NCLEX RN Practice Test 4

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

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?

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

She was the daughter of Hungarian kings, who feed 300-900 people everyday in their gate, builds hospitals, and care of the poor and sick herself.

The nurse explains to a breastfeeding mother that breast milk is sufficient for all of the baby’s nutrient needs only up to:

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?

What is the primary prevention of leprosy?

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

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?

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?

During surgery, the patient has the following intake and output: intravenous fluid 650cc, intravenous antibiotic 50cc, I unit of packed red blood cells (PRBC) 350cc,nasogastric output 120cc, estimated blood loss 80cc, and urine in the Foley catheter 240cc. What is the patient’s total output?

Amother 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?

The most unique characteristic of nursing as a profession is

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

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

The mid-deltoid injection site is seldom used for I.M. injections because it:

Mang Jose with rheumatoid arthritis states, “the only time I am without pain is when I lie in bed perfectly still”. During the convalescent stage, the nurse in charge with Mang Jose should encourage:

Nurse Judith 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)?

The client has an order for heparin to prevent post-surgical thrombi. Immediately following a heparin injection the nurse should:

Situation:– Ricky is a 12 year old-boy with Down’s syndrome. He stands 5′ ½” and weight 100 lbs. He is slim and walks sluggishly with a limp. He wears a neck brace as support for his neck. X – ray of cervical spine showed “subluxation of CI in relation to C2 with cord compression.” He attends a school for special education.
Q. Ricky’s mother visited the school nurse. She asked, ” What should I do when Ricky fond his genitalia?” Appropriate response of the nurse is for the mother to:

A patient who had abdominal surgery is in the post anesthesia care unit (PACU). Which of the following nursing diagnosis takes PRIORITY?

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

The nurse observes that Mr. Adams 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:

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

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

Mr. Duffy 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 MI, 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. Duffy suffers a life-threatening cardiac arrhythmia. Considering his diagnosis, which is the most probable arrhythmia?

The nurse is preparing to administer regular insulin by continuous IV infusion to a client with diabetic ketoacidosis. The nurse should:

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?

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:

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.

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

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?

How many ml of blood is loss during the first 24 hours post delivery of Myrna?

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?

Situation : Team efforts is best demonstrated in the OR.
Q. 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?

Which test should be added to the yearly physical of a patient who has recently turned 50 years old?

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?

Situation: Joanna Marie, a 40 year old client was diagnosed with breast cancer.
Q. 30. A 52-year-old female tells the nurse that she has found a painless lump in her right breast during her monthly self-examination. Which assessment finding would strongly suggest that this client’s lump is cancerous?
1. Non encapsulated mass
2. Fixed, irregular and hard
3. Presence of Orange peel skin
4. Soft and mobile

In pouring a plain NSS into a receptacle located in a sterile field, how high should the nurse hold the bottle above the receptacle?

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

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

Estrada, the Philippine president, has been unexpectedly impeached and was out of office before the end of his term. He is in what type of crisis?

Situation : Nurse Gloria 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.
Q. Peptic ulcer disease particularly gastric ulcer is thought to be cause by which of the following microorganisms?

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?

Achild is placed in skeletal traction for treatment of a fractured femur. The nurse creates a plan of care and should include which intervention?

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

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

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:

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?

Mr. Gutierrez 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?

Which of the following danger signs should be reported promptly during the antepartum period?

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

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

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?

Nursing diagnosis is:

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

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?

Mrs. Chua 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:

The nurse is teaching a group of patient about hepatitis A(HAV). The nurse should state that HAV is MAINLY transmitted Via:

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

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?

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?

What kind of illness precursor, according to DUNN is cigarette smoking?

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.

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?

SITUATION : John Smith was diagnosed with Acute Close Angle Glaucoma. He is being seen by Nurse Jet.
Q. Nurse jet knew that Acute close angle glaucoma is caused by

As per of a neurological assessment, which of the following is associated with the higher score on the Glasgow coma scale?

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:

A client has been inhalation vasopressin therapy. What will the nurse evaluate to determine the therapeutic response to this medication?

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 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?

A nurse is caring for a child who is post-tonsillectomy and adenoidectomy. The nurse should plan to assess which of the following complications?

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:

Situation : Nurse Nico is caring to a 38-year-old female, G3P3 client who has been diagnosed with hemorrhoids.
Q. Nurse Nico 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?

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:

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.Postoperatively Mr. Snyder needs vigilant nursing care including all of the following except:

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:

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?

Situation : Arnold, age 67, has had successfully treated depressive disease for more than 10 years. Lately he has been developing a plan of action. Arnold is admitted to hospital for reassessment.
Q. The psychiatrist prescribes Electro convulsive therapy for Arnold. The nurse when discussing ECT with Arnold, should tell him which of the following information?

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:

Acute pulmonary edema caused by heart failure is usually a result of damage to which of the following areas of the heart?

While evaluating the nutritional intake of a bedridden patient with multiple pressuresores, the nurse should make sure the patient INCREASES the intake of:

Situation: Mr. Ramos is a 60 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. Ramos for culture and sensitivity. This study is to ascertain which of the following facts?

A child diagnosed with conjunctivitis. Which statement reflects that the child understood the nurse’s teaching?

Situation : – Nette, a nurse palpates the abdomen of Mrs. Medina, 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.
Nette explains this because the fundus is:

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

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.

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

Situation : Mang Cardo, 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, Mang Cardo has difficulty putting his pyjamas. In Alzheimer’s disease, this is known as:

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:

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:

Which statement by the patient with hyperlipidemia shows a basic understanding of the disease and it treatment?

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?

Situation : Mrs. Andres brought his son, Juanito, 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 Juanito 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?

A client has autoimmune thrombocytopenic purpura. To determine the clients response to treatment the nurse would monitor:

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?

Situation: – Records contain those, comprehensive descriptions of patient’s health conditions and needs and at the same serve as evidences of every nurse’s accountability in the, caregiving process. Nursing records normally differ from institution to, institution nonetheless they follow similar patterns of meeting needs for specifics, types of information. The following pertains to documentation/records management.

Q. This flip-over card is usually kept in a portable file at the Nurses Station. It has 2-parts: the activity and treatment section and a nursing care plan section. This carries information about basic demographic data, primary medical diagnosis, current orders of the physician to be carried out by the nurse, written nursing care plan, nursing orders, scheduled tests and procedures, safety precautions in-patient care and factors related to daily living activities/ this record is used in the charge-of-shift reports or during the bedside rounds or walking rounds. What record is this?

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:

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?

Which of the following is not an anti-emetic?