NCLEX-RN | QB1 | Practice Exam #18 (50 questions)
1. The following are all nursing diagnoses appropriate for a gravida 4 para 3 in labor. Which one would be most appropriate for the client as she completes the latent phase of labor?
- Impaired gas exchange related to hyperventilation
- Alteration in placental perfusion related to maternal position
- Impaired physical mobility related to fetal-monitoring equipment
- Potential fluid volume deficit related to decreased fluid intake
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2. Situation: Mr Gil age 86 years, has been diagnosed with Alzheimer's disease.Q. What type of environment should be provided by the health care team for Mr. Gil?
- Familiar
- Variable
- Challenging
- Non-stimulating
3. The nurse's most important legal responsibility after a patient's death in a hospital is:
- Obtaining a consent of an autopsy
- Notifying the coroner or medical examiner
- Labeling the corpse appropriately
- Ensuring that the attending physician issues the death certification
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4. The absence of which pulse may not be a significant finding when a patient is admitted to the hospital?
- Apical
- Radial
- Pedal
- Femoral
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5. A nurse educates a patient about the use of incentive spirometry to prevent atelectasis after a surgery.The nurse is performing what step of the nursing process?
- Diagnosis
- Assessment
- Implementation
- evaluation
6. A couple is seeking infertility counseling. The practitioner has identified the factors listed below in the woman's health history. Which of these findings may be con- tributing to the couple's infertility?
- The client is 36 years old.
- The client was 13 years old when she started to menstruate.
- The client works as a dental hygienist 3 days a week.
- The client jogs 2 miles every day.
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7. Situation: IBD is a common inflammatory functional bowel disorder also known as spastic bowel, functional colitis and mucous colitis.Q. Mr. Jung, had ulcerative colitis for 5 years and was admitted to the hospital. Which of the following factors was most likely of greatest significance in causing an exacerbation of the disease?
- A demanding and stressful job
- Changing to a modified vegetarian diet
- Beginning a weight training program
- Walking 2 miles everyday
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8. Palpation, there is guarding and rebound tenderness. Further investigation reveals a small stone which is trapped in the common bile duct On admission: Blood pressure: 148/80 mmHg. Heart rate: 90/min. Respiratory rate:21 shallow Temperature: 36.3°C . Which additional clinical finding is most likely?
- Yellowing of the sclera
- Dark and tarry stools
- light-amber coloured urine
- Clubbing of the fingers
9. The most appropriate nursing order for a patient who develops dyspnea and shortness of breath would be...
- Maintain the patient on strict bed rest at all times
- Maintain the patient in an orthopneic position as needed
- Administer oxygen by Venturi mask at 24% as needed
- Allow a 1 hour rest period between activities
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10. Meryl, age 19, is highly dependent on her parents and fears leaving home to go away to college. Shortly before the semester starts, she complains that her legs are paralyzed and is rushed to the emergency department. When physical examination rules out a physical cause for her paralysis, the physician admits her to the psychiatric unit where she is diagnosed with conversion disorder. Meryl asks the nurse, “Why has this happened to me?" What is the nurse's best response?
- "You've developed this paralysis so you can stay with your parents. You must deal with this conflict if you want to walk again.”
- "It must be awful not to be able to move your legs. You may feel better if you realize the problem is psychological, not physical."
- "Your problem is real but there is no physical basis for it. We'll work on what is going on in your life to find out why it's happened"
- "It isn't uncommon for someone with your personality to develop a conversion disorder during times of stress."
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11. Situation: Leukemia is the most common type of childhood cancer. Acute Lymphoid Leukemia is the cause of almost 1/3 of all cancer that occurs in children under age 15.Q. Adriamycin, Vincristine, Prednisone and L asparaginase are given to the client for long term therapy. One common side effect, especially of adriamycin is alopecia. The child asks: " Will I get my hair back once again?" The nurse respond is by saying:
- "Don't be silly, of course you will get your hair back."
- "We are not sure, let's hope it'll grow.”
- "This side effect is usually permanent, but I will get the doctor to discuss it for you.”
- "Your hair will regrow in 3 -6 months but of different color, usually darker and of different texture"
12. The nurse is performing wound care on a foot ulcer in a client with type 1 diabetes mellitus. Which technique demonstrates surgical asepsis?
- Putting on sterile gloves then opening a container of sterile saline.
- Cleaning the wound with a circular motion, moving from outer circles toward the center.
- Changing the sterile field after sterile water is spilled on it.
- Placing a sterile dressing (1.3 cm) from the edge of the sterile field.
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13. Jerome who has eating disorder often exhibits similar symptoms. Nurse Laney would expect an adolescent client with anorexia to exhibit:
- Affective instability
- Dishered, unkempt physical appearance
- Depersonalization and derealization
- Repetitive motor mechanisms
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14. Situation: Mr Gil age 86 years, has been diagnosed with Alzheimer's disease.Q. Mr Gil frequently switches from being pleasant and happy to being hostile and sad without apparent external cause. How can the nurse best care for Mr. Gil?
- Try to point out reality to him
- Avoid Mr. Gil when he is angry and sad
- Encourage him to talk about his feelings
- Attempt to give nursing care when he is in a pleasant mood
15. What is the BMI Of Budy, weighing 120 lbs and has a height of 5 feet 7 inches.
- 20
- 19
- 15
- 25
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16. Which of the following theorem addresses the four modes of adaptation?
- Madeleine Leininger
- Sr Callista Roy
- Florence Nightingale
- Jean Watson
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17. A health care provider's prescription reads phenytoin 0.2 g orally twice daily. The medication label states that each capsule is 100 mg. The nurse prepares how many capsule(s) to administer 1 dose?
- 1 capsule.
- 2 capsules.
- 3 capsules.
- 4 capsules.
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18. Situation: Nurse's in all practice areas are likely to come in contact with clients suffering from acute or chronic drug abuse.Q. During the detoxification stage, it is a priority for the nurse to:
- teach skills to recognize and respond to health threatening situations
- increase the client's awareness of unsatisfactory protective behaviors
- implement behavior modification
- promote homeostasis and minimize the client's withdrawal symptoms
19. The nurse is caring for a client immediately after removal of the endotracheal tube. The nurse should report which sign immediately if experienced by the client?
- Stridor
- Occasional pink-tinged sputum
- Respiratory rate of 24 breaths/minute
- A few basilar lung crackles on the right
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20. Which of the following communication skill is most effective in dealing with covert communication?
- Validation
- Listening
- Evaluation
- Clarification
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21. The client is admitted to the hospital with a diagnosis of Guillain-Barre syndrome. Which past medical history finding makes the client most at risk for this disease?
- Meningitis or encephalitis during the last
- 5 years Seizures or trauma to the brain within the last year
- Back injury or trauma to the spinal cord during the last 2 years
- Respiratory or gastrointestinal infection during the previous month
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22. The nurse should implement which interventions for a child older than 2 years with type 1 diabetes meilitus who has a blood glucose level of 60 mg/dL (3.4 mmol/L)? Select all that apply. 1. Administer regular insulin.2. Encourage the child to ambulate.3. Give the child a teaspoon of honey.4. Provide electrolyte replacement therapy intravenousiy.5. Wait 30 minutes and confirm the blood glucose reading.6. Prepare to administer glucagon subcutaneously if unconsciousness occurs.
- 3,6
- 1,3,5
- 2,4,6
- 1,2,3,4
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23. When prioritizing care, which of the following clients should the nurse Olivia assess first? A 17-year-old clients 24-hours post appendectomy
- A 33-year-old client with a recent diagnosis of Guillain-Barre syndrome
- A 50-year-old client 3 days post myocardial infarction
- A 50-year-old client with diverticulitis
- A 17-year-old clients 24-hours post appendectomy
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24. In which of the following areas is an abdominal aortic aneurysm most commonly located?
- Distal to the iliac arteries
- Distal to the rena arteries
- Adjacent to the aortic branch
- Proximal to the renal arteries
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25. A male client receiving prolonged steroid therapy complains of always being thirsty and urinating frequently. The best initial action by the nurse would be to:
- Perform a finger stick to test the clients blood glucose level
- Have the physician assess the client for an enlarged prostate
- Obtain a urine specimen from the client for screening purposes
- Assess the client's lower extremities for the presence of pitting edema
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26. A client with a missed abortion at 29 weeks gestation is admitted to the hospital. The client will most likely be treated with:
- Magnesium sulfate
- Calcium gluconate
- Dinoprostone (Prostin E.)
- Bromocrystine (Parlodel)
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27. The doctor order is 300 cc of normal saline solution, to be finished within 4 hours, how many drop/min you will regulate this IV (drop factor is 20 drop/minute).
- 10 drop/min
- 15 drop/min
- 25 drop/min
- 35 drop/min
28. In caring for a psychotic patient who is experiencing hallucinations, which of the following interventions is considered critical?
- Setting fewer limits in order to allow for more expressions of feeling
- Maintaining constant observation.
- Providing more frequent opportunities for interaction with others.
- Constantly negating the patient's hallucinatory Ideations.
29. A client who undergone appendectomy 3 days ago is scheduled for discharge today. The nurse notes that the client is restless, picking at bedclothes and saying, "I am late on my appointment," and calling the nurse by the wrong name. The nurse suspects:
- Panic reaction.
- Medication overdose.
- Toxic reaction to an antibiotic.
- Delirium tremens.
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30. Joey is a newly-appointed nurse manager of The Holy Spirit Medical Center, a tertiary hospital located within the heart of the metropolis. He thinks of scheduling planning workshop with his staff in order to ensure an effective and efficient management of the department. Should he decide to conduct a strategic planning workshop, which of the following is NOT a characteristic of this activity?
- Long-term goal-setting
- Extends to 3-5 years in the future
- Focuses on routine tasks
- Determines directions of the organization
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31. Protein digestion begins where?
- Mouth
- Esophagus
- Small intestine
- Stomach
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32. Prior to providing care for a hospitalized infant, the nurse MUST:
- Introduce self to parent
- Perform hand hygiene
- Have a witness present
- Assess the child's developmental level
33. The nurse is developing a care plan for a client with anorexia nervosa. Which action should the nurse include in the plan?
- Restrict visits with the family until the client begins to eat.
- Provide privacy during meals.
- Set up a strict eating plan for the client.
- Encourage the client to exercise, which will reduce her anxiety.
34. RA 1054 is also known as the Occupational Health Act. Aside from the number of employees, what other factor must be considered in determining the occupational health privileges to which the workers will be entitled?
- Type of occupation: agriculture, commercial, industrial
- Location of the workplace in relation to health facilities
- Classification of the business enterprise based on net profit
- Sex and age composition of employees
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35. 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. After Mr. Roberto completed his hemodialysis, The nurse should use which indicators to evaluate the client's status after dialysis?
- Potassium level and weight
- Vital signs and Blood Urea Nitrogen
- Blood Urea Nitrogen and Creatinine level
- Vital signs and weight
36. Capillary glucose monitoring is being performed every 4 hours for a client diagnosed with diabetic ketoacidosis. Insulin is administered using a scale of regular insulin according to glucose results. At 2 p.m., the client has a capillary glucose level of 250 mg/dl for which he receives 8II of regular insulin. The nurse should expect the dose's:
- onset to be at 2 p.m. and its peak at 3 p.m.
- onset to be at 2:15 p.m. and its peak at 3 p.m.
- onset to be at 2:30 p.m. and its peak at 4 p.m.
- onset to be at 4 p.m. and its peak at 6 p.m.
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37. SITUATION : Wide knowledge about the human ear, it's parts and it's functions will help a nurse assess and analyze changes in the adult client's health.Q. After mastoidectomy, Nurse John should be aware that the cranial nerve that is usually damage after this procedure is
- CN I
- CN II
- CN VII
- CN VI
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38. During newborn nursing assessment, a positive Ortolani's sign would be indicated by:
- A unilateral droop of hip
- A broadening of the perineum
- An apparent shortening of one leg
- An audible click on hip manipulation
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39. A child age 7 was unable to receive the measles, mumps, and rubella (MMR) vaccine at the recommended scheduled time. When would the nurse expect to administer MMR vaccine?
- In a month from now
- In a year from now
- At age 10
- At age 13
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40. Nurse Trish is aware that the laboratory test result that most likely would indicate acute pancreatitis is an elevated:
- Serum bilirubin level
- Serum amylase level
- Potassium level
- Sodium level
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41. A nurse is caring a patient who had a left mastectomy with lymph node removal seven days ago. The patient asks about exercises to regain function of the left arm. Which of the following activities would be MOST appropriate?
- Walking fingers up the wall
- Using five pound weights
- Knitting with a large needle
- Rhythmic clapping
42. All of the following are characteristics of crisis except
- The client may become resistive and active in stopping the crisis
- It is self-limiting for 4-6 weeks
- It is unique in every individual
- It may also affect the family of the client
43. A home health nurse is making preparations for morning visits. Which one of the following clients should the nurse visit first?
- A client with a stroke with tube feedings
- A client with congestive heart failure complaining of nighttime dyspnea
- A client with a thoracotomy six months ago
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44. Papanicolaou smear is usually done to determine cancer of:
- Cervix
- Ovaries
- Fallopian tubes
- Breast
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45. The nurse is preparing to teach a prenatal class about fetal circulation. Which statements should be included in the teaching plan? Select all that apply. 1. "The ductus arteriosus allows blood to bypass the fetal lungs."2. "One vein carries oxygenated blood from the placenta to the fetus.”3. "The normal fetal heart tone range is 140 to 160 beats per minute in early pregnancy."4. "Two arteries carry deoxygenated blood and waste products away from the fetus to the placenta "5. "Two veins carry blood that is high in carbon dioxide and other waste products away from the fetus to the placenta."
- 1,2,4
- 2,3,4,5
- 1,3,5
- 2,3,5
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46. The nurse is providing postpartum instructions to a client who will be breast-feeding her newborn. The nurse determines that the client has understood the instructions if she makes which statements? Select all that apply. 1."I should wear a bra that provides support.” 2."Drinking alcohol can affect my milk supply." 3."The use of caffeine can decrease my milk supply." 4."I will start my estrogen birth control pills again as soon as I get home." 5."I know if my breasts get engorged, I will limit my breast-feeding and supplement the baby." 6."I plan on having bottled water available in the refrigerator so I can get additional fluids easily.”
- 1,2,3,6
- 1,2,3,4,5,6
- 3,5,6
- 1,4,6
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47. Situation: In your professional nursing role, it is essential to establish a meaningful nurse patient relationship. Q. Which of the following approaches will most likely make your patient accept your help?
- Attending to all his needs
- Calling him by first name
- Demonstrating a relaxed and attending attitude
- Asking personal questions for health information
48. Mary finally decides to use judgment sampling on her research. Which of the following actions of is correct?
- Plans to include whoever is there during his study.
- Determines the different nationality of patients frequently admitted and decides to get representations samples from each.
- Assigns numbers for each of the patients, place these in a fishbowl and draw 10 from it.
- Decides to get 20 samples from the admitted patients
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49. As part of the diagnostic workup for pulmonic stenosis, a child has cardiac catheterization. Nurse Julius is aware that children with pulmonic stenosis have increased pressure:
- In the pulmonary vein
- In the pulmonary artery
- On the left side of the heart
- On the right side of the heart
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50. A newborn is having difficulty maintaining a temperature above 98 degrees Fahrenheit and has been placed in a warming isolette. Which action is a nursing priority?
- Protect the eyes of the neonate from the heat lamp
- Monitor the neonate's temperature
- Warm all medications and liquids before giving
- Avoid touching the neonate with cold hands
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NCLEX-RN | QB1 | Practice Exam #18 (50 questions)