NCSBN NCLEX Review Questions and Answers with
complete solution
A severely injured client is moved into an examination area of the emergency department. The family
member who accompanied the client to the ED is scream
...
NCSBN NCLEX Review Questions and Answers with
complete solution
A severely injured client is moved into an examination area of the emergency department. The family
member who accompanied the client to the ED is screaming at the nurse, saying that someone better
start doing something right away. What is the best response by the nurse?
1. "I need you to go to the waiting area. You can come back when you're more in control."
2. "I'm going to give you a few minutes alone so you can calm down."
3 "I can't think when you are yelling at me. Talk to me in a normal voice."
4. "I know you are upset. But please control yourself and sit down. Otherwise I will have to call security."
Correct Answer- "I know you are upset. But please control yourself and sit down. Otherwise I will have
to call security."
Most violent behavior is preceded by warning signs, such as yelling or swearing. The challenge for nurses
is to apply interventions that de-escalate a person's response to stressful or traumatic events. The keys
to effective limit setting are using commands to express the desired behavior and providing logical and
enforceable consequences for noncompliance. Nurses should acknowledge the agitated person's
feelings and be empathetic, reminding him or her that they are there to help.
The clinic nurse assists the health care provider with physical examinations and the collection of
laboratory specimens. Which of these findings does the nurse recognize as being reportable to the
public health department?
Positive eye discharge confirming conjunctivitis
Clinical findings of impetigo
Skin scraping confirming the presence of ringworm
Positive stool culture for shigella Correct Answer- Positive stool culture for shigellaThe Centers for Disease Control and Prevention (CDC) have a list of notifiable infectious diseases that is
updated yearly. Shigellosis is the only reportable infection of those listed. Shigella are bacteria that can
infect the digestive tract and cause (painful) diarrhea, cramping, vomiting, nausea; in severe cases it can
cause seizures and kidney failure. Ringworm is a contagious fungal infection. Impetigo is a contagious,
superficial bacterial skin infection. Conjunctivitis has many causes and is usually diagnosed from signs
and symptoms and patient history.
Mass casualty survivors are brought to the emergency department (ED) after a disaster. The nurse is
assigned to four clients who were triaged in the field and have just arrived in the ED. Which client will
the nurse care for first?
The person with multiple wounds and an open fracture
The person with hypotension and a sucking chest wound
The person with head trauma requiring mechanical ventilation
The person with an undisplaced fracture of the radius Correct Answer- Typically, the tab colors used in
triage are black, yellow, green and red. Red-tagged clients have immediate threats to life and require
care right away; this would be the survivor with hypotension and a sucking chest wound. Yellow-tagged
clients have major injuries that need treatment within 30 minutes to two hours (the client with the open
fracture), and green-tagged client have injuries that can be delayed more than two hours (the closed
fracture). Black-tagged clients are treated last during a mass casualty situation because there is little
chance for survival.
A parent calls the hospital hotline and is connected to the triage nurse. The caller states: "I found my
child with odd stuff coming from the mouth and an unmarked bottle nearby." Which of these comments
would provide the best information to help the nurse to determine if the child has swallowed a
corrosive substance?
"Ask the child if the mouth is burning or throat pain is present."
"Has the child had vomiting, diarrhea or stomach cramps?""Take the child's pulse at the wrist and see if the child has trouble breathing lying flat."
"What color are the child's lips and nails and has the child voided today?" Correct Answer- "Ask the child
if the mouth is burning or throat pain is present."
Local irritation of tissues indicates a corrosive poisoning. The other comments may be helpful in
determining the child's overall condition. However, the question concerns evaluation for ingestion of a
caustic substance.
The nurse is checking on clients in the unit. Which of these findings indicates that an infusion pump set
to deliver a morphine drip basal rate of 10 mL per hour, plus PRN dosages for breakthrough pain, is not
functioning correctly?
The client states: "I just can't get relief from my pain."
The level of the drug is 100 mL at 9 am and is 50 mL at 12 noon
The level of the drug is 100 mL at 8 am and is 80 mL at 12 noon
The client complains of discomfort at the IV insertion site Correct Answer- The level of the drug is 100
mL at 8 am and is 80 mL at 12 noon
The minimal dose is 10 mL per hour, which would mean 40 mL is given in a four-hour period. If any PRN
doses were given then less would be in the bag. Minimally, 60
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