NLE NURSING PRACTICE 04

Answer the 20 item exam
and get your scores below!

1. For most patients with Personality Disorders, the treatment of choice is usually:

A. Group therapy
B. Individual Psychotherapy
C. Self-help support groups
D. Hospitalization


2. Lorna is diagnosed with Borderline Personality Disorder. Which symptom would the nurse expect to assess related to her expression of anger?

A. Controlled, subtle anger
B. Inappropriate, intense anger
C. Inability to recognize anger
D. Substitution of physical symptoms


3. Lorna tells the nurse that she is the best nurse in the hospital, and then tells her she is when the nurse sets limits on her behavior. The nurse interprets this behavior as:

A. Denial
B. Splitting
C. Rationalization
D. Projection


4. One effective treatment modality for persons with Antisocial personality is:

A. Behavior therapy
B. Light therapy
C. Play therapy
D. ECT


5. In the assessment of a client diagnosed with Narcissistic Personality disorder, prominent behavioral characteristics to be observed is:

A. Suspiciousness
B. Splitting
C. Hypersensitivity to negative remarks
D. Sense of entitlement


6. During morning medication, Mang Nano, a patient with dementia, could not be located in the unit. Later he was found walking aimlessly in front of the hospital. When asked he say that his only son is coming to bring him home. What should you do?

A. Encourage him to interact with other patients
B. Explain to him that his medication time should be followed
C. Reorient him to reality and assess the reason for the behavior
D. Hold him by his hands and gently guide him back to his room


7. Assessment data of Mang Nano reveals disorientation to time and place after dark. The nurse interprets this finding as:

A. Amnesia
B. Degeneration
C. Perseveration
D. Sundown syndrome


8. The family of the client with Alzheimer's disease asks the nurse about what to expect as the disease progress. The answer of the nurse is based on which fact?

A. Improvement depends on the treatment given
B. Improvement can occur when underlying medical problems are treated
C. The disorder occurs in a chronic, progressive manner over time
D. The disorder typically involves periods of remission and exacerbation


9. Which nursing intervention would be most appropriate for Mang Nano if he is upset and agitated?

A. Decrease environmental stimuli while remaining with the client
B. Firmly tell the client that the behavior is not acceptable
C. Offer medication that will have a calming effect
D. Question the client about the cause of the problem



10. A client was admitted with the chief complaint of increasing confusion for about a month. Which assessment question to the family will differentiate delirium from dementia?

A. How long have you noticed the confusion in your family member?
B. Has there been a history of dementia in the family?
C. Do you think something happened that was upsetting to your family member?
D. Does your family member live alone or with someone?


11. In the late stages of Alzheimer's disease, which of the following outcomes would be most realistic for the client?

A. The client will verbalize increased feelings of self-worth
B. The client will identify life areas that require alterations due to illness
C. The client will maintain reality orientation
D. The client will remain safe in the least restrictive environment


12. Sui is in his senior year in Nursing. He is an active student leader, an honor student & a part-time tutor. He has little time to rest and often complains of having difficulty in falling asleep, especially at night. He can be suffering from:

A. Initial Insomnia
B. Intermittent insomnia
C. Maintenance insomnia
D. Terminal insomnia


13. How can you help Sui overcome his Insomnia?

A. Ask him to lessen his food intake
B. Limit activities just before bedtime
C. Advise him to buy sleep meds
D. Ask him to drink warm coffee


14. Mr. TokAn 30y/o experienced sudden wave of overwhelming sleepiness in his job and this problem lasted for more than a month. What can be the appropriate nursing intervention for persons with narcolepsy?

A. Ask him to drink at least 4-5 cups of espresso especially during working hours
B. Offer a tall glass of warm milk
C. Suggest taking scheduled naps
D. Tell him to always bring an Ipod or Discman filled with dance tunes


15. Lumen, the mother of an 8 y/o boy remarked, - I'm sick & tired of washing his soiled bed sheets twice a week. This has been going on for 2 months. What can I do to lessen the episode of my son's bedwetting? The best answer to her query is:

A. Transfer him to a sleeping mat
B. Punish him for his bedwetting
C. Ask him to wear snuggly fit diapers
D. Empty his bladder before sleeping


16. BusogBoy, a 20 y/o college student needs help for uncontrolled eating & self-induced vomiting. He has been diagnosed with Bulimia Nervosa. What would be an appropriate nursing intervention for him?

A. Observe BusogBoy for the next 24 hrs. for any incidence of purging
B. Tell BusogBoy that he'll be forced to eat soon after purging
C. Tell BusogBoy that he'll be given extra food tray
D. BusogBoy must be observed two hours after each meal


17. One of the most common characteristic of persons suffering from Bulimia is binge-eating. This refers to:

A. Insatiable appetite
B. Eating unusually large amount of food over a short period of time
C. Self-induced vomiting
D. Use of laxatives, diuretics & enemas to compensate for calories consumed


18. Payatita, 18 y/o was admitted due to rapid weight loss associated with Anorexia Nervosa. The nursing diagnosis identified in her present condition is:

A. Altered nutrition: less than body requirements
B. Impaired gas exchange
C. Alteration in Perception
D. Anxiety


19. The most important goal for clients with eating disorders such as anorexia nervosa is:

A. Be able to cope with stresses & conflicts
B. Develop a more realistic body image
C. Be able to identify significant others
D. Develop a positive outlook in life


20. Payatita's refusal to eat serves the primary purpose of allowing her to:


A. Gain the sympathy of others
B. Gain a sense of control and power
C. Remain free from anxiety
D. Openly assert her own identity







Score =


Correct answers:

from: Philippine Nurse

NLE PRACTICE EXAM 03

Answer the 20 item exam 

and get your scores below! 

1. Jenny is placed on Lithium therapy. Early signs of toxicity include:

A. tinnitus
B. vomiting
C. ataxia
D. stupor


2. The therapeutic blood lithium level is:

A. 2.5 MEq/L and above
B. 1.5-2.5 MEq/L
C. 0.5-1.5 MEq/L
D. 1.5-2.0 MEq/L


3. To reduce overt aggression from a manic patient the following are appropriate measures EXCEPT:

A. Participation in competitive games
B. Encouraging relaxation techniques
C. Reduction in environmental stimuli
D. Encourage client to discuss angry feelings


4. The biochemical theory of manic behavior may be related to:

A. Neurotransmitter deficiency
B. Excessive level of Norepinephrine
C. Increased cholinergic activity
D. Increased noreadrenergic activity


5. Karla was given a diagnosis of Depression with Suicidal tendencies. In planning the nursing care for her, which of the following should be given priority?

A. Allow relatives to visit him
B. Meet his daily self-care needs
C. Keep him safe from self-harm
D. Maintain his daily nutritional needs


6. You noticed that Karla combed her hair for the first time while in the hospital. You validate the meaning of her behavior by saying:

A. Tell me how you did that
B. I sense that you feel good today. Tell me what's happening
C. I like the way you arranged your hair. It's nice.
D. Is that your favorite hairdo?


7. Karla was scheduled for ECT. The most frequent complication of ECT is:

A. Loss of consciousness and headache
B. Restlessness and confusion
C. Fractures of the vertebra & long bones
D. Temporary memory loss and apnea


8. The appropriate activity for a depressed withdrawn client should be:

A. reading a novel
B. playing chess
C. taking a walk
D. listening to music


9. Suicide precaution should be strictly observed when the client exhibits which of the following manifestations?

A. the client feels weak and tired
B. the client expresses hostile feelings
C. the client has sudden cheerfulness
D. the client is agitated


10. Tricyclic Antidepressant was prescribed for Karla. While taking the TCA, she should be observed for:

A. diarrhea
B. constipation
C. muscle rigidity
D. polyuria


11. Carlos, age 35 was brought to the rehabilitation center for detoxification. He is a known alcoholic for ten years. Upon assessment, the reason he was asked when was his last intake of alcohol is:

A. Specific period when withdrawal symptoms may set in
B. How far the dependency has progressed
C. To determine the development of delirium tremens
D. Severity of withdrawal client may experience


12. Carlos tells the nurse how he hit his wife after an argument they had and asked if he would ever be forgiven. The best response of the nurse is:

A. You seem to have bad feelings about hitting your wife.
B. You may ask her when she visits you.
C. That depends if you'll be good enough during your confinement.
D. If it's okay with you, we can discuss that during the family therapy.


13. During the night, Carlos suddenly cries out as he saw shadows on the wall, - No, don't take me, noooh!! The nurse's best response would be:

A. What do the shadows mean to you, Carlos?
B. Go back to sleep you're just having a nightmare.
C. No one's here but you and me Carlos, You're safe here.
D. Tell me what you feel Carlos, I'm here to help.


14. Carlos is noted to fabricate information due to his memory lapses. The nurse is aware that this is done to:

A. maintain self-esteem
B. gain sympathy
C. manipulate others
D. attract attention


15. An attitude that the nurse must assume to be most help to Carlos is:

A. Warm and accommodating
B. Firmly consistent yet accepting
C. Acceptance and permisiveness
D. Judgmental and moralistic


16. Robin, known to be substance dependent for 3 years is admitted to the ER. Upon assessment he was found to be on drugs, with pinpoint pupils with RR of 9. Robin is likely to be suffering from:

A. Cocaine intoxication
B. Cocaine withdrawal
C. Heroine intoxication
D. Heroine withdrawal


17. Most appropriate nursing diagnosis for Robin is:

A. alteration in social interaction
B. alteration in sensory perception
C. ineffective individual coping
D. impaired adjustment


18. The medication likely to be to Robin for the withdrawal from the substance will be:

A. Methadone
B. Librium
C. Narcan
D. Disulfiram


19. During withdrawal Robin will likely manifest:

A. rapid respiration, dilated pupils, rapid pulse
B. synesthesia, increased vital signs, aggression
C. lacrimation, yawning restlessness
D. sleepy languor, poor concentration, euphoria


20. Chronic use of marijuana may lead to:

A. Emphysema and lung cancer
B. Korsakoffs and Wernickes syndrome
C. Hepatitis and AIDS
D. Cardiomyopathy







Score =


Correct answers:

from: Philippine Nurse

NLE PRACTICE EXAM 02

Answer the 20 item exam
and get your scores below!

1. Romy, 14 y/o was admitted to a medical ward due to bronchial asthma after learning that his mother is leaving for UK to work as a nurse. Romy's behavioral symptoms may be conveying which of the following message?

A. I am alone and helpless
B. I hate you for leaving me
C. Everyone needs attention
D. I deserve to be punished


2. The initial goal in the nursing care for Romy is:

A. Teach relaxation techniques
B. Encourage verbalization of feelings and concerns
C. Teach alternative ways of coping
D. Alleviate the patient's physical symptoms


3. The individual with essential hypertension is thought to:

A. Suppress anger and hostility
B. Fear social interactions with others
C. Project feelings onto environment
D. Deny responsibility for own behavior


4. Mr. Jose, bank executive is described by his subordinates as meticulous, scrupulous and wants every work to be on time. What physical illness would he be vulnerable?

A. Essential Hypertension
B. Bronchial Asthma
C. Migraine
D. D. Dermatitis


5. An appropriate nursing diagnosis for Mr. Jose would be:

A. Alteration in health maintenance related to knowledge deficit
B. Ineffective individual coping related to inadequate psychological resources
C. Ineffective denial related to poorly developed defensive function
D. Altered thought process related to withdrawal to the self


6. Chad, 23 years old, was admitted to the psychiatric unit with a diagnosis of Schizophrenia Paranoid type. As you approach Chad, he says, "If you come any closer, I'll die". This is an example of:

A. Hallucination
B. Delusion
C. Illusion
D. Ideas of reference



7. Your best response for this behavior is:

A. How can I hurt you?
B. Chad, I am your Nurse
C. Tell me more about this.
D. That's a silly thing to say


8. When communicating with a paranoid client, the main principle is to:

A. Use logic and be persistent
B. Express doubt and do not argue
C. Provide an anxiety free environment
D. Encourage ventilation of anger


9. In planning for a client who has negative symptoms of Schizophrenia, the nurse would anticipate a problem with:

A. bizarre behaviors
B. motivation for activities
C. ideas of reference
D. tactile hallucinations


10. The patient is asked, "Have you eaten?" and answered, "Have you eaten, Have you eaten, Have you eaten?" This phenomenon is called as:

A. Echolalia
B. Verbigeration
C. Dissociation
D. Neologism



11. How will you help a patient anticipate and deal with future recurrence of hallucination?

A. Stay with the patient all the time
B. Examine the patient's ways of dealing with hallucinations
C. Help patient accept that hallucination is a part of his mental illness
D. Assigning permanent staff who knows when the patient hallucinates


12. Your assessment of a patient with a diagnosis of catatonic schizophrenia will most likely reveal the following sets of behavior?

A. Aloofness, distrust, suspiciousness, grandiosity
B. Regression, giggling, smiling, laughing
C. Anxious, bizarre behavior, depression, elation
D. Stupor, hallucinations, negativism and automatism


13. Which of the following is an adverse effect associated with the use of Antipsychotic drug?

A. Sedation
B. Neuroleptic Malignant Syndrome
C. Extrapyramidal symptoms
D. Anticholinergic effects


14. Anton diagnosed with Schizophrenia Disorganized type was observed sitting alone, looking frightened. How should the nurse approach him?

A. Approach Anton, touch him on the arm and say: I'm your nurse.
B. Sit across him and say: Hi, I'm Rose your nurse. You appear frightened.
C. Greet him and say: Come I'll show you around.
D. Allow him to remain alone until he feels more comfortable


15. The goal of rehabilitation of a Schizophrenic is to:

A. learn effective coping
B. involve the family in client care
C. find employment for the client
D. facilitate optimal functioning of patient


16. Jenny was admitted to the Psychiatric unit exhibiting elation, incessant chattering and hyperactivity. Which of the following nursing diagnostic categories would hold the highest priority for her?

A. Hopelessness
B. Potential for injury
C. Personal identity disturbance
D. Ineffective individual coping


17. Jenny starts saying, "You will be promoted. Just go to Malacanang, see my cousin GMA. She is experiencing:

A. illusion
B. verbigeration
C. hallucination
D. delusion


18. Sensing that people don't believe her, she shouted," I'm really the cousin of GMA. Why don't you believe me? I own 10 buildings in Makati and the Fort Area. An effective approach of the nurse should be to:

A. listen attentively
B. leave her to a co-patient
C. start presenting reality
D. give reasons for not believing her


19. The primary reason for assigning a private room for Jenny is:


A. Decrease environmental stimuli
B. Prevent the patient's excessive activity from disturbing others
C. Deter the patient from interrupting the nurses
D. Provide the patient with a quiet place to thinking about her problems


20. The highest priority nursing intervention for a hyperactive patient like Jenny would be:

A. Discourage her from manipulating the staff
B. Prevent her assaulting other patients
C. Protect her against suicidal attempts
D. Provide adequate food and fluid intake








Score =


Correct answers:

from: Philippine Nurse

NLE PRACTICE EXAM 01

Answer the 20 item exam
and get your scores below!

1. Which theoretical model is being applied if the nurse views mental illness as a learned behavior?
A. Humanistic Model
B. Medical Model
C. Interpersonal Model
D. Behavioral Model

2. The essential foundation that must be established early in the therapeutic relationship is:
A. confidence
B. insight
C. trust
D. change
3. The basis for building a strong therapeutic nurse-client relationship begins with the nurse's:
A. sincere desire to help others
B. acceptance of others
C. self-awareness and understanding
D. sound knowledge of Psychiatric Nursing

4. For a beginning nurse practitioner in a psychiatric-mental health setting, which behavior would be least effective in helping to achieve personal and professional growth?
A. Completing a task for a client instead of repeatedly prompting him to finish it
B. Taking time to adjust to a slower pace
C. Avoiding frustration when a client refuses to interact
D. Use listening and observation skills

5. You are planning a treatment care for a client who has been on the streets for several years. The client has delusions, and frequently responds to auditory hallucinations. Which of the following client needs would be the priority?
A. Self-esteem
B. Love and Belongingness
C. Self-Actualization
D. Physical safety

6. Which contribution of the psychoanalytical model is particularly useful to psychiatric nurses?
A. All behavior has meaning
B. Behavior that is reinforced will be perpetuated
C. The first 6 years of a person's life determine his personality
D. Behavioral deviations result from an incongruence between verbal and nonverbal communication

7. The Psychiatric nurses' role in tertiary prevention is:
A. Prevent the spread of disease
B. Promote mental health through anticipatory guidance
C. Case finding to limit severity of disease
D. Prevent the crippling defects of illness through rehabilitation programs

8. A nurse who uses nurturing activities such as bathing or feeding the patient is assuming the role of a:
A. Counselor
B. Teacher
C. Ward Manager
D. Parent Surrogate

9. In the application of the nursing process, the nursing diagnoses are prioritized according to:
A. the established goals of care
B. the nurses' priority of care
C. life threatening potential
D. focus on resolution of patient's problems

10. During the assessment process, the nurse:
A. establishes a therapeutic contract
B. participates in nursing conferences
C. collaborates with other nurse
D. utilizes a system of data collection

11. Mrs. Dimalanta age 40 was admitted because of bouts of insomnia, nervousness and poor concentration becoming worst in the last 6 months. What is the initial responsibility of the nurse?
A. Assess her level of anxiety
B. Encourage husband to stay with her
C. Orient her to the unit
D. Administer medication to allay anxiety

12. During the orientation phase of the N-C-R initiated by the nurse, the appropriate topic would be:
A. Effective coping patterns
B. Facts about stress and coping
C. Mrs. Dimalanta's perception of her illness
D. Feelings about her family

13. All of the following are physical responses to anxiety EXCEPT:
A. Perspiration
B. Headache
C. Increased pulse & respiration
D. Forgetfulness

14. In planning the discharge of a client with chronic anxiety, the goal should focus on which of the following?
A. Eliminating all anxiety from daily situations
B. Ignoring feelings of anxiety
C. Identifying anxiety producing situations
. Continued contact with crisis counselor

15. Primary gain associated with Somatoform Disorders, is referred to as:
A. Financial compensation from disability
B. Relief from anxiety associated with conflict
C. Love & attention from support system
D. Financial aid from relatives

16. Management of client with Somatoform Disorders includes the following EXCEPT:
A. Use of Matter-of-fact attitude
B. Help develop insight into his/her condition
C. Help use effective coping skills to reduce stress and anxiety
D. Ignore somatic complaints

17. The desired outcome for the nursing care of client with Hypochondriasis is:
A. Nurse will respond in an authoritative manner when client complains pain
B. Client will seek 2nd opinion from healthcare providers
C. Client will state the relationship between life events & physical symptoms
D. Nurse will reinforce physical symptoms experienced by the client

18. Defense mechanisms used by clients experiencing Dissociative Disorder:
A. Dissociation & Undoing
B. Dissociation & Repression
C. Repression & Projection
D. Regression & Denial

19. The Nurse working with a client who has Dissociative Disorder understands that this disorder is likely to begin as a/an:
A. gradual loss of memory
B. means to avoid responsibilities
C. effect of Drug abuse
D. protective defense against anxiety

20. Nursing intervention for patients with Dissociative Disorder should be based on the understanding that:
A. Patients can recall his identity if he wants to
B. Memory Loss is due to their dislike of their original personality
C. Patient can recall his anxiety when anxiety subsides
D. Memory loss is due to an emotional conflict or an external stressor


Score =
Correct answers:

from: Philippine Nurse

NCLEX PRACTICE EXAM 05

Answer the 20 item exam
and get your scores below!

1. The client's chest tube is having removed. Which of the following actions is most appropriate in caring for a person who undergoes this procedure?

A. assist the client to assume a prone position
B. medicate the client for pain half hour prior to removal
C. encourage deep breathing during removal
D. empty the collection chambers before removal


2. The nurse is caring for a client with cystic fibrosis. Which of the following nursing diagnoses would most likely take highest priority?

A. Activity intolerance
B. Anxiety
C. Risk for ineffective airway clearance
D. Risk for fluid volume deficit


3. The client has a lung abscess. Which nursing intervention should be included in the plan to increase the client's level of comfort?

A. encourage activity prior to meals
B. offer frequent oral hygiene
C. provide easy to eat milk products
D. restrict fluid intake


4. The nurse is assessing the laboratory values of a male client being evaluated for GI bleeding. Which laboratory value, if present, would be most suggestive of hemorrhage?

A. RBC = 5 million/mm3
B. hematocrit = 35%
C. Potassium = 4 mg/L
D. Sodium = 140 mg/L


5. The nurse administers an anticholinergic drug to a client scheduled for an endoscopy. What effect should be expected from this medication?

A. sedation
B. increased peristalsis
C. muscle relaxation
D. decreased secretion


6. Metoclopramide is prescribed for an individual with GERD. The nurse is explaining the action of this drug. Which statement most accurately describes the action of the drug?

A. it decreases the time food and fluids are in the stomach
B. it acts as an antacid to reduce gastric acidity
C. it helps to promote movement in the esophagus
D. it has a local anesthetic effect on the lower esophagus and stomach


7. The nurse is teaching a family member how to position a client who is to receive tube feedings in the home. Which instruction is most appropriate?

A. place the client in a left side- lying position
B. elevate head of the bed slightly
C. encourage the client to sit out of bed in a chair
D. allow the client to assume a position of comfort


8. A client who has to have an accumulation of gas and fluid removed from the gastrointestinal tract is connected to intermittent suction. If there were no drainage from the suction, which of the following actions should the nurse take?

A. discontinue the suction
B. increase the amount of suction
C. obtain orders to irrigate the tube
D. advance the tube down the GI tract


9. What measure should the nurse employ to ensure that a client receiving TPN does not develop osmotic diuresis as a complication?

A. monitor the flow rate carefully
B. administer the solution slowly
C. protect the solution from light
D. keep the infusion at room temperature


10. When caring for a client with TPN, which action by the nurse has the potential to cause serious adverse effects in the client?

A. abruptly discontinuing TPN at any time
B. administering the TPN solution via an infusion pump
C. applying an antibiotic ointment to the insertion site
D. maintaining the normal flow rate when the infusion is behind schedule


11. The nurse is recording data from a man newly admitted to the hospital. Which notation, if made by the nurse, is most consistent with the presence of a duodenal ulcer?

A. food causes pain
B. the client complains of spitting blood
C. pain may awaken the client in the middle of the night
D. certain types of food increase distress


12. A client is admitted with a history of fatigue and melena and tentatively diagnosed to have duodenal ulcer. The nurse administers alternating doses of calcium carbonate and magnesium oxide. Which finding best indicates that this drug regimen has been successful?

A. absent nasogastric tube drainage
B. increase gastric pH
C. mild diarrhea
D. decreased abdominal rigidity


13. The severely damaged liver cannot produce the important plasma protein, albumin. Identify the clinical problem that would be expected in a client with a low albumin level.

A. abnormal bleeding
B. polyuria
C. edema
D. weight loss


14. The nurse is assessing a client with gallbladder disease. Which of these findings, if present in the client's history, is commonly found in individuals with gallbladder disease?

A. she complains of her skin being very itchy
B. she is 30 pounds overweight for her height
C. she has had several nosebleeds
D. she feels tired all the time


15. The nurse is participating in a screening program. The nurse should NOT have a high index of suspicion for diabetes mellitus for which individual.

A. an obese 43 year old woman
B. a man complaining of thirst and weight loss
C. a young woman who has had two babies weighing 10 pounds each
D. an adolescent whose grandmother has type I diabetes


16. The nurse is evaluating a young man with diabetes. The client reports a number of symptoms. Which symptom is considered a cardinal sign of diabetes?

A. overwhelming fatigue
B. excessive thirst
C. recurrent blurred vision
D. gradual weight loss


17. A client complains of headache and tells the nurse she feels weak. She is also diaphoretic. The client has been a diabetic for 20 years. The client tells the nurse, "I've been managing my diabetes for a long time; please let me lie down. What is the most appropriate nursing action?

A. assist the client to bed
B. insist that the client eat a snack
C. page the physician
D. start an IV line


18. The nurse assessing the client with hypothyroidism should assign the highest priority to the assessment of which laboratory value?

A. serum calcium levels
B. serum cholesterol levels
C. serum potassium levels
D. urine specific gravity


19. A client has hyperthyroidism. He is admitted to the hospital for the emergency treatment of thyroid storm (thyrotoxicosis). What symptoms should the nurse plan to address?

A. fluid overload
B. hypothermia
C. respiratory distress
D. tachycardia


20. A client is returning to the surgical ward after undergoing a subtotal thyroidectomy. What emergency equipment should the nurse have available at the bedside for this client?

A. an ECG monitor
B. a defibrillator
C. an intra-aortic balloon pump
D. a tracheostomy unit









Score =


Correct answers:

from: Philippine Nurse

NCLEX PRACTICE EXAM 04

Answer the 20 item exam
and get your scores below!

1. The nurse should encourage clients with intermittent claudication to:

A. give up smoking
B. decrease physical activity, especially walking
C. increase calcium intake
D. restrict caffeine intake


2. A client is to undergo a bone marrow aspiration. When teaching the client about this procedure, the nurse should explain that it is used to:

A. identify blood abnormalities
B. determine long term prognosis
C. assess for presence of infection
D. determine the RBC indices


3. Following the client�s bone marrow aspiration, which of the following nursing intervention should be instituted?

A. apply firm pressure to the area until bleeding stops
B. provide a warm, moist compress to the site
C. encourage the client to assume a supine position
D. place an occlusive dressing on the area for 24 hours


4. Which of the following laboratory test results would be most helpful to the nurse in the assessment of a client with a bleeding disorder?

A. red blood cell count
B. platelet count
C. hematocrit
D. differential count


5. While performing an admission assessment on a severely anemic client, the nurse would expect to find a history of:

A. blurred vision
B. increased appetite
C. cardiac palpitations
D. warm flushing sensations


6. The nurse is explaining the diagnosis of pernicious anemia to the client, which of the following is accurate concerning the disease?

A. shortness of breath often occurs
B. the risk for dehydration is increased
C. it is caused by a deficiency of intrinsic factor
D. there is no treatment for this disorder


7. The nurse is caring for a client with Aplastic anemia. Which of the following nursing diagnoses would have priority in the care of this client?

A. Potential for infection due to decreased leukocyte count
B. Impaired gas exchanged due to low RBC count
C. Potential for impairment of skin integrity due to poor nutritional status
D. Alteration in bowel elimination: constipation due to iron overload


8. Emphysema destroys alveolar walls. The physiological effect that the nurse expects from this damage is:

A. a decrease level of carbon dioxide in the body
B. a decrease in the amount of oxygen diffusing into the blood
C. severe constriction of the segmental and subsegmental bronchi
D. an accumulation of excess fluid in the lungs


9. The nurse received a report that the client has hypercapnia. What respiratory disorder will the nurse expect to note?

A. excessive respiratory secretions
B. inability to take a deep breath
C. increased respiratory rate
D. retention of carbon dioxide


10. The nurse is caring for a client who is having difficulty of breathing. The muscles between the ribs retract with inspiratory effort. The nurse noted that the client is having retraction of which muscles?

A. articular
B. bronchoesophageal
C. intercostal
D. latissimus dorsi


11. A client has a chronic productive cough and is being treated for emphysema. What physical assessment findings are most consistent with this patient�s history?

A. barrel chest
B. lordosis
C. pectus excavatum
D. whispered pectoriloquy


12. The nurse is caring for an adult who has congenital pulmonary disorder that has resulted in a decrease in the production of surfactant. What effect is most consistent with this deficiency?

A. alveolar hypertrophy
B. sleep apnea
C. stiff lungs
D. ventilator dependence


13. The nurse hears a high, hollow drum-like sound when percussing the chest of the client with a large pneumothorax. How should this sound be noted on documentation

A. dullness
B. flatness
C. resonance
D. tympany


14. The nurse percusses an area of dullness on the anterior chest at the level of the 10th right rib of the client who has been diagnosed for many years with COPD. The most appropriate interpretation of this finding is the percussion note was elicited over:

A. a pneumothorax
B. an area of pneumonia
C. liver tissue
D. a pleural effusion


15. The nurse is assessing the PaO2 of a client with asthma. This blood gas result will best assist the nurse to obtain information of what nature?

A. the effectiveness of ventilation
B. the degree of dyspnea
C. the degree of hypoxia
D. the status of tissue oxygenation


16. To prevent the leaking of blood into surrounding tissue following the blood extraction for ABG determination, the nurse should implement which nursing measure:

A. apply ice to the puncture site
B. maintain manual compression over the puncture site for five minutes
C. place bandage over a sterile cotton swab over the puncture site for at least one minute
D. elevate the limb on several pillows


17. The client is an asthmatic and in acute respiratory distress. The nurse auscultates the lungs and notes no inspiratory wheezing. What should this finding suggest to the nurse?

A. airway constriction requiring intensive interventions
B. an appropriate reaction to the medications used in the management of client
C. the need to assess the client further for signs of a pleural effusion
D. overuse of the intercostals muscles resulting in poor exchange


18. Which nursing intervention is most appropriate for a 76 year old client with COPD who has the nursing diagnosis of airway clearance ineffective related to excessive secretions and ineffective coughing?

A. encourage breathing using a panting pattern
B. have the client sit in a low Fowler�s position
C. instruct the client to drink at least eight glasses of water a day
D. discourage pursed-lip breathing


19. A client is hospitalized with pneumonia. The nurse has made the nursing diagnosis, breathing pattern, ineffective related to tachypnea secondary to chest pain. The nurse administers analgesia as prescribed. What additional assessment is needed following medication administration?

A. auscultation of the chest
B. ECG
C. evaluation of pupillary reaction
D. testing of muscle strength


20. Intermittent bubbling is noted in the water seal chamber of a client who has a chest tube in place due to a pneumothorax. Which action of the nurse is most appropriate based on this observation?

A. clamp the chest tube
B. encourage respiratory exercises
C. change the drainage unit
D. place a Vaseline gauze around the chest tube

Score = Correct answers: from: Philippine Nurse

NCLEX PRACTICE EXAM 03

Answer the 20 item exam 

and get your scores below! 

1. Which of the following is the most common manifestations of osteoporosis?

A. significant weight loss
B. fractures
C. urinary calculi
D. long bone pain


2. The nurse is teaching a class on osteoarthritis. The nurse�s understanding of this disorder is best described as:

A. degeneration of articular cartilage in synovial joints
B. enzymatic breakdown of tissue in non-weight bearing joints
C. joint destruction caused by an autoimmune process
D. the overproduction of synovial fluid resulting in joint destruction


3. How does nicotine, a substance in cigarette smoke, increase the prevalence of CAD?

A. it decreases the oxygen-carrying capacity of the blood
B. it increases the deposits of fat containing substances along the intima of blood vessels
C. it causes smooth muscle cell proliferation
D. it increases the likelihood of dysrhythmias and elevated heart rate, BP, & oxygen consumption


4. In most cases, which of the following is the cause of sudden cardiac death?

A. ventricular fibrillation
B. severe congestive heart failure
C. myocardial ischemia
D. unstable angina


5. Nurses can best help prevent CAD by teaching clients:

A. low fat, low-cholesterol diets
B. the importance of exercise
C. how to maintain normal BP
D. how to handle stress


6. The nurse is instructing a client in the proper administration of sublingual Nitroglycerin. Which of the following is correct and should be included in the teaching plan?

A. tablets should be stored in the refrigerator
B. repeat dosage after 5 minutes if pain is not relieve. Seek medical help if pain is not relieved after 3 sublingual nitroglycerin tablets
C. assess BP for reactive hypertension after each dose
D. headache is a rare side effect and should be reported to the physician



7. When administering Nifedipine (Procardia) to a client with a history of angina, the nurse should:

A. observe for signs of respiratory depression
B. monitor the client�s BP
C. observe for manifestation of GI bleeding
D. force fluids


8. When caring for a client immediately after an MI, the nurse�s first priority is:

A. relief of pain
B. monitoring for presence of dysrhythmias
C. prevention of embolism
D. relieving client�s apprehension


9. Which of the following nursing orders would be found on the care plan for a client for the first 24 hours after an MI?

A. utilize bedside commode for bowel movements
B. 200 calorie, soft diet
C. feed the patient
D. administer promethazine regularly



10. Which of the following would be included in the discharge teaching plan for a client after MI?

A. don�t begin sexual intercourse until after 3 months
B. begin walking frequently
C. take one aspirin every 8 hours as ordered
D. continue previous lifestyle when ready


11. When auscultating the respirations of a client in left ventricular heart failure, the nurse will most likely detect:

A. wheezing
B. loud expiratory sounds
C. loud inspiratory sounds
D. crackling sounds


12. In which position should the nurse place the client who is experiencing acute congestive heart failure (CHF)?

A. Sim�s position
B. supine
C. Trendelenburg
D. high Fowler�s with feet dependent


13. The most important action of Digitalis derivatives on the heart of a client in CHF is to:

A. re-establish normal heart rhythm
B. increase ventricular contractility
C. decrease dysrhythmias
D. decrease AV node refractory period



14. What is the long term effect of rheumatic fever?

A. Cardiomegaly
B. cardiac tamponade
C. sudden cardiac death syndrome
D. pericarditis


15. The client admitted for the treatment of rheumatic fever and has fever of 101 degrees F should have which activity order?

A. activity ad lib
B. bed rest
C. out of bed in a chair
D. exercise until the point of fatigue


16. The nurse is conducting a ward class for a group of client who are to undergo cardiac surgery. What information should the nurse include when discussing the use of the ventilation in the ICU immediately after surgery?

A. no visitors will be allowed while the client is intubated
B. refraining from coughing is especially important while using the ventilator
C. while being ventilated the client must remain on bed rest
D. the client will be unable to talk while being ventilated


17. A client is admitted to the hospital with chronic venous disease. Physical assessment of the client�s legs would most likely reveal:

A. erythema
B. reduced muscle mass
C. overgrowth of hair
D. decreased pulses


18. Which of the following manifestations would the nurse expect when assessing a client with arterial insufficiency?

A. warm, erythematous legs
B. thin fragile toenails
C. muscular atrophy
D. bounding arterial pulses


19. Which of the following is the most common cause of secondary hypertension?

A. chronic renal disease
B. primary hyperaldosteronism
C. pregnancy induced hypertension
D. oral contraceptive use


20. A client is admitted to the ICU with malignant hypertension. Assessment of the client would most likely reveal symptoms of:

A. fluid overload
B. livery dysfunction
C. renal failure
D. exercise intolerance

Score = Correct answers: from: Philippine Nurse