NCLEX-RN | QB1 | Practice Exam #2 (50 questions)
1. 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. Why will Josh be unable to use toothbrush postoperatively?
- The suture line might be injured
- Josh would probably have no teeth
- The toothbrush might be frightening to Josh
- Josh would not be accustomed to a brush at home
2. Situation: - Please respond as a professional nurse in the other health situations through the following question.Q. The nurse would anticipate a cesarean birth for a client who has which infection present at the onset of labor?
- Herpes simplex virus
- Human papillomavirus
- Hepatitis
- Toxoplasmosis
3. What is the primary prevention of leprosy?
- Nutrition
- Vitamins
- BCG vaccination
- DPT vaccination
4. The clinic nurse reviews the record of an infant and notes that the health care provider has documen- ted a diagnosis of suspected Hirschsprung's dis- ease. The nurse reviews the assessment findings documented in the record, knowing that which sign most likely led the mother to seek health care for the infant?
- Diarrhea
- Projectile vomiting
- Regurgitation of feedings
- Foul-smelling ribbon-like stools
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5. A child is placed in skeletal traction for treatment of a fractured femur. The nurse creates a plan of care and should include which intervention?
- Ensure that all ropes are outside the pulleys.
- Ensure that the weights are resting lightly on the floor.
- Restrict diversional and play activities until the child is out of traction.
- Check the health care provider's (HCP's) prescriptions for the amount of weight to be applied.
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6. Situation: Mr. Brown, Age 72, is a widower with moderate Alzheimer's disease. Was brought to the home for the Aged by his married daughter. On admission, she says to the nurse, "I never thought this would happen to us. I really feel guilty about bringing him here, I can't bear to part with him." Q. One morning, Mr. Brown has difficulty putting his pyjamas. In Alzheimer's disease, this is known as:
- Aphasia
- Agnosia
- Apraxia
- Anomia
7. Diego with rheumatoid arthritis states, "the only time 1 am without pain is when 1 lie in bed perfectly still". During the convalescent stage, the nurse in charge with Diego should encourage:
- Active joint flexion and extension
- Continued immobility until pain subsides
- Range of motion exercises twice daily
- Flexion exercises three times daily
8. A client has been inhalation vasopressin therapy. What will the nurse evaluate to determine the therapeutic response to this medication?
- Urine specific gravity
- Blood glucose
- Vital signs
- Oxygen saturation levels
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9. The nurse explains to a breastfeeding mother that breast milk Is sufficient for all of the baby's nutrient needs only up to:
- 5 months
- 6 months
- 1 year
- 2 years
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10. The client has an order for heparin to prevent post-surgical thrombi. Immediately following a heparin injection the nurse should:
- Aspirate for blood
- Check the pulse rate
- Massage the site
- Check the site for bleeding
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11. What kind of illness precursor, according to DUNN is cigarette smoking?
- Heredity
- Social
- Behavioral
- Environmental
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12. To gain access to a vein and an artery an external shunt may be used for clients who require hemodialysis. The most serious problem with an external shunt is.
- Septicemia
- Clot-formation
- Exsanguination
- Sclerosis of vessels
13. What should the nurse emphasize when providing discharge instructions for a client with the diagnosis of Addison disease?
- Limit physical activity.
- Restrict sodium in the diet.
- Continue steroid replacement therapy.
- Schedule frequent health care appointments.
14. Mr Christopher is to receive 1 liter of D5RL to run for 12 hours. The drop factor of the IV infusion set is 10 drops per minute. Approximately how many drops per minutes should the IV be regulated?
- 13-14 drops
- 17-18 drops
- 10-12 drops
- 15-16 drops
15. In pouring a plain NSS into a receptacle located in a sterile field, how high should the nurse hold the bottle above the receptacle?
- 1 inch
- 3 inches
- 6 inches
- 10 inches
16. The nurse is teaching a group of patient about hepatitis A(HAV). The nurse should state that HAV is MAINLY transmitted Via:
- Blood contact
- Food
- Sexual activity
- Saliva
17. An ultrasound is performed on a client at term gestation who is experiencing moderate vaginal bleeding. The results of the ultrasound indicate that abruptio placentae is present. On the basis of these findings, the nurse should prepare the client for which anticipated prescription?
- Delivery of the fetus
- Strict monitoring of intake and output
- Complete bed rest for the remainder of the pregnancy
- The need for weekly monitoring of coagulation studies until the time of delivery
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18. Which of the following danger signs should be reported promptly during the antepartum period?
- Constipation
- Breast tenderness
- Nasal stuffiness
- Leaking amniotic fluid
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19. As per of a neurological assessment, which of the following is associated with the higher score on the Glasgow coma scale?
- Eye opening to pain, no verbalization
- Confused, obey commands
- Localized pain, abnormal extension
- Eye opening to speech confused
20. While evaluating the nutritional intake of a bedridden patient with multiple pressuresores, the nurse should make sure the patient INCREASES the intake of:
- Protein-rich foods
- Water
- Foods rich in vitamin A
- Fiber rich foods
21. The nurse is assessing a 15-year-old female who's being admitted for treatment of anorexia nervosa. Which clinical manifestation is the nurse most likely to find?
- Tachycardia
- Warm, flushed extremities
- Parotid gland tenderness
- Coarse hair growth
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22. The physician ordered Betamethasone to a pregnant woman at 34 weeks of gestation with sign of preterm labor. The nurse expects that the drug will:
- Treat infection.
- Suppress labor contraction.
- Stimulate the production of surfactant.
- Reduce the risk of hypertension.
23. SITUATION : Robert was diagnosed with Acute Close Angle Glaucoma. He is being seen by nurse Olivia. Q. Nurse Olivia knew that Acute close angle glaucoma is caused by:
- Sudden blockage of the anterior angle by the base of the iris
- Obstruction in trabecular meshwork
- Gradual increase of IOP
- An abrupt rise in IOP from 8 to 15 mmHg
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24. Which statement by the patient with hyperlipidemia shows a basic understanding of the disease and it treatment?
- Exercise has no effect on cholesterol levels
- Hyperlipidemia is usually symptomatic until significant target organ damage is done
- HDL cholesterol level of greater the 60 mg/dl increases the chance of coronary artery disease
- Cholestyramine (Quesram) should be taken in the morning with other medications
25. The nurse is assisting in the care of a patient who is two days post-operative from a hemorrhoidectomy. The nurse would be correct in instructing the patient to:
- Avoid a high-fiber diet
- Continue to use ice packs
- Take a laxative daily to prevent constipation
- Use a sitz bath after each bowel movement
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26. A newborn is Rh positive, and the mother is Rh negative. The infant is to receive an exchange transfusion. The nurse explains to the parents that their baby will receive Rh-negative blood because:
- it is the same as the mother’s blood.
- it is neutral and will not react with the baby’s blood.
- the possibility of a transfusion reaction is eliminated.
- the red blood cells will not be destroyed by maternal anti-Rh antibodies.
27. Nurse Isabella obtains a specimen of clear nasal drainage from a client with a head injury. Which of the following tests differentiates mucus from cerebrospinal fluid (CSF)?
- Protein
- Specific gravity
- Glucose
- Microorganism
28. A miotic medication has been prescribed for the client with glaucoma and the client asks the nurse about the purpose of the medication. Which response should the nurse provide to the client?
- "The medication will help dilate the eye to prevent pressure from occurring"
- "The medication will relax the muscles of the eyes and prevent blurred vision"
- "The medication causes the pupil to constrict and will lower the pressure in the eye"
- "The medication will help block the responses that are sent to the muscles in the eye"
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29. A male client had undergone Mantoux skin test. Nurse Ronald notes an 8mm area of indurations at the site of the skin test. The nurse interprets the result as:
- Negative
- Uncertain and needs to be repeated
- Positive
- Inconclusive
30. The clinic nurse is assessing a child who is scheduled to receive a live virus vaccine (immunization). What are the general contraindications associated with receiving a live virus vaccine? Select all that apply. 1. The child has symptoms of a cold.2. The child had a previous anaphylactic reaction to the vaccine.3. The mother reports that the child is having intermittent episodes of diarrhea.4. The mother reports that the child has not had an appetite and has been fussy.5. The child has a disorder that caused a severely deficient immune system.6. The mother reports that the child has recently been exposed to an infectious disease.
- 1,3,5
- 2,4,5
- 2,5
- 1,2,3,4
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31. A client has autoimmune thrombocytopenic purpura. To determine the clients response to treatment the nurse would monitor:
- Platelet count
- White blood cell count
- Potassium levels
- Partial prothrombin time (PTT)
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32. How many ml of blood is loss during the first 24 hours post delivery of Myrna?
- 100
- 200
- 400
- 500
33. A client with diabetes asks the nurse for advice regarding methods of birth control Which method of birth control is most suitable for the client with diabetes?
- Intrauterine device
- Oral contraceptives
- Diaphragm
- Contraceptive sponge
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34. Situation: Elderly clients usually produce unusual signs when it comes to different diseases. The ageing process is a complicated process and the nurse should understand that it is an inevitable fact and she must be prepared to care for the growing elderly population.Q. The older patient is at higher risk for incontinence because of:
- dilated urethra
- increased glomerular filtration rate
- diuretic use
- decreased bladder capacity
35. Nursing diagnosis is:
- A statement that describes actual health problem only.
- A statement that describes potential health problem only.
- A statement that describes actual and potential health problems.
- Puts the nursing care plan into action.
36. Mrs. Davis a 78 year old client is admitted with the diagnosis of mild chronic heart failure. The nurse expects to hear when listening to client's lungs indicative of chronic heart failure would be:
- Stridor
- Crackles
- Wheezes
- Friction rubs
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37. A patient who had abdominal surgery is in the post anesthesia care unit (PACU). Which of the following nursing diagnosis takes PRIORITY?
- Disturbed sleep pattern
- Acute pain
- Risk for infection
- Ineffective airway clearance
38. A nurse is caring for a child who is post-tonsillectomy and adenoidectomy. The nurse should plan to assess which of the following complications?
- Pulmonary hypertension
- Hemorrhage
- Hearing loss
- Corpulmonale
39. The mid-deltoid injection site is seldom used for I.M. injections because it:
- Can accommodate only 1ml or less of medication
- Bruises too easily
- Can be used only when the patient is lying down
- Does not readily parenteral medication
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40. Situation: Mrs. Daniel brought his son, Daniel, age 3 to the Pediatric clinic. She noticed that her son is not speaking and tend to repeat everything she says. The mother also told the nurse that Daniel prefers to be alone, will cry when someone will come near him and tend to rock himself from morning till he will fell asleep.Q. Chlorpromazine was given to the child. Which is true with regards to this medication?
- Expect that the child will be unusually alert and hyperactive during the therapeutic period
- The mother should decrease the fluid intake of the child as this drug causes fluid retention
- That the drug is given in order to decrease the child's hyperactivity
- The mother should avoid overexposing the child to sunlight for the child might develop rashes due to photosensitivity
41. The nurse is caring for a client with leukemia who is receiving the drug doxorubicin (Adriamycin). Which toxic effects of this drug would be reported to the physician immediately?
- Rales and distended neck veins
- Red discoloration of the urine
- Nausea and vomiting
- Elevated BUN and dry flaky skin
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42. Situation: Colostomy is a surgically created anus- It can be temporary or permanent, depending on the disease condition.Q. What sensation is used as a gauge so that patients with ileostomy can determine how often their pouch should be drained?
- Sensation of taste
- Sensation of pressure
- Sensation of smell
- Urge to defecate
43. The nurse is preparing to administer regular insulin by continuous IV infusion to a client with diabetic ketoacidosis. The nurse should:
- Mix the insulin with Dextrose 5% in water
- Flush the IV tubing with the insulin solution and discard the first 50mL.
- Avoid using a pump or controller with the infusion.
- Mix the insulin with Ringer lactate.
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44. A child diagnosed with conjunctivitis. Which statement reflects that the child understood the nurse's teaching?
- "It's okay for me to let my friends use my sunglasses while we are playing together"
- "It's okay for me to softly rub my eye, as long as I use the back of my hand"
- "I can pick the crusty stuff out of my eyelashes with my fingers when I wake up in the morning."
- "I will use my own washrag and towel while my eyes are sick"
45. Acute pulmonary edema caused by heart failure is usually a result of damage to which of the following areas of the heart?
- Left atrium
- Right atrium
- Left ventricle
- Right ventricle
46. The nurse observes that Mr. Clark begins to have Increased difficulty breathing. She elevates the head of the bed to the high Fowler position, which decreases his respiratory distress. The nurse documents this breathing as:
- Tachypnea
- Eupnea
- Orthopnea
- Hyperventilation
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47. The nurse is describing Piaget's cognitive developmental theory to pediatric nursing staff. The nurse should tell that staff that which child behavior is characteristic of the formal operations stage?
- The child has the ability to think abstractly.
- The child begins to understand the environment.
- The child is able to classify order, and sort facts.
- The child learns to think in terms of past, present and future.
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48. During surgery, the patient has the following intake and output: intravenous fluid 650cc, intravenous antibiotic 50cc, I unit of packed red biood cells (PRBC) 350cc,nasogastric output 120cc, estimated blood loss 80cc, and urine in the Foley catheter 240cc. What is the patients total output?
- 120cc
- 200cc
- 240cc
- 440cc
49. Mr Wilson 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. Postop er atively Mr Wilson needs vigilant nursing care including all of the following except:
- Keeping his head flat
- Assessments q fe hour of LOC, VS, pupillary responses, and mental status
- Helping him avoid straining at stool, vomiting, or coughing
- Providing a caring, supportive atmosphere for him and his family
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50. The most unique characteristic of nursing as a profession is
- Education
- Theory
- Caring
- Autonomy
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NCLEX-RN | QB1 | Practice Exam #2 (50 questions)