NCLEX RN Practice Test 3

A client with anorexia nervosa tells the nurse, “When I look in the mirror, I hate what I see. I look so fat and ugly.” Which strategy should the nurse use to deal with the client’s distorted perceptions and feelings?

John has a fever of 39.5 degrees 2 days ago, But yesterday, he has a normal temperature of 36.5 degrees. Today, his temperature surges to 40 degrees. What type of fever is John having?

Situation : You are actively practicing nurse who has just finished your graduate studies. You learned the value of research and would like to utilize the knowledge and skills gained in the application of research to the nursing service. The following questions apply to research.
Q. Which of the following studies is based on the qualitative research?

Which of the following should the nurse do first after noting that a child with Hirschsprung disease has a fever and watery explosive diarrhea?

Situation : – Please continue responding as a professional nurse in varied health situations through the following questions.
Q. Which of the following medications would the nurse expect the physician to order for recurrent convulsive seizures of a 10-year old child brought to your clinic?

Dyspnea, cough, expectoration, weakness, and edema are classic signs and symptoms of which of the following conditions?

The patient is prescribed metronidazole (Flagyl) for adjunct treatment for a duodenal ulcer. When teaching about this medication the nurse would include:

Situation :– Fe is experiencing left sharp pain and occasional hematuria. She was advised to undergo IVP by her physician.
Q. Fe was so anxious about the procedure and particularly expressed her low pain threshold. Nursing health instruction will include:

The patient should be fasts (NPO) before the surgery for:

Situation: In your professional nursing role, it is essential to establish a meaningful nurse-patient relationship.
Q. The client said “I am troubled that my Son is starting to use drugs.” The nurse replied, “It’s troubling and painful for you, I feel sorry about this.” The nurse’s reply is an example of:

How long will nurse John obtain an accurate reading of temperature via oral route?

The correct method for determining the vastus lateralis site for I.M. injection is to:

Situation :– You are now working as a staff nurse in a general hospital. You have to be prepared to handle situations with ethico-legal and moral implications.
Q. You are on duty in the medical ward. The mother of your patient who is also a nurse came running to the nurse station and informed you that Fiolo went into cardiopulmonary arrest. Which among the following will you do first?

A client is being treated for alcoholism. After a family meeting, the client’s spouse asks the nurse about ways to help the family deal with the effects of alcoholism. The nurse should suggest that the family join which organization?

Prior to initiating therapy with unfractionated heparin for a patient hospitalized with a deep vein thrombosis, this treatment requires:

Situation :- After an abdominal surgery, the circulating and scrub nurses have critical responsibility about sponge and Instrument count.
Q. When is the first sponge/instrument count reported?

Situation : Rosanna 20 y/0 unmarried patient believes that the toilet for the female patient in contaminated with AIDS virus and refuses to use it unless she flushes it three times and wipes the toilet seat the same number of times with antiseptic solution.
Q. The goal for treatment for Rosana must be directed toward helping her to:

At what APGAR score at 5 minutes after birth should resuscitation be initiated?

Glimepiride is prescribed for a client with diabetes mellitus. The nurse instructs the client that which food items are most acceptable to consume while taking this medication? Select all that apply.
1. Alcohol
2. Red meats
3. Whole-grain cereals
4. Low-calorie desserts
5. Carbonated beverages

The nurse is working in the trauma unit of the emergency room when a 24-year-old female is admitted after an MVA. The client is bleeding profusely and a blood transfusion is ordered. Which would the nurse be prepared to administer without a type and crossmatch?

Among the following diseases, which is airborne?

Which of the following action is an accurate tracheal suctioning technique?

An 87 year old widow was hospitalized for treatment of chronic renal disease. She lives with her daughter and son-in- law and their family, who are very supportive. She is now ready for discharge. The doctor has ordered high carbohydrates, low-protein, low sodium diet for her and the family has asked for assistance in planning low-sodium diet meals. Which of the following choices best reflects the pre-discharge information the nurse should provide for the client’s family regarding low-sodium diet?

A nurse is providing care to a patient with a new skin graft on the leg. The patient is upset and the nurse notes copious red drainage oozing around the dressing the nurse should immediately:

The spouse of a client admitted to the mental health unit for alcohol withdrawal says to the nurse, “I should get out of this bad situation.” Which is the most helpful response by the nurse?

A client taking Coumadin is to be educated on his diet. As a nurse, which of the following food should you instruct the client to avoid?

Which interventions are appropriate for the care of an infant? Select all that apply.
1. Provide swaddling.
2. Talk in a loud voice.
3. Provide the infant with a bottle of juice at nap time.
4. Hang mobiles with black and white contrast designs.
5. Caress the infant while bathing or during diaper changes.
6. Allow the infant to cry for at least 10 minutes before responding.

Situation : As a nurse you are expected to participate in initiating or participating in the conduct of research students to improve nursing practice. You to be updated on the latest trends and issues affected the profession and the best practices arrived at by the profession.
Q. You are interested to study the effects of medication and relaxation on the pain experienced by the cancer patients. What type of variable is pain?

Situation : Mr Gil age 86 years, has been diagnosed with Alzheimer’s disease.
Q. What is the nurse’s primary objective for Mr. Gil when he is experiencing dementia and delirium?

Situation :– As a nurse in the Oncology Unit, you have to be prepared to provide efficient and effective care to your patients.
Q. What is the purpose of wearing a film badge while caring for the patient who is radioactive?

Which paranasal sinus is found over the eyebrow?

Situation : – Nurse Michelle works with a Family Nursing Team in Calbayog Province specifically handling a UNICEF project for children. The following conditions pertain, to CARE OP THE FAMILIES PRESCHOOLERS.
As a nurse. You reviewed infant safety procedures with Bryan’s mother. What are two of the most common types of accidents among infants?

A male client has the following arterial blood gas values: pH 7.30; Pao2 89 mmHg; Paco2 50 mmHg; and HCO3 26 mEq/L. Based on these values, Nurse Patricia should expect which condition?

The nurse is assessing a patient with a history of a seizure disorder. While checking the patient’s vital signs, the patient develops rhythmic, jerking movements of the arms and legs. The nurse should IMMEDIATELY place the patient in which of the following positions?

The physician orders dextrose 5% in water, 1,000 ml to be infused over 8 hours. The I.V. tubing delivers 15 drops/ml. The nurse should run the I.V. infusion at a rate of:

A patient has exacerbation of congestive heart failure, with one of the nursing diagnosis being excess fluid (Lasix). The nurse closely monitors fluid intake and output and administers furosemide (Lasix). Which of the following indicates the efficacy of the nursing intervention?

A nurse is caring a patient who had a left mastectomy with lymph node removal seven days ago. The patient asks about exercises to regain function of the left arm. Which of the following activities would be MOST appropriate?

A 21 year-old male has been seen in the clinic for a thickening in his right testicle. The physician ordered a human chorionic gonadotropin (HCG) level. The nurse’s explanation to the client should include the fact that:

To improve compliance to treatment, what innovation is being implemented in DOTS?

The pregnant woman visits the clinic for check –up. Which assessment findings will help the nurse determine that the client is in 8-week gestation?

What event occurring in the second trimester helps the expectant mother to accept the pregnancy?

Situation : Rene is a 3 y/o boy brought to the health center for fever and cough. You noted grayish pinpoint dots located at the buccal mucosa. A maculopapular rash was noted on his face.
Q. The nurse knows that the most common complication of Measles is:

Which of the following is the ileostomy for an

A patient has an elevated prothrombin (PT) time. Which medication should the Nurse consider as a possible cause of the elevated PT Time?

A client in labor admits to using alcohol throughout the pregnancy. The most recent use was the day before. Based on the clients history the nurse should give priority to assessing the newborn for:

Situation : Melamine contamination in milk has brought world wide crisis both in the milk production sector as well as the health and economy. Being aware of the current events is one quality that a nurse should possess to prove that nursing is a dynamic profession that will adapt depending on the patient’s needs.
Q. Which government agency is responsible for testing the melamine content of foods and food products?

The nurse prepares to palpate a client’s maxillary sinus. For this procedure, where should the nurse place the hands?

Barangay Pinoy had an outbreak of German measles. To prevent congenital rubella, what is the BEST advice that you can give to women in the first trimester of pregnancy in the Barangay Pinoy?

SITUATION : Wide knowledge about the human ear, it’s parts and it’s functions will help a nurse assess and analyze changes in the adult client’s health.
Q. Nurse Oca will do a caloric testing to a client who sustained a blunt injury in the head. He instilled a cold water in the client’s right ear and he noticed that nystagmus occurred towards the left ear. What does this finding indicates?

A female victim of a sexual assault is being seen in the crisis center. The client states that she still feels “as though the rape just happened yesterday,” even though it has been a few months since the incident. Which is the most appropriate nursing response?

The day care nurse is observing a 2-year-old child and suspects that the child may have strabismus. Which observation made by the nurse indicates the presence of this condition?

A healthy 26-year-old patient is at 39-weeks-gestation. The patient is not considered high risk at the time of admission to the labor and delivery unit. Which of the following pending laboratory test results should receive PRIORITY?

Pain control is an important nursing goal for the client with pancreatitis. Which of the following medications would the nurse plan to administer in this situation?

Gina is using Oresol in the management of diarrhea of her 3-year old child. She asked you what to do if her child vomits. As a nurse you will tell her to:

The nurse calls the heath care provider (HCP) regarding a new medication prescription because the dosage prescribed is higher than the recommended dosage. The nurse is unable to locate the HCP, and the medication is due to be administered. Which action should the nurse take?

The minimum birth weight for full term babies to be considered normal is:

Which of the following statement is TRUE about pulse?

SITUATION: John Lloyd, a 27 basketball player sustained inhalation burn that required him to have tracheostomy due to massive upper airway edema.
Q. If a Wall unit is used, What should be the suctioning pressure required by John Lloyd?

Which of the following prenatal laboratory test values would the nurse consider as significant?

Joy who has just experienced her second spontaneous abortion expresses anger towards her physician, the hospital and the “rotten nursing care”. When assessing the situation, the nurse recognizes that the client may be using the coping mechanism of:

Nurse Patricia is aware that the average length of time from human immunodeficiency virus (HIV) infection to the development of acquired immunodeficiency syndrome (AIDS)?

A healthy 26-year-old patient is at 39-weeks-gestation. The patient is not considered high risk at the time of admission to the labor and delivery unit.Which of the following pending laboratory test results should receive PRIORITY?

Which of the following actions is the first priority care for a client exhibiting signs and symptoms of coronary artery disease?

A client with chronic kidney disease returns to the nursing unit following a hemodialysis treatment. On assessment, the nurse notes that the client’s temperature is 38.5 °C (101.2 °F). Which nursing action is most appropriate?

A patient who is receiving total parenteral nutrition has an elevated blood glucose eve! and is to be administered intravenous insulin. Which of the following types of insulin should a nurse has available?

Marco who was diagnosed with brain tumor was scheduled for craniotomy. In preventing the development of cerebral edema after surgery, the nurse should expect the use of:

A patient is scheduled for a bowel resection. The preoperative plan of care includes putting on antiembolism stockings prior to the transferring the patient to the operating room. What these stockings will do‘?

While the nurse aide tries to dress a resident who is confused, the resident keeps trying to grab a hairbrush. The nurse aide should

The client with an above the knee amputation is to use crutches until the prosthesis is being adjusted. In which of the following exercises would the nurse instruct the client to best prepare him for using crutches?

A patient scheduled for an abdominal aneurysm repair. This is what type of surgical intervention?

The nurse is caring for a client with a diagnosis of influenza who first began to experience symptoms yesterday. Antiviral therapy is prescribed and the nurse provides instructions to the client about the therapy. Which statement by the client indicates an understanding of the instructions?

The nurse is assessing a client with pleural effusion. The nurse expect to find:

The doctor has ordered Ampicillin 100mg every six hours IV push for an infant weighing 7kg. The suggested dose for infants is 25 to 50mg/kg/day in equally divided doses. The nurse should:

A health care provider’s prescription reads clindamycin phosphate 0.3 g in 50 mL normal saline (NS) to be administered intravenously over 30 minutes. The medication label reads clindamycin phosphate 900 mg in 6 mL. The nurse prepares how many milliliters of the medication to administer the correct dose?

Situation : Melamine contamination in milk has brought world wide crisis both in the milk production sector as well as the health and economy. Being aware of the current events is one quality that a nurse should possess to prove that nursing is a dynamic profession that will adapt depending on the patient’s needs.
Q. Most of the milks contaminated by melamine came from which country?

Jennifer, an adolescent who is depressed and reported by his parents as having difficulty in school is brought to the community mental health center to be evaluated. Which of the following other health problems would the nurse suspect?

Following emergency endotracheal intubation, you must verify tube placement and secure the tube. List in order the steps that are required to perform this function?
a. Obtain an order for a chest x-ray to document tube placement.
b. Secure the tube in place.
c. Auscultate the chest during assisted ventilation.
d. Confirm that the breath sounds are equal and bilateral.

The nurse calls together an inter disciplinary team with members from medicine, social services, the clergy, and nutritional services to care for a patient with aterminal illness. Which of the following types of care would the team MOST likely is providing?

The nurse is caring for a client with suspected AIDS dementia complex. The first sign of dementia in the client with AIDS is:

The health education nurse provides instructions to a group of clients regarding measures that will assist in preventing skin cancer. Which instructions should the nurse provide? Select all that apply.
1. Sunscreen should be applied every 8 hours.
2. Use sunscreen when participating in out-door activities.
3. Wear a hat, opaque clothing, and sunglasses when in the sun.
4. Avoid sun exposure in the late afternoon and early evening hours.
5. Examine your body monthly for any lesions that may be suspicious.

Physicians orders for a client with acute pancreatitis include the following: strict NPO and nasogastric tube to low intermittent suction. The nurse recognizes that withholding oral intake will:

Situation: – Nurse Anna is a new BSEN graduate and has just passed her Licensure Examination for Nurses in the Philippines. She has likewise been hired as a new Community Health Nurse in one of the Rural Health Units in their City, which of the following conditions may be acceptable TRUTHS applied to Community Health Nursing Practice.

Q. . A very important part of the Community Health Nursing Assessment Process includes:

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.
Q. Which of the following studies is based on quantitative research?

The nurse is checking the clients central venous pressure. The nurse should place the zero of the manometer at the:

SITUATION: Mr. Dela Isla, a client with early Dementia exhibits thought process disturbances.
Q. As the nurse talks to the daughter of Mr. Dela Isla, which of the following statement of the daughter will require the nurse to give further teaching?

Situation : – You are the nurse in the Out-Patient-Department and during your shift you encountered multiple children’s condition. The following questions apply.
Q. You assessed a child with visible severe wasting, he has:

Immobility impairs bladder elimination, resulting in such disorders as

A female client with cancer is being evaluated for possible metastasis. Which of the following is one of the most common metastasis sites for cancer cells?

Situation :– At the medical-surgical ward, the nurse must also be concerned about drug interactions.
Q. The RN should also know that some drugs have increased absorption when infused in PVC container. How will you administer drugs such as insulin, nitroglycerine hydralazine to promote better therapeutic drug effects?

A patient with a pulmonary embolus and a nursing diagnosis of impaired gas exchange has an order to obtain arterial blood gases. The FIRST intervention by the nurse is to:

Which of the following meal selections is appropriate for the client with celiac disease?

Nurse Sarah expects to note an elevated serum glucose level in a client with hyperosmolar hyperglycemic nonketotic syndrome (HHNS). Which other laboratory finding should the nurse anticipate?

A patient with the deep vein thrombosis (DVT) is being treated with a low-molecular weight heparin.(LMWH). The patient reports increased pain in the affected extremely. The nurse observe the affected extremity has increased in size by 0.2 cm (0.8 inches) during the past 24 hours. Which of the following actions should the nurse take?

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. All of the following are factors that said to contribute to the development of breast cancer EXCEPT:

Situation : An entry level nurse should be able to apply theoretical knowledge in the performance of the basic nursing skills.
Q. The best time for collecting the sputum specimen for culture:

A woman she is on the18 week gestation her physicaian will insert a fine needle in her abdomen for anlaysis the nurse is assistant in this procedure as nurse what is the color of liquid you expect to come out:

CHN is a community-based practice. Which best explains this statement?

Situation :– Concerted work efforts among members of the surgical team is essential to the success of the surgical procedure.
Q. Minimally invasive surgery is very much into technology. Aside from the usual surgical team who else to be present when a client undergoes laparoscopic surgery?

A high school student is referred to the school nurse for suspected substance abuse. Following the nurse’s assessment and interventions, what would be the most desirable outcome?

Nurse Michelle calculates the IV flow rate for a postoperative client. The client receives 3,000 ml of Ringer’s lactate solution IV to run over 24 hours. The IV infusion set has a drop factor of 10 drops per milliliter. The nurse should regulate the client’s IV to deliver how many drops per minute?