NCLEX-RN | QB1 | Practice Exam #22 (50 questions)

 

1. A postpartum client is diagnosed with cystitis. The nurse should plan for which priority action in the care of the client?

• Providing sitz baths
• Encouraging fluid intake
• Placing ice on the perineum
• Monitoring hemoglobin and hematocrit levels

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2. The client has had a right-sided cerebrovascular accident In transferring the client from the wheelchair to bed, in what position should a client be placed to facilitate safe transfer?

• Weakened (L) side of the client next to bed.
• Weakened (R) side of the client next to bed.
• Weakened (L) side of the client away from bed.
• Weakened (R) side of the client away from bed.

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3. 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.The nurse s that the infant is wearing a plastic-coated diaper. If a topical medication were to be prescribed and it were to go on the stomachs or buttocks, the nurse would teach the caregivers to:

• avoid covering the area of the topical medication with the diaper
• avoid the use of clothing on top of the diaper
• put the diaper on as usual
• apply an icepack for 5 minutes to the outside of the diaper

4. The home care nurse is providing wound care for a patient The nurse evaluates the wound and s the presence of granulation tissue in the wound bed. This observation represents which phase of wound healing?

• Maturation
• Inflammation
• Proliferation
• Finalization

5. The nurse caring for a client scheduled for an angiogram should prepare the client for the procedure by telling him to expect:

• Dizziness as the dye is injected
• Nausea and vomiting after the procedure is completed
• A decreased heart rate for several hours after the procedure is completed
• A warm sensation as the dye is injected

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6. The nurse is caring for a 13 year-old following spinal fusion for scoliosis. Which of the following interventions is appropriate in the immediate post-operative period?

• Raise the head of the bed at least 30 degrees
• Encourage ambulation within 24 hours
• Maintain in a flat position, logrolling as needed
• Encourage leg contraction and relaxation after 48 hours

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7. Situation: Care of clients with tracheotosmy is often a challenge to a beginning nurse. The following questions will test your knowledge on Tracheostomy and its related care.Q. The nurse knows that in Tracheostomy creation, 1% Lidocaine and 1:100,000 Epinephrine is injected at the incision site. The purpose of Lidocaine is mainly to provide anesthetic effect while the Epinephrine is needed to:

• Relax the bronchus and dilate the airway for easier insertion
• To promote faster healing
• To prevent the Vasovagal reflex that might cause bradycardia
• For Hemostasis

8. 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. Wally is undergoing blood transfusions of the first unit. The EARLIEST signs of transfusion reactions are:

• oliguria and jaundice
• urticaria and wheezing
• headache, chills, fever
• hypertension and flushing

9. The physician has ordered a placebo for a chronic pain client You are newly hired nurse and you feel very uncomfortable administering the medication. What is the first action that you should take?

• Prepare the medication and hand it to the physician
• Check the hospital policy regarding use of the placebo
• Follow a personal code of ethics and refuse to give it.
• Contact the charge nurse for advice.

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10. As the scrubbed nurse, when should you apply the goggles, shoe cap and mask prior to the operation?

• Immediately after entering the sterile field
• After surgical hand scrub
• Before surgical hand scrub
• Before entering the sterile field

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11. This is the enzyme secreted by the pancrease that completes the protein digestion

• Trypsin
• Enterokinase
• Enterogastrone
• Amylase

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12. A client admitted to the psychiatric unit for treatment of substance abuse says to the nurse, "It felt so wonderful to get high? Which of the following is the most appropriate response?

• "if you continue to talk like that I'm going to stop speaking to you."
• 'You told me you got fired from your last job for missing too many days after taking drugs all night”
• "Tell me more about how it felt to get high ”
• "Don't you know it's illegal to use drugs?"

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13. The client would be experiencing a typical symptom of Meniere's disease if, before an attack, he experienced:

• A severe headache
• Blurred vision
• Nausea
• A feeling of inner ear fullness

14. The nurse is caring for a client diagnosed with antisocial personality disorder The client has a history of fighting, cruelty to animals, and stealing. Which of the following traits would the nurse be most likely to uncover during assessment?

• History of gainful employment
• Frequent expression of guilt regarding antisocial behavior
• Demonstrated ability to maintain close, stable relationships
• A low tolerance for frustration

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15. Situation: A nurse should be aware that some problems in the emergency setting are not always physiologic. Sometimes, Crisis can affect the patient in an emergency setting.Q. An 18-year-old male client was rushed to the hospital due to burns, bruises and cuts on the face and body. The teenager confessed that he was raped by 4 of his classmates, all of which are also male. Male to male rape also occurs and the nurse must know that:

• If there is an erection, the male victim also consents to the rape itself.
• That all male to male rape cases occurs at home, which is statutory most of the time.
• That male rape victims are usually homosexuals. Which are very much deserving to be raped.
• Most victims of male to male rapes never dare to report the incident.

16. Situation : Ronald 23 years old was voluntarily admitted to the in-patient unit with a diagnosis of paranoid schizophrenia.Q. The best response for the nurse to make to this behavior is:

• "How can I hurt you?"
• Tm the nurse"
• "Tell me more about this"
• 'That's a silly thing to say"

17. 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.Mr. Lim verbalized pain on the right iliac region. Nurse Dorina knows that the organ affected would be the:

• liver
• sigmoid colon
• appendix
• duodenum

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18. A regular pap smear for woman every 3 years after establishing normal pap smear for 3 consecutive years Is advocated. What level of prevention does this belongs?

• Primary
• Secondary
• Tertiary
• None of the above

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19. The nurse is assessing the client admitted for possible oral cancer. The nurse identifies which of the following to be a late-occurring symptom of oral cancer?

• Warmth
• Odor
• Pain
• Ulcer with flat edges

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20. A client in sinus bradycardia, with a heart rate of 45 beats/minute, complains of dizziness and has a blood pressure of 82/60 mm Hg. Which prescription should the nurse anticipate will be prescribed?

• Administer digoxin.
• Defibrillate the client
• Continue to monitor the client.
• Prepare for transcutaneous pacing.

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21. A client with cancer is admitted to the oncology unit Stat lab values reveal Hgb 12.6 WBC 6500 K+ 1.9 uric acid 7.0 Na+ 136 and platelets 178 000. The nurse evaluates that the client is experiencing which of the following?

• Hypernatremia
• Hypokalemia
• Myelosuppression
• Leukocytosis

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22. Nurse Leri refers a female client with terminal cancer to a local hospice. What is the goal of this referral?

• To help the client find appropriate treatment options.
• To provide support for the client and family in coping with terminal illness.
• To ensure that the client gets counseling regarding health care costs.
• To teach the client and family about cancer and its treatment.

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23. The nurse is monitoring a hospitalized client who abuses alcohol. Which findings should alert the nurse to the potential for alcohol withdrawal delirium?

• Hypotension, ataxia, hunger
• Stupor, lethargy, muscular rigidity
• Hypotension, coarse hand tremors, lethargy
• Hypertension, changes in level of consciousness, hallucinations

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24. While caring for a child with in effective airway clearance related to increased mucus production, the nurse should encourage fluids to:

• Maintain nutrition
• Prevent boredom
• Stimulate coughing
• Thin secretions

25. During a shift report, the nurse learns that she'll be providing care for a client who is vulnerable to panic attack. Treatment for panic attacks includes behavioral therapy, supportive psychotherapy, and medication such as:

• barbiturates
• antianxiety drugs.
• depressants.
• amphetamines.

26. A 3 year old child is brought to the office by the parents who have been toilet training the child for the past 5 months, with little success. The parent has been using rewards for the keeping the parent clean and dry. Today the parent realizes that the child abdomen was very firm, the appetite was poor, and there had not been bowel movement for 6 days. With a nursing diagnosis of alteration in bowel elimination, what is BEST goal?

• The child will recognize the urge to defecate daily
• The parent will use praise when the child defecates in the toilet
• Predictable, regular bowel habits will be restored and maintained
• Toilet training will be delayed until the child is cognitively ready

27. A 30-year-old male from Haiti is brought to the emergency department in sickle cell crisis. What is the best position for this client?

• Side-lying with knees flexed
• Knee-chest
• High Fowlers with knees flexed
• Semi-Fowlers with legs extended on the bed

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28. During the intra operative period of surgical procedure a 39 year old male has the following vital signs: core temperature 37 C(98.6F)( heart rate 62, blood pressurel 26/78 mm Hg,and an 02 saturation level of 89%. The patient has received two units of packed cell volume(PRBs) and is intubated. Which of the vital signs is considered out of normal range?

• heart rate
• O2 saturation
• Core temperature
• Blood pressure

29. Potassium chloride intravenously is prescribed for a client with hypokalemia. Which actions should the nurse take to plan for preparation and administration of the potassium? Select all that apply. 1.Obtain an intravenous (IV) infusion pump. 2.Monitor urine output during administration. 3.Prepare the medication for bolus administration. 4.Monitor the IV site for signs of infiltration or phlebitis. 5.Ensure that the medication is diluted in the appropriate volume of fluid. 6.Ensure that the bag is labeled so that it reads the volume of potassium in the solution.

• 1,2,4,5,6
• 1,2,3,4
• 2,3,4,5,6
• 2,4,6

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30. Kegel's exercise is done in pregnancy in order to:

• Strengthen perineal muscles
• Relieve backache
• Strengthen abdominal muscles
• Prevent leg varicosities and edema

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31. A male client has jugular distention. On what position should the nurse place the head of the bed to obtain the most accurate reading of jugular vein distention?

• High Fowler's
• Raised 10 degrees
• Raised 30 degrees
• Supine position

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32. A nurse is administering a blood transfusion to a client on the oncology unit Which clinical manifestation indicates an acute hemolytic reaction to the blood?

• Low back pain
• Headache
• Urticaria
• Neck vein distention

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33. Which of the following would be disadvantage of breast feeding?

• Involution occurs more rapidly
• The incidence of allergies increases due to maternal antibodies
• The father may resent the infant's demands on the mother's body
• There is a greater chance for error during preparation

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34. Apregnant client is seen for a regular prenatal visit and tells the nurse that she is experiencing irregular contractions. The nurse determines that she is experiencing Braxton Hicks contractions. On the basis of this finding, which nursing action is appropriate?

• Contact the health care provider.
• Instruct the client to maintain bed rest for the remainder of the pregnancy.
• Inform the client that these contractions are common and may occur throughout the pregnancy.
• Call the maternity unit and inform them that the client will be admitted in a preterm labor condition.

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35. A client visits the clinic after the death of a parent Which statement made by the clients sister signifies abnormal grieving?

• My sister still has episodes of crying and its been three months since Daddy died
• Sally seems to have forgotten the bad things that Daddy did in his lifetime.
• She really had a hard time after Daddys funeral. She said that she had a sense of longing.
• She has not been saddened at all by Daddy's death. She acts like nothing has happened.

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36. Situation: A computer analyst, Mr. Ricardo J. Santos, 25 was brought to the hospital for diagnostic workup after he had experienced seizure in his office.Q. Usually, how does the patient behave after his seizure has subsided?

• Most comfortable walking and moving about.
• Becomes restless and agitated.
• Sleeps for a period of time
• Say he is thirsty and hungry.

37. When caring for a client with the nursing diagnosis Impaired swallowing related to neuromuscular impairment, the nurse should:

• position the client in a supine position
• elevate the head of the bed 90 degrees during meals
• encourage the client to remove dentures
• encourage thin liquids for dietary intake

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38. Spasm of the neck muscles developed in a patient who is taking phenothiazine (Nemazine). Which of the following medications should the nurse administer?

• Vistaril
• Acetaminophen (Tylenol)
• Acetylsalicylic acid (Aspirin)
• Benztropine mesylate (Cogentin)

39. The nurse is caring for an adult patient with extensive burns on the front of the trunk, including the genitalia, and the fronts of right legs. Using the rule of nines, the nurse would document that the burn size as:

• 13%
• 17%
• 28%
• 37%

40. When monitoring a client recently admitted for treatment of cocaine addiction, the nurse s sudden increases in the arterial blood pressure and heart rate. To correct these problems, the nurse expects the physician to prescribe:

• norepinephrine (Levophed) and lidocaine (Xylocaine).
• nifedipine (Procardia) and lidocaine.
• nitroglycerin (Nitro-Bid IV) and esmolol (Brevibloc).
• nifedipine and esmolol

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41. Situation: Colostomy is a surgically created anus- It can be temporary or permanent, depending on the disease condition^ Skin care around the stoma is critical Which of the following is not indicated as a skin care barriers?

• Apply liberal amount of mineral oil to the area
• Use karaya paste and rings around the stoma
• Clean the area daily with soap and water before applying bag
• Apply talcum powder twice a day

42. A nurse visits the home of a patient who is 1 week post-left-breast mastectomy. Which of the following should be including in patient education?

• It is OK to use a straight edge razor when shaving
• Blood pressure checks should be done in the left arm
• Cuticle should not be cut
• Avoid insect repellent on the left arm

43. According to the Philippine Nursing Law, a registered nurse is allowed to handle mothers in labor and delivery with the following considerations: 1.The pregnancy is normal; 2.The labor and delivery is uncomplicated; 3.Suturing of perineal laceration is allowed provided the nurse had special training; 4.As a delivery room nurse she is not allowed to insert intravenous fluid unless she had special training for it.

• 1 and 2
• 1,2 and 3
• 3 and 4
• 1,2 and 4

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44. Conceptualizes that health Is a condition of actualization or realization of person's potential. Avers that the highest aspiration of people is fulfillment and complete development actualization.

• Clinical Model
• Role performance Model
• Adaptive Model
• Eudaemonistic Model

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45. A client is scheduled for a below-the-knee amputation of the right leg. Legally the client may not sign the operative consent if:

• Ambivalent feelings regarding operation are present
• Any sedative type of medication has recently been administration
• A discussion of alternative with 2 physicians have not been performed and recorded
• A complete history and physical have not been performed

46. The nurse collects a urine specimen preoperatively from a child with epispadias who is scheduled for surgical repair When analyzing the results of the urinalysis, which should the nurse most likely expect to?

• Hematuria
• Proteinuria
• Bacteriuria
• Glucosuria

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47. A client is admitted with suspected abdominal aortic aneurysm (AAA). A common complaint of the client with an abdominal aortic aneurysm is:

• Loss of sensation in the lower extremities
• Back pain that lessens when standing
• Decreased urinary output
• Pulsations in the periumbilical area

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48. A 62-year-old patient has been treated for congestive heart failure and a Nursing diagnosis of fluid volume excess. After diuretic therapy and dietary Interventions, the patient has met all short-term goals. The nurse should:

• Revise the care plan with a diagnosis of risk for alteration in fluid balance
• Add a new diagnosed of risk of fluid volume deficit
• Discontinue the care plan as the diagnosis is resolved
• Continue the care plan as written

49. A pregnant woman accompanied by her husband, seeks admission to the labor and delivery area. She states that she's in labor and says she attended the facility clinic for prenatal care. Which question should the nurse Oliver ask her first?

• "Do you have any chronic illnesses?"
• "Do you have any allergies?"
• "What is your expected due date?"
• "Who will be with you during labor?"

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50. A client receiving chemotherapy for breast cancer has an order for Zofran (ondansetron) 8mg PO to be given 30 minutes before induction of the chemotherapy. The purpose of the medication is to:

• Prevent anemia
• Promote relaxation
• Prevent nausea
• Increase neutrophil counts

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NCLEX-RN | QB1 | Practice Exam #22 (50 questions)