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Bundle for NCSBN exam 2023
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NCSBN test bank Questions 16-30 correctly answered 2023
The nurse is performing a physical assessment on a client who just had an endotracheal tube (ET) inserted with a connection to a ventilator. Which finding ... [Show More] should prompt the nurse to take immediate action to resolve the issue? A. Client is unable to speak B. Mist is visible in the T-Piece of the ventilator circuit C. Pulse oximetry of 86% saturation D. Breath sounds are heard bilaterally C Pulse oximetry should not be lower than 90% saturation. Breath sounds are heard bilaterally so the placement of an ET is most likely in proper position. The ventilator settings will need to be rechecked. A client with an ET tube in place will not be able to talk when the ET tube balloon is inflated. In order to enhance a client's response to medication for chest pain from acute angina, the nurse should emphasize which approach? A. Eat smaller meals B. Limiting alcohol use C. Avoiding passive smoke D. Learning relaxation techniques D The only factor that can enhance the client's response to pain medication for angina is reduction of anxiety through relaxation methods. Anxiety may increase intensity to a point where pain medication outcomes are totally ineffective. 00:22 01:39 The clinic nurse is counseling a postpartum client who has a substance-abuse problem and is at risk for continued cocaine use. In order to provide continuity of care, which nursing diagnosis should be a priority? A. Altered parenting B. Social isolation C. Ineffective coping D. Sexual dysfunction A The mother who abuses cocaine puts her newborn and any other children at risk for neglect and abuse. The continued use of drugs has the potential to impact parenting behaviors. Social service referrals are indicated for evaluation and follow-up. A nurse is caring for a client with end-stage heart failure. The family members are distressed about the client's impending death. Which intervention should the nurse take first? A. Assess the family's patterns for dealing with death B. Ask about their present religious affiliations C. Explain the stages of death and dying to the family D. Recommend an easy-to-read book on grief A When a new problem is identified, it is important for the nurse to first collect accurate information. This is crucial to ensure that the client and the family's needs are adequately identified in order to plan and implement nursing care. Once the situation has been assessed and a plan has been established, the nurse can focus on teaching or referral to other resources. A client was admitted to the psychiatric unit after refusal to get out of the bed. Once admitted, the client is observed talking to unseen people and voiding on the floor. The nurse should handle the problem of voiding on the floor by which of these approaches? A. Require the client to mop the floor after each incident B. Restrict the client's fluids throughout the day C. Toilet the client more frequently with supervision D. Withhold privileges each time the voiding occurs C With a client that has altered thought processes, the appropriate nursing approach to change behaviors is to take an active role in attending to the physical needs of the client. The other options are incorrect approaches. A client on warfarin therapy after coronary artery stent placement calls the clinic to ask: "Can I take Alka-Seltzer for an upset stomach?" What is the best response by the nurse? A. "Use about half the recommended dose of Alka-Seltzer." B. "Select another antacid that does not inactivate warfarin (Coumadin)." C. "Avoid Alka-Seltzer because it contains aspirin." D. "Take Alka-Seltzer at a different time of day than you take the warfarin (Coumadin)." C Alka-Seltzer is an over-the-counter aspirin-antacid combination. Aspirin is an antiplatelet drug and taking this with warfarin will potentiate the anticoagulant effects of warfarin (Coumadin), which may increase the risk of bleeding. At a well-child checkup, the nurse is assessing a 1 year-old who was born prematurely and is being evaluated for cerebral palsy (CP). Which information provided by the parents would support this diagnosis? A. "Our child isn't talking yet." B. "We think our child seems smaller than other babies this age." C. "Mealtime is so messy when he tries to feed himself." D. "He crawls by pushing off with one hand and leg while dragging the opposite hand and leg." D Cerebral palsy refers to a group of conditions that affect movement, balance and posture. Prematurity, infections during pregnancy, and asphyxia during labor and delivery are risk factors for CP. Some children with CP may have delays in learning to roll over, sit, crawl or walk. Because this child was born prematurely, it would be expected that he would be smaller than other babies. At this age, most children can say a few words (like "mama"), but they are not talking, and mealtime can get pretty messy. The parent of an 8-month-old infant asks the nurse if the child's language development is normal for this age. Which sounds should the nurse expect at this age? (Select all that apply.) A. Single vowel sounds such as ah, eh and uh B. Combining syllables (e.g., "dada") C. Cooing, gurgling and laughing aloud D. Imitating sounds E. Crying for 1-1 1/2 hours per day B,D In the first few weeks of life, crying has a reflexive quality and is mostly related to the child's physiologic needs. Infants cry for 1-1 1/2 hours per day until up to 3 weeks of age and then build up to 2 hours and even 4 hours by 6 weeks of age. Crying tends to decrease by 12 weeks. Normal infant language development milestones: Around 2 months: Single vowel sounds such as ah, eh and uh By 3-4 months: Cooing, gurgling and laughing aloud By 6 months: Imitating sounds and combining syllables (e.g., "dada") A nurse is teaching a mother who will breast-feed for the first time. Which of these approaches is a priority? A. Show the mother films on the physiology of lactation B. Give the mother several illustrated pamphlets C. Give the mother privacy for the initial feeding D. Assist the mother to position the newborn at the breast D All of the approaches should be helpful in teaching. However, the priority is to place the infant to the breast as soon after birth as possible to establish contact and allow the newborn to begin to suck. [Show Less]
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NCSBN NCLEX RN Review(updated 2023)
A client is being prepped for a surgical procedure and the nurse is reviewing the informed consent with the client. The client asks, "Is there any other wa... [Show More] y to take care of this without have surgery?" The nurse has a duty to first: A. Reassure the client that the surgery is the best treatment option B. Tell the client if they don't want they surgery, they don't have to have it C. Notify the surgeon that the client has additional question about alternatives to surgery D. Call the surgeon and cancel the surgery until the consent form is signed C A nurse has unintentionally given an incorrect dose of medication to their client. No harm was done to the client. What is the next action, if any, required by the nurse? A. The nurse is not required to report the mistake because the client was not harmed B. The nurse is not responsible for the mistake because they have not been provided current education by their employer C. The nurse will immediately be suspended and their license will be revoked D. The nurse will report the incident to their nurse manager and follow their organizational procedures for reporting D The 83 year old client, who lives in a retirement community, is admitted to the hospital. The daughter reports the client no longer calls her every day, has not been participating in previously enjoyed activities, such as weekly card games, and has allowed the garden to become overgrown with weeds. The nurse should assign this client to a room with which of the following clients? A. An elderly person who was admitted 3 hours ago with a diagnosis of cyclothymia B. A young adult who was admitted 24 hours ago for treatment following detoxification C. An adolescent who was admitted the day before with a diagnosis of disruptive mood dysregulation D. A middle aged person who has been on the unit for 72 hours with a diagnosis of persistent depressive disorder D A Bosnian Muslim woman who doesn't speak English seeks care at a community care clinic. Through physical gestures, the woman indicates that she has pain originating in either the pelvic or genital region. Assuming several people are available to interpret, who would be the most appropriate choice? A. A female interpreter who doesn't know the client B. A female neighbor of the client who is also from Bosnia C. The client's adult daughter D. A Bosnian male, who is a certified medical interpreter A The charge nurse in the ED receives a call from the ambulance crew stating that there has been a two car accident with multiple casualties. What action would the nurse take first, before the victims arrive in the ED? A. Set up multiple 1000 mL NaCl IV solutions with tubing and notify the blood bank B. Notify the nursing supervisor and request additional staff C. Activate the disaster plan D. Prepare the trauma room and select supplies B The nurse manager is discussing the goals of total quality management (TQM) with the health care team. Which statement correctly identifies a key element of TQM? A. Top administrators are responsible for establishing plans for problem management B. All employees participate in systematically working toward common goals C. It's a reactionary approach used to investigate the root cause of a problem D. It is an incident management technique that focuses on employee retention B [Show Less]
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NCSBN Practice Questions 31-45 correctly answered 2023
A client is admitted with a diagnosis of myocardial infarction (MI) and reports having chest pain. The nurse provides care based on the knowledge that pain... [Show More] associated with an MI is related to which of the following findings? A. Insufficient oxygenation of the cardiac muscle B. Fluid volume excess C. Arrhythmia D. An electrolyte imbalance A Due to ischemia of the heart muscle, the client will experience pain. This happens because destroyed myocardial tissue can block or interfere with the normal cardiac circulation. Decentralized scheduling is used on a nursing unit. What is the advantage of this management strategy? A. Conserves time spent on planning B. Considers client and staff needs C. Frees the nurse manager to handle other priorities D. Allows requests for special privileges B Decentralized staffing takes into consideration specific client needs and staff abilities and interests. This means the staffing is decided on the lowest level which is at the unit level. Upon entering an adult client's room, the client is found to be unresponsive. After calling for help, what is the next action that should be taken by the nurse? A. Give two rescue breaths B. Deliver five abdominal thrusts C. Maintain an open airway D. Check for a carotid pulse D According to the American Heart Association's basic life support, the first step after determining a victim is unresponsive is to call for help. The next step is to check for a pulse (for no more than 10 seconds). If there is no pulse, the rescuer should begin CPR (30 chest compressions followed by 2 ventilations). A mother, who has been exclusively breastfeeding her 6 month-old, requests more information about meeting the nutritional needs of her infant. What information will the nurse provide? A. Begin a regular schedule of meals and snacks, offering a variety of foods B. Offer finger foods to encourage self-feeding during family meals C. Cut back on the number of times a day the infant receives breastmilk D. Gradually begin adding pureed iron-rich meat and/or cereal as the first foods D The nurse should recommend increasing the number of times a day that complementary foods are offered while continuing to breastfeed. Pureed iron-rich meat, meat alternatives, and/or iron-fortified cereal should be the first complementary foods. After pureed foods, the next transition should be to add strained or mashed foods and then finger foods. From about one year of age, young children begin to have a regular schedule of meals and snacks. The nurse works in the pediatric emergency department. In which situation would a child be treated by using enemas followed by an antitoxin? A. A school-aged child who has swallowed a handful of iron-fortified vitamins B. A toddler who has eaten an undetermined number of ibuprofen tablets C. A preschooler who bit into a laundry detergent pod D. An infant who is diagnosed with botulism D Food-borne botulism can be treated by removing whatever contaminated food is in the stomach by using enemas (or by inducing vomiting) and administering a Botulinum antitoxin. Children with iron poisoning and who are breathing normally can be given a strong laxative fluid; severe poisonings require IV chelation therapy. For NSAID poisoning, sometimes activated charcoal is given (usually within 1 hour of ingestion); massive overdoses may require orogastric lavage because there is no specific antidote for ibuprofen. Since laundry detergent is an alkaline substance, the most commonly used therapy is dilution/irrigation/wash, especially for burns to the skin and eyes. Tracheal intubation with ventilation may be required if the child swallowed the laundry detergent. The client is prescribed a new antipsychotic medication. The nurse is teaching a client about the medication and possible side effects, including tardive dyskinesia (TD). Which statement is true about tardive dyskinesia? A. The high fever, sweating and muscle stiffness will last about one week B. TD occurs within minutes of the first dose of any antipsychotic drug C. The longer someone is treated with an antipsychotic medication, the higher the risk for developing TD D. Almost every client treated with antipsychotic medications will eventually develop TD C The symptoms of tardive dyskinesia (TD) are characterized by random movements of different muscles and the tongue, lips or jaw. Longer treatment with antipsychotic medication, being female, being African American or Asian American are common risk factors for developing TD. Research shows that the overall risk of developing TD is about 30-50%. Decreasing the dose of the antipsychotic or switching antipsychotic medication can help, but there is no cure. Neuroleptic malignant syndrome is a rare and potentially life-threatening reaction to antipsychotic medications, when the client presents with hyperthermia, rigidity and autonomic dysregulation (hypertension, tachycardia, tachypnea, agitation, diaphoresis). A client with schizophrenia receives haloperidol 5 mg three times a day. The client's family is alarmed and calls the clinic nurse when "his eyes rolled upward." The nurse should recognize this finding as what type of side effect? A. Dysphagia B. Nystagmus C. Tardive dyskinesia D. Oculogyric crisis D This refers to involuntary muscles spasm of the eye. There are medications to treat such side effects, for example trihexyphenidyl or benztropine. A nurse is teaching about nonsteroidal anti-inflammatory agents (NSAIDs) to a group of clients diagnosed with arthritis. The nurse should emphasize which of these actions to minimize a side effect of these drugs? A. Continue to take aspirin for short-term pain relief B. Use alcohol in moderation when driving or operating heavy machinery C. Take the medication after meals or with food D. Report joint stiffness in the morning C Taking NSAIDs after meals or with food should help to minimize gastric irritation. The client should also take the medication with a full glass of water and remain in an upright position for 15 to 30 minutes after administration. Clients should be cautioned to avoid concurrent use of aspirin or alcohol with these medications to minimize possible gastric irritation; three or more glasses of alcohol per day may increase the risk of GI bleeding. The nurse is caring for a 14 year-old child in the postanesthesia care unit (PACU) following corrective surgery for scoliosis. Which action should receive priority in the plan? A. Assist to stand up at bedside within the first few hours B. Initiate the antibiotic therapy prescribed for 10 days C. Evaluate the movement and sensation of extremities D. Teach client isometric exercises for the legs C Following corrective surgery for scoliosis, the neurological status of the extremities requires priority attention in the PACU, as well as on the postop surgical unit. The other options may be done after the neurological status. A 35-year-old client of Puerto Rican-American descent is diagnosed with ovarian cancer. The client states, "I refuse both radiation and chemotherapy because they are 'hot.'" Which action should the nurse take next? A. Ask the client to talk about concerns regarding "hot" treatments B. Report the situation to the health care provider C. Document the situation and client response in the notes D. Talk with the client's family about the situation A In Hispanic folk medicine, it is believed that disease is caused by an imbalance between hot and cold principles. Health is maintained by avoiding exposure to extreme temperatures and by consuming appropriate foods and beverages. Examples of "hot" diseases or states include pregnancy, hypertension, diabetes and indigestion. "Cold" diseases include pneumonia. These designations are symbolic and do not necessarily indicate temperature or spiciness. Care and treatment regimens can often be negotiated with clients within this framework. Also note that the correct response is the best answer because it is client-centered. [Show Less]
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NCSBN questions with complete solution 2023
Assistive devices are used when a caregiver is required to lift more than 35 lbs/15.9 kg true or false True During any patient transferring task, if a... [Show More] ny caregiver is required to lift a patient who weighs more than 35 lbs/15.9 kg, then the patient should be considered fully dependent, and assistive devices should be used for transfer If a draining wound tests positive for MRSA, the patient is placed on contact precautions True or False True Patients with abscess or draining wounds who tests positive for MRSA are placed on contact precautions 00:26 01:39 Hands can be cleaned with alcohol-based hand rub after caring for a patient with C. diff True or False False Alcohol does not kill C diff spores and soap and water should be used for hand hygiene as recommended by CDC Disaster triage differs from route emergency department triage True or False True Disaster triage categories range from most urgent (first priority), urgent, nonurgent (the walking wounded), and dead/catastrophic/coma. Newborns are fitted with tamperproof security sensors during their stay at the hospital True or False True Wearing a tamper proof safety device reduces the risk of abduction. The sensor shows the location of the infant and the security system can activate other devices (such as cameras, door locks, public address systems, sirens, and other alarms) in the event of an attempted abduction Restraints can be ordered prn by health care providers True or False False HCP are required to specify duration and circumstances for which restraints are required and for how they should be used. Nurses and HCPs must frequently monitor patients to reassess for the continued need for restraints. Sensor pads may be used on beds of individuals who are a fall risk True or False True Bed alarms and sensor pads can be used to alert caregivers when a patient is attempting to get up from a bed or chair, especially for a patient that is at risk for a fall. This is an effective alternative to the use of restraintts The 3 elements of radiation protection are time, duration, and shielding True or False True The farther away people are from a radiation source, the less their exposure; as a rule, if you double the distance, you reduce the exposure by a factor of four. The amount of radiation exposure typically increases with the time people spend near the source of radiation You should quickly remove contaminated clothing by pulling it over your head True or False False Contaminated clothing should never be removed quickly, but it should be cut off instead of pulled over your head. place contaminated clothing inside a plastic bag, seal the bag, and then place inside another plastic bag Standard precautions also includes respiratory/cough etiquette True or False True Standard precautions are used to reduce the risk of transmission of bloodborne and other pathogens from both recognized and unrecognized sources. Respiratory hygiene/cough etiquette is now considered part of standard precautions The nurse is making patient room assignments. In order to minimize the risk of a hospital acquired infection, which of these children would be the most appropriate roommate for a 3-year-old child diagnosed with minimal change disease a. 3 year old with fracture, with a sibling that has Fifth disease b. 2 year old diagnosed with respiratory infection c. 6 year old with sickle cell disease experiencing vaso-occlusive crisis d. 4 year old with bilateral inguinal hernia repair d. 4 year old with bilateral inguinal hernia repair Minimal change disease is a kidney disorder that can lead to nephrotic syndrome. Corticosteroids can cure the disease in most children but cytotoxic therapy and other drugs may be needed, but this treatment can reduce the child's ability to fight infection. The charge nurse must select a roommate who does not have an infection, which is the child child who had surgery. The sickle cell crisis may have triggered an infection. The child's sibling who has a viral disease has the potential to develop an infection. [Show Less]
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Ncsbn nclex rn questions and answers 2023
Tetracycline Taken on empty stomach, not given to children < 8yo bcoz it can stain teeth, not known to cause hearing loss Propranolol Can help con... [Show More] trol essential tremors Potassium iodide Used preoperatively to reduce size & vascularity of thyroid gland Clozapine (Clozaril) Common s/e is extreme salivation (sialorrhea), may increase risk of hyperglycemia Serum albumin Most sensitive measure of nutritional status Normal: 3.4-5.4 g/dl Normal BUN 7-20 mg/dl High risk for CT scan with contrast reaction - (+) pregnancy test - hx of asthma - past rxns to contrast - hx of ❤️, kidney & thyroid dse. - taking beta blockers & metformin - poor renal fxn Earliest s/s of poor oxygenation Increased pulse Late signs of poor oxygenation Abnormal breath sounds & cyanosis Pulsus paradoxus Fall in systolic BP with inspiration > 10mmHg Dressler's syndrome Also called post MI syndrome Digoxin Take pulse for 1 full minute, withhold if < 60 Has had valve surgery? Monitor for arrhythmias & hypotension, long term anticoagulation therapy Tx for pulmonary edema M - Morphine D - Diuretics (furosemide) O - Oxygen G - Gases (blood gases) 3 classic findings of pulmonary stenosis & aortic stenosis Dyspnea, chest pain & syncope - 2nd most common congenital ❤️ defect Cardiac tamponade 3 classic triad of signs: Hypotension Muffled ❤️ sounds Marked jugular vein distention S-T elevation on ECG MI DIC Bleeding, blood clots, bruising and drop in blood pressure Heart failure Dyspnea, fatigue and weakness, edema in legs, ankles, feet Raynaud's phenomenon Sequence of color changes in skin in response to cold or stress Occlusive arterial disease Pain, pallor, paresthesia, pulselessness, paralysis, poikilothermia Sickle cell disease Anemia, episodes of pain, frequent infections A fib Fluttering or thumping sensation in the chest Cardiac tamponade Hypotension, tachycardia with muffled heart sounds and jugular vein distention Hemophilia Excessive bruising, swollen and painful joints, lengthy bleeding Cor pulmonale Cough, exertional dyspnea, fatigue, fainting, swelling of feet or ankles Emphysema Barrel chest, chronic cough, SOB , wheezing & weight loss Tension pneumothorax Chest pain, muffled ❤️ & lung sounds, mediastinal shift, respiratory distress [Show Less]
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NCSBN Practice Questions 31-45 questions and answers 2023
A client is admitted with a diagnosis of myocardial infarction (MI) and reports having chest pain. The nurse provides care based on the knowledge that pain... [Show More] associated with an MI is related to which of the following findings? A. Insufficient oxygenation of the cardiac muscle B. Fluid volume excess C. Arrhythmia D. An electrolyte imbalance A Due to ischemia of the heart muscle, the client will experience pain. This happens because destroyed myocardial tissue can block or interfere with the normal cardiac circulation. Decentralized scheduling is used on a nursing unit. What is the advantage of this management strategy? A. Conserves time spent on planning B. Considers client and staff needs C. Frees the nurse manager to handle other priorities D. Allows requests for special privileges B Decentralized staffing takes into consideration specific client needs and staff abilities and interests. This means the staffing is decided on the lowest level which is at the unit level. 00:29 01:39 Upon entering an adult client's room, the client is found to be unresponsive. After calling for help, what is the next action that should be taken by the nurse? A. Give two rescue breaths B. Deliver five abdominal thrusts C. Maintain an open airway D. Check for a carotid pulse D According to the American Heart Association's basic life support, the first step after determining a victim is unresponsive is to call for help. The next step is to check for a pulse (for no more than 10 seconds). If there is no pulse, the rescuer should begin CPR (30 chest compressions followed by 2 ventilations). A mother, who has been exclusively breastfeeding her 6 month-old, requests more information about meeting the nutritional needs of her infant. What information will the nurse provide? A. Begin a regular schedule of meals and snacks, offering a variety of foods B. Offer finger foods to encourage self-feeding during family meals C. Cut back on the number of times a day the infant receives breastmilk D. Gradually begin adding pureed iron-rich meat and/or cereal as the first foods D The nurse should recommend increasing the number of times a day that complementary foods are offered while continuing to breastfeed. Pureed iron-rich meat, meat alternatives, and/or iron-fortified cereal should be the first complementary foods. After pureed foods, the next transition should be to add strained or mashed foods and then finger foods. From about one year of age, young children begin to have a regular schedule of meals and snacks. The nurse works in the pediatric emergency department. In which situation would a child be treated by using enemas followed by an antitoxin? A. A school-aged child who has swallowed a handful of iron-fortified vitamins B. A toddler who has eaten an undetermined number of ibuprofen tablets C. A preschooler who bit into a laundry detergent pod D. An infant who is diagnosed with botulism D Food-borne botulism can be treated by removing whatever contaminated food is in the stomach by using enemas (or by inducing vomiting) and administering a Botulinum antitoxin. Children with iron poisoning and who are breathing normally can be given a strong laxative fluid; severe poisonings require IV chelation therapy. For NSAID poisoning, sometimes activated charcoal is given (usually within 1 hour of ingestion); massive overdoses may require orogastric lavage because there is no specific antidote for ibuprofen. Since laundry detergent is an alkaline substance, the most commonly used therapy is dilution/irrigation/wash, especially for burns to the skin and eyes. Tracheal intubation with ventilation may be required if the child swallowed the laundry detergent. The client is prescribed a new antipsychotic medication. The nurse is teaching a client about the medication and possible side effects, including tardive dyskinesia (TD). Which statement is true about tardive dyskinesia? A. The high fever, sweating and muscle stiffness will last about one week B. TD occurs within minutes of the first dose of any antipsychotic drug C. The longer someone is treated with an antipsychotic medication, the higher the risk for developing TD D. Almost every client treated with antipsychotic medications will eventually develop TD C The symptoms of tardive dyskinesia (TD) are characterized by random movements of different muscles and the tongue, lips or jaw. Longer treatment with antipsychotic medication, being female, being African American or Asian American are common risk factors for developing TD. Research shows that the overall risk of developing TD is about 30-50%. Decreasing the dose of the antipsychotic or switching antipsychotic medication can help, but there is no cure. Neuroleptic malignant syndrome is a rare and potentially life-threatening reaction to antipsychotic medications, when the client presents with hyperthermia, rigidity and autonomic dysregulation (hypertension, tachycardia, tachypnea, agitation, diaphoresis). A client with schizophrenia receives haloperidol 5 mg three times a day. The client's family is alarmed and calls the clinic nurse when "his eyes rolled upward." The nurse should recognize this finding as what type of side effect? A. Dysphagia B. Nystagmus C. Tardive dyskinesia D. Oculogyric crisis D This refers to involuntary muscles spasm of the eye. There are medications to treat such side effects, for example trihexyphenidyl or benztropine. A nurse is teaching about nonsteroidal anti-inflammatory agents (NSAIDs) to a group of clients diagnosed with arthritis. The nurse should emphasize which of these actions to minimize a side effect of these drugs? A. Continue to take aspirin for short-term pain relief B. Use alcohol in moderation when driving or operating heavy machinery C. Take the medication after meals or with food D. Report joint stiffness in the morning C Taking NSAIDs after meals or with food should help to minimize gastric irritation. The client should also take the medication with a full glass of water and remain in an upright position for 15 to 30 minutes after administration. Clients should be cautioned to avoid concurrent use of aspirin or alcohol with these medications to minimize possible gastric irritation; three or more glasses of alcohol per day may increase the risk of GI bleeding. The nurse is caring for a 14 year-old child in the postanesthesia care unit (PACU) following corrective surgery for scoliosis. Which action should receive priority in the plan? A. Assist to stand up at bedside within the first few hours B. Initiate the antibiotic therapy prescribed for 10 days C. Evaluate the movement and sensation of extremities D. Teach client isometric exercises for the legs C Following corrective surgery for scoliosis, the neurological status of the extremities requires priority attention in the PACU, as well as on the postop surgical unit. The other options may be done after the neurological status. A 35-year-old client of Puerto Rican-American descent is diagnosed with ovarian cancer. The client states, "I refuse both radiation and chemotherapy because they are 'hot.'" Which action should the nurse take next? A. Ask the client to talk about concerns regarding "hot" treatments B. Report the situation to the health care provider C. Document the situation and client response in the notes D. Talk with the client's family about the situation A In Hispanic folk medicine, it is believed that disease is caused by an imbalance between hot and cold principles. Health is maintained by avoiding exposure to extreme temperatures and by consuming appropriate foods and beverages. Examples of "hot" diseases or states include pregnancy, hypertension, diabetes and indigestion. "Cold" diseases include pneumonia. These designations are symbolic and do not necessarily indicate temperature or spiciness. Care and treatment regimens can often be negotiated with clients within this framework. Also note that the correct response is the best answer because it is client-centered. The client is seen in the emergency one day after falling in his bathroom at home. The client reports having "a few drinks" prior to the fall. Which finding requires the nurse's immediate attention? A. Bruise behind one ear B. Blurred vision C. Nausea and vomiting D. Headache A Bruising behind one ear (over the mastoid process) requires the nurse's immediate attention. Known as "Battle's sign", this injury is seen a day or so following a basilar skull fracture. A CT scan of the brain will confirm a skull fracture. The client may report loss of hearing, smell or vision and he may have blood leaking from the ear. The vomiting and headache could be due to his alcohol intake, as well as the skull fracture. The parents of a 2 year-old child report that the child has been holding the breath during temper tantrums. What is an appropriate approach for the response by a nurse? A. Recommend that the parents give in when the child holds the breath to prevent anoxia B. Advise the parents to ignore breath holding because breathing will begin as a reflex C. Instruct the parents on how to reason with the child about possible harmful effects D. Teach the parents how to perform cardiopulmonary resuscitation B If temper tantrums are accompanied by breath holding, the parents need to know that this behavior will not result in harm to the child. Ignoring the breath holding is the best response to this benign behavior. 00:02 01:39 The nurse enters a client's room just as the client begins to experience a generalized tonic clonic seizure. What action should the nurse take? A. Place the client on one side B. Elevate the head of the bed C. Hold the client's arms at the side D. Insert a padded tongue blade in client's mouth A Clients should be positioned on their side. This position keeps the airway patent and allows saliva to drain from the mouth, which prevents aspiration. The nurse should also protect the client from injury by clearing furniture (if the client is on the floor). The client should not be restrained nor should anything be forced in the client's mouth. Which statement by an older adult with chronic obstructive lung disease (COPD) indicates an understanding of the major reason to use pursed-lip breathing for episodes of dyspnea? A. "This position of my lips helps to keep my lungs open." B. "I can breathe better when I pucker up my lips because I can control how fast I breathe in and out." C. "I can breathe better using pursed-lip breathing because less air will be trapped in my chest." D. "My mouth doesn't get as dry when I breathe with pursed lips." C Clients with chronic obstructive pulmonary disease (COPD) have difficulty exhaling fully as a result of air trapping in the alveoli due to the weakened alveolar walls from the disease process. Alveolar collapse can be avoided with the use of pursed-lip breathing, allowing the client to exhale more effectively. This technique facilitates appropriate gas exchange as carbon dioxide-rich air that has been trapped in the lungs is blown off, allowing oxygen-rich air to be inhaled. This is the major reason to use pursed-lip breathing. The other options are additional beneficial effects of this breathing technique. A staff nurse complains to the nurse manager that an unlicensed assistive personnel (UAP) consistently leaves the work area untidy and does not restock supplies. The initial response by the nurse manager should be which of these statements? A. "I would like for you to approach the UAP about the problem the next time it occurs." B. "I can assure you that I will look into the matter in due time." C. "I will add this concern to the agenda for the next unit meeting so we can discuss it." D. "I will arrange for a conference with you and the UAP within the next week" A Part of the manager's role is to help the staff manage conflict among themselves. It is appropriate to urge the nurse to confront the other staff member to work out problems without a manager's intervention when possible. This is an approach at the first level of management. If the two staff members cannot resolve the issue then the manager would have a conference with the two staff to facilitate a negotiation for a win-win result. Which of these client's behaviors would indicate that the nurse-client relationship has passed from the orientation phase to the working phase? A. Identifies feelings about situations and expresses them appropriately B. Revitalizes a relationship with the family to help cope with the death of a child C. Expresses a desire to be cared for and pampered D. Recognizes regressive behaviors as a defense mechanism A The working phase of the nurse-client relationship is also called exploration or the identification stage. That's because the client identifies his/her problems and works with the nurse to solve problems and develop coping skills, a positive self concept and, eventually, independence. These skills will help the client to adapt and behave more appropriately. A client is scheduled for a CT scan with contrast. What interventions should be taken by the nurse prior to sending the client to the imaging department? (Select all that apply.) A. Reassess the client's allergies B. Administer prescribed medication to sedate the client C. Confirm that a signed consent is in the chart D. Ask the client to remove all metal jewelry E. Ensure the client is well-hydrated A,C,D Usually the client is NPO prior to a CT scan, particularly when contrast material is being used. Allergies and past reactions to contrast media should be reviewed with the client. Any metal, including body piercings, jewelry, hearing aids and removable dental work should be removed and safely stored prior to the test. Sedation is necessary only in cases of extreme anxiety. A client reports bilateral knee pain from osteoarthritis and is taking the prescribed nonsteroidal anti-inflammatory drug (NSAID). The nurse should instruct the client to make which lifestyle change to manage this condition? A. Avoid foods high in citric acid B. Start a regular exercise program C. Rest the knees as much as possible D. Keep the legs elevated when sitting B A regular exercise program is beneficial in the treatment of osteoarthritis. It can restore self-esteem and improve physical functioning. The nurse is preparing a client diagnosed with deep vein thrombosis (DVT) for a venous doppler evaluation. Which of these actions should be necessary to prepare the client for this test? A. Determine if the client has any allergies to the contrast material B. Ask client not to eat or drink anything after midnight C. Administer a sedating medication prior to the test D. Ensure the client is wearing a hospital gown prior to the test D A venous doppler examination uses ultrasound to create a 2-dimensional picture of the veins in the legs. The purpose is to detect blood clots. This is a noninvasive test and does not require sedation; a venography would require injecting contrast material into a vein. The client may eat or drink prior to the test. During a nursing staff meeting, there is discussion of perceived inequities in weekend staff assignments. As a follow-up, the nurse manager should initially take which action? A. Help staff see the complexity of issues B. Facilitate creative thinking about staffing C. Allow the staff to change assignments D. Clarify reasons for current assignments B The manager, as a change agent, can facilitate the staff's solving the problem. Referred to as the "moving phase" of Lewin's change theory, the problem is first viewed from a different perspective and a variety of solutions are examined and decided upon; a new approach for weekend assignments can then be tried out. [Show Less]
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NCSBN- Post Test A-L correctly answered 2023
A nurse is caring for a 69 year-old client with end stage renal disease. What action should the nurse take to assess for patency in a fistula used for hemo... [Show More] dialysis? a. Irrigate with 5 mL of 0.9% normal saline b. Palpate for a thrill over the fistula c. Observe for edema proximal to the site d. Feel for a bruit over the fistula . Palpate for a thrill over the fistula The RN is working in a clinic where a client presents with a painful, blistering rash on the hip. The health care provider diagnoses shingles (herpes zoster). What is the priority nursing diagnosis? a.Knowledge deficit related to disease process b.Pain related to nerve root inflammation and skin lesions c. Risk for infection related to skin lesions d. Risk for impaired skin integrity related to skin lesions b.Pain related to nerve root inflammation and skin lesions 00:52 01:39 A 2 year-old child is brought to the emergency department at 2:00 pm. The mother states: "My child has not had a wet diaper all day." The child is pale, with a heart rate of 132 beats per minute. What other assessment data would the nurse obtain next to help determine an admitting diagnosis? a. History of fluid intake b. Dietary patterns in the past 48 hours c. Description of play activity d. Status of the eyes and the tongue d. Status of the eyes and the tongue A nurse from the mental health unit is reassigned to the pediatrics unit and will be caring for a child with asthma. Which of these findings would the charge nurse emphasize as the first thing to indicate a worsening condition in the child? a. Increased need to use bronchodilators b. A downward trend in peak flow rates as measured by a peak flow meter c. Coughing, especially if the cough is frequent and occurs in spasms d. An audible whistling or wheezing when the child exhales b. A downward trend in peak flow rates as measured by a peak flow meter A nurse is assessing a client who is cachectic and has developed an enterocutaneous fistula following surgery to relieve a small bowel obstruction. The client's total protein level is reported as 4.5 g/dL. Which approach to therapy should the nurse anticipate? a. Total parenteral nutrition (TPN) via central line b. Blood for coagulation studies daily c. Additional potassium via IV administration d. Serum lipase levels every 12 hours a. Total parenteral nutrition (TPN) via central line The nurse is working in a community health clinic answering telephone calls. Which client would the nurse recommend to be seen immediately by a health care provider? a. "I started my period and now my urine has turned bright red." b. "I was started on some medicine yesterday for a urine infection and now my lower belly hurts when I go to the bathroom." c. "I went to the bathroom and my urine looked very red but it didn't hurt when I went." d. "I am an diabetic and today I have been going to the bathroom every hour." c. "I went to the bathroom and my urine looked very red but it didn't hurt when I went." The nurse works in an ambulatory care clinic where there are four children with gastrointestinal findings waiting to be seen by the health care provider. Which child is at greatest risk for developing metabolic acidosis? a. The child who has been vomiting for more than 48 hours b. The child with nausea and anorexia c. The child with severe diarrhea for 24 hours d. The child with alternating constipation and diarrhea c. The child with severe diarrhea for 24 hour A client comes into the community health center upset and crying, stating: "I will die of cancer now that I have this disease." The client hands the nurse a piece of paper with the word "pheochromocytoma" written on it. What would be the best initial response by the nurse? a. "You probably have had episodes of sweating, heart pounding and headaches. Is that correct?" b. "Pheochromocytomas are usually noncancerous, but they do need to be treated to avoid complications." c. "This problem is diagnosed by blood and urine tests that reveal elevated levels of adrenaline and noradrenaline." d. "Computerized tomography (CT) or magnetic resonance imaging (MRI) are used to detect an adrenal tumor." b. "Pheochromocytomas are usually noncancerous, but they do need to be treated to avoid complications." The nurse is providing care to a client who has just received an epidural for anesthesia during labor. The nurse recognizes which of the following as the most important nursing intervention following this procedure? a. Monitor maternal blood pressure for possible hypotension b. Reduce the intravenous fluid infusion to a keep open rate c. Monitor the fetus for possible tachycardia d. Monitor maternal pulse for possible bradycardia a. Monitor maternal blood pressure for possible hypotension A nurse is assessing a newborn infant and observes low-set ears, short palpebral fissures, flat nasal bridge and indistinct philtrum. What priority focus in the maternal history should the nurse ask about? a. Alcohol use during pregnancy b. Maternal and paternal ages c. Family genetic disorders d. Use of vitamins and supplements during pregnancy a. Alcohol use during pregnancy A 3 year-old child is brought to the health clinic. The grandmother reports that the child is always "scratching his bottom" and is "extremely irritable." Based on this information, which health issue would the nurse assess for initially? Ringworm Scabies Allergies Pinworm Pinworm The nurse is caring for a client with urinary incontinence. The client asks the nurse about the use of biofeedback to treat this condition. What is the most appropriate response by the nurse? a. "Biofeedback has not been shown to be very helpful for urinary incontinence problems." b. "Surgery is generally needed in order to produce any real improvement." c. "Medications are the approved method of treating this type of problem." d. "This type of treatment has been used successfully to manage urinary incontinence." d. "This type of treatment has been used successfully to manage urinary incontinence." The nurse is caring for a client in the coronary care unit who has developed acute renal failure as a consequence of cardiogenic shock. Which of the following findings are consistent with the diagnosis? (Select all that apply.) Oliguria Jugular vein distention Crackles on auscultation in bilateral bases Weight loss Pitting sacral edema Oliguria Jugular vein distention Crackles on auscultation in bilateral bases Pitting sacral edema Findings related to fluid retention and heart failure are expected, because the kidneys are unable to function properly due to a decrease in glomerular filtration rate and tubular necrosis. In the bed-bound client, pitting sacral edema would be seen, since fluid follows gravity. Weight gain, jugular vein distention, oliguria and crackles in the lungs would also be expected with fluid overload in this client. Treatment consists of diuresis, with a possible small fluid challenge, if the client can tolerate it, to correct pre-renal azotemia. If these options are not effective or inappropriate for the client, dialysis or ultrafiltration may be used to remove excess fluid. In many cases, this type of treatment is temporary, and can be stopped as the kidney function improves with improved urine output and decreasing creatinine levels. The client has undergone a dilation and curettage (D & C) following a spontaneous abortion at 8 weeks. To promote an optimal recovery, what information should the nurse include in the discharge teaching? (Select all that apply.) a. Expect heavy bleeding for at least a week b. Use sanitary pads until vaginal bleeding has stopped c. Strenuous sport activities should be postponed until bleeding stops d. Resume vaginal intercourse 6 weeks after the procedure e. Referral for grief counseling b. Use sanitary pads until vaginal bleeding has stopped c. Strenuous sport activities should be postponed until bleeding stops . Referral for grief counseling A family arrives at the emergency department. A parent believes the child ingested an undetermined number of acetaminophen tablets approximately 1 hour ago. The serum acetaminophen level confirms acute poisoning. Which of these orders should be implemented first? Oral activated charcoal therapy N-acetylcysteine (NAC) (Mucomyst) Ondansetron (Zofran) 0.1 mg/kg for nausea Consultation with a medical toxicologist N-acetylcysteine (NAC) (Mucomyst) [Show Less]
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NCSBN test bank Questions 1-15 with correct answers 2023
Which individual is at greatest risk for the development of hypertension? A. 40 year-old Caucasian nurse B. 60 year-old Asian-American shop owner C. 4... [Show More] 5 year-old African-American attorney D. 55 year-old Hispanic teacher C The incidence of hypertension is greater among African-Americans than other groups in the United States. The incidence among the Hispanic population is rising. A woman, who delivered five days ago and who had been diagnosed with pregnancy induced hypertension (PIH), calls a hospital triage nurse hotline to ask for advice. She states, "I have had the worst headache for the past two days. It pounds and by the middle of the afternoon everything I look at looks wavy. Nothing I have taken helps." What should the nurse do next? A. Advise the client to have someone bring her to the emergency room as soon as possible B. Ask the client to explain what she has taken and how often, and then evaluate other specific complaints C. Advise the client that the swings in her hormones may be the problem; suggest that she call her health care provider D. Ask the client to stay on the line, get the address, and send an ambulance to the home D The woman is at risk for seizure activity. The ambulance needs to bring the woman to the hospital for evaluation and treatment. For at-risk clients, PIH may progress to preeclampsia and eclampsia prior to, during, or after delivery; this may occur up to 10 days after delivery. There's a new medication order that reads: "administer 1 gtt ciprofloxacin solution OD Q 4 h" What action should the nurse take? A. Squeeze one drop of the medication in the left eye every 4 hours B. Apply one drop in the right ear every 4 hours C. Call the prescriber to clarify and rewrite the order D. Ask other nurses for their interpretation of the order C Abbreviations, symbols and dose designations can be misinterpreted and lead to medication errors. "OD" can mean "right eye" (oculus dexter) or "once daily"; it should never be used when communicating medical information. The abbreviation "Q" should be written out as "every." Although "gtt" is not on the official "Do Not Use List", it's best to use "drop" instead. Asking other nurses to interpret an order is a potentially dangerous "workaround." The nurse should call the health care provider who prescribed the medication and clarify the order. A client expresses anger when a call light is not answered within five minutes. The client demanded a blanket. How should the nurse respond? A. "I see this is frustrating for you. I have a few minutes so let's talk." B. "I am surprised that you are upset. The request could have waited a few more minutes." C. "Let's talk. Why are you upset about this?" D. "I apologize for the delay. I was involved in an emergency." A This is the best response because it gives credence to the client's feelings and then concerns. To say "let's talk" and ask a why question is not a therapeutic approach because it does not acknowledge or validate the client's feelings. To apologize and not notice the client's feelings is inappropriate. To say it could have waited a few minutes is rude and non-accepting of the client's verbalized needs. The clinic nurse is assisting with medical billing. The nurse uses the DRG (Diagnosis Related Group) manual for which purpose? A. Determine reimbursement for a medical diagnosis B. Identify findings related to a medical diagnosis C. Classify nursing diagnoses from the client's health history D. Implement nursing care based on case management protocol DRGs are the basis of prospective payment plans for reimbursement for Medicare clients. Other insurance companies often use it as a standard for determining payment. A nurse is planning care for a 2 year-old hospitalized child. Which issue will produce the most stress at this age? A. Fear of pain B. Separation anxiety C. Loss of control D. Bodily injury B While a toddler will experience all of the stresses, separation from parents is the major stressor. Separation anxiety peaks in the toddler years. The nurse receives a client from the post anesthesia care unit following a left femoral-popliteal bypass graft procedure. Which of the following assessments requires immediate notification of the health care provider? A. Left foot is cool to the touch B. Absent left pedal pulse using Doppler analysis C. Inability to palpate the left pedal pulse D. Acute pain in the left lower leg B Although the inability to palpate the left pedal pulse, a cool extremity, and increased pain in the left lower leg are important findings, they all require additional nursing assessment prior to contacting the health care provider. In clients without palpable pedal pulses, the next step in the assessment is to perform a Doppler analysis. The inability to locate the left pedal pulse using the Doppler analysis requires immediately notifying the health care provider. The nurse is reviewing the laboratory results for several clients. Which of the laboratory result indicates a client with partly compensated metabolic acidosis? A. PaCO2 30 mm Hg B. Hemoglobin 15 g/dL (150 g//L) C. Sodium 130 mEq/L (130 mmol/L) D. Chloride 100 mEq/L (100 mmol/L) A Metabolic acidosis can be caused by many conditions, including renal failure, shock, severe diarrhea, dehydration, diabetic acidosis, and salicylate poisoning. With metabolic acidosis, you should expect a low pH (less than 7.35) and a low HCO3 (less than 22 mEq/L.) Compensation means the body is trying to get the pH back in balance; therefore, a pure metabolic acidosis should elicit a compensatory decrease in PaCO3 (normal is 35-45 mm Hg.) The hemoglobin is within normal limits (WNL) for both males and females. The chloride and sodium results are also WNL. A nurse is teaching a group of adults about modifiable cardiac risk factors. Which of the following should the nurse focus on first? A. Weight reduction B. Stress management C. Smoking cessation D. Physical exercise C Smoking cessation is the priority for clients at risk for cardiac disease. Smoking's effects result in reduction of cell oxygenation and constriction of the blood vessels. All of the other factors should be addressed at some point in time. The client is admitted to an ambulatory surgery center and undergoes a right inguinal orchiectomy. Which option is the priority before the client can be discharged to home? A. Able to tolerate a regular diet B. Post-operative pain is managed C. Psychological counseling is scheduled D. Able to ambulate in the hallway with assistance B An orchiectomy is the surgical removal of one or both testicles. It is usually performed to treat cancer (testicular, prostate or cancer of the male breast), but it may also be performed to prevent cancer (with an undescended testicle.) Due to the location of the incision, pain management is the priority. Most men will be able to eat regularly when they get home; they should at least tolerate liquids before discharge. It's important that the client is able to get up and walk with assistance, but this is not the priority. Psychological counseling may be needed as part of long-term aftercare, but this is not an immediate priority. A client is transported to the emergency department after a motor vehicle accident. When assessing the client 30 minutes after admission, the nurse notes several physical changes. Which finding would require the nurse's immediate attention? A. Increased restlessness B. Tachypnea C. Tachycardia D. Tracheal deviation D Tracheal deviation is a sign that a mediastinal shift has occurred, most likely due to a tension pneumothorax. Air escaping from the injured lung into the pleural cavity causes pressure to build, collapsing the lung and shifting the mediastinum to the opposite side. This obstructs venous return to the heart, leading to circulatory instability and may result in cardiac arrest. This is a medical emergency, requiring emergency placement of a chest tube to remove air from the pleural cavity relieving the pressure. A client has a chest tube inserted immediately after surgery for a left lower lobectomy. During the repositioning of the client during the first postop check, the nurse notices 75 mL of a dark, red fluid flowing into the collection chamber of the chest drain system. What is the appropriate nursing action? A. Continue to monitor the rate of drainage B. Call the surgeon immediately C. Check to see if the client has a type and cross match D. Turn the client back to the original position A It is not unusual for blood to collect in the chest and be released into the chest drain when the client changes position this soon after surgery. The dark color of the blood indicates it is not active bleeding inside of the chest. Sanguinous drainage should be expected within the initial 24 hours postop, progressing to serosanguinous and then to a serous type. If the drainage exceeds 100 mL/hr, the nurse should call the surgeon. The client with a T-2 spinal cord injury reports having a "pounding" headache. Further assessment by the nurse reveals excessive sweating, rash, pilomotor erection, facial flushing, congested nasal passages and a heart rate of 50. What action should the nurse take next? A. Assist client with relaxation techniques B. Measure the client's respirations, blood pressure, temperature and pupillary responses C. Check the client for bladder distention and the urinary catheter for kinks D. Place the client into the bed and administer the ordered PRN analgesic C These are findings of autonomic dysreflexia, also called hyperreflexia. This response occurs in clients with a spinal cord injury above the T-6 level. It is typically initiated by any noxious stimulus below the level of injury such as a full bladder, an enema or bowel movement, fecal impaction, uterine contractions, changing of the catheter and vaginal or rectal examinations. The stimulus creates an exaggerated response of the sympathetic nervous system and can be a life-threatening event. The BP is typically extremely high. The priority action of the nurse is to identify and relieve the cause of the stimulus. A child is treated with succimer for lead poisoning. Which of these assessments should the nurse perform first? A. Check serum potassium level B. Check blood calcium level C. Test deep tendon reflexes D. Check complete blood count (CBC) with differential D Succimer (Chemet) is used in the management of lead or other heavy metal poisoning. Although it has generally well tolerated and has a relatively low toxicity, it may cause neutropenia. Therapy should be withheld or discontinued if the absolute neutrophil count (ANC) is below 1200/µ. A client with a diagnosis of methicillin-resistant Staphylococcus aureus (MRSA) has died. Which type of precautions is appropriate to use when performing postmortem care? A. Contact precautions B. Droplet precautions C. Compromised host precautions D. Airborne precautions A The resistant bacteria remain alive for up to three days after the client dies. Therefore, contact precautions must still be used. The body should also be labeled as MRSA-contaminated so that the funeral home staff can protect themselves as well. Gown and gloves are required. The client is diagnosed with cystic fibrosis (CF). The nurse would expect the client to be treated with oral pancreatic enzymes and which type of diet? A. High fat, high-calorie B. Gluten-free, low fiber C. Dairy-free D. Sodium-restricted A CF affects the cells that produce mucus, sweat and digestive juices. Someone with CF needs a high-energy diet that includes high-fat and high-calorie foods, extra fiber to prevent intestinal blockage and extra salt (especially during hot weather.) People with CF are at risk for osteoporosis and need calcium and dairy products. Someone with celiac disease or with a gluten intolerance, not CF, needs a gluten-free diet. The nurse is assessing a 4 year-old child who is in skeletal traction 24 hours after surgical repair of a fractured femur. The child is crying and reports having severe pain. The right foot is pale and there is no palpable pulse. What action should the nurse take first? A. Notify the health care provider B. Administer the ordered PRN medication C. Reassess the extremity in 15 minutes D. Readjust the traction for comfort A Pain and absence of a pulse within 48-72 hours after a severe injury to an extremity suggests acute compartment syndrome. This condition occurs when there's a build up of pressure within the muscles; this pressure decreases blood flow and can cause muscle and nerve damage. Acute compartment syndrome is a medical emergency. Surgery is needed immediately; delaying surgery can lead to permanent damage to the extremity. A 67 year-old client is admitted with substernal chest pressure that radiates to the jaw. The admitting diagnosis is acute myocardial infarction (MI). What should be the priority nursing diagnosis for this client during the first 24 hours? A. Altered tissue perfusion B. Activity intolerance C. Anxiety D. Risk for fluid volume excess A In the immediate post MI period, altered tissue perfusion is priority, as an area of myocardial tissue has been damaged by a lack of blood flow and oxygenation. Interventions should be directed toward promoting tissue perfusion and oxygenation. The other problems are also relevant, but tissue perfusion is the priority. The nurse is examining a 2 year-old child with a tentative diagnosis of Wilm's tumor. The nurse would be most concerned about which statement by the mother? A. "Urinary output seems to be less over the past two days." B. "The child prefers some salty foods more than others." C. "My child has lost three pounds in the last month." D. "All the pants have become tight around the waist." A Wilm's tumor is a malignant tumor of the kidney that can lead to kidney dysfunction; therefore, a recent decrease in urinary output should be investigated further as it may be a sign of renal dysfunction. Increasing abdominal girth is a common finding in Wilm's tumor, but does not require immediate intervention by the nurse. An external disaster has occurred in the town. The triage nurse from the emergency department is transported to the site and assigned to triage the injured. Which of these clients would the nurse tag as "to be seen last" by the providers at the scene? A. An older adult person with a open fracture of the left arm B. An infant with bilateral fractured lower legs with no active bleeding C. A teenager with small amount of bright red blood dripping out of the nose D. A middle-aged person with deep abrasions that are over 90% of the body D The clients that are least likely to survive are to be tagged as the "last to be seen." Deep abrasions are usually treated as second or third degree burns because the fluid loss is great. Today's prothrombin time for a client receiving warfarin 20 seconds. The normal range listed by the lab is 10 to 14 seconds. What is an appropriate nursing action? A. Recognize that this is a therapeutic level B. Assess for bleeding gums or IV sites C. Notify the health care provider immediately D. Observe the client for hematoma development A For the client on warfarin therapy, this prothrombin level is within the therapeutic range. Therapeutic levels for warfarin are usually 1 1/2 to 2 times the normal levels. The nurse is teaching the client with chronic renal failure (CRF) about medications. The client questions the purpose of taking aluminum hydroxide. What is the best explanation for the nurse to give the client about the therapeutic effects of this medication? A. Amphojel increases urine output B. It decreases serum phosphate C. The drug is taken to control gastric acid secretion D. It will reduce serum calcium B Aluminum binds phosphates that tend to accumulate in the client with chronic renal failure due to decreased filtration capacity of the kidney. Antacids such as Amphojel are commonly used to decrease serum phosphate. The nurse is caring for a client diagnosed with acute angina. The client is receiving an intravenous infusion of nitroglycerin. What is the priority assessment during this treatment? A. Heart rate B. Neurologic status C. Urine output D. Blood pressure D The vasodilatation that occurs as a result of this medication can cause profound hypotension. The client's blood pressure must be evaluated every 15 minutes until stable, and then every 30 minutes to every hour thereafter. Clients receiving IV nitroglycerin also require continuous ECG monitoring. The nurse is caring for a client in the late stages of amyotrophic lateral sclerosis (ALS). Which finding would the nurse expect? A. Confusion B. Loss of half of visual field C. Tonic-clonic seizures D. Shallow respirations D ALS is a chronic progressive neurodegenerative disease that affects nerve cells in the brain and spinal cord. In ALS, upper and lower motor neurons degenerate (die) and stop sending messages to muscles; all muscles under voluntary control eventually weaken and atrophy. People eventually lose their ability to speak, eat, move and breathe. However, ALS does not impair a person's mind or intelligence. ALS does not affect a person's ability to see, smell, taste, hear or recognize touch. During assessment of orthostatic vital signs on a client with cardiomyopathy, the nurse finds that the systolic blood pressure (BP) decreased from 145 to 110 mm Hg between the supine and upright positions while the heart rate (HR) rose from 72 to 96 beats per minute. In addition, the client reports feeling lightheaded when standing up. The nurse should implement which of the following actions? A. Increase fluids that are high in protein B. Instruct client to increase fluid intake for several hours C. Instruct the client to increase fluid intake for the next two days D. Restrict fluids for the next few hours B This client is experiencing postural hypotension, a decrease in systolic blood pressure 15 mm Hg accompanied by an increase in heart rate 15 to 20 beats above the baseline with a change in position from supine to upright. This is often accompanied by lightheadedness. Fluid replacement is appropriate, but must be instituted very cautiously, as this client with cardiomyopathy will also be very sensitive to changes in fluid status and fluid overload may develop rapidly with aggressive rehydration. After the client increases fluid intake for one to two hours, the client should be reassessed for resolution of the postural hypotension. The client, who is receiving chemotherapy through a central venous access device (CVAD) at home, is admitted to the intensive care unity (ICU) with a diagnosis of sepsis. Which of the following nursing interventions is the priority? A. Restrict contact with persons having known, or recent, infections B. Change the dressing over the site of the existing CVAD C. Insert an indwelling catheter D. Prepare the client for insertion of a new CVAD D Many cases of sepsis occur in immunocompromised clients and clients with chronic and debilitating diseases. Since it's likely the existing CVAD is the source of the infection, it should be cultured and removed. A new central line (usually an internal jugular or subclavian) needs to be inserted since large amounts of IV fluids are needed to restore perfusion. The new central line will also allow venous access for labs, medications and measuring central venous pressure. Together with central venous pressure monitoring, an indwelling urinary catheter will help guide fluid volume replacement. Many hospitals have restrictions on visitors with known or recent infections to help protect all clients. The client is scheduled for coronary artery bypass. Based on principles of teaching and learning, what is the best initial approach by the nurse during pre-op teaching? A. Tour the coronary intensive unit B. Mail a videotape to the home C. Assess the client's learning style D. Administer a written pretest C As with any anticipatory teaching, assessment of the client's level of knowledge and learning style should occur first. If possible, the three senses of hearing, seeing and touching should be used during any teaching to enhance recall. The nurse is caring for a client who is in the advanced stage of multiple myeloma. Which action should be included in the plan of care? A. Careful repositioning B. Administer diuretics as ordered C. Place in protective isolation D. Monitor for hyperkalemia A Multiple myeloma occurs when abnormal plasma cells (myeloma cells) collect in several bones. This disease may also harm other tissues and organs, especially the kidneys. This type of cancer causes hypercalcemia, renal failure, anemia,and bone damage. Because multiple myeloma can cause erosion of bone mass and fractures, extra care should be taken when moving or positioning a client due to the risk of pathological fractures. [Show Less]
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NCSBN Practice Questions 76-90 questions with complete solutions 2023/2024
An 18 month-old weighing 22 pounds is admitted to the pediatric unit with a diagnosis of dehydration. A replacement bolus of normal saline at 20 mL/kg is o... [Show More] rdered to be administered intravenously over 40 minutes. In mL/hour, what will be the setting for the IV delivery system? 300 Using ratio proportion:First, convert 22 pounds to kilograms (22/2.2) = 10 kg20 mL/kg = 20 x 10 kg = 200 mL200 mL/40 minutes = x mL/60 minutes (in an hour)200 x 60 = 12000/40 = 300 mL/hrUsing dimensional analysis:20 mL/kg x 1 kg/2.2 lb x 22 lb x 60 min/hr x 1/40 min = 300 mL/hr The mother of a 2 month-old baby calls a pediatrician's nurse two days after the first DTaP, inactivated polio vaccine (IPV), Hepatitis B and Haemophilus influenzae type B (HIB) immunizations. She reports that the baby feels very warm, cries inconsolably for as long as three hours, and has had several shaking spells. Which immunization would the nurse expect to be primarily responsible with these findings? A. DTaP B. IPV C. Hepatitis B D. HIB A DTaP immunization is a vaccine that protects against diptheria, tetanus and pertussis (whooping cough). The majority of reactions described in this question occur with the administration of the DTaP vaccination. Contraindications to giving repeat DTaP immunizations include the occurrence of severe side effects after a previous dose, as well as signs of encephalopathy within seven days of the immunization. 00:26 01:39 A client diagnosed with angina has been instructed about the use of sublingual nitroglycerin. Which statement made by the client is incorrect and indicates a need for further teaching? A. "I'll call the health care provider if pain continues after three tablets five minutes apart." B. "I will rest briefly right after taking one tablet." C. "I understand that the medication should be kept in the dark bottle." D. "I can swallow two or three tablets at once if I have severe pain." D Clients must understand that just one sublingual tablet should be taken at a time and placed under the tongue. After rest and a five-minute interval, a second and then eventually a third tablet may be necessary. The nurse is working with victims of domestic abuse. The nurse should understand which of these factors is a reason why domestic violence or emotional abuse remains extensively undetected? A. The expenses due to police and court costs are prohibitive B. Little knowledge is known about batterers and battering relationships C. There are typically many series of minor, vague complaints D. Few people who have been battered seek medical care C Signs of domestic violence or emotional abuse may not be clearly manifested and include many series of a minor complaints such as headache, abdominal pain, insomnia, back pain and dizziness. These may be covert indications of violence or abuse that go undetected. These complaints may be vague and reflect ambivalence about the disclosure of any violence or abuse. The nurse is obtaining an aerobic wound culture from a client with stage two pressure injury. The nurse first removes a gauze dressing and observes a moderate amount of purulent drainage on the dressing and then the nurse performs hand hygiene. What is the next correct step in the procedure? A. Swab the gauze dressing that was removed from the wound B. Irrigate the wound with normal saline C. Obtain a culture by rotating a sterile swab in the open wound D. Remove wound exudate from the wound edges with a cotton tip applicator B After removing the dressing and performing hand hygiene, the wound needs to be irrigated to remove surface pathogens before the nurse can obtain a wound culture. Cultures are not obtained from wound exudate on the dressing or wounds that have not been irrigated since the exudate may be contaminated with normal skin flora. The nurse is caring for a client who is experiencing frightening hallucinations that are markedly increased at night. The client's partner asks to stay a few hours beyond the visiting time, in the client's private room. What would be the best response by the nurse? A. "Yes, staying with the client and orienting the client to the surroundings may decrease any anxiety." B. "No, your presence may cause the client to become more anxious." C. "No, it would be best if you brought the client some reading material that the client could read at night." D. "Yes, would you like to spend the night when the client's behavior indicates that the client is or will be frightened?" A Encouragement of a family member or a close friend to stay with the client in a quiet surrounding cannot only help increase orientation, but can also minimize confusion and anxiety. The visitor could also report to the nurse any unusual findings of the client. This would be the most supportive approach for this client. The RN, who is functioning as the charge nurse, needs to determine shift assignments. How will the charge nurse determine which client assignments are appropriate for the licensed practical nurse (LPN)? A. Ask the LPN about prior experience caring for clients with similar diagnoses B. Determine how many nursing assistants are available to help the LPN with client care C. Refer to the list of technical tasks LPNs are trained to perform D. Review the procedure manual with the LPN prior to making an assignment A The definition of assignment is the routine care, activities and procedures that are within the authorized scope of practice of the RN or LPN/LVN. The RN must determine the needs of the clients and make assignments not only based on scope of practice, but also education, demonstrated competency and skill level. Regardless if the LPN received education and training to perform specific skills, the RN needs to determine the LPN's experience with caring for clients with similar diagnoses. While the RN is responsible for ensuring an assignment given to a delegatee is carried out completely and correctly, the LPN must be able to perform the skills or tasks independently. The nurse is caring for a school-aged child with a diagnosis of secondary hyperparathyroidism after treatment for chronic renal disease. Which serum lab data should receive priority attention by the nurse? A. Osmolality and sodium B. Blood urea nitrogen and magnesium C. Calcium and phosphorus D. Glucose and potassium C The parathyroid regulates the calcium and phosphorus serum levels. Calcium and phosphorous levels will be elevated in hyperfunction of this gland until the client is stabilized. To recall this information think of a see-saw. Associate that calcium is first in the alphabet and thus calcium follows the direction of the abnormality - hyper or hypo function - of the parathyroid. Put the calcium on one side and the phosphorus on the other side of the see-saw. The nurse is caring for a client who just had a central venous catheter line inserted at the bedside. Which of these assessments requires immediate attention by the nurse? A. Pallor in the extremities B. Increased temperature by one degree C. Involuntary coughing spells D. Dyspnea at rest D Complications of central catheter insertion include pneumothorax and hemothorax. Air embolism is another potential complication. Dyspnea, shallow respirations, sudden sharp chest pain that worsens with coughing or deep breathing are indications of pneumothorax. Other potential complications of central catheters may include thrombosis, local or systemic infection, or even cardiac tamponade (if the central line perforates the heart). When considering the options listed, the client who is dyspneic after central line insertion would be the greatest concern for the nurse. The nurse is providing preprocedural education to the client preparing for a barium enema. What statement made by the client indicates a need for further education? A. "I will need to drink plenty of fluids and eat foods high in fiber after the procedure." B. "I will use the prescribed laxative before the procedure." C. "I will not eat or drink anything after midnight before the procedure." D. "A barium enema is used to examine the upper and lower GI tracts." D A barium enema involves filling the large intestine (lower GI tract) with diluted barium liquid while x-ray images are taken. After the procedure, a small amount of barium will be immediately expelled and the remainder will be excreted in the stool. Because barium liquid may cause constipation, clients should eat foods high in fiber and drink plenty of fluids to help expel the barium from the body. A client admitted with heart failure is experiencing severe shortness of breath and states, "I feel like something is terribly wrong!" The client is restless and begins to cough up large amounts of pink frothy sputum. The client's skin is a dusky grayish color and the oxygen saturation levels have decreased from 92% to 76% in the last hour. What is the first action the nurse should take? A. Check vital signs B. Administer the PRN ordered oxygen C. Call the health care provider D. Place the bed in high Fowler's position B When dealing with a medical emergency, the rule is to assess airway first, then breathing, and then circulation. Starting oxygen is the priority. The other actions should also be implemented as quickly as possible, including activation of the rapid response team. The client is experiencing an acute episode of fulminant pulmonary edema, likely as a result of a new and severe cardiac event and possible cardiogenic shock. Emergency assessment and intervention is indicated to prevent cardiac arrest and possible death. There is an order for a continuous lidocaine infusion at a rate of 4 mg/minute to treat PVCs. The IV solution contains 2 grams of lidocaine in 500 mL of D5W. The infusion pump delivers 60 microdrops/mL. What rate in microdrops/minute would deliver 4 mg of lidocaine/minute? Report the response using a whole number. 60 Dimensional analysis (DA): Remember in DA, you always want to start your equation with what's called for in the solution. In this case, you want to know microdrops/minute.microdrops/minute = 4 mg/min X 1 g/1000 mg X 500 mL/2 g X 60 microdrops/mL = 4 X 500 X 60/1000 X 2 = 120000/2000 = 60 microdrops/mLAnother way to solve for X:What you have: 2 grams (2000 mg) lidocaine in 500 mL AND you are using a microdrip set (60 microdrops/mL)What you want/need: 4 mg lidocaine to infuse/minute4 mg/min X 500 mL/2000 mg X 60 (microdrops)/min = 60 microdrops/minute 00:02 01:39 The nurse is reviewing client assignments at the beginning of the shift. Which task could be safely assigned to an unlicensed assistive person (UAP)? A. Stay with a client during the self-administration of insulin B. Clean and apply a dressing to a small pressure ulcer on the leg C. Empty a client's colostomy bag D. Monitor a client's response to passive range of motion exercises C If the UAP has demonstrated competency in the task, s/he may empty a client's colostomy bag. This is an uncomplicated, routine task with an expected outcome. The other tasks involve one or more parts of the nursing process and cannot be assigned to an UAP. The school nurse is screening the children for scoliosis. At what time of development should the nurse expect to see early findings of scoliosis? A. During the years when children begin to run and jump B. During a preadolescent growth spurt C. In early infancy before 8 months of age D. When a child begins to play competitive sports B Idiopathic scoliosis is seldom apparent before 10 years of age and is most noticeable at the beginning of the preadolescent growth spurt. It is more common in females than in males. The home care nurse is admitting a new client with a diagnosis of COPD, atrial fibrillation and gout. After reviewing the client's medication list, the nurse would arrange for periodic monitoring of blood drug levels for which of the following medications? (Select all that apply.) A. Beclomethasone inhaled (Qvar) B. Digoxin (Lanoxin) C. Theophylline (Elixophyllin, Theo-24, Uniphyl) D. Allopurinol (Aloprim, Zyloprim) E. Glipizide (Glucotrol) B,C It is necessary to monitor blood levels for the client taking theophylline and digoxin to prevent the client from developing toxicity. The nurse is working with clients who are diagnosed with eating disorders. Which eating disorder would the nurse expect to cause the greatest fluctuation in serum potassium levels? A. Dysthymic disorder B. Anorexia nervosa C. Binge eating disorder D. Bulimia nervosa D Hypokalemia can be caused by overuse of laxatives and by prolonged fasting and starvation. But the greatest fluctuation in potassium levels is associated with bulimia, due to the purging process that causes dehydration and potassium loss. Low potassium levels can cause weakness, abdominal cramping and irregular heart rhythms. Dysthymic disorder is associated with poor appetite or overeating. The nurse has an order to insert an indwelling urinary catheter for a male client. What is the best reason for lubricating the tip of the catheter prior to insertion? A. Reduce the friction within the urethra B. Diminish the leakage of urine around the catheter C. Minimize risk for infection D. Prevent bladder distention A Due to the somewhat long length of the male urethra, lubrication reduces potential discomfort and localized tissue irritation as the catheter is passed. [Show Less]
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