NCLEX-RN | QB1 | Practice Exam #13 (50 questions)
1. 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 function of the obturator is:
- To direct the outer cannula to traverse the curvature of the trachea for easier insertion
- In cases of emergency when outer cannula accidentally dislodges
- To facilitate dilation of the stoma for the insertion of the outer cannula
- To prevent too much pressure on the jugular vein after the tie has been placed
2. The client returns to the unit from surgery with a blood pressure of 90/50 pulse 132 respirations 30. Which action by the nurse should receive priority?
- Continue to monitor the vital signs
- Contact the physician
- Ask the client how he feels
- Ask the LPN to continue the post-op care
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3. Situation: Ms. J., a 34-year old white female, is admitted via the emergency room complaining of abdominal pain, fatigue, anorexia, muscle cramping, and nausea. She is a diabetic who been managed at 30 U NPH insulin every AM and a 1200-calorie ADA diet. Her glucose in ER 700 mg/dL. Regular insulin 30 U was given and a repeat glucose were drawn. Results were not available upon transfer to the unitQ. The nurse received the lab results from the blood sample drawn in ER. Her glucose is now-100. However, her WBC count is 25,000. What conclusion can the nurse draw basing on this information?
- Lab results are within normal limits, no action is necessary
- Her diabetes is out of control
- insulin administration increase WBC count
- Infection has increased her insulin needs
4. The most important nursing action before gastrostomy feeding is:
- Assess for patency of the tube
- Measure residual feeding
- Check the placement of the tube
- Check V/S
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5. A priority goal of involuntary hospitalization of the severely mentally ill client is
- Re-orientation to reality
- Elimination of symptoms
- Protection from harm to self or others
- Return to independent functioning
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6. Prolonged occlusion of the right coronary artery produces an infarction in which of he following areas of the heart?
- Anterior
- Apical
- Inferior
- Lateral
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7. Situation: - Nurse's in all practice areas are likely to come in contact with clients suffering from acute or chronic drug abuse. Q. Commonly known as "shabu" is:
- Cannabis Sativa
- Lysergic add diethylamide
- Methylenedioxy methamphetamine
- Methamphetamine hydrochloride
8. The vomiting center is found in the:
- Medulla Oblongata
- Pons
- Hypothalamus
- Cerebellum
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9. A gravid 3, para 2 presents to the Labor and Delivery Unit with contractions occurring every 3-5 minutes and lasting for 60-90 seconds. During contractions, she closed her eyes and is focused on breathing to cope with the pain. At the end of each contraction she opens her eyes and resumes talking with the nurse and her husband. What is the expected cervical dilatation in centimeters?
- 01-3
- 04-7
- 08-10
- 11-13
10. An elderly client who experiences nighttime confusion wanders from his room into the room of another client The nurse can best help with decreasing the clients confusion by:
- Assigning a nursing assistant to sit with him until he falls asleep
- Allowing the client to room with another elderly client
- Administering a bedtime sedative
- Leaving a nightlight on during the evening and night shifts
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11. All of the following are physical assessment techniques except:
- Inspection.
- Percussion.
- Puncturing.
- Palpation
12. The client with AIDS tells the nurse that he has been using acupuncture to help with his pain. The nurse should question the client regarding this treatment because acupuncture uses:
- Pressure from the fingers and hands to stimulate the energy points in the body
- Oils extracted from plants and herbs
- Needles to stimulate certain points on the body to treat pain
- Manipulation of the skeletal muscles to relieve stress and pain
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13. A 4-year-old child is admitted to the hospital for abdominal pain. The mother reports that the child has been pale and excessively tired and is bruising easily. On physical examination, lymphadenopathy and hepatosplenomegaly are noted. Diagnosticstudies are being performed because acute lymphocytic leukemia is suspected. The nurse determines that which laboratory result confirms the diagnosis?
- Lumbar puncture showing no blast cells
- Bone marrow biopsy showing blast cells
- Platelet count of 350,000 mm3 (350A109/L)
- White blood cell count 4500 mm3 (4.5A109/L)
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14. As the charge nurse, you are reviewing the charts of clients who were assigned to a newly graduated RN. The RN has correctly charted dose and time of medication, but there is no documentation regarding non-pharmaceutical measures. What action should you take first?
- Make a note in the nurse's file and continue to observe clinical performance
- Refer the new nurse to the in-service education department.
- Quiz the nurse about knowledge of pain management
- Give praise for the correct dose and time and discuss the deficits in charting.
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15. Situation: Pharmacological treatment was not effective for Johnny's hyperthyroidism and now he is scheduled for Thyroid ectomy. Q. Instruments that do not touch the patient or have contact only to the intact skin is classified as:
- Critical
- Semi critical
- Non critical
- Ultra critical
16. A client has been discharged to home on parenteral nutrition (PN). With each visit, the home care nurse should assess which parameter most closely in monitoring this therapy?
- Pulseandweight
- Temperature and weight
- Pulse and blood pressure
- Temperature and blood pressure
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17. A nurse teaches a client about warfarin (Coumadin). Which juice to avoid identified by the client indicates that the teaching is effective?
- Apple juice
- Grape juice
- Orange juice
- Cranberry juice
18. The nurse is reviewing the assessment data of a client admitted to the mental health unit The nurse notes that the admission nurse documented that the client is experiencing anxiety as a result of a situational crisis. The nurse plans care for the client, determining that this type of crisis could be caused by which event?
- Witnessing a murder
- The death of a loved one
- A fire that destroyed the client's home
- A recent rape episode experienced by the client
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19. Nurse Pauline determines whether resources were maximized in implementing Ligtas Tigdas, she is evaluating:
- Effectiveness
- Efficiency
- Adequacy
- Appropriateness
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20. A 66-year-old client has been complaining of sleeping more, increased urination, anorexia, weakness, irritability, depression, and bone pain that interferes with her going outdoors. Based on these assessment findings, the nurse would suspect which of the following disorders?
- Diabetes mellitus
- Diabetes insipidus
- Hypoparathyroidism
- Hyperparathyroidism
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21. The nurse should make which statement to a pregnant client found to have a gynecoid pelvis?
- "Your type of pelvis has a narrow pubic arch"
- "Your type of pelvis is the most favorable for labor and birth."
- "Your type of pelvis is a wide pelvis, but it has a short diameter"
- "You will need a cesarean section because this type of pelvis is not favorable for a vaginal delivery."
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22. A new staff nurse is on an orientation tour with the head nurse. A client approaches her and says, "I don't belong here. Please try to get me out." The staff nurse's best response would be:
- "What would you do if you were out of the hospital?"
- "I am a new staff member, and I'm on a tour. I'll come back and talk with you later."
- "I think you should talk to the head nurse about that.'
- "I can't do anything about that"
23. A client with diabetes mellitus has had a right below-knee amputation. Given the client's history of diabetes mellitus, which complication is the client at most risk for after surgery?
- Hemorrhage
- Edema of the residual limb
- Slight redness of the incision
- Separation of the wound edges
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24. The basic delivery set for normal vaginal delivery includes the following instruments/ articles EXCEPT:
- 2 clamps
- Pair of scissors
- Kidney basin
- Retractor
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25. The nurse is reviewing a surgeon's prescription sheet for a preoperative client that states that the client must be nothing by mouth (NPO) after midnight. The nurse should call the surgeon to clarify that which medication should be given to the client and not withheld?
- Prednisone
- Ferrous sulfate
- Cyclobenzaprine
- Conjugated estrogen
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26. A client is admitted for suspected bladder cancer. Which one of the following factors is most significant in the clients diagnosis?
- Smoking a pack of cigarettes a day for 30 years
- Use of nonsteroidal anti-inflammatories
- Eating foods with preservatives
- Past employment involving asbestos
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27. Situation. As a nurse you need to anticipate the occurrence of complications of stroke so that life threatening situations can be preventedWhen performing a neurological assessment on Walter, you find that his pupils are fixed and dilated. This indicated that he:
- probably has meningitis
- is going to ibe blind because of trauma
- is permanently paralyzed
- has received a significant brain injury
28. A client who undergone left nephrectomy has a large flank incision. Which of the following nursing action will facilitate deep breathing and coughing?
- Push fluid administration to loosen respiratory secretions.
- Have the client lie on the unaffected side.
- Maintain the client in high Fowler's position.
- Coordinate breathing and coughing exercise with administration of analgesics.
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29. Mr. Duffy is admitted to the CCU with a diagnosis of R/O Ml. He presented in the ER with a typical description of pain associated with an Mi, and is now cold and clammy, pale and dyspneic. He has an IV of D5W running, and is complaining of chest pain. Oxygen therapy has not been started, and he is not on the monitor. He is frightened.Q. One of the clients has noted a raised yellow plaque on the nasal side of the conjunctiva. You explain that this is called:
- A a pinguecula, which is normal slightly raised fatty structure under the conjunctiva that may gradually increase with age.
- Icterus, which may be due to liver disease.
- A pterygium, which will interfere with vision.
- Ciliary flush caused by congestion of the ciliary artery.
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30. A client with a C3 spinal cord injury experiences autonomic hyperreflexia. After placing the client in high Fowlers position the nurses next action should be to:
- Notify the physician
- Make sure the catheter is patent
- Administer an antihypertensive
- Provide supplemental oxygen
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31. Toy with a tentative diagnosis of myasthenia gravis is admitted for diagnostic make up. Myasthenia gravis can confirmed by:
- Kernigs sign
- Brudzinski's sign
- A positive sweat chloride test
- A positive edrophonium (Tensilon) test
32. The nurse knows which of the following is the proper technique for medical asepsis?
- gloving for all the client contact
- changing hospital linens weekly
- using your hands to turn off the faucet after handwashing
- gowning to care for a 1 year old child w/ infections diarrhea
33. An obstetrical client calls the clinic with complaints of morning sickness. The nurse should tell the client to:
- Keep crackers at the bedside for eating before she arises
- Drink a glass of whole milk before going to sleep at night
- Skip breakfast but eat a larger lunch and dinner
- Drink a glass of orange juice after adding a couple of teaspoons of sugar
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34. A client with paranoid schizophrenia has an order for Thorazine (chlorpromazine) 400mg orally twice daily. Which of the following symptoms should be reported to the physician immediately?
- Fever sore throat weakness
- Dry mouth constipation blurred vision
- Lethargy slurred speech thirst
- Fatigue drowsiness photosensitivity
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35. A patient requiring long-term antibiotics has a central line catheter inserted into the right subclavian vein by the physician.Which of the following must be verified prior to the first use of the catheter?
- Blood return
- Catheter patency
- X-ray
- Length of catheter
36. A client who recently had a cerebrovascular accident requires a cane to ambulate. When teaching about cane use, the rationale for holding a cane on the uninvolved side is to:
- prevent leaning
- distribute weight away from the involved side
- maintain stride length
- prevent edema
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37. A client with acquired immunodeficiency syndrome (AIDS) is receiving a treatment protocol that includes a protease inhibitor. When assessing the client’s response to this drug, which common side effect should the nurse expect?
- Diarrhea
- Hypoglycemia
- Paresthesias of the extremities
- Seeing yellow halos around lights
38. Which of the following would be least likely to indicate anticipated bonding behaviors by new parents?
- The parents1 willingness to touch and hold the newborn.
- The parents expression of interest about the size of the newborn.
- The parents indication that they want to see the newborn.
- The parents interactions with each other.
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39. Nurse Tony was caring for a 41 year old female client. Which behavior by the client indicates adult cognitive development?
- Generates new levels of awareness
- Assumes responsibility for her actions
- Has maximum ability to solve problems and learn new skills
- Her perception are based on reality
40. A baby girl Is born 8 weeks premature. At birth, she has no spontaneous respirations but is successfully resuscitated. Within several hours she develops respiratory grunting, cyanosis, tachypnea, nasal flaring, and retractions. She's diagnosed with respiratory distress syndrome, intubated, and placed on a ventilator. Which nursing action should be included in the baby's plan of care to prevent retinopathy of prematurity?
- Cover his eyes while receiving oxygen.
- Keep her body temperature low.
- Monitor partial pressure of oxygen (PaO2) levels.
- Humidify the oxygen.
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41. The nurse is providing home care instructions to a client who has recently had a skin graft. Which instruction is most important for the client to remember?
- Use cosmetic camouflage techniques.
- Protect the graft from direct sunlight.
- Continue physical therapy.
- Apply lubricating lotion to the graft site.
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42. As the manager in a long-term-care (LTC) facility you are in charge of developing a standard plan of care for residents with Alzheimer's disease. Which of these nursing tasks is best to delegate to the LPN team leaders working in the facility?
- Check for improvement in resident memory after medication therapy is initiated.
- Use the Mini-Mental State Examination to assess residents every 6 months.
- Assist residents to toilet every 2 hours to decrease risk for urinary intolerance.
- Develop individualized activity plans after consulting with residents and family.
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43. A 6-year-old patient has presented to the clinic with fever, malaise and anorexia. The patient was treated 2 weeks ago for a streptococcal infection of the throat The nurse should expect the physician to order what test?
- Electrocardiogram
- Jones test
- Spinal tap
- Heart biopsy
44. Mr. Smith, a 61 year old American client was mobbed by teen gangsters near New york, Cubao. He was rushed to the Hsopital and was Unconscious. You are his nurse and you are to suction his secretions. In which position should you place Mr. Smith?
- High fowlers
- Semi fowlers
- Prone
- Side lying
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45. Mr Snyder is admitted to your unit with a brain tumor The type of tumor he has is currently unknown. You begin to think about the way brain tumors are classified.Q. Acoustic neuromas produce symptoms of progressive nerve deafness, tinnitus, and vertigo due to pressure and eventual destruction of:
- CN5
- CN7
- CN8
- The ossicles
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46. The schizophrenic client has become disruptive and requires seclusion. Which staff member can institute seclusion?
- The security guard
- The registered nurse
- The licensed practical nurse
- The nursing assistant
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47. The newly admitted client has a large burned area on the right arm. The burned area appears red, has blisters, and is very painful. How should this injury be categorized?
- Superficial
- Partial-thickness superficial
- Partial-thickness deep
- Full thickness
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48. When the uterus is firm and contracted after delivery but there is vaginal bleeding, the nurse should suspect
- Laceration of soft tissues of the cervix and vagina
- Uterine atony
- Uterine inversion
- Uterine hypercontractility
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49. A client recovering from a head injury is participating in care. The nurse determines that the client understands measures to prevent elevations in intracranial pressure if the nurse observes the client doing which activity?
- Blowing the nose
- Isometric exercises
- Coughing vigorously
- Exhaling during repositioning
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50. Which of the following blood tests is most indicative of cardiac damage?
- Lactate dehydrogenase
- Complete blood count
- Troponin I
- Creatine kinase
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NCLEX-RN | QB1 | Practice Exam #13 (50 questions)