anxious behavior
- Increased heart rate and decreased blood pressure.
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31. Which client is most likely to receive opioids for extended periods of time?
- A client with fibromyalgia
- A client with phantom limb pain
- A client with progressive pancreatic cancer
- A client with trigeminal neuralgia
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32. Situation: Mr. Roberto was long diagnosed with chronic renal failure. You are his nurse and the following question assesses your knowledge in the different fluid and electrolyte imbalances that are associated with chronic renal failure.Q. Disequilibrium syndrome is always a risk in all clients undergoing hemodialysis for chronic renal failure. The nurse should assess Mr. Roberto for which of the following sign and symptom associated with Disequilibrium syndrome?
- Hypertension, Tachycardia and Fever
- Imbalance, gait abnormality and inability to stand up
- Restlessness, irritability and generalized weakness
- Headache, deteriorating level of consciousness and twitching
33. Robert, a 57-year-old client with acute arterial occlusion of the left leg undergoes an emergency embolectomy. Six hours later, the nurse isn't able to obtain pulses in his left foot using Doppler ultrasound. The nurse immediately notifies the physician, and asks her to prepare the client for surgery. As the nurse enters the client's room to prepare him, he states that he won't have any more surgery. Which of the following is the best initial response by the nurse?
- Explain the risks of not having the surgery
- Notifying the physician immediately
- Notifying the nursing supervisor
- Recording the client's refusal in the nurses's
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34. Nurse Carla knows that the common cardiac anomalies in children with Down Syndrome (trisomy 21) is:
- Atrial septal defect
- Pulmonic stenosis
- Ventricular septal defect
- Endocardial cushion defect
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35. A child is admitted to the hospital with dehydration. The nurse should Give PRIORITY to which of the following nursing diagnoses?
- Anxiety related to hospitalization
- Fluid volume deficit related to vomiting
- Imbalance nutrition less than body requirements related diarrhea
- Risk for infection relatedto presence of invasivelines
36. Situation: Nurse Dorina is going to perform an abdominal examination to Mr. Lim who was admitted due to on and off pain since yesterday.Q. How will you position Mr. Lim prior to procedure?
- supine with knees flexed
- prone
- lying on back
- sim's
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37. Situation: Joanna Marie, a 40 year old client was diagnosed with breast cancer. Q. Allowing Joanna to perform deep breathing exercise will prevent:
- Pneumonia
- Bronchitis
- Atelectasis
- Lymphedema
38. Situation: As a member of the health and nursing team you have a crucial role to play in ensuring that all the members participate actively is the various tasks agreed upon.Q. You are a member of the infection control team, of the hospital. Based on a feedback during the meeting of the committee there is an increased incidence of pseudomonas infection in the Burn Unit (3 out of 10 patients had positive blood and wound culture). What is your priority activity?
- Establish policies for surveillance and monitoring
- Do data gathering about the possible sources of infection (observation, chart review, interview)
- Assign point persons who can implement policies
- Meet with the nursing group working in the burn unit and discuss problem with them feel
39. During Pre-operative preparation of a patient for amputation of the left leg. The nurse has primary responsibility for:
- Witnessing the patient signature on the consent form
- Explaining the procedure to the patient
- Explaining the risks of the surgery to the patient
- Making appropriate incision lines on the leg.
40. Important teaching for a client receiving risperidone (Risperdal) would include advising the client to:
- double the dose if missed to maintain a therapeutic level.
- be sure to take the drug with a meal because it's very irritating to the stomach.
- discontinue the drug if the client reports weight gain.
- notify the physician if the client notices an increase in bruising.
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41. Blood and urine analysis confirm a diagnosis of salicylate overdose. The client is treated with gastric lavage. Which of the following positions would be most appropriate for the client during this procedure?
- Lateral
- Trednelenburg's
- Supine
- Lithotomy
42. Surfactant is produced by what cells in the alveoli?
- Type I pneumocytes
- Type II pneumocytes
- Goblet cells
- Adipose cells
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43. A client experiences problems in body temperature regulation associated with a skin impairment Which gland is most likely involved?
- Eccrine
- Sebaceous
- Apocrine
- Endocrine
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44. A client arrives at the emergency department with complaints of low abdominal pain and hematuria. The client is afebrile. The nurse next assesses the client to determine a history of which condition?
- Pyelonephritis
- Glomerulonephritis
- Trauma to the bladder or abdomen
- Renal cancer in the client's family
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45. Which non antipsychotic medication is used to treat some clients with schizoaffective disorder?
- phenelzine (Nardil)
- chlordiazepoxide (Librium)
- lithium carbonate (Lithane)
- imipramine (Tofranil)
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46. Situation: Burn is cause by transfer of heat source to the body, it can be thermal, electrical radiation or chemical.Q. When a client accidentally splashes chemicals to his eyes. The initial priority care of the following the chemical burns is to:
- irrigate with normal saline for 1 to 15 minutes
- transport to a physician immediately
- irrigate with water for 15 minutes or longer
- cover the eyes with a sterile gauze
47. The client admitted two days earlier with a lung resection accidentally pulls out the chest tube. Which action by the nurse indicates understanding of the management of chest tubes?
- Order a chest x-ray.
- Reinsert the tube
- Cover the insertion site with a Vaseline gauze.
- Call the doctor.
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48. Which of the following when present in the urine may cause a reddish stain on the diaper of a newborn?
- Mucus
- Uric acid crystals
- Bilirubin
- Excess iron
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49. Situation: As a member of the health and nursing team you have a crucial role to play in ensuring that all the members participate actively is the various tasks agreed upon.Q. While eating his meal, Matthew accidentally dislodges his IV line and bleeds. Blood oozes on the surface of the over-bed table. It is most appropriate that you instruct the housekeeper to clean the table with:
- Acetone
- Alcohol
- Ammonia
- Bleach
50. At a senior citizens meeting a nurse talks with a client who has diabetes mellitus Type 1, Which statement by the client during the conversation is most predictive of a potential for impaired skin integrity?
- "I give my insulin to myself in my thighs"
- "Sometimes when I put my shoes on I don't know where my toes are"
- "Here are my up and down glucose readings that I wrote on my calendar"
- "If I bathe more than once a week my skin feels too dry"
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NCLEX-RN | QB1 | Practice Exam #24 (50 questions)