NCLEX-RN | QB1 | Practice Exam #11 (50 questions)

 

1. Which of the following solutions would be best for the nurse to use when cleaning the inner cannula of a tracheostomy tube?

• Isopropyl alcohol
• Sodium hydrochloride
• Hydrogen peroxide
• Providone-iodine

2. Pelvic rocking is an appropriate exercise in pregnancy to relieve which discomfort?

• Leg cramps
• Urinary frequency
• Orthostatic hypotension
• Backache

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3. Tony is aware the Chairman of the Municipal Health Board is:

• Mayor
• Municipal Health Officer
• Public Health Nurse
• Any qualified physician

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4. Autism is diagnosed at:

• Infancy
• 3 years old
• 5 years old
• School age

5. The nurse is monitoring a client receiving levothyroxinesodium for hypothyroidism.Which findings indicate the presence of a side effect associated with this medication? Select all that apply. 1. Insomnia 2. Weight Ioss 3. Bradycardia 4. Constipations 5. Mild heat intolerance

• 1,2,5
• 1,2,3,4
• 2,3,5
• 2,3,4,5

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6. What type of relaxation technique does Lyza uses if a machine is showing her pulse rate, temperature and muscle tension which she can visualize and assess?

• Biofeedback
• Massage
• Autogenic training
• Visualization and Imagery

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7. A patient required long-term antibiotic 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
• X-ray
• Catheter potency
• Length of catheter

8. Situation: Overpopulation is one problem in the Philippines that case economic drain. Most Filipinos are against in legalizing abortion. As a nurse. Mastery of contraception is needed to contribute to the society and economic growth.Dana has asked about GIFT procedure. What makes her a good candidate for GIFT?

• She has patent fallopian tubes, so fertilized ova can be implanted on them.
• She is RH negative, a necessary stipulation to rule out RH incompatibility.
• She has normal uterus, so the sperm can be injected through the cervix into it.
• Her husband is taking sddenafil (Viagra), so all sperms will be motile.

9. During surgery, the nurse is assigned the following duties: setting up the sterile field, preparing sutures and ligatures assisting the surgeon during the procedure by anticipating the instruments and supplies that will be required and labeling tissue specimen obtained during surgery. The nurse MOST likely performing in what role?

• Circulating nurse
• Scrub Nurse
• RN first assistance
• Nurse anesthetist

10. RN assumes 24 hour responsibility for the client to maintain continuity of care across shifts, days or visits.

• Functional nursing
• Team nursing
• Primary nursing
• Total patient care

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11. A client has a regular 30-day menstrual cycles. When teaching about the rhythm method. Which the client and her husband have chosen to use for family planning, nurse Dianne should emphasize that the client's most fertile days are:

• Days 9 to 11
• Days 12 to 14
• Days 15 to 17
• Days 18 to 20

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12. Which of the following are qualities of a good recording? 1.Brevity 2. Completeness and chronology 3. Appropriateness 4. Accuracy

• 1,2
• 3,4
• 1,2,3
• 1,2,3,4

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13. 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. Oral analgesics are most frequently used to control burn injury pain:

• upon patient request
• during the emergent phase
• after hospital discharge
• during the cute phase

14. Which of the following can be used to determine if a prescribed pain management therapy is effective for a non-verbal patient?

• Papanicolaoutest
• Faces rating scale
• Braden's scale
• Apgar assessment tool

15. What is the first intervention for a client experiencing MI?

• Administer morphine
• Administer oxygen (wasn't from the list)
• Administer sublingual nitroglycerin
• Obtain an ECG

16. Which of the following may happen if the uterus becomes overstimulated by oxytocin during the induction of labor?

• Weak contraction prolonged to more than 70 seconds
• Tetanic contractions prolonged to more than 90 seconds
• Increased pain with bright red vaginal bleeding
• Increased restlessness and anxiety

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17. An adult client was burned in an explosion. The burn initially affected the client's entire face (anterior half of the head) and the upper half of the anterior torso, and there were circumferential burns to the lower half of both arms. The client's clothes caught on fire, and the client ran, causing subsequent burn injuries to the posterior surface of the head and the upper half of the posterior torso. Using the rule of nines, what would be the extent of the burn injury?

• 0.18
• 0.24
• 0.36
• 0.48

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18. The nurse caring for an adult client who is receiving TPN will need to be monitored for which of the following metabolic complications?

• Hypoglycemia and Hypercalcemia
• Hyperglycemia and Hypokalemia
• Hyperkalemia and Hypercalcemia

19. Which of the following complications is of greatest concern when caring for a preoperative abdominal aneurysm client?

• Aneurysm rupture
• Cardiac arrhythmias
• Diminished pedal pulses
• HPN

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20. The nurse is ready to begin an exam on a nine-month-old infant The child is sitting in his mothers lap. Which should the nurse do first?

• Check the Babinski reflex
• Listen to the heart and lung sounds
• Palpate the abdomen
• Check tympanic membranes

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21. Sally Baker, a 40-year-old woman, is admitted to the hospital with an established diagnosis of mitral stenosis. She is scheduled for surgery to repair her mitral valve.Q. On physical exam of Ms. Baker, several abnormal findings can be observed. Which of the following is not one of the usual objective findings associated with mitral stenosis?

• low-pitched rumbling diastolic murmur, precordial thrill, and parasternal lift
• small crepitant rales at the bases of the lungs
• weak, irregular pulse, and peripheral and facial cyanosis in severe disease
• chest x-ray shows left ventricular hypertrophy

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22. The following are important considerations to teach the woman who is on low dose (mini­ pill) oral contraceptive EXCEPT:

• The pill must be taken everyday at the same time
• If the woman fails to take a pill in one day, she must take 2 pilIs for added protection
• If the woman fails to take a pill in one day, she needs to take another temporary method until she has consumed the whole pack
• If she is breast feeding, she should discontinue using mini-pill and use the progestin-only type

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23. The physician has prescribed Nexium (esomeprazole) for a client with erosive gastritis. The nurse should administer the medication: A

• 30 minutes before a meal
• With each meal
• In a single dose at bedtime
• 30 minutes after meals

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24. A client with preeclampsia has been receiving an infusion containing magnesium sulfate for a blood pressure that is 160/80; deep tendon reflexes are 1 plus and the urinary output for the past hour is lOOmL. The nurse should:

• Continue the infusion of magnesium sulfate while monitoring the clients blood pressure.
• Stop the infusion of magnesium sulfate and contact the physician.
• Slow the infusion rate and turn the client on her left side.
• Administer calcium gluconate IV push and continue to monitor the blood pressure.

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25. Jose Miguel is a little bit nauseous. Among the following beverages, Which could help relieve JMs nausea?

• Coke
• Sprite
• Mirinda
• Orange Juice or Lemon Juice

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26. Situation: A nurse should be aware that some problems in the emergency setting are not always physiologic. Sometimes, Crisis can affect the patient in an emergency setting.Q. One of four factors describing the experience of sexually abused children and the effect it has on their growth and development is stigmatization. Stigma will occur when:

• child blames him or herself for the sexual abuse and begins to withdraw and Isolate
• Newspapers and the media don't keep sexual abuse private and accidentally or on purpose reveal the name of the victim
• The child has been blamed by the abuser for his or her sexual behaviors, saying that the child asked to be touched or did not make the abuser to stop
• The child's agony is shared by other members of the family or friends when the sexual abuse becomes public knowledge

27. A client with benign prostatic hypertrophy has been started on Proscar (finasteride). The nurses discharge teaching should include:

• Telling the clients wife not to touch the tablets
• Explaining that the medication should be taken with meals
• Telling the client that symptoms will improve in 1-2 weeks
• Instructing the client to take the medication at bedtime to prevent nocturia

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28. A client with schizophrenia is receiving antipsychotic medication. Which nursing diagnosis may be appropriate for this client?

• Ineffective protection related to blood dyscrasias
• Urinary frequency related to adverse effects of antipsychotic medication
• Risk for injury related to a severely decreased level of consciousness
• Risk for injury related to electrolyte disturbances

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29. The nurse is assessing a client with multiple trauma who is at risk for developing acute respiratory distress syndrome. The nurse should assess for which earliest sign of acute respiratory distress syndrome?

• Bilateral wheezing
• Inspiratory crackles
• Intercostal retractions
• Increased respiratory rate

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30. A client with major depression has not verbalized problem areas to staff or peers since admission to a psychiatric unit Which activity should the nurse recommend to help this client express himself?

• Art therapy in a small group
• Basketball game with peers on the unit
• Reading a self-help book on depression
• Watching movie with the peer group

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31. The difference between rectal and auxiliary temp is:

• 0.5 c
• 0.8 c
• 2c
• 1c

32. A 50-year-old patient is being admitted to the hospital in a vegetative state of unknown etiology what is the PRIORITY nursing diagnosis?

• Risk for impaired skin integrity
• Impaired swallowing
• Altered cerebral tissue perfusion
• Altered thought processes

33. Serious adverse effects of oral contraceptives include:

• Increase in skin oil followed by acne.
• Headache and dizziness.
• Early or mid-cycle bleeding.
• Thromboembolic complications.

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34. SituationIn the OR, there are safety protocols that should be followed. The OR nurse should be well versed with all these to safeguard the safety and quality to patient delivery outcome.Q. OR nurses should be aware that maintaining the client's safety is the overall goal of nursing care during the intraoperative phase. As the circulating nurse, you make certain that throughout the procedure...

• the surgeon greets his client before induction of anesthesia
• the surgeon and anesthesiologist are in tandem
• strap made of strong non-abrasive material are fastened securely around the joints of the knees and ankles and around the 2 hands around an arm board
• client is monitored throughout the surgery by the assistant anesthesiologist

35. A Roman Catholic couple is infertile. Their health care practitioner advises them that their best chance of getting pregnant is via in vitro fertilization with a mixture of the man's sperm and donor sperm. Which of the following issues, related to this procedure, should the nurse realize may be in conflict with the couple's religious beliefs? Select all that apply. 1. The man will ejaculate by masturbation into a specially designed condom. 2. The woman may become pregnant with donor sperm. 3. Fertilization is occurring in the artificial environment of the laboratory. 4. More embryos will be created than will be used to inseminate the woman. 5. The woman will receive medications to facilitate the ripening of her ova.

• 1, 2, 3 and 4
• 1,3,5
• 1,2,4
• 1, 2, 3, 4 and 5

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36. Situation:- it is the first day of clinical experience of nursing students at the Psychiatry Ward- During the orientation, the nurse emphasizes that the team members including nursing students are legally responsible to safeguard patient's records from loss or destruction or from people not authorized to bead it.Q. In an extreme situation and when no other resident or intern is available, should a nurse receive, telephone orders, the order has to be correctly written and signed by the physician within.

• 24 hours
• 36 hours
• 48 hours
• 12 hours

37. A type of heat loss that occurs when the heat is dissipated by air current

• Convection
• Conduction
• Radiation
• Evaporation

38. Situation: Mr Sean is admitted to the hospital with a bowel obstruction. He complained of colicky pain and inability to pass stool.Q. Client education should be given in order to prevent constipation. Nurse Leonard's health teaching should include which of the following? A

• use of natural laxatives
• fluid intake of 6 glasses per day
• use of OTC laxatives
• complete bed rest

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39. Situation: A nurse should be aware that some problems in the emergency setting are not always physiologic. Sometimes, Crisis can affect the patient in an emergency setting.Q. Which of the following statements best describes acquaintance rape?

• Sexuai intercourse when one person engaging in the activity is unsure about wanting to do so
• When two people don't love each other and engage in sexual activities
• When someone on a date tricks the other person into having sexual intercourse
• Sexual intercourse committed with force or the threat of force without a person's consent

40. A 19 year-old client is paralyzed in a car accident. Which statement used by the client would indicate to the nurse that the client was using the mechanism of “suppression"?

• "I don't remember anything about what happened to me
• I'd rather not talk about it right now
• "It's the other entire guy's fault! He was going too fast"
• "My mother is heartbroken about this"

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41. The nurse is completing an obstetric history of a woman in labor Which event in the obstetric history will help the nurse suspects dysfunctional labor in the current pregnancy?

• Total time of ruptured membranes was 24 hours with the second birth.
• First labor lasting 24 hours.
• Uterine fibroid noted at time of cesarean delivery.
• Second birth by cesarean for face presentation.

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42. A patient suffered a head trauma which resulted in a nasal fracture requiringsurgical intervention. Which of the following nursing diagnoses would MOST likely be a problem this patient? A

• Delayed surgical recovery
• Impaired gas exchange system
• Ineffective breathing pattern
• Risk for perioperative-positioning injury

43. In planning a lecture for a community group effect of acquired immunodeficiency syndrome gerontological community, the nurse would be correct in including which of the following stat regarding the incidence of the illness in people be 55 and 64 years of age?

• The illness is almost unheard of in this age group prior to 2003
• The illness has more than doubled between 1998 and 2003
• There are not many people living with the disease as it quickly fatal
• Treatment is more effective in this age group

44. Situation: Josh is a 2-year old child who was bom with a unilateral cleft lip and palate. He is being readmitted for a palate repair.Q. Which of the following would be the most important factor in preparing Josh for his hospitalization?

• Gratification of Josh wishes
• Josh's previous hospitalization
• Never leaving Josh with strangers
• Assurance of affection and security

45. A nurse is administering IM injection to an infant, the nurse should use any area:

• Left glottal
• Right glottal
• Rectus femoris
• None of the above

46. A child with p-thalassemia is receiving long-term blood transfusion therapy for the treatment of the disorder. Chelation therapy is prescribed as a result of too much iron from the transfusions. Which medication should the nurse anticipate to be prescribed?

• Fragmin
• Meropenem
• Metoprolol
• Deferoxamine

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47. 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. Potential post intracranial surgery problems include all but which of the following?

• increased ICP
• extracranial hemorrhage
• seizures
• leakage of cerebrospinal fluid

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48. A client calls the nurse in the emergency department and states that he was just stung by a bumblebee while gardening. The client is afraid of a severe reaction because the client's neighbor experienced such a reaction just 1 week ago. Which action should the nurse take?

• Advise the client to soak the site in hydrogen peroxide.
• Ask the client if he ever sustained a bee sting in the past.
• Tell the client to call an ambulance for transport to the emergency department.
• Tell the client not to worry about the sting unless difficulty with breathing occurs.

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49. Which of the following foods would the nurse encourage the client in sickle cell crisis to eat?

• Steak
• Cottage cheese
• Popsicle
• Lima beans

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50. The nurse implements a teaching plan for a preg- nant client who is newly diagnosed with gesta- tional diabetes meliitus. Which statement made by the client indicates a need for further teaching?

• "I should stay on the diabetic diet."
• "I should perform glucose monitoring at home."
• "I should avoid exercise because of the negative effects on insulin production."
• "I should be aware of any infections and report signs of infection immediately to my health care provider (HCP)"

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NCLEX-RN | QB1 | Practice Exam #11 (50 questions)