NCLEX-RN | QB1 | Practice Exam #21 (50 questions)
1. Situation: - Nurse Michelle works with a Family Nursing Team in Calbayog Province specifically handling a UNICEF project for children. The following conditions pertain, to CARE OF THE FAMILIES PRESCHOOLERS.Q. Ronnie asks constant questions. How many does a typical 3-year-old ask in a day's time?
- 1,200 or more
- Less than 50
- 100-200
- 300-400
2. The client has developed atrial fibrillation, with a ventricular rate of 150 beats/minute. The nurse should assess the client for which associated signs and/or symptoms?
- Flatneckveins
- Nausea and vomiting
- Hypotension and dizziness
- Hypertension and headache
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3. A patient who underwent a right knee arthroplasty two days ago has a nursing diagnosis of impaired mobility. The patient refuses to get out of bed and ambulate due to chest pain. Which of the following actions would the nurse MOST likely implement?
- Medicate the patient prior to ambulation
- Add a nursing diagnosis of non-compliance
- Let the patient rest now and then try to ambulate later
- Assess to determine the cause of the chest pain
4. You are supervising a senior nursing student who is caring for a patient with a right hemisphere stroke. Which action by the student nurse requires that you intervene?
- The student instructs the patient to sit up straight resulting in the patient's puzzled expression.
- The student moves the patient's tray to the right side of her over-bed tray.
- The student assists the patient with passive range-of-motion (ROM) exercises.
- The student combs the left side of the patient's hair when the patient combs only the right side.
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5. Caring involves 5 processes: KNOWING, BEING WITH, DOING FOR, ENABLING and MAINTAINING BELIEF.
- Benner
- Watson
- Leininger
- Swanson
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6. The mother of a 6-year-old child who has type 1 diabetes mellitus calls a clinic nurse and tells the nurse that the child has been sick. The mother reports that she checked the child's urine and it was positive for ketones. The nurse should instruct the mother to take which action?
- Hold the next dose of insulin.
- Come to the clinic immediately.
- Encourage the child to drink liquids.
- Administer an additional dose of regular insulin.
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7. Situation: Because severe burn can aff ect the person's totality it is important that you apply interventions focusing on the various dimensions of man. You also have to understand the rationale of the treatment Q. Hypertrophic burns scars are caused by:
- exaggerated contraction
- random layering of collagen
- wound ischemia
- delayed epithelialization
8. When assessing a child for possible intussusception, which of the following would be least likely to provide valuable information?
- Stool inspection
- Pain pattern
- Family history
- Abdominal palpation
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9. Which of the following is the nurse's initial action when umbilical cord prolapse occurs?
- Begin monitoring maternal vital signs and FHR
- Place the client in a knee-chest position in bed
- Notify the physician and prepare the client for delivery
- Apply a sterile warm saline dressing to the exposed cord
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10. A nine-year-old is admitted with suspected rheumatic fever. Which finding is suggestive of Sydenhams chorea?
- Irregular movements of the extremities and facial grimacing
- Painless swellings over the extensor surfaces of the joints
- Faint areas of red demarcation over the back and abdomen
- Swelling inflammation and effusion of the joints
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11. SITUATION: A 65 year old woman was admitted for Parkinson's Disease. The charge nurse is going to make an initial assessment.Q. You are discussing with the dietician what food to avoid with patients taking levodopa?
- Vitamin C rich food
- Vitamin E rich food
- Thiamine rich food
- Vitamin B6 rich food
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12. You are providing care for a patient with an acute hemorrhage stroke. The patient's husband has been reading a lot about strokes and asks why his wife did not receive alteplase. What is your best response?
- "Your wife was not admitted within the time frame that alteplase is usually given."
- "This drug is used primarily for patients who experience an acute heart attack."
- "Alteplase dissolves clots and may cause more bleeding into your wife's brain.”
- "Your wife had gallbladder surgery just 6 months ago and this prevents the use of alteplase."
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13. Situation: - Still in your self-managed Child Health Nursing Clinic, your encounter these cases pertaining to the CARE OF CHILDREN WITH PULMONARY AFFECTIONS.Q. Josie brought her 3-months old child to your clinic because of cough and colds. Which of the following is your primary action?
- Give cotrimoxazole tablet or syrup
- Assess the patient using the chart on management of children with cough
- Refer to the doctor
- Teach the mother how to count her child's bearing
14. Situation: Concerted work efforts among members of the surgical team is essential to the success of the surgical procedure.Q. The sterile nurse or sterile personnel touch only sterile supplies and instruments. When there is a need for sterile supply which is not in the sterile field, who hands out these items by opening its outer cover?
- Circulating nurse
- Anesthesiologist
- Surgeon
- Nursing aide
15. Which of the following questions asked to the resident is most likely to encourage conversation?
- Are you feeling tired today?
- Do you want to wear this outfit?
- What are your favorite foods?
- Is this water warm enough?
16. The nurse is reviewing the history of a client with bladder cancer The nurse expects to note documentation of which most common sign or symptom of this type of cancer?
- Dysuria
- Hematuria
- Urgency on urination
- Frequency of urination
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17. Situation: As a Nurse, you have specific responsibilities as professional. You have to demonstrate specific competencies.Q. You are assigned to care for four (4) patients. Which of the following patients should you give first priority?
- Grace, who is terminally ill with breast cancer
- Emma, who was previously lucid but is now unarousable
- Ara, who is newly admitted and is scheduled for an executive check-up
- Claire, who has cholelithiasis and is for operation on call
18. To ensure adequate lactation the nurse should teach the mother to:
- Breast feed the baby on self-demand day and night
- Feed primarily during the day and allow the baby to sleep through the night
- Feed the baby every 3-4 hours following a strict schedule
- Breastfeed when the breast are engorged to ensure adequate supply
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19. The nurse receives an order to obtain an arterial blood gas (ABG) specimen on a patient The nurse will use the radial artery to obtain the specimen. Which of the following will the nurse assess before puncturing the radial artery?
- Allen test
- Partial pressure of arterial oxygen
- Partial carbon dioxide
- Prothrombin time
20. Situation: In the OR, there are safety protocols that should be followed. The OR nurse should be well versed with ail these to safeguard the safety and quality to patient delivery outcome.Q. Another nursing check that should not be missed before the induction of general anesthesia is:
- check for presence underwear
- check for presence dentures
- check patients blood studies
- check baseline vital signs
21. A nurse is giving a health teaching to a woman who wants to breastfeed her newborn baby. Which hormone, normally secreted during the postpartum period, influences both the milk ejection reflex and uterine involution?
- Oxytocin.
- Estrogen
- Progesterone
- Relaxin
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22. A female client is admitted with a diagnosis of delusions of GRANDEUR. This diagnosis reflects a belief that one is:
- Being Killed
- Highly famous and important
- Responsible for evil world
- Connected to client unrelated to oneself
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23. Situation: Sexually Transmitted Diseases are important to identify during pregnancy because of their potential effect on the pregnancy, fetus, or newborn. The following questions pertain to STD's.Another client in the Maternal Clinic was Ms. Celbong. Her doctor examined Ms. Celbong's vaginal secretions and found out that she has a Trichomoniasis infection. Trichomoniasis is diagnosed through which of the following method?
- Vaginal secretions are examined on a wet slide that has been treated with potassium hydroxide.
- Vaginal speculum is used to obtain secretions from the cervix.
- A iitmus paper is used to test if the vaginal secretions are infected with trichomoniasis.
- Vaginal secretions are examined on a wet slide treated with zephiran solution.
24. While assessing a child with pyloric stenosis, the nurse is likely to note which of the following?
- Regurgitation
- Steatorrhea
- Projectile vomiting
- "Currant jelly" stools
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25. Patrick who is hospitalized following a myocardial infarction asks the nurse why he is taking morphine. The nurse explains that morphine:
- Decrease anxiety and restlessness
- Prevents shock and relieves pain
- Dilates coronary blood vessels
- Helps prevent fibrillation of the heart
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26. Situation: Leo lives in the squatter area. He goes to nearby school. He helps his mother gather molasses after school. One day, he was absent because of fever, malaise, anorexia and abdominal discomfortQ. Which of the following must be emphasized during mother's class to Leo's mother?
- Administration of immunoglobulin to families
- Thorough hand washing before and after eating and toileting
- Use of attenuated vaccines
- Boiling of food especially meat .
27. If a nasogastric tube has been misplaced in the trachea during preparation to obtain a gastric specimen, the nurse should anticipate that the patient will:
- Have difficulty in breathing
- Swallow every few seconds
- Gage without relief
- Complain of feeling nauseated
28. Nurse Reese is reviewing the record of a pregnant client for her first prenatal visit. Which of the following data, if noted on the client's record, would alert the nurse that the client is at risk for a spontaneous abortion?
- Age 36 years
- History of syphilis
- History of genital herpes
- History of diabetes mellitus
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29. Situation: Mastery of Psychotropic medications is necessary for the therapeutic improvement in the health of the psychiatric clients. Q. Lithium is only given:
- PO
- IM
- IV
- SQ
30. A patient with pneumonia has a temperature, 40 C (104 F); heart rate 20; respiratory rate 32 and dyspnea patient has an ineffective airway clearance related to excessive tracheobronchial secretions. Which of the following interventions would the nurse implement to enhance the patient's airway clearance?
- Administer oxygen as ordered
- Maintain a comfortable position
- Increase fluid intake
- Administer prescribed analgesic
31. A client is admitted to the hospital with a temperature of 99.8A/F complaints of blood- tinged hemoptysis fatigue and night sweats. The clients symptoms are consistent with a diagnosis of:
- Pneumonia
- Reaction to antiviral medication
- Tuberculosis
- Superinfection due to low CD4 count
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32. The nurse is caring for a postrenal transplantation client taking cyclosporine. The nurse notes an increase in one of the clients vital signs and the client is complaining of a headache. What vital sign is most likely increased?
- Pulse
- Respirations
- Blood pressure
- Pulse oximetry
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33. It is the science of organism as affected by factors in their environment It deals with the relationship between disease and geographical environment
- Epidemiology
- Ecology
- Statistics
- Geography
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34. Situation: Records contain those, comprehensive descriptions of patient's health conditions and needs and at the same serve as evidences of every nurse's accountability in the, caregiving process. Nursing records normally differ from institution to, institution nonetheless they follow similar patterns of meeting needs for specifics, types of information. The following pertains to documentation/records management. Q:This special form used when the patient is admitted to the unit. The nurse completes, the information in this records particularly his/her basic personal data, current illness, previous health history, health history of the family, emotional profile, environmental history as well as physical assessment together with nursing diagnosis on admission. What do you call this record?
- Nursing Kardex
- Nursing Health History and Assessment Worksheet
- Medicine and Treatment Record
- Discharge Summary
35. Epinephrine is administered to a female patient The nurse should expect this agent to rapidly affect:
- Adrenergic receptors.
- Muscarinic receptors.
- Cholinergic receptors.
- Nicotinic receptors.
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36. A client with paranoid schizophrenia is admitted to the psychiatric unit of a hospital Nursing assessment should include careful observation of the client's:
- thinking, perceiving, and decision-making skills.
- verbal and nonverbal communication processes.
- affect and behavior
- psychomotor activity.
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37. A client with myocardial infarction is developing cardiogenic shock. Because of the risk of myocardial ischemia, what condition should the nurse carefully assess the client for?
- Bradycardia
- Ventricular dysrhythmias
- Rising diastolic blood pressure
- Falling central venous pressure
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38. Which of the following is the most distinguishing feature of a client with an antisocial personality disorder?
- Attention to detail and order
- Bizarre mannerisms and thoughts
- Submissive and dependent behavior
- Disregard for social and legal norms
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39. The client has an order for sliding scale insulin at 1900 hours and Lantus insulin at the same hour. The nurse should:
- Administer the two medications together
- Administer the medications in two injections.
- Draw up the Lantus insulin and then the regular insulin and administer them together.
- Contact the doctor because these medications should not be given to the same client.
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40. A child with asthma has an order for albuterol. Prior to administration of medication the nurse must:
- Pre-oxygenate the patient
- Assess the patient's heart rate
- Obtain venous access
- Feed the patient a snack
41. SITUATION: Mr. Dela Isla, a client with early Dementia exhibits thought process disturbances.Q. Mr. Dela Isla said he cannot comprehend what the nurse was saying. He suffers from:
- Insomnia
- Aphraxia
- Agnosia
- Aphasia
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42. The client's history that alerts nurse Henry to assess closely for signs of postpartum infection would be:
- Three spontaneous abortions
- negative maternal blood type
- Blood loss of 850 ml after a vaginal birth
- Maternal temperature of 99.9°F 12 hours after delivery
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43. A home care nurse visits a patient who is wheelchair bound due to a recent motor vehicle accident The patient has been sitting in the wheelchair for extended periods of time, which has resulted in the development of a stage I pressure sore on the right buttocks. What is the BEST nursing intervention?
- Instruct the 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 a wound care specialist for debridement
- Encourage the patient to consume an increased amount of calcium
44. Situation: Nanette was rushed to the hospital due to burns. Witnesses told the emergency team that Nanette fell asleep while she is holding her cigarette thus, burning the bed sheets and herself. 2nd and 3rd degree burns are on the face, neck, anterior and posterior trunk as well as the anterior of the left leg and the whole right arm was burned. First degree burns are located on the anterior portion of the right leg and the anterior portion of the right and left arm. Nanette is a 110 lbs female client.Q. The rationale in giving IV fluids for Miss Nanette is to prevent:
- Cardiogenic shock
- Septic Shock
- Hypovolemic shock
- Neurogenic Shock
45. A client with a deep decubitus ulcer is receiving therapy in the hyperbaric oxygen chamber Before therapy the nurse should:
- Apply a lanolin-based lotion to the skin.
- Wash the skin with water and pat dry.
- Cover the area with a petroleum gauze.
- Apply an occlusive dressing to the site.
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46. These patients present to the ED complaining of acute abdominal pain. Prioritize them in order of severity.a. A 35-year-old male complaining of severe, intermittent cramps with three episodes of watery diarrhea, 2 hours after eatingb. A11-year-old boy with a low- grade fever, left lower quadrant tenderness, nausea, and anorexia for the past 2 daysc. A 40-year-old female with moderate left upper quadrant pain, vomiting small amounts of yellow bile, and worsening symptoms over the past weekd. A 56-year-old male with a pulsating abdominal mass and sudden onset of pressure-like pain in the abdomen and flank within the past hour
- D, B, C, A
- A, B, C, D
- A, D, B, C
- C, B, A, D
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47. Situation: - Nurse Joanna works as an OB-Gyn Nurse and attends to several HIGH- RISK PREGNANCIES: Particularly women with preexisting or newly acquired illness. The following conditions apply.Q.Bernadette develops a deep-vein thrombosis following an auto accident and is prescribed heparin sub-Q. What should Joanna educate her about in regard to this?
- Some infants will be born with allergic symptoms to heparin
- Her infant will be born with scattered petechiae on his trunk
- Heparin can cause darkened skin in newborns
- Heparin does not cross the placenta and so does not affect a fetus
48. Situation: Team efforts is best demonstrated in the OR.Q. Who usually act as an important part of the OR personnel by getting the wheelchair or stretcher, and pushing/pulling them towards the operating room?
- Orderly/clerk
- Nurse Supervisor
- Circulating Nurse
- Anesthesiologist
49. For an infant with hydrocephalus, a nurse should plan to monitor for what sign or symptom of increased intracranial pressure?
- High-pitched, shrill cry
- Decrease in systolic blood pressure
- Depressed fontanelle
- Increase in respirations
50. Which of the following would nurse Ronald use as the best measure to determine a clients progress in rehabilitation?
- The way he gets along with his parents
- The number of drug-free days he has
- The kinds of friends he makes
- The amount of responsibility his job entails
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NCLEX-RN | QB1 | Practice Exam #21 (50 questions)