NCLEX RN Practice Test 7

Following an open-cholecystectomy, the nurse would instruct the patient to expect to resume normal activities in:

NMS is characterized by :

The client with confusion says to the nurse I havent had anything to eat all day long. When are they going to bring breakfast? The nurse saw the client in the day room eating breakfast with other clients 30 minutes before this conversation. Which response would be best for the nurse to make?

The nurse is completing an assessment on a client who is being admitted for a diagnostic workup for primary hyperparathyroidism. Which client complaint would be characteristic of this disorder? Select all that apply.
1. Polyuria
2. Headache
3.Bonepain
4. Nervousness
5. Weight gain

Situation : Nurse Macarena is a Family Planning and Infertility Nurse Specialist and currently attends to FAMILY PLANNING CLIENTS AND INFERTILE COUPLES. The following conditions pertain to meeting the nursing needs of this particular population group.
Prioritization is important to test a nurse’s good judgment towards different situations. Priorities when caring for the elderly trauma patient:

The nurse is providing dietary teaching for a client with a diagnosis of chronic gastritis. The nurse instructs the client to include which foods rich in vitamin B12 in the diet? Select all that apply.
1. Nuts
2. Corn
3. Liver
4. Apples
5. Lentils
6. Bananas

The nurse is teaching exercises that are good for pregnant women increasing tone and fitness and decreasing lower backache. Which of the following should the nurse exclude in the exercise program?

The nurse is caring for the client receiving Amphotericin B. Which of the following indicates that the client has experienced toxicity to this drug?

A school nurse refers a child who failed the school vision screening for eye doctor. The child returns with glasses to be worn at all times. The nurse should monitor this child for:

Situation: Michelle is a 6 year old preschooler. She was reported by her sister to have measles but she is at home because of fever, upper respiratory problem and white sports in her mouth.
Rubeola is an Arabic term meaning Red, the rash appears on the skin in invasive stage prior to eruption behind the ears. As a nurse, your physical examination must determine complication especially:

The nurse is giving the client with a left cast crutch walking instructions using the three point gait. The client is allowed touchdown of the affected leg. The nurse tells the client to advance the:

Which of the following is considered as subjective data?

Situation: Miss Matias, found out that Mr. Carding, newly admitted patient, has terminal cancer and that his nurse has not yet informed him of the diagnosis.
Q. In caring of a dying client during post mortem, the most important thing that the nurse should remember is:

The nurse hears a client calling out for help, hurries down the hallway to the client’s room, and finds the client lying on the floor. The nurse performs an assessment, assists the client back to bed, notifies the health care provider of the incident, and completes an incident report. Which statement should the nurse document on the incident report?

Which of the following principles of primary nursing has proven the most satisfying to the patient and nurse?

A 32 year-old female has an adrenocortical hormone disorder. The nurse notes the patient has thin scalp hair, a large trunk and thin extremities.
Blood pressure : 152/84 mmHg
Heart rate : 64/mm
Respiratory rate : 16/mm
Temperature : 37.2°C
Oxygen Saturation : 98% on room air
Which clinical findings are most likely?

When caring for child with spina bifida, the nurse knows that the child has an increased risk of allergy to:

The nurse has made an error in a narrative documentation of an assessment finding on a client and obtains the client’s record to correct the error. The nurse should take which actions to correct the error? Select all that apply.
1. Document a late entry in the client’s record.
2. Draw 1 line through the error, initialing and dating it.
3. Try to erase the error for space to write in the correct data.
4. Use whiteout to delete the error to write in the correct data.
5. Write a concise statement to explain why the correction was needed.
6. Document the correct information and end with the nurse’s signature and title.

During surgery requiring general anesthesia, the patient heart’s stops and a carotid pulse is not palpated. How many compressions per minute should be administered?

During the postoperative period, a nurse is assigned to care for a morbidly obese patient with an abdominal incision. The nurse knows that this patient’s weight increases the risk of:

Situation :– In the hospital, you are aware that we are helped by the .use of a variety of equipment/devices to enhance quality patient care delivery;
Q. What will you do to ensure that Kyle, who is febrile, will have a liberal oral fluid intake?

When a woman is 10 weeks pregnant which of the following hematology test results would need further Investigation?

Which of the following is considered the best indicator of nutritional status of an individual?

The nurse is planning activities for a client diagnosed with bipolar disorder with aggressive social behavior. Which activity would be most appropriate for this client?

All of the followings are etiologies of self-care deficit EXCEPT:

A nurse educates a patient diagnosed with diabetes, on the importance of exercise and a well-balanced, low-carbohydrate diet. The patient takes metforin(Glucophage) 500 mg once a day. Which following indicates the patient’s plan of Care needs to be re-evaluated?

Adult patient suffers from hoarseness of voice, and difficulty in speech may be suffering from an injury of which of the following cranial nerves:

The burned client relates the following history of previous health problems. Which one should alert the nurse to the need for alteration of the fluid resuscitation plan?

The nurse prepares to give a bath and change the bed linens of a client with cutaneous Kaposi’s sarcoma lesions. The lesions are open and draining a scant amount of serous fluid. Which would the nurse incorporate into the plan during the bathing of this client?

Roger has been seen agitated, shouting and running. As Nurse Aida approaches, he shouts and swear, calling Aida names. Nurse Aida told Roger “That is an unacceptable behavior Roger, Stop and go to your room now.” The situation is most likely in what phase of NPR?

Graciel has been injected TT5, her last dosed for tetanus toxoid immunization. Graciel asked you, what type of immunity is TT Injections? You correctly answer her by saying Tetanus toxoid immunization is a/an

While performing a physical assessment of a male client with gout of the great toe, Nurse Vivian should assess for additional tophi (urate deposits) on the:

Situation: Elvira is a 26 year old woman you admit to a birthing room. She’s been having contractions 45 seconds long and 3 minutes apart for the last 6 hours. She tells you she wants to have her baby “naturally” without any analgesia or anesthesia. Her husband is in the Army and assigned overseas, so he is not with her. Although her sister lives only two blocks from the hospital, Elvira doesn’t want her called. She asks if she can talk to her mother on the telephone instead.
Elvira didn’t recognize for over an hour that she was in labor. A sign of true labor is:

Situation: -Mariah is a 31 year old lawyer who has been married for 6 moths. She is now pregnant.She consults you for guidance.
Which of the following interventions will likely ensure compliance of Mariah?

A nurse is assessing a 4-month-old formula-fed infant. The parent reports the infant has been irritable, crying excessively, not sleeping well, and vomiting. Gastro-esophageal reflux is expected. What nursing intervention should the nurse expect to teach the parent?

In what level of prevention according to Leavell and Clark does the nurse support the client in obtaining OPTIMAL HEALTH STATUS after a disease or injury?

A client with full-thickness burns on the chest has a skin graft. During the first 24 hours after a skin graft, care of the donor site includes immediately reporting.

A client with chronic kidney disease is receiving epoetin alfa. Which laboratory result would indicate a therapeutic effect of the medication?

A 7-years-old child is brought to the physician office due to sudden onset of bright redness on the cheeks. The nurse observes that the child has a temperature of 380 C (100.40 F) With chills the nurse suspects that the MOST like diagnosis would be:

A client whose husband recently left her is admitted to the hospital with severe depression. The nurse suspects that the client is at risk for suicide. Which of the following questions would be most appropriate and helpful for the nurse to ask during an assessment for suicide risk?

The nurse notes that a client’s arterial blood gas (ABG) results reveal a pH of 7.50 and a PaCO2 of 30 mm Hg (30 mm Hg). The nurse monitors the client for which clinical manifestations associated with these ABG results? Select all that apply.
1. Nausea
2. Confusion
3. Bradypnea
4. Tachycardia
5. Hyperkalemia
6. Lightheadedness

Aclient has an as needed prescription for ondansetron. For which condition(s) should the nurse administer this medication?

When planning care for a client at 30-weeks gestation, admitted to the hospital after vaginal bleeding secondary to placenta previa, the nurse’s primary objective would be:

500 mg of a drug is order. It is supplied in tablets of 1 gm per tablet. How many tablets should be administered?

When giving a backrub, the nurse aide should

SITUATION: Mr. Roxas, an obese 35 year old MS Professor is admitted due to pain in his weight bearing joint. The diagnosis was Osteoarthritis.
Q. You also told Mr. Roxas to hold the cane

Nurse John is talking with a client who has been diagnosed with antisocial personality about how to socialize during activities without being seductive. Nurse John would focus the discussion on which of the following areas?

Situation : Mr. Baldo , 36 years old patient complaints of fatigue, weight loss, and low-grade fever. He also has pain his fingers, elbows, and ankles.
Q. Mr Balao asks the nurse as to the source of this disease. The nurse is aware that this is a disease of:

Nurse Marie is caring for a 32-year-old client admitted with pernicious anemia. Which set of findings should the nurse expect when assessing the client?

A nurse is caring for a patient who is 6-hours post-left lobectomy. On assessment the nurse observes that the patient has become very restless and the nail beds are blue. The vital signs reveal tachycardia, tachypnoea and the blood pressure is rising. Which of the following complications is most likely?

Nurse Fay is aware that isolation of a child with measles belongs to what level of prevention?

A client has ear surgery. An early response that may be associated with possible damage to the motor branch of the facial nerve is:

Using the principles of standard precautions, the nurse would wear gloves in what nursing interventions?

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. Acoustic neuromas produce symptoms of progressive nerve deafness, tinnitus, and vertigo due to pressure and eventual destruction of:

The nurse caring for a client who has been receiving intravenous (IV) diuretics suspects that the client is experiencing a fluid volume deficit. Which assessment finding would the nurse note in a client with this condition?

A client with a history of gastrointestinal bleeding hasaplateletcountof300,000mm3 (300AÌ‚109/L). The nurse should take which action after seeing the laboratory results?

Situation: The national objective for maintaining the health of all Filipinos is a primary responsibility of the DOH.
A 4-month-old child was brought to your clinic because of cough and colds. Which of the following is your primary action?

Situation : – One important toot a community health nurse uses in the conduct of his/her activities is the CHN Bag. Which of the following BEST DESCRIBES the use of this vital facility for our practice?
This is an important procedure of the nurse during home visits?

Aclientarrivesattheclinicforthefirstprenatalassess- ment. She tells the nurse that the first day of her last normal menstrual period was October 19, 2018. Using Na ̈gele’s rule, which expected date of delivery should the nurse document in the client’s chart?

The mother of a 3-year-old asks a clinic nurse about appropriate and safe toys for the child. The nurse should tell the mother that the most appropriate toy for a 3-year-old is which?

Situation : Mang Jose, 39 year old farmer, unmarried, had been confined in the National Center for Mental Health for three years with a diagnosis of schizophrenia.
Q. During mealtime, Jose refused to eat telling that the food was poisoned. The nurse considers the following except:

A client admitted to the hospital with chest pain and a history of type 2 diabetes mellitus is scheduled for cardiac catheterization. Which medication would need to be withheld for 24 hours before the procedure and for 48 hours after the procedure?

An adolescent client with type 1 diabetes mellitus is admitted to the emergency department for treatment of diabetic ketoacidosis. Which assessment findings should the nurse expect to note?

Miss Kate is a bread vendor and you are buying a bread from her. You noticed that she receives and changes money and then hold the bread without washing her hand. As a nurse, What will you say to Miss Kate?

Nurse Trisha teaches a client with heart failure to take oral Furosemide in the morning. The reason for this is to help

Which of the following best reflects the frequency of reported postpartum “blues”?

A Child is diagnosed with asthma exacerbation. Which of the following nursing diagnoses should be the FIRST priority?

Tonny has undergoes a left thoracotomy and a partial pneumonectomy. Chest tubes are inserted, and one-bottle water-seal drainage is instituted in the operating room. In the postanesthesia care unit Tonny is placed in Fowler’s position on either his right side or on his back. The nurse is aware that this position:

While caring for a patient prior to surgery to amputate the leg. What is the MOST affective measure to prevent phantom limb sensation after the amputation?

A nurse administers albuterol nebulizer to a child with asthma exacerbation. The nurse measures pulse oximetry and auscultates the lungs to determine whether the goal of clear respiratory status has been met. The step of nursing is called :

Situation : Two children were brought to you. One with chest indrawing and the other had diarrhea. The following questions apply:
Being a community health nurse, you have the responsibility of participating in protecting the health of people. Consider this situation: Vendors selling bread with their bare hands. They receive money with these hands. You do not see them washing their hands. What should you say or do?

Situation:– Camila, 25 years old, was reported to be gradually withdrawing and isolating herself from friends and family members. She became neglectful of her personal hygiene. She was observed to be talking irrelevantly and incoherently. She was diagnosed as schizophrenia
Q. Schizophrenia is a/an:

The adolescent’s inability to develop a sense of who he is and what he can become results in a sense of which of the following?

The nurse is planning care for a client during the acute phase of a sickle cell vaso-occlusive crisis. Which of the following actions would be most appropriate?

A patient who is preparing for hip surgery has an order for external pneumatic compression devices. The nurse teaches the patient that pneumatic compression can help prevent:

Situation: Blood transfusion was ordered for Andre after an episode of severe bleeding.
Q. Solutions that are said to be compatible with the osmolarity of the body are called:

The following are natural childbirth procedures EXCEPT:

A 21-year-old male with Hodgkins lymphoma is a senior at the local university. He is engaged to be married and is to begin a new job upon graduation. Which of the following diagnoses would be a priority for this client?

A 21-year-old female is being discharged after a 2-day admission for pelvic inflammatory disease (PID). Which statement BEST identifies the patients understanding of follow-up care for PID?

The nurse describes a client as anxious. Which of the following statement about anxiety is true?

Situation : John Mark is a 21 year old male client who was rushed following an automobile accident. He is very anxious, dyspneic and in severe pain.
Q. The right chest wall of Peter moves in during inspiration and balloons out when he exhales. He is very dyspneic. The nurse understands that this symptom is indicative of:

The doctor has prescribed a diet high in vitamin B12 for a client with pernicious anemia. Which foods are good sources of B12?

Which assessment finding indicates dehydration?

The nurse determines that the wife of an alcoholic client is benefiting from attending an Al-Anon group if the nurse hears the wife make which statement?

Heartburn and flatulence, common in the second trimester, are most likely the result of which of the following?

The nurse is discussing breastfeeding with a postpartum client. Breastfeeding is contraindicated in the postpartum client with:

Thenurseisassessingthecolostomyofaclientwho has had an abdominal perineal resection for a bowel tumor. Which assessment finding indicates that the colostomy is beginning to function?

Which of the following arteries primarily feeds the anterior wall of the heart?

Situation : – Nurse Lorena is a Family Planning and Infertility Nurse Specialist and is currently attending to a meeting. The following conditions pertain to meeting the nursing of this particular population group.
Client names Lilia is diagnosed as having endometriosis. This condition interferes with the fertility because:

Situation : Understanding different models of care is a necessary part of the nurse patient relationship.
Q. The nurse knows that in group therapy, the maximum number of members to include is:

The nurse is caring for a client with lung cancer and bone metastasis. What signs and symptoms would the nurse recognize as indications of a possible oncological emergency? Select all that apply.
1. Facial edema in the morning
2. Weight loss of 20 lb (9 kg) in 1 month
3. Serum calcium levelof12 mg/dL(3.0 mmol/L)
4. Serum sodium level of 136 mg/dL (136mmol/L)
5. Serum potassium level of 3.4 mg/dL (3.4 mmol/L)
6. Numbness and tingling of the lower extremities

The nurse is teaching a patient about spironolactone (aldactone). Which of the following instructions should the nurse review with the patient?

Before Jacob undergoes arthroscopy, the nurse reviews the assessment findings for contraindications for this procedure. Which finding is a contraindication?

Situation : Nurse Nico is caring to a 38-year-old female, G3P3 client who has been diagnosed with hemorrhoids.
Q. Which position would be ideal for the client in the early postoperative period after hemorrhoidectomy?

The nurse formulates a nursing diagnosis of Impaired verbal communication for a client with schizotypal personality disorder. Based on this nursing diagnosis, which nursing intervention is most appropriate?

Situation : A patient was admitted in the Medical Floor at St. Luke’s Hospital. He was asymptomatic. The doctor suspects diverticulosis.
Q. To improve Mr. Trinidad’s condition, your best nursing intervention and teaching is:

While obtaining information about the clients current medication use the nurse learns that the client takes ginkgo to improve mental alertness. The nurse should tell the client to:

To ensure that medications are prepared and administered correctly, the nurse should:

The relationship between the pulse and respiratory rate is represented by Which of the following ratios:

You are assessing a patient who has sustained a cat bite to the left hand. The cat is up-to-date immunizations. The date of the patient’s last tetanus shot is unknown. Which of the following is the priority nursing diagnosis?