NCLEX-RN | QB1 | Practice Exam #1 (50 questions)

 

1. Situation : Team efforts is best demonstrated in the OR. While team effort is needed in the OR for efficient and quality patient care delivery, we should limit the number of people in the room for infection control. Who comprise this team?

• Surgeon, anesthesiologist, scrub nurse, radiologist, orderly
• Surgeon, assistants, scrub nurse, circulating nurse, anesthesioloaist
• Surgeon, assistant surgeon, anesthesiologist, scrub nurse, pathologist
• Surgeon, assistant surgeon, anesthesiologist, intern, scrub nurse

2. The nurse is caring for child admitted with viralpneumonia. Which of the following nursing diagnoses should receive PRIORITY?

• Nutrition altered: less than body requirements
• Ineffective airway clearance
• Fluid volume deficit
• Risk for injury

3. The client with an above the knee amputation is to use crutches until the prosthesis is properly lifted. When teaching the client about using the crutches, the nurse instructs the client to support her weight primarily on which of the following body areas?

• Axillae
• Elbows
• Upper arms
• Hands

4. How many minutes are allowed to pass if the client had engaged in strenuous activities, smoked or ingested caffeine before taking his/ her BP?

• 5
• 10
• 15
• 30

5. In this stage, the person tries to find answers for his illness. He wants his illness to be validated, his symptoms explained and the outcome reassured or predicted

• Symptom Experience
• Assumption of sick role
• Medical care contact
• Dependent patient role

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6. Which intervention is most important to use to prevent infection by autocontamination in the burned client during the acute phase of recovery?

• Changing gloves between wound care on different parts of the client's body.
• Avoiding sharing equipment such as blood pressure cuffs between clients.
• Using the closed method of burn wound management.
• Using proper and consistent handwashinq.

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7. Which of the following guidelines should be least considered in formulating objectives for nursing care?

• Written nursing care plan
• Holistic approach
• Prescribed standards
• Staff preferences

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8. A client is admitted with a diagnosis of polycythemia vera. The nurse should closely monitor the client for:

• Increased blood pressure
• Decreased respirations
• Increased urinary output
• Decreased oxygen saturation

9. The Glasgow coma scale is used to evaluate the level of consciousness in the neurological and neurological patients. The three assessment factors included in this scale are:

• pupil size, response to pain, motor responses
• Pupil size, verbal response, motor response
• Eye opening, verbal response, motor response
• Eye opening, response to pain, motor response

10. Situation : Nurse Maria is caring to a 38-year-old female, G3P3 client who has been diagnosed with hemorrhoids.Q. Nurse Maria instructs her client who has had a hemorrhoidectomy not to used sitz bath until at least 12 hours postoperatively to avoid which of the following complications?

• Hemorrhage
• Rectal Spasm
• Urinary retention
• Constipation

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11. If a patient develops a complication during a blood transfusion, the nurse's first action should do to:

• Stop the transfusion
• Notify the practitioner
• Administer an antihistamine
• Administer an anti-inflammatory medication

12. A 2-year-old child is treated in the emergency department for a burn to the chest and abdomen. The child sustained the burn by grabbing a cup of hot coffee that was left on the kitchen counter. The nurse reviews safety principles with the parents before discharge. Which statement by the parents indicates an understanding of measures to provide safety in the home?

• "We will be sure not to leave hot liquids unattended.”
• "I guess our children need to understand what the word hot means."
• "We will be sure that the children stay in their rooms when we work in the kitchen.”
• "We will install a safety gate as soon as we get home so the children cannot get into the kitchen."

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13. An adult is to have a tepid sponge bath to lower his fever. What temperature should the nurse make the water?

• 65 F
• 90 F
• 110 F
• 105 F

14. Situation : Nurse Maria is the staff nurse assigned at the Emergency Department. During her shift, a patient was rushed - in the ED complaining of severe heartburn, vomiting and pain that radiates to the flank. The doctor suspects gastric ulcer. Peptic ulcer disease particularly gastric ulcer is thought to be cause by which of the following microorganisms?

• E. coli
• H. pylori
• S. aureus
• K. pneumoniae

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15. What is the Proper procedure for doing a breast self-exam?

• Use the palm of the hand to feel for lumps.
• Apply three different levels of pressure to feel breast tissue.
• Stand when performing a breast self-exam.
• Perform self-exam annually

16. The client is taking prednisone 7.5mg po each morning to treat his systemic lupus erythematosis. Which statement best explains the reason for taking the prednisone in the morning?

• There is less chance of forgetting the medication if taken in the morning.
• There will be less fluid retention if taken in the morning.
• Prednisone is absorbed best with the breakfast meal.
• Morning administration mimics the body natural secretion of corticosteroid.

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17. The nurse is caring for a patient who sustained a traumatic brain injury 4 days ago. The patient remains in a pharmacologic induced coma while receiving mechanical ventilation. The patient is on NPO status and the vital signs are within the normal range. The patients bowel sounds are absent and nasogastric tube is connected to low, intermittent suction. The nurse should prepare to begin:

• NG feeding
• Rapid weaning from the ventilator
• Total parenteral nutrition
• Chest physiotherapy

18. A mother arrives at the emergency department with her 5-year-old child and states that the child fell off a bunk bed. A head injury is suspected. The nurse checks the child's airway status and assesses the child for early and late signs of increased intracranial pressure (ICP). Which is a late sign of increased ICP?

• Nausea
• Irritability
• Headache
• Bradycardia

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19. The district nurse attends a mother and a girl who was born five days previously. At birth, the baby had weighed 3.5 kilograms. The mother becomes worried when she hears that the baby weighs 3.3 kilograms today. The infant is pink, alert and active with 6-8 wet diapers and four stools per day. Blanching of the skin shows a light yellow color of the forehead but a pink sternum.What is the most appropriate nursing action?

• Notify the pediatrician
• Obtain blood for bilirubin analysis
• Reassure the mother and continue observing
• Request the mother go to the clinic to re-weigh

20. Situation : Dan, age 69, has had successfully treated depressive disease for more than 10 years. Lately he has been developing a plan of action. Dan is admitted to hospital for reassessment.Q. The psychiatrist prescribes Electro convulsive therapy for Dan. The nurse when discussing ECT with Dan, should tell him which of the following information?

• Sleep will be induced and treatment will not cause pain
• There will be a memory loss aa a result of the treatment
• It is better not to talk about it, but he can asks any question
• None of these

21. All of the followings are risk factors for nosocomial infections EXCEPT:

• Poor hand washing.
• Using sterile techniques.
• Contamination of closed drainage system.
• Improper procedure technique (dressing, suctioning, catherization).

22. A physician orders Lactated Ringer Solution to infuse at 125 cc/hour. This is an example of which type of solution?

• Hypotonic
• Isotonic
• Hypertonic
• Hyper alimentation

23. A nurse is caring for an infant with respiratory distress syndrome. Which of the following nursing intervention is appropriate

• Measure oxygen saturation level once a shift
• Suction frequently for 30-45 second each time
• Monitor for symptoms of hyperglycemia
• Maintain infant temperature between 36.70 & 37.80 C

24. A client is admitted with a diagnosis of myxedema. An initial assessment of the client would reveal the symptoms of:

• Slow pulse rate, weight loss, diarrhea, and cardiac failure
• Weight gain, lethargy, slowed speech, and decreased respiratory rate
• Rapid pulse, constipation, and bulging eyes
• Decreased body temperature, weight loss, and increased respirations

25. Questions that are answerable only by choosing an option from a set of given alternatives are known as?

• Survey
• Close ended
• Questionnaire
• Demographic

26. In preparation for cataract surgery, the nurse is to administer cyclopentolate eye drops at 0900 for surgery that is scheduled for 0915. What initial action should the nurse take in relation to the characteristics of the medication action?

• Provide lubrication to the operative eye prior to giving the eye drops.
• Call the surgeon, as this medication will further constrict the operative pupil.
• Give the medication as prescribed; the surgeon needs optimal constriction of the pupil.
• Consult the surgeon, as there is not sufficient time for the dilative effects to occur.

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27. The nurse is assigned to teach a class in health behaviors to young man. Which of the following can be stated as a probably cause of cancer of the penis?

• A diet high in acidic foods
• Poor personal hygiene
• Exercise
• Circumcision

28. A client's medication sheet contains a prescription for sertraline. To ensure safe administration of the medication, how should the nurse administer the dose?

• On an empty stomach
• At the same time each evening
• Evenly spaced around the clock
• As needed when the client complains of depression

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29. Which early morning activity helps to reduce the symptoms associated with rheumatoid arthritis?

• Brushing the teeth
• Drinking a glass of juice
• Holding a cup of coffee
• Brushing the hair

30. Situation : Patricia Zeno is a client with history myasthenia gravis.Q. Mrs. Zeno continues to become a weaker despite .treatment with neostigmine. Edrophonium HCL is ordered:

• For its synergistic effect
• To rule out cholinergic crisis
• To confirm the diagnosis of myasthenia
• Because of the client's resistance to Neostigmine

31. The laboratory calls to state that a client's lithium level is 1.9 mEq/ L after 10 days of lithium therapy. Nurse Reese should:

• Notify the physician of the findings because the level is dangerously high
• Monitor the client closely because the level of lithium in the blood is slightly elevated
• Continue to administer the medication as ordered because the level is within the therapeutic range
• Report the findings to the physician so the dosage can be increased because the level is below therapeutic range

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32. A 25-year-old male is brought to the emergency room with a piece of metal in his eye. The first action the nurse should take is:

• Use a magnet to remove the object.
• Rinse the eye thoroughly with saline.
• Cover both eyes with paper cups.
• Patch the affected eye.

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33. After 1 week of hospitalization, Mr. Gray develops hypokalemia. Which of the following is the most significant symptom of his disorder?

• Lethargy
• Increased pulse rate and blood pressure
• Muscle weakness
• Muscle irritability

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34. Situation: Mr. Mateo is a 62 year old male client admitted to the hospital with the diagnosis of pneumonia. He complains of pain when coughing.Q. A sputum specimen was collected from Mr. Mateo for culture and sensitivity. This study is to ascertain which of the following facts?

• The virulence of microorganism involved
• The antibiotics which would be most helpful
• The patients probably reaction to the causative microorganism
• The patient's sensitivity to antibiotics

35. A visiting nurse is performing home assessment for a 59-yr old man recently discharged after hip replacement surgery. Which home assessment finding warrants health promotion teaching from the nurse?

• A bathroom with grab bars for the tub and toilet
• Items stored in the kitchen so that reaching up and bending down aren't necessary
• Many small, unsecured area rugs
• Sufficient stairwell lighting, with switches to the top and bottom of the stairs

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36. Mr.Wilson is admitted to the CCU with a diagnosis of R/O MI. He presented in the ER with a typical description of pain associated with an Ml, 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. On his second day in CCU Mr. Wilson suffers a life-threatening cardiac arrhythmia. Considering his diagnosis, which is the most probable arrhythmia?

• atrial tachycardia
• ventricular fibrillation
• atrial fibrillation
• heart block

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37. Which of the following is not an anti-emetic?

• Marinol
• Dramamine
• Benadryl
• Alevaire

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38. Which stage of pressure ulcer development does the ulcer extend into the subcutaneous tissue?

• Stage I
• Stage II
• Stage III
• Stage IV

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39. A nurse is admitting a two year-old child with an umbilical hernia.Which of the following interventions does NOT meet the child's developmental needs?

• Allowing the child to make choices when possible
• Providing rooming in and unlimited visitation
• Attempting to continue rituals used house
• Maintaining strict bed rest

40. Situation:- It is common that client ask the nurse personal questions.Q. It is 10 o'clock of your watch. The client asks, “What time is it?” The nurse's appropriate response is:

• "Are you bored?"
• "It is 10 o’clock."
• "Why do you ask?"
• "Guess, what time is it?"

41. She is the first one to coin the term "NURSING PROCESS." She introduced three (3) steps of nursing process, which are: Observation, Ministration and Validation.

• Nightingale
• Johnson
• Rogers
• Hall

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42. Ellen thinks about primary nursing as a system to deliver care. Which of the following activities is NOT done by a primary nurse?

• Collaborates with the physician
• Provides care to a group of patients together with a group of nurses
• Provides care for 5-6 patients during their hospital stay.
• Performs comprehensive initial assessment

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43. The nurse performs an admission assessment on a client with a diagnosis of tuberculosis. The nurse should check the results of which diagnostic test that will confirm this diagnosis?

• Chest x-ray
• Bronchoscopy
• Sputum culture
• Tuberculin skin test

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44. Situation : - You are actively practicing nurse who just finished your Graduate Studies. You earned the value of Research and would like to utilize the knowledge and skills gained in the application of research to Nursing service. The following questions apply to research.An 85 year old client in a nursing home tells a nurse, "I signed the papers for that research study because the doctor was so insistent and I want: him to continue taking care of me." Which client right is being violated?

• Right of self determination
• Right to privacy and confidentiality
• Right to full disclosure
• Right not to be harmed

45. A client with iron-deficiency anemia is prescribed liquid iron supplements. The nurse evaluates the client's understanding of how to take this drug. Which of the following statements indicates the client has adequate knowledge?

• I can use antidiarrheal drugs if I develop diarrhea
• I will report any black stools to the physician
• I will check my gums for any bleeding
• I will dilute the medication and drink it with a straw

46. The nurse is teaching a client with Parkinson’s disease ways to prevent curvatures of the spine associated with the disease. To prevent spinal flexion, the nurse should tell the client to:

• Periodically lie prone without a neck pillow
• Sleep only in dorsal recumbent position
• Rest in supine position with his head elevated
• Sleep on either side, but keep his back straight

47. Situation : Olivia, a nurse palpates the abdomen of Mrs. Victoria, a primigravida. She is unsure of the date of her last menstrual period. Leopold's Maneuver is done. The obstetrician told mat she appears to be 20 weeks pregnant.Olivia explains this because the fundus is:

• At the level the umbilicus, and the fetal heart can be heard with a fetoscope
• 18 cm, and the baby is just about to move
• is just over the symphysis, and fetal heart cannot be heard
• 28 cm, and fetal heart can be heard with a Doppler

48. An adult client is on extreme pain. He is moaning and grimacing. What is the best way to assess the client's pain?

• Perform physical assessment
• Have the client rate his pain on
• Active listening on what the patient says
• Observe the client’s behavior

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49. Which cell secretes mucus that help protect the lungs by trapping debris in the respiratory tract?

• Type I pneumocytes
• Type II pneumocytes
• Goblet cells
• Adipose cells

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50. When preparing to administer the vitamin K injection to a neonate, the nurse would select which of the following sites as appropriate for the injection?

• Deltoid muscle
• Anterior femoris muscle
• Vastus lateralis muscle
• Gluteus maximus muscle

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NCLEX-RN | QB1 | Practice Exam #1 (50 questions)