NCLEX-RN | QB1 | Practice Exam #17 (50 questions)

 

1. Situation: Colostomy is a surgically created anus- It can be temporary or permanent, depending on the disease condition. The following are appropriate nursing interventions during colostomy irrigation EXCEPT:

• Increase the irrigating solution flow rate when abdominal cramps is felt
• Insert 2-4 inches of an adequately lubricated catheter to the stoma
• Position client in semi-Fowler
• Hand the solution 18 inches above the stoma

2. Situation: Records and Records management is one of the core of professional nursing practice. Q. All of the following are purposes of the chart EXCEPT:

• To document the quality of care
• A vehicle for communication
• For the prerecording of nursing actions
• For research and education

3. A home health nurse is at the home of a client with diabetes and arthritis. The client has difficulty drawing up insulin. It would be most appropriate for the nurse to refer the client to

• A social worker from the local hospital
• An occupational therapist from the community center
• A physical therapist from the rehabilitation agency
• Another client with diabetes mellitus and takes insulin

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4. A client with otosclerosis is scheduled for a stapedectomy. Which finding suggests a complication involving the seventh cranial nerve?

• Diminished hearing
• Sensation of fullness in the ear
• Inability to move the tongue side to side
• Changes in facial sensation

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5. A burn client is receiving treatments of topical mafenide acetate to the site of injury. The nurse monitors the client, knowing that which finding indicates that a systemic effect has occurred?

• Hyperventilation
• Elevated blood pressure
• Local rash at the burn site
• Local pain at the burn site

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6. A 60 year-old man with a history of long-term alcohol use presents to the clinic with an enlarged abdominal girth, hemoptysis and pruritus. His eyes and skin are visibly yellow­ coloured. Which additional finding would indicate the need for immediate hospital admission?

• Azotemia
• Asterixis
• Tachycardia
• Lower extremity edema

7. Dr. Marquez is about to defibrillate a client in ventricular fibrillation and says in a loud voice "clear". What should be the action of the nurse?

• Places conductive gel pads for defibrillation on the client's chest
• Turn off the mechanical ventilator
• Shuts off the client's IV infusion
• Steps away from the bed and make sure all others have done the same

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8. Situation: Nurses are generalist, in order to cope up with the works demand you must have broad knowledge on anything. Nurse Joan was assigned in the medical ward. During the endorsement she found out that she was assigned to several patients of different case Q. Which of the conditions is an early symptoms commonly seen in Myasthenia Gravis?

• Dysphagia
• Fatigue improving at the end of the day
• Ptosis
• Respiratory Distress

9. Situation:- A research study was under taken in order to identify and analyze a disabled boy's coping reaction pattern during stress.Q. Which of these does NOT happen in a descriptive study?

• Exploration of relationship between two or more phenomena
• Exploration of relationships between two or more phenomena
• Manipulation of phenomenon in real life context
• Manipulation of a variable

10. Which nursing intervention is appropriate for a client with skeletal traction?

• Pin care
• Prone positioning
• Intermittent weights
• 5lb weight limit

11. When caring for a client with total parenteral nutrition (TPN), what is the most important action on the part of the nurse?

• Record the number of stools per day
• Maintain strict intake and output records
• Sterile technique for dressing change at IV site
• Monitor for cardiac arrhythmias

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12. This is the amount of air remained in the lungs after a forceful expiration

• Inspiratory reserve volume
• Expiratory reserve volume
• Functional residual capacity
• Residual volume

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13. Jonas comes into the local blood donation center. He says he is here to donate platelets only today. The nurse knows this process is called:

• Directed donation.
• Autologous donation.
• Allogeneic donation.
• Apheresis.

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14. To assess orientation to place in a client suspected of having dementia of the alzheimers type, nurse Chris should ask:

• "Where are you?"
• "Who brought you here?"
• "Do you know where you are?"
• "How long have you been there?"

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15. The nurse is caring for a patient who had an acute pulmonary edema. The nurse should understand that which of the following prescribed medications will help to reduce the increased pressure?

• Morphine sulfate
• Potassium chloride
• Warfarin sodium(coumadin)
• Bisacodyl (dulcolax)

16. Mrs. Hogan, a 43-year-old woman, is admitted to your unit for cholecystectomy.Q. Mrs. Hogan is transported to the recovery room following her cholecystectomy. As you continue to check her vital signs you note a continuing trend in Mrs. Hogan's status: her BP is gradually dropping and her pulse rate is increasing. Your most appropriate nursing action is to:

• order whole blood for Mrs. Hogan from the lab
• increase IV fluid rate of infusion and place in trendelenburg position
• immediately report signs of shock to the head nurse and/or surgeon and monitor VS closely
• place in lateral sims position to facilitate breathing

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17. A 7-week-old infant boy is admitted with projectile vomiting decreased urine output, decreased bowel movements and weight loss, He has poor turgor and appears hungry. The nurse observes left-to right peristaltic waves after he vomits. The nurse would expect to find which of the following during the physical assessment?

• Hepato-spleenomegaly
• A palpable pyloric mass
• Lymphadenopathy
• Bulging fontanelles

18. Situation: Nursing informatics is a way of using information technology computers and the internet in the improvement of nursing care. The first nursing informatics conference was held during 1977.Q. When is the first certification of Nursing Informatics given?

• 1992-1993
• 1994-1995
• 2001-2002
• 2004-2005

19. The nurse is performing an assessment on a client who has just been told that a pregnancy test is positive. Which assessment finding indicates that the client is at risk for preterm labor?

• The client is a 35-year-old primigravida.
• The client has a history of cardiac disease.
• The clients hemoglobin level is 13.5 g/dL (135 mmol/L).
• The client is a 20-year-old primigravida of average weight and height.

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20. A patient recently underwent coronary artery bypass graft surgery (CABG). The Nursing diagnosis includes sleep deprivation related to intensive care environment. The goal for this diagnosis would be that the patient:

• Gets 4 hours of uninterrupted sleep during the right
• Takes naps during the day
• Is free of pain in the first hour post-surgery
• Ambulates 3 hours post-surgery

21. Who postulated the WHOLISTIC concept that the totality is greater than sum of its parts?

• Roy
• Rogers
• Henderson
• Johnson

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22. Situation: - Please continue responding as a professional nurse in varied health situations through the following questions.Q. Which of the following medications would the nurse expect the physician to order for recurrent convulsive seizures of a 10-year old child brought to your clinic?

• Phenobarbital
• Nifedipine
• Butorphanol
• Diazepam

23. Situation: Clients with Bipolar disorder receives a very high nursing attention due to the increasing rate of suicide related to illness.Q. The nurse assesses a client with admitted diagnosis of bipolar affective disorder mania. The symptom presented by the client that requires the nurse's immediate intervention is the client's:

• Outlandish behaviour and inappropriate dress
• Grandiose delusion of being a royal descendant of King Arthur
• Nonstop physical activity and poor nutritional intake
• Constant incessant talking that includes sexual topic and teasing.

24. Which of the following would the nurse assess in a client with an intracapsular hip fracture?

• Internal rotation
• Muscle flaccidity
• Shortening of the affected leg
• Absence of pain the fracture area

25. For prevention of Hepatitis A, you decided to conduct health education activities. Which of the following is Irrelevant?

• Use of sterile syringes and needles
• Safe food preparation and food handling by vendors
• Proper disposal of human excreta and personal hygiene
• Immediate reporting of water pipe leaks and illegal water connections

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26. The doctor has ordered the patient to be on 1 to 3 litters of oxygen using a nasal cannula at all times, the home care nurse notes the oxygen is currently at 2 L/minut. the oxygen saturation( SaO2) reading is currently 85% and the partial pressure of CO2 is within normal limits. Based on an evaluation of this information, which of the following actions would the nurse MOST likely perform?

• Decrease the O2 to 1 L/minut and monitor O2 saturation
• continue the O2 at 2 L/minut and monitor O2 saturation
• Increase the O2 to 3 L/minut and monitor O2 saturation
• continue to monitor O2 saturation and call the doctor for new orders

27. The best example of the nursing order is:

• Encourage fluids.
• Change patient position every 2 hours on even hours.
• Provide oral fluid.
• All of the above.

28. An adult had a left above the knee amputation two weeks ago. The nurse places him in a prone position three times a day because:

• Prevents pressure ulcer on the sacrum
• helps the prosthesis to fit correctly
• prevents flexion contractures
• allow better blood flow to the heart

29. The most common deficiency seen in alcoholics is:

• Thiamine
• Riboflavin
• Pyridoxine
• Pantothenic acid

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30. Situation: The question with regards to the OPERATING ROOM.Q. PACU Vital signs monitoring is performed every:

• 5 minutes
• 10 minutes
• 15 minutes
• 30 minutes

31. 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. What should you do FIRST before you administer blood transfusion?

• verify client identity and blood product, serial number, blood type, cross matching results, expiration date
• verify client identity and blood product serial number, blood type, cross matching results, expiration date with another nurse
• check IV site and use appropriate BT set and needle
• verify physician's order

32. All of the followings are Signs of systematic infection EXCEPT:

• Fever.
• Vomiting.
• Fatigue and loss of energy.
• Enlargement and tenderness of lymph node.

33. The nurse should plan which goals of the termination stage of group development? Select all that apply. 1.The group evaluates the experience. 2.The real work of the group is accomplished. 3.Group interaction involves superficial conversation. 4.Group members become acquainted with one another. 5.Some structuring of group norms, roles, and responsibilities takes place. 6.The group explores members'feelings about the group and the impending separation.

• 1,3,5,6
• 2,4,6
• 1,3,5
• 1,6

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34. The child with a history of respiratory infections has an order for a sweat test to be done. Which finding would be positive for cystic fibrosis?

• A serum sodium of 135meq/L
• A sweat analysis of 69 meq/L
• A potassium of 4.5meq/L
• A calcium of 8mg/dL

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35. 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. In contrary with Tracheostomy tubes, sizes of chest tubes are expressed in terms of:

• French
• Gauge
• M2
• Diameter

36. Situation: Mastery of research design determination is essential in passing the Nurse Licensure Examination.Q. Marco is to perform a study about how nurses perform surgical asepsis during World War II. A design for this study is:

• Historical
• Ethnographic
• Case Study
• Phenomenological

37. After a precipitous delivery, the nurse notes that the new mother is passive and touches her newborn infant only briefly with her fingertips. What should the nurse do to help the woman process the delivery?

• Encourage the mother to breast-feed soon after birth.
• Support the mother in her reaction to the newborn infant.
• Tell the mother that it is important to hold the newborn infant.
• Document a complete account of the mother's reaction on the birth record.

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38. In the late 1950s, consumers and health care professionals began challenging the routine use of analgesics and anesthetics during childbirth. Which of the following was an outgrowth of this concept?

• Labor, delivery, recovery, postpartum (LDRP)
• Nurse-midwifery
• Clinical nurse specialist
• Prepared childbirth

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39. The nurse is providing instructions to the parents of a child with scoliosis regarding the use of a brace. Which statement by the parents indicates a need for further instruction?

• "I will encourage my child to perform prescribed exercises"
• "I will have my child wear soft fabric clothing under the brace."
• "I should apply lotion under the brace to prevent skin breakdown"
• "I should avoid the use of powder because it will cake under the brace"

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40. A five-year-old client with hyperthyroidism is admitted to the pediatric unit. What would the nurse expect the admitting assessment to reveal?

• Bradycardia
• Decreased appetite
• Exophthalmos
• Weight gain

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41. How can you assess a child who is mentally retarded?

• let the child make story
• observe for the developmental milestone
• ask the mother what food the child is eating
• ask the child to sing

42. The nurse is reviewing the laboratory results of a client receiving chemotherapy. The platelet count is 10,000 cells/mm. Based on this laboratory value, the priority nursing assessment is which of the following?

• Assess level of consciousness
• Assess temperature
• Assess bowel sounds
• Assess skin turgor

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43. What is given to a woman within a month after the delivery of a baby?

• Malunggay capsule
• Ferrous sutfate 100mg O.D.
• Retinol 200.000 IU 1 capsule
• Potassium Iodate 200 mg, 1 capsule

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44. The nurse assesses the postpartum vaginal discharge (lochia) on four clients. Which of the following assessments would warrant notification of the physician?

• A dark red discharge on a 2-day postpartum client
• A pink to brownish discharge on a client who is 5 days postpartum
• Almost colorless to creamy discharge on a client 2 weeks after delivery
• A bright red discharge 5 days after delivery

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45. When ambulating a client following surgical removal of a protruded intervertebral lumbar disc, the nurse would do which of the following?

• Maintain proper body alignment
• Administer analgesia after walking
• Provide a cane for support
• Immobilize the head and neck

46. Situation: - Nurse's in all practice areas are likely to come in contact with clients suffering from acute or chronic drug abuse.Q. Substance abuse is different from substance dependence is than, substance dependence:

• includes characteristics of adverse consequences and repeated use
• requires long term treatment in a hospital based program
• produces less severe symptoms than that of abuse
• includes characteristics of tolerance and withdrawal

47. Hypercabnia is:

• Bluish discoloration of the skin nails beds and mucosal membrane.
• Inadequate alveolar ventilation can lead to hypoxia.
• Accumulation of carbon dioxide in the blood.
• Slow respiration rate.

48. A couple who has sought fertility counseling has been told that the man's sperm count is very low. The nurse advises the couple that spermatogenesis is impaired when which of the following occurs?

• The testes are overheated.
• The vas deferens is ligated.
• The prostate gland is enlarged.
• The flagella are segmented.

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49. Tyra experienced painless vaginal bleeding has just been diagnosed as having a placenta previa. Which of the following procedures is usually performed to diagnose placenta previa?

• Amniocentesis
• Digital or speculum examination
• External fetal monitoring
• Ultrasound

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50. What is the most appropriate nursing action to help manage a manic client who is monopolizing a group therapy session?

• Ask the client to leave the group for this session only.
• Refer the client to another group that includes other manic clients.
• Tell the client to stop monopolizing in a firm but compassionate manner
• Thank the client for the input but inform the client that others now need a chance to contribute.

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NCLEX-RN | QB1 | Practice Exam #17 (50 questions)