NCLEX-RN | QB1 | Practice Exam #19 (50 questions)
1. Which of the following symptoms during the icteric phase of viral hepatitis should the nurse expect the client to inhibit?
- Watery stool
- Yellow sclera
- Tarry stool
- Shortness of breath
Answer: Only for registered users. Please login!
2. The following are skin changes in pregnancy EXCEPT:
- Chloasma
- Striae gravidarum
- Linea negra
- Chadwick's sign
Answer: Only for registered users. Please login!
3. Situation: Organ donation is a new form of treatment that provides multiple complication such as rejection^ Among children candidates for organ transplant, when all selected children have appropriate tissue matches for the same donated organ, the basis for the decision as to which child gets the organ is given to the child who:
- will receive the most benefit from the new organ
- is most likely to die without the transplant
- is selected by the lottery system for available organs
- is at the top of the list and has waited the longest time
4. The nurse is caring for a client with ascites. Which is the best method to use for determining early ascites?
- Inspection of the abdomen for enlargement
- Bimanual palpation for hepatomegaly
- Daily measurement of abdominal girth
- Assessment for a fluid wave
Answer: Only for registered users. Please login!
5. Situation: ENTEROSTOMAL THERAPY is now considered a specialty in nursing. You are participating in the OSTOMY CARE CLASS.Q. When observing a return demonstration of a colostomy irrigation, you know that more teaching is required if Fermin:
- Lubricates the tip of the catheter prior to inserting into the stoma
- Hangs the irrigating bag on the bathroom door cloth hook during fluid insertion
- Discontinues the insertion of fluid after only 500 ml of fluid has been instilled
- Clamps of the flow of fluid when feeling uncomfortable
6. The nurse is preparing a group of Cub Scouts for an overnight camping trip and instructs the Scouts about the methods to prevent Lyme disease. Which statement by one of the Scouts indicates a need for further instruction?
- "I need to bring a hat to wear during the trip."
- "I should wearlong-sleeved topsand longpants."
- "I should not use insect repellents because it will attract the ticks”
- "I need to wear closed shoes and socks that can be pulled up over my pants"
Answer: Only for registered users. Please login!
7. The nurse is assisting in the assessment of the patient admitted with extreme abdominal pain.[si The nurse asks the client about the medication that he has been taking because:
- Interactions between medications will cause abdominal pain.
- Various medications taken by mouth can affect the alimentary tract.
- This will provide an opportunity to educate the patient regarding the medications used.
- The types of medications might be attributable to an abdominal pathology not already identified.
Answer: Only for registered users. Please login!
8. Situation: Mr. Gonzales was admitted to the hospital with ascites and jaundice. To rule out cirrhosis of the liver:Q. When Mr. Gonzales regained consciousness, the physician orders 50 ml of Lactulose p.o. every 2 hours. Mr. Gonzales develops diarrhea. The nurse best action would be:
- 'TH see if your physician is in the hospital".
- "Maybe you're reacting to the drug; I will withhold the next dose".
- "I'll lower the dosage as ordered so the drug causes only 2 to 4 stools a day".
- "Frequently bowel movements are needed to reduce sodium level".
Answer: Only for registered users. Please login!
9. 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. Mr. Roberto's chronic renal failure was caused by a crush injury to the lower leg right after an accident. The acute renal failure progresses to chronic renal failure until now, his case is irreversible. The nurse is correct in determining that the cause of Mr. Roberto's Acute renal failure before was:
- Prerenal
- Post renal
- Renal
- Extrarenal
10. The nurse is teaching the client regarding use of sodium warfarin. Which statement made by the client would require further teaching?
- I will have blood drawn every month.
- I will assess my skin for a rash.
- I take aspirin for a headache.
- I will use an electric razor to shave.
Answer: Only for registered users. Please login!
11. Prior to administering a client's daily dose of digoxin, the nurse reviews the client's laboratory data and notes the following results: serum calcium, 9.8 mg/dL (2.45 mmol/L); serum magnesium, 1.0 mEq/L (0.5 mmol/L); serum potassium, 4.1 mEq/L (4.1 mmol/L); serum creatinine, 0.9 mg/ dL (79.5 mcmol/L). Which result should alert the nurse that the client is at risk for digoxin toxicity?
- Serum calcium level
- Serum potassium level
- Serum creatinine level
- Serum magnesium level
Answer: Only for registered users. Please login!
12. He was called the father of sanitation:
- Abraham
- Hippocrates
- Moses
- Wiliam Halstead
Answer: Only for registered users. Please login!
13. A 4 week old baby was brought to the health center for his first immunization. Which can be given to him?
- DPT1
- OPV1
- Infant BCG
- Hepatitis B Vaccin
Answer: Only for registered users. Please login!
14. Dorsal recumbent position is used when performing the following procedures EXCEPT:
- Suppository insertion
- Cystoscopic examination
- Urinary catheter insertion
- Vaginal examination
15. Situation: Anesthesia is used even during the Ancient times. In its evolution, modern marvels in the use of anesthesia enables the nurses to develop a more competitive approach in patient care.Q. After spinal anesthesia, to prevent spinal headache, the client is placed on which of the following position?
- Sitting position
- Side Lying position affected side
- Flat on bed, supine
- Flat on bed, prone
16. A child came to the emergency complaining of diarrhea, abdominal pain and vomiting. After the investigation it reveals that he eats contaminated food and got germs, what kind of germs you suspect to find in the test result?
- Streptococcus
- typhoid
- Atrial Flutter
- None of the above.
17. Nurse Daisy is aware that the following pharmacologic agents are sedative hypnotic medication is used to induce sleep for a client experiencing a sleep disorder is:
- Triazolam (Halcion)
- Paroxetine (Paxil)
- Fluoxetine (Prozac)
- Risperidone (Risperdal)
Answer: Only for registered users. Please login!
18. Situation: Mr. Punsalan is 36 years old, was admitted to the hospital with complaints of a burning sensation in the epigastric area after eating and inability to sleep at night. He was placed on bed rest and schedule for diagnostic studies. A diagnosis of Peptic Ulcer was made.Q. Diet that prevents gastric irritation in case of Mr. Punsalan is:
- Bland Diet
- Liquid Diet
- Full Diet
- High Protein low fat diet
19. A 32 year old client came for consultation at the health center with the chief complaint of fever for a week. Accompanying symptoms were muscle pains and body malaise. A week after the start of fever, the client noted yellowish discoloration of his sclera. History showed that he waded in flood waters about 2 weeks before the onset of symptoms. Based on this history/ which disease condition will you suspect?
- Hepatitis A
- Hepatitis B
- Tetanus
- Leptospirosis
Answer: Only for registered users. Please login!
20. The nurse is assisting in planning care for a client with a diagnosis of immunodeficiency and should incorporate which action as a priority in the plan?
- Protecting the client from infection
- Providing emotional support to decrease fear
- Encouraging discussion about lifestyle changes
- Identifying factors that decreased the immune function
Answer: Only for registered users. Please login!
21. A client visiting a family planning clinic is suspected of having an STL The best diagnostic test for treponema pallidum is:
- Venereal Disease Research Lab (VDRL)
- Rapid plasma reagin (RPR)
- Fluorescent treponemal antibody (FTA)
- Thayer-Martin culture (TMC)
Answer: Only for registered users. Please login!
22. A nurse caring for a patient with acute pulmonary edema observes that the patient's cough produces white, frothy and that the patient is extremely dyspneic. The patient has inspiratory and expiratory wheezing on auscultation of the lungs. The immediate objective of treatment is to:
- Improve oxygenation
- Decrease anxiety
- Improve tissue perfusion
- Decrease risk for aspiration
23. Situation: Miss Matias, found out that Mr. Carding, newly admitted patient, has terminal cancer and that his nurse has not yet informed him of the diagnosis.Q. Initially, Miss Matias should:
- Tell the doctor the Mang Carding hinted that he feels he has Cancer
- Be available to listen when the patient decides to discuss his illness
- Call in the family and the team to prepare Mr. Carding about his impending death
- Inform Mr. Carding about his Diagnosis
24. A 32-year-old mother of three is brought to the clinic. Her pulse is 52 there is a weight gain of 30 pounds in four months and the client is wearing two sweaters. The client is diagnosed with hypothyroidism. Which of the following nursing diagnoses is of highest priority?
- Impaired physical mobility related to decreased endurance
- Hypothermia r/t decreased metabolic rate
- Disturbed thought processes r/t interstitial edema
- Decreased cardiac output r/t bradycardia
Answer: Only for registered users. Please login!
25. For point of clarification a patient asks for the importance of Folic Acid in pregnancy. The nurse explains that vitamin is especially needed during pregnancy as it:
- assists in growth of heart and lungs
- helps in coagulation of red blood cells
- is essential for cell and RBC formation
- helps in maternal circulation
26. A client has just returned to a nursing unit after an above-knee amputation of the right leg. The nurse should place the client in which position?
- Prone
- Reverse Trendelenburg's
- Supine, with the residual limb flat on the bed
- Supine, with the residual limb supported with pillows
Answer: Only for registered users. Please login!
27. A client with angina is being discharged with a prescription for Transderm Nitro (nitroglycerin) patches. The nurse should tell the client to:
- Shave the area before applying the patch
- Remove the old patch and clean the skin with alcohol
- Cover the patch with plastic wrap and tape it in place
- Avoid cutting the patch because it will alter the dose
Answer: Only for registered users. Please login!
28. When planning the discharge of a client with chronic anxiety, Nurse Chris evaluates achievement of the discharge maintenance goals. Which goal would be most appropriately having been included in the plan of care requiring evaluation?
- The client eliminates all anxiety from daily situations
- The client ignores feelings of anxiety
- The client identifies anxiety producing situations
- The client maintains contact with a crisis counselor
Answer: Only for registered users. Please login!
29. A nurse is preparing an assessment of a patient's nutritional status. Which of the following diagnostic test would be the best measure of the patient's recent nutritional status with a half- life of 2-3 days?
- Prealbumin
- Hemoglobin
- Albumin
- 24-urine creatinine
30. A client arrives at the clinic for the first prenatal assessment She tells the nurse that the first day of her last normal menstrual period was October 19, 2018. Using Na gele's rule, which expected date of delivery should the nurse document in the clients chart?
- July 12, 2019
- July 26, 2019
- August 12, 2019
- August 26, 2019
Answer: Only for registered users. Please login!
31. The nurse has received a prescription to transfuse a client with a unit of packed red blood cells. Before explaining the procedure to the client, the nurse should ask which initial question?
- "Have you ever had a transfusion before?”
- "Why do you think that you need the transfusion?"
- "Have you ever gone into shock for any reason in the past?"
- "Do you know the complications and risks of a transfusion?"
Answer: Only for registered users. Please login!
32. Situation: Mrs. Andres brought his son, Juanito, age 3 to the Pediatric clinic. She noticed that her son is not speaking and tend to repeat everything she says. The mother also told the nurse that Juanito prefers to be alone, will cry when someone will come near him and tend to rock himself from morning till he will fell asleep.Q. There is no definite cause identified for autism, but a strong link has been found on:
- Environmental factors
- Genetic factors
- Upbringing
- MMR vaccination
33. Situation: After abdominal surgery the circulating and scrub nurses have critical responsibility about sponge and instrument countQ. Like any nursing intervention, counts should be documented. To whom does the scrub nurse report any discrepancy of counts so that immediate and appropriate action is instituted?
- Anaesthesiologist
- Surgeon
- OR nurse supervisor
- Circulating nurse
34. When caring for a patient with new sigmoid colostomy, the nurse knows that the stoma may be expected to decrease in size from up to:
- One months
- Two months
- Six months
- One year
35. A nursing home resident with chronic osteoarthritis complains of knee pain. A routine order of acetaminophen (Tylenol) 500 mg every 6 hours was administered 2 hours ago with no relief. The patient also has an order for ibuprofen (Motrin) 400 mg every 6 hours as needed. The patient reports some relief, but is still bothered by mild pain. The nurse should
- Administer ibuprofen (Motrin) 400mg
- Educate the patient that mild pain is expected with osteoarthritis
- Call the physician for additional pain medication
- Administer acetaminophen (Tylenol) 500 mg
36. A client with a 3-day history of nausea and vomiting presents to the emergency department. The client is hypo ventilating and has a respiratory rate of 10 breaths/min. The electrocardiogram (ECG) monitor displays tachycardia, with a heart rate of 120 beats/min. Arterial blood gases are drawn and the nurse reviews the results, expecting to note which of the following?
- A decreased pH and an increased CO2
- An increased pH and a decreased CO2
- A decreased pH and a decreased HCO3
- An increased pH with an increased HCO3
37. 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.Syphilis is another infection that may impose risk during pregnancy. Since we are under the practice of health science, you know that Syphilis is caused by:
- Treponema Syphilis
- Neisseria gonorrhoeae
- Chlamydia Trachomatis
- Treponema Pallidum
38. The nurse is admitting a client who is diagnosed with syndrome of inappropriate antidiuretic hormone secretion (SIADH) and has serum sodium of 118 mEq/L (118 mmol/ L). Which health care provider prescriptions should the nurse anticipate receiving? Select all that apply. 1. Initiate an infusion of 3% NaCI. 2.Administer intravenous furosemide. 3.Restrict fluids to 800 mL over 24 hours. 4.Elevate the head of the bed to high Fowler's. 5.Administer a vasopressin antagonist as prescribed.
- 1,3,5
- 1,2,4,5
- 1,3,4
- 1,2,3
Answer: Only for registered users. Please login!
39. In preventing the development of an external rotation deformity of the hip in a client who must remain in bed for any period of time, the most appropriate nursing action would be to use:
- Trochanter roll extending from the crest of the ileum to the midthigh.
- Pillows under the lower legs.
- Footboard
- Hip-abductor pillow
Answer: Only for registered users. Please login!
40. Ricardo is scheduled for a prostatectomy, and the anesthesiologist plans to use a spinal (subarachnoid) block during surgery. In the operating room, the nurse positions the client according to the anesthesiologist's instructions. Why does the client require special positioning for this type of anesthesia?
- To prevent confusion
- To prevent seizures
- To prevent cerebrospinal fluid (CSF) leakage
- To prevent cardiac arrhythmias
Answer: Only for registered users. Please login!
41. A boy with skin disease, when you recommend the boy to go back to school?
- When you see scaly over the skin
- When he has temperature
- When all symptom of skin disease are disappear
- None of the above.
42. A client has undergone surgery for retinal detachment Which of the following goal should be prioritized?
- Prevent an increase intraocular pressure
- Alleviate pain
- Maintain darkened room
- Promote low-sodium diet
Answer: Only for registered users. Please login!
43. A client receiving a transfusion of packed red blood cells (PRBCs) begins to vomit. The clients blood pressure is 90/50 mm Hg from a baseline of 125/ 78 mm Hg. The clients temperature is 100.8 T (38.2 °C) orally from a baseline of 99.2 °F (37.3 °C) orally. The nurse determines that the client may be experiencing which complication of a blood transfusion?
- Septicemia
- Hyperkalemia
- Circulatory overload
- Delayed transfusion reaction
Answer: Only for registered users. Please login!
44. A client has a serum glucose of 385 mg/dl. Which of these orders would the nurse question first?
- Repeat glycohemoglobin in 24 hours
- Document Accu-checks, intake and output every 4 hours
- Humulin N 20 units IV push
- IV fluids of 0.9% normal saline at 125 ml per hour
45. Postpartum blues is said to be normal provided that the following characteristics are present. These are 1.Within 3-10 days only; 2.Woman exhibits the following symptoms- episodic tearfulness, fatigue, oversensitivity, poor appetite; 3.Maybe more severe symptoms in primpara
- All of the above
- 1 and 2
- 2 only
- 2 and 3
Answer: Only for registered users. Please login!
46. Situation: ENTEROSTOMAL THERAPY is now considered especially in nursing. You are participating in the OSTOMY CARE CLASS.Q. You are aware that teaching about colostomy care is understood when Fermin states, "I will contact my physician and report:
- If I have any difficulty inserting the irrigating tub into the stoma.”
- If I notice a loss of sensation to touch in the stoma tissue.”
- The expulsion of flatus while the irrigating fluid is running out.”
- When mucus is passed from the stoma between irrigation”
47. Following mitral valve replacement surgery a client develops PVC’s. The health care provider orders a bolus of Lidocaine followed by a continuous Lidocaine infusion at a rate of 2 mgm/minute. The IV solution contains 2 grams of Lidocaine in 500 cc's of D5W. The infusion pump delivers 60 microdrops/cc. What rate would deliver 4 mgm of Lidocaine/ minute?
- 60 microdrops/minute
- 20 microdrops/minute
- 30 microdrops/minute
- 40 microdrops/minute
48. The nurse is preparing to insert a nasogastric tube into a client The nurse should place the client in which position for insertion?
- Rightside
- Low Fowler's
- High Fowler's
- Supine with the head flat
Answer: Only for registered users. Please login!
49. The nurse is caring for a client who is receiving a blood transfusion. The transfusion was started 30 mins ago at a rate of 100 ml/hr. The client begins to complain of low back pain and headache and is increasing restless, what is the first nursing action?
- Slow the infusion and evaluate the V/S and client's history of transfusion reaction.
- Stop the transfusion, disconnect the blood tubing and begin a primary infusion of normal saline solution
- Stop the infusion of blood and begin infusion of NSS from the Y connector.
- Recheck the unit of blood for correct identification numbers and cross-match information
50. A client is recovering from a gastric resection for peptic ulcer disease. Which of the following outcomes indicates that the goal of adequate nutritional intake is being achieved 3 weeks following surgery?
- Increases food intake and tolerance gradually
- Experiences occasional episodes of nausea and vomiting
- Drinks 2000 mL/day of water
- Experiences a rapid weight gain within 1 week
NCLEX-RN | QB1 | Practice Exam #19 (50 questions)