NCLEX-RN | QB1 | Practice Exam #10 (50 questions)
1. Considered as the first line of defense of the body against infection
- Skin
- WBC
- Leukocytes
- Immunization
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2. An infant of a mother infected with human immunodeficiency virus (HIV) is seen in the clinic each month and is being monitored for symptoms indicative of HIV infection. With knowledge of the most common opportunistic infection of children infected with HIV, the nurse assesses the infant for which sign?
- Cough
- Liver failure
- Watery stool
- Nuchal rigidity
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3. Which of the following best describes the action of a nurse who documents her nursing diagnosis?
- She documents it and charts it whenever necessary
- She can be accused of malpractice
- She does it regularly as an important responsibility
- She charts it only when the patient is acutely ill
4. A client is admitted with sickle ceil crises and sequestration. Upon assessing the client the nurse would expect to find:
- Decreased blood pressure
- Moist mucus membranes
- Decreased respirations
- Increased blood pressure
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5. During the change of shift report a nurse writes in her notes that she suspects illegal drug use by a client assigned to her care. During the shift the notes are found by the clients daughter. The nurse could be sued for:
- Libel
- Slander
- Malpractice
- Negligence
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6. Twelve hours after the client was initially burned, bowel sounds are absent in all four abdominal quadrants. What is the nurse's best action?
- Reposition the client onto the right side.
- Document the finding as the only action.
- Notify the emergency team.
- Increase the IV flow rate.
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7. The nurse is caring for a client with Meniere's disease. When teaching the client about the disease, the nurse should explain that the client should avoid foods high in
- calcium
- fiber
- sodium
- carbohydrate
8. A patient with bowlegs due to abnormal bone formations and deformities has calcium level of 7.5 mg/100ml.Which of the following foods would the nurse most likely instruct the patient to add to a diet?
- Organ meats
- Whole grains
- Egg yolks
- Chicken meat
9. The nurse is conducting a teaching session with a client on their diagnosis of pemphigus. Which statement by the client indicates that the client understands the diagnosis?
- "My skin will have tiny red vesicles.”
- 'The presence of the skin vesicles is caused by a virus.”
- "I have an autoimmune disease that causes blistering in the epidermis."
- "The presence of red, raised papules and large plaques covered by silvery scales will be present on my skin."
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10. A client with a hip fracture asks the nurse about Buck's (extension) traction that is being applied before surgery and what is involved. The nurse should provide which information to the client?
- Allows bony healing to begin before surgery and involves pins and screws
- Provides rigid immobilization of the fracture site and involves pulleys and wheels
- Lengthens the fractured leg to prevent severing of blood vessels and involves pins and screws
- Provides comfort by reducing muscle spasms, provides fracture immobilization, and involves pulleys and wheels
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11. Trimethoprim-sulfamethoxazole is prescribed for a client. The nurse should instruct the client to report which symptom if it develops during the course of this medication therapy?
- Nausea
- Diarrhea
- Headache
- Sore throat
12. When developing the teaching plan for the client with rheumatoid arthritis to promote rest, which of the following would the nurse expect to instruct the client to avoid during the rest periods?
- Proper body alignment
- Elevating the part
- Prone lying positions
- Positions of flexion
13. Patient came to the clinic with pimples over all his body, the patient start to be alone and keep away from people arround him. As well he starts to disappear due to how he looks?
- Social isolation
- anxiety
- depression
- None of the above.
14. The nurse has received the assignment for the day shift. After making initial rounds and checking all of the assigned clients, which client should the nurse plan to care for first?
- A client who is ambulatory demonstrating steady gait
- A postoperative client who has just received an opioid pain medication
- A client scheduled for physical therapy for the first crutch-walking session
- A client with a white blood cell count of 14,000 mm3 (14A109/L) and a temperature of 38.4 °C
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15. They put girls clothes on male infants to drive evil forces away
- Chinese
- Egyptian
- Indian
- Babylonian
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16. The nurse is monitoring a 3-month-old infant for signs of increased intracranial pressure. On palpation of the fontanels, the nurse notes that the anterior fontanel is soft and fiat. On the basis of this finding, which nursing action is most appropriate?
- Increase oral fluids.
- Document the finding.
- Notify the health care provider (HCP).
- Elevate the head of the bed to 90 degrees.
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17. An asthmatic patient presents with wheezing and coughing. Oxygen saturation is 88% on room air Which of the following nursing diagnosis would take priority?
- Imbalanced nutrition related to decreased food intake
- Activity intolerance related to inefficient breathing
- Anxiety-related dyspnea and concern of illness
- Ineffective gas exchange related to broncho spasm
18. The nurse is caring for an 87 year-old client with urinary retention. Which finding should be reported immediately?
- Fecal impaction
- Infrequent voiding
- Stress incontinence
- Burning with urination
19. The nurse is making initial rounds on the nursing unit to assess the condition of assigned clients. Which assessment findings are consistent with infiltration? Select all that apply. 1. Pain and erythema 2. Pallor and coolness 3. Numbness and pain 4. Edema and blanched skin 5. Formation of a red streak and purulent drainage
- 1,4,5
- 2,3,4
- 1,2,3,5
- 3,4,5
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20. A client is admitted to the psychiatric clinic for treatment of anorexia nervosa. To promote the clients physical health, the nurse should plan to:
- severely restrict the clients physical activities.
- weigh the client daily after the evening meaL
- monitor vital signs, serum electrolyte levels, and acid-base balance.
- instruct the client to keep an accurate record of food and fluid intake.
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21. A 9-month-oid child who has had four ear infections in the past 6 months is being discharged. Which statement by the parent indicates the need for further discharge teaching?
- I should never put my baby to bed with bottle
- My child should not use a pacifier after age 6 months
- My child should drink his bottle while lying flat in my lap
- My child should not be around people who smoke
22. Situation:In the OR, there are safety protocols that should be followed. The OR nurse should be well versed with ail these to safeguard the safety and quality to patient delivery outcome.Q. Some different habits and hobbies affect postoperative respiratory function. If your client smokes 3 packs of cigarettes a day for the part 10 years, you will anticipate increased risk for:
- perioperative anxiety and stress
- delayed coagulation time
- delayed wound healing
- postoperative respiratory dysfunction
23. Situation: Breast cancer is the 2nd most common type of cancer after lung cancer and 99% of which, occurs in women. Survival rate is 98% if this is detected early and treated promptly. Carmen is a 53 year old patient in the high risk group for breast cancer was recently diagnosed with Breast Cancer.Q. Carmen being treated with radiation therapy. What should be included in the plan of care to minimize skin damage from the radiation therapy?
- Cover the areas with thick clothing materials
- Apply a heating pad to the site
- Wash skin with water after therapy
- Avoid applying creams and powder to the area.
24. A patient present to the clinic with"pins and needles" sensations of the left foot and complains that objects appear" Shimmering".The patient is diagnosed with opticneuritis and referred for further testing. The patient is MOST likely to be tested for:
- Glaucoma
- Multiple sclerosis
- Lesion of brain stem
- Psychosis
25. patient with an unnecessary gait and a history of falls has a care plan intervention that includes keeping the walker in reach and pathway free of obstacle. On evaluation after 1 week, the patient has had no falls, but the gait remains unsteady. The nurse should:
- Continue the plan of care as written
- Allow the patient to replace the walker with a cane
- Allow the patient to ambulate short distance without the walker
- Have the patient practice stepping over small objects
26. Halfway through the administration of blood, the female client complains of lumbar pain. After stopping the infusion Nurse Hazel should:
- Increase the flow of normal saline
- Assess the pain further
- Notify the blood bank
- Obtain vital signs.
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27. A 23 year old client has been admitted with a diagnosis of schizophrenia says to the nurse "Yes, its march, March is little woman". That's literal you know". These statement illustrate:
- Neologisms
- Echolalia
- Flight of ideas
- Loosening of association
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28. A client being treated with sodium warfarin has an 1NR of 8.0. Which intervention would be most important to include in the nursing care plan?
- Assess for signs of abnormal bleeding.
- Anticipate an increase in the Coumadin dosage.
- Instruct the client regarding the drug therapy.
- Increase the frequency of neurological assessments.
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29. Situation: You are assigned to take care of a group of patients across the lifespan.Which of the following factors is most important in determining the success of relationships used in delivering nursing care?
- Type of illness of the client
- Transference and countertransference
- Effective communication
- Personality of the participants
30. 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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31. The nurse is teaching a group about aerobics exercises. When discussing the target heart rate for exercise, the nurse should state that this is calculated by:
- Counting the number of the heart beats during exercise for 6 sections, then multiply this number by 10
- Subtracting the chronological age from the number 220
- Counting then number of heart beats during exercise for 10 seconds, then multiply by 6
- Subtracting he chronological age from 240
32. A client with a history of schizophrenia is seen in the local health clinic for medication follow-up. To maintain a therapeutic level of medication the nurse should tell the client to avoid:
- Taking over-the-counter allergy medication
- Eating cheese and pickled foods
- Eating salty foods
- Taking over-the-counter pain relievers
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33. Situation: The preoperative nurse collaborates with the client significant others, and healthcare providers.Q. The documentation of all nursing activities performed is legally and professionally vital. Which of the following should NOT be included in the patients chart?
- Presence of prosthetic devices such as dentures, artificial limbs hearing aid, etc.
- Baseline physical, emotional, and psychosocial data
- Arguments between nurses and residents regarding treatment
- Observed untoward signs and symptoms and interventions including contaminant intervening factors.
34. The ambulatory care nurse is discussing preoperative procedures with a Japanese American client who is scheduled for surgery the following week. During the discussion, the client continually smiles and nods the head. How should the nurse interpret this nonverbal behavior?
- Reflecting a cultural value
- An acceptance of the treatment
- Client agreement to the required procedures
- Client understanding of the preoperative procedures
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35. A client is admitted to the acute care unit. Initial laboratory values reveal serum sodium of 170meq/L. What behavior changes would be most common for this client?
- Anger
- Mania
- Depression
- Psychosis
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36. A client is admitted to the psychiatric unit with active psychosis. The physician diagnoses schizophrenia after ruling out several other conditions. Schizophrenia is characterized by:
- loss of identity and self-esteem.
- multiple personalities and decreased self-esteem.
- disturbances in affect, perception, and thought content and form.
- persistent memory impairment and confusion.
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37. What's the best time of nursing home care evaluation?
- end of each Visit
- end of the first months
- after 2 months
- None of the above.
38. The nurse is caring for the client with increased intracranial pressure. The nurse would note which trend in vital signs if the intracranial pressure is risin g?
- Increasing temperature, increasing pulse, increasing respirations, decreasing blood pressure
- Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure
- Decreasing temperature, decreasing pulse, increasing respirations, decreasing blood pressure
- Decreasing temperature, increasing pulse, decreasing respirations, increasing blood pressure
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39. SITUATION: Alfred, a 40 year old construction worker developed cough, night sweats and fever He was brought to the nursing unit for diagnostic studies. He told the nurse he did not receive a BCG vaccine during childhood. Q. Mang Alfred returns after the Mantoux Test. The test result read POSITIVE. What should be the nurse's next action?
- Call the Physician
- Notify the radiology dept, for CXR evaluation
- Isolate the patient
- Order for a sputum exam
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40. Situation: Annie has a morbid fear of heights. She asks the nurse what desensitization therapy is:Q. The accurate information of the nurse the goal of desensitization is:
- To help the clients relax and progressively work up a list of anxiety provoking situations through imagery
- To provide corrective emotional experiences through a one-to-one intensive relationship
- To help clients in a group therapy setting to take on specific roles and reenact in front of an audience, situations in which interpersonal conflict is involved.
- To help clients cope with their problems by learning behaviors that we are more functional and be better equipped to face reality and make decisions.
41. A 50 year old mailman carried a mail with anthrax powder in it. A minute after exposure, he still hasn't developed any signs and symptoms of anthrax. In what stage of infectious process does this man belongs?
- Incubation period
- Prodromal period
- Illness period
- Convalescent period
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42. Situation: Mr Sean is admitted to the hospital with a bowel obstruction. He complained of colicky pain and inability to pass stool.Q. Nasogastric tube was inserted to Mr. Sean. The NGT's primary purpose is:
- nutrition
- decompression of bowel
- passage for medication
- aspiration of gastric contents
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43. During the first 24 hours post burn, fluid replacement is the treatment priority. The assessment that would alert the nurse that the fluid protocol is ineffective is:
- Marked edema in the burn area.
- Rectal temperature of 101° F
- Crackles in the lower left lobe.
- Urine output of 20 mL/hour.
44. The nurse is assigned to care for a patient who has recently been diagnosed with Crohn's disease. The initial treatment is usually:
- Dietary changes
- Reversible colostomy
- Permanent colostomy
- Watchful waiting
45. When performing Leopold maneuvers on a client at 32 weeks gestation the nurse would expect to find:
- No fetal movement
- Minimal fetal movement
- Moderate fetal movement
- Active fetal movement
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46. After administering naloxone (Narcan), an opioid antagonist Nurse Ronald should monitor the female client carefully for which of the following?
- Respiratory depression
- Epilepsy
- Kidney failure
- Cerebral edema
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47. The physician has prescribed Gantrisin (sulfasoxazole) Igm in divided doses for a client with a urinary tract infection. The nurse should administer the medication:
- With meals or a snack
- 30 minutes before meals
- 30 minutes after meals
- At bedtime
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48. Which of the following concept is most important in establishing a therapeutic nurse patient relationship?
- The nurse must fully understand the patient's feelings, perception and reactions before goals can be established
- The nurse must be a role model for health fostering behavior
- The nurse must recognize that the patient may manifest maladaptive behavior after illness
- The nurse should understand that patients might test her before trust is established
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49. Which of the following describes the Babinski reflex?
- The newborn's toes will hyperextend and fan apart from dorsiflexion of the big toe when one side of foot is stroked upward from the ball of the heel and across the ball of the foot.
- The newborn abducts and flexes all extremities and may begin to cry when exposed to sudden movement or loud noise.
- The newborn turns the head in the direction of stimulus, opens the mouth, and begins to suck when cheek, lip, or corner of mouth is touched.
- The newborn will attempt to crawl forward with both arms and legs when he is placed on his abdomen on a flat surface
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50. Situation:- “Group Approach" in Nursing.Q. The working phase in therapy group is usually characterized by which of the following?
- Caution
- Cohesiveness
- Confusion
- Competition
NCLEX-RN | QB1 | Practice Exam #10 (50 questions)