NCSBN Practice Questions 1-15 Latest Updated Already Passed. Questions with accurate answers

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NCSBN Practice Questions 1-15 Latest Updated Already Passed Which individual is at greatest risk for the development of hypertension? A. 40 year-old Caucasian nurse B. 60 year-old Asian-American s... hop owner C. 45 year-old African-American attorney D. 55 year-old Hispanic teacher Correct Answer-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 Correct Answer-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 hoursB. 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 Correct Answer-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." Correct Answer-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 Correct Answer-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 Correct Answer-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 Correct Answer-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) Correct Answer-AMetabolic 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 Correct Answer-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 Correct Answer-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 Correct Answer-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 Correct Answer-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 techniquesB. 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 Correct Answer-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 Correct Answer-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 Correct Answer-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 Correct Answer-A CF affects the cells that produce mucus, sweat and digestive juices. Someone with CF needs a highenergy 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 glutenfree 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 Correct Answer-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 intoleranceC. Anxiety D. Risk for fluid volume excess Correct Answer-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." Correct Answer-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 Correct Answer-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 Correct Answer-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 Correct Answer-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 Correct Answer-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 Correct Answer-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 Correct Answer-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 CVADC. Insert an indwelling catheter D. Prepare the client for insertion of a new CVAD Correct Answer-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 Correct Answer-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 Correct Answer-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.A nurse is caring for a client two hours after a right lower lobectomy. During the assessment of the chest drainage unit (CDU), the nurse notes bubbling in the water-seal chamber. What is the first action the nurse should take? A. Call the health care provider as soon as possible B. Check for any increase in the amount of drainage C. Reposition the client to improve the level of comfort D. Assess the chest tube dressing, tubing and drainage system Correct Answer-D The first action the nurse should take is to thoroughly check the dressing, tubing and drainage system. Usually intermittent bubbling in the water-seal chamber right after surgery indicates an air leak from the pleural space; this is a common finding and should resolve as the lung re-expands. Continuous bubbling usually means a leak in the CDU, such as a loose connection or a leak around the insertion site. Other nursing actions will include assessing the color and amount of the drainage and assessing the lungs. After the initial post-operative period, the nurse will assist the client to change positions and cough and deep breath to help re-expand the lung and promote fluid drainage. The nurse is teaching a client with coronary artery disease about nutrition. What information should the nurse be sure to emphasize? A. Eat three balanced meals a day B. Avoid large and heavy meals C. Add complex carbohydrates to each meal D. Limit sodium to 7 grams per day Correct Answer-B Eating large, heavy meals can pull blood away from the heart for the digestion process. This may result in angina for clients with coronary artery disease. Sodium for clients with cardiac disease is limited to two grams per day. Three meals a day is a correct approach. However, it does not mention the size of the meal, which is more important. A nurse is providing care to a primigravida whose membranes spontaneously ruptured (ROM) four hours ago. At the time of rupture, maternal vital signs were within normal limits, she was dilated to 2 centimeters, and the baseline fetal heart rate (FHR) was 150 beats per minute (BPM). The nurse is now reassessing the client. Which of these assessment findings may be an early indication that the client is developing a complication of the labor process?A. Maternal temperature is 100 F (37.7 C) B. Cervical dilation of 4 centimeters C. Blood pressure is 138/88 mm Hg D. Fetal heart rate is 188 beats/minute Correct Answer-D Prolonged ruptured membranes may lead to maternal infection (as suggested by the slightly elevated temperature). But the primary concern is the fetal heart rate of 188; fetal heart rate is typically somewhere between 120 and 160 BPM. Fetal tachycardia may be an early sign of hypoxia. The nurse should contact the health care provider, assist the client to change positions, and administer oxygen and intravenous fluids. The registered nurse (RN) is planning the care of an 80-year-old client with skin abrasions from a fall in the home. What aspect of this client's care is the primary responsibility of the nurse? A. Perform a head-to-toe assessment B. Apply lotion to areas of the skin not affected by the fall C. Report findings of any break in the skin's integrity D. Identify changes in skin color Correct Answer-A The RN is responsible to conduct a thorough assessment and evaluation of all body systems for this client. The nurse would document information collected during the focused assessment, such as changes in skin color and breaks in the skin's integrity. Applying lotion would not be a primary responsibility. The nurse needs to accurately assess gastric placement of a nasogastric tube prior to the administration of an enteral feeding. What is the priority action the nurse should take before starting the infusion? A. Check the pH of the aspirate B. Measure the length of tubing from nose to epigastrium C. Auscultate the abdomen while instilling 10 mL of air into the tube D. Place the end of the tube in water to check for air bubbles Correct Answer-A Once the initial placement of the tube has been confirmed by x-ray, the nurse will check the pH of the aspirate before administering medications or enteral feeding solutions. Current practice recommendations include assessing the feeding tube placement by testing the pH of aspirates, measuring the external portion of the tube, and observing for changes in the volume and appearance offeeding tube aspirates. If tube placement is in doubt, an x-ray should be obtained. The other methods are older approaches that are no longer recommended. There is an order to administer intravenous gentamicin three times a day. What diagnostic finding indicates the client may be more likely to experience a toxic side effect of this medication? A. Low serum albumin B. Low serum blood urea nitrogen C. High gastric pH D. High serum creatinine Correct Answer-D Gentamicin is excreted unmodified by the kidneys. If there is any reduced renal function, toxicity can result. An elevated serum creatinine indicates reduced renal function and this puts the client at greater risk for toxicity. Reduced renal function will delay the excretion of many medications. A nurse is working in an OB-GYN clinic. A 40 year-old woman in the first trimester of an unplanned pregnancy provides a health history to the nurse. Which information should receive priority attention? A. She has taken 800 mcg of folic acid daily for the past year B. Her father and brother have type 1 diabetes C. Her husband was treated for tuberculosis as a child D. She has been taking an ACE inhibitor for her blood pressure for the past two years. Correct Answer-D A report by the client that she has been taking medications in the first trimester of pregnancy should be followed up immediately. ACE inhibitors, commonly used to control high blood pressure, are pregnancy category X, as they can cause teratogenic effects on the developing fetus, increasing the risk of birth defects. Women who are taking medications and who are planning a pregnancy should be switched to medications that are not harmful to the developing fetus before they begin trying to get pregnant. A mother asks about expected motor skill development for her 3 year-old child. Which activity is considered a typical motor skill for the 3 year-old? A. Tying shoelaces B. Riding a tricycleC. Jumping rope D. Playing hopscotch Correct Answer-B Three year-old children are developing gross motor skills that require large muscle movement. While there will always be some variation between children, movement milestones typically include pedaling a tricycle, standing on one foot for a few seconds, walking backwards and jumping with both feet. The other activities listed require more coordination and are movement milestones for older children. A client has been prescribed dexamethasone by mouth daily for transplant rejection prophylaxis. The client asks the nurse for more information about the medication. What information should the nurse include? (Select all that apply) A. "Take the medication with food" B. "Take acetaminophen for minor pain or aches." C. "You might experience an increase in weight." D. "Avoid dairy products" E. "Do not stop taking the drug abruptly." Correct Answer-A,B,C,E Adverse effects (ADEs) of long-term corticosteroid therapy include: behavioral/psychological changes, eye changes such as cataracts and glaucoma, and increased susceptibility to infections, hyperglycemia, hypocalcemia, fluid retention, HTN, edema, myopathy, muscle wasting, osteoporosis and peptic ulcers.To reduce the aforementioned ADEs, it is recommended to take the drug with food, avoid using NSAIDs for pain and increase dietary intake of calcium, found in dairy products.To prevent or avoid adrenal atrophy and acute adrenal insufficiency, discontinue corticosteroids gradually. Never discontinue corticosteroids abruptly! The nurse is developing a teaching plan for parents on safety and risk-reduction in the home. Which of the following should the nurse give priority consideration to during teaching? A. Number of children in the home B. Age and knowledge level of the parents C. Proximity to emergency services D. Age of children in the home Correct Answer-D Age and developmental level of the child are the most important considerations in the provision of a framework for anticipatory guidance associated with safety, and should be given priority when teaching safety.The nurse is providing information to a client about a prescribed medication. Which one of these statements, if made by a client, indicates that teaching about propranolol (Inderal) has been effective? A. "I will expect to feel nervousness the first few weeks." B. "I can have a heart attack if I stop this medication suddenly." C. "I could have an increase in my heart rate for a few weeks." D. "I may experience seizures if I stop the medication abruptly." Correct Answer-B Propranolol is commonly used to treat hypertension, abnormal heart rhythms, heart disease and certain types of tremor. It is in a class of medications called beta blockers. Suddenly discontinuing a beta blocker can cause angina, hypertension, arrhythmias, or even a heart attack. A client, admitted to the unit because of severe depression and suicidal threats, is placed on suicidal precautions. The nurse should be aware that the danger of the client committing suicide is greatest at what period of time? A. During the night shift when staffing is limited B. When the client's mood improves with an increase in energy level C. At the time of the client's greatest despair D. After a visit from the client's estranged partner Correct Answer-B Suicide potential is often increased when there is an improvement in mood and energy level. At this time ambivalence is often decreased and a decision is made to commit suicide. The clients have the energy to carry through with the plan for suicide. The nurse, who is participating in a community health fair, assesses the health status of attendees. When would the nurse conduct a mental status examination? A. The individual reports memory lapses B. There are obvious signs of depression C. The individual displays restlessness D. As part of every health assessment Correct Answer-DA mental status assessment is a critical part of baseline information and should be a part of every examination. A nurse uses the New Ballard Scale to assess gestational age of a newborn. The assessment score total is very high. What is a reasonable interpretation of this result? A. The baby is post-term B. The baby is premature C. The baby experienced distress during labor D. The baby is large for gestational age Correct Answer-A Birth weight and gestational age are important indicators of the newborn's health and are used to identify any (potential) problems. The New Ballard Scale can help differentiate, for example, between a small for gestational age baby and one that is premature. The New Ballard Scale scoring system adds up the individual scores for 6 external physical assessments and 6 neuromuscular assessments; the total score may range from -10 to 50. Premature babies have lower scores; higher scores correlate with postmaturity. Fetal distress during labor can result in lower scores. A nurse is reviewing laboratory results on a client diagnosed with acute renal failure. Which lab result should be reported immediately? A. Serum potassium 6 mEq/L (6 mmol/L) B. Hemoglobin of 9.3 mg/dL (93 g/L) C. Venous blood pH 7.30 D. Blood urea nitrogen 50 mg/dL (17.9 mmol/L) Correct Answer-A Although all of these findings are abnormal, the elevated potassium level is a life-threatening finding and must be reported immediately. Serious consequences of hyperkalemia include heart block, asystole and life-threatening ventricular dysrhythmias. Anemia (hemoglobin less than 13 g/dL [130 g/L] in men or less than 12 mg/dL [120 g/L] in women) is common with kidney disease. Blood urea nitrogen (BUN) will be increased in acute renal failure (7 to 30 mg/dL [2.5 to 10.7 mmol/L] is a considered normal). A nurse is talking by telephone with a parent of a 4 year-old child who has chickenpox. Which approach demonstrates appropriate teaching by the nurse?A. The illness is only contagious when the lesions are present B. Chewable aspirin is the preferred analgesic C. Recommend an antiviral medication to relieve itching D. Papules, vesicles and crusts will be present at one time Correct Answer-D All three stages of the chickenpox lesions will be present on the child's body at the same time. Children should not be medicated with aspirin due the possibility of developing Reye's syndrome. A person with chickenpox is contagious one to two days before their blisters appear and remain contagious until all the blisters have crusted over. Antiviral medications are not usually prescribed to otherwise healthy children. Over-the-counter hydrocortisone creams can help relieve itchy skin. A nurse is working with one licensed practical nurse (LPN) and a mental health tech (an unlicensed assistive personnel). Which newly admitted client would be appropriate to assign to the mental health tech? A. An adolescent diagnosed with dehydration and anorexia B. A young adult who reports to be a heroin addict and states, "I am in withdrawal and seeing spiders." C. A 76 year-old client diagnosed with severe depression D. A middle-aged client diagnosed with an obsessive compulsive disorder Correct Answer-D The mental health tech (a type of unlicensed assistive personnel or UAP) can be assigned to care for a client with a chronic condition after an initial assessment by the nurse. This client has minimal risk of instability of condition and has a situation of expected outcomes. A nurse is caring for a client diagnosed with chronic obstructive pulmonary disease (COPD) and who becomes dyspneic. The nurse should take which action? A. Administer oxygen at six liters per minute via nasal cannula B. Place the client in a low Fowler's position C. Instruct the client to breathe into a paper bag D. Assist the client with pursed-lip breathing Correct Answer-D Pursed-lip breathing should be encouraged during periods of dyspnea in COPD to control rate and depth of respiration, to prevent alveolar collapse and to improve respiratory muscle coordination. Clients with COPD are usually on lower doses of oxygen, titrated to maintain an oxygen saturation of 88-91%. SemiFowler's position is usually most comfortable for someone with COPD, because this position allows the client's diaphragm to expand. A client taking isoniazid for tuberculosis (TB) asks the nurse about the side effects of this medication. The client should be instructed to report which of these findings? A. Extremity tingling and numbness B. Confusion and light-headedness C. Double vision and visual halos D. Photosensitivity and photophobia Correct Answer-A Peripheral neuropathy is a common side effect of isoniazid and other antitubercular medications and should be reported to the health care provider. Daily doses of pyridoxine (vitamin B6) may lessen or even reverse peripheral neuropathy due to isoniazid use. During a yearly health screening, a 54 year-old female reports having irregular menstrual cycles, mood swings and hot flashes. She requests a more natural approach to manage these symptoms of perimenopause. What education about non-pharmacological interventions will the nurse include in client teaching? (Select all that apply.) A. "You should drink at least 8-10 glasses of water a day." B. "Yoga may help you manage stress and relieve symptoms." C. "A glass or two of red wine with dinner can help you manage stress." D. "Try exercising just before bedtime to help you sleep more soundly." E. "Incorporate more vegetables and legumes in your diet." F. "Use deep breathing exercises when you start having a hot flash." Correct Answer-A,B,E,F Measures that have been found to be effective in helping manage symptom of hot flashes include exercise, stress reduction and getting enough sleep at night. Reducing the temperature in the room at night and taking a warm bath or shower before bedtime can help clients get a better night's sleep. Slow abdominal breathing (6-8 breaths a minute) at the onset of hot flashes can help. Other measures that can lessen the number of and severity of hot flashes include yoga, as well as avoiding alcohol, spicy foods and caffeine. Eating a more plant-based diet can also help.A 15 year-old client has been placed in a Milwaukee brace. Which statement made by the client is incorrect and indicates a need for additional teaching? "I should inspect my skin under the brace every day" "The brace has to be worn all day and night." "I will only have to wear this for six months." "I can take it off when I shower or take a bath." Correct Answer-C The brace must be worn long-term, during periods of growth, usually for one to two years. It is used to correct scoliosis, the lateral curvature of the spine. A new task force has been created at a hospital to address a recent increase in patient falls. The first meeting is scheduled with members from several departments. Which of the following statements by the nurse leader indicate intent to increase meeting effectiveness? (Select all that apply.) A. "During our meeting today we will share the information we have on falls." B. "Let's discuss when next we should meet and what information we will bring." C. "Please introduce yourselves and your departments." D. "Let's focus on the number of falls first and then we can talk about staffing." E. "Today I will review the problem with falls on our units." F. "This meeting can go as long as needed to get things done." Correct Answer-A,B,C,D A leader increases meeting effectiveness by not permitting one person not to dominate the discussion, encouraging brainstorming, encouraging others to further develop ideas and helping to engage the team in future discussions. An effective team leader will periodically summarize the information and ensure that all ideas are recorded for all to see (for example, on a whiteboard) and then follow up with minutes of the meeting. Beginning and ending on time is also important to keep everyone focused on the task at hand and to demonstrate respect team members' other commitments. A nurse is teaching a client to select foods rich in potassium to prevent digitalis toxicity. Which choice indicates the client understands this dietary requirement and recognizes which foods are highest in potassium? A. Naval orange B. Three apricotsC. Small banana D. Baked potato Correct Answer-D A baked potato contains 610 milligrams of potassium. Apricots, oranges and bananas do have higher potassium content, but because of their size they are not the highest in potassium. A baked potato is the highest in potassium of the given options. A client has returned from a cardiac catheterization that was two hours ago. Which finding would indicate that the client has a potential complication from the procedure? A. No pulse in the affected extremity B. Increased blood pressure C. Increased heart rate D. Decreased urine output Correct Answer-A Loss of the pulse in the extremity would indicate a potential severe spasm of the artery or clot formation to the extent of an occlusion below the site of insertion. It is not uncommon that initially the pulse may be intermittently weaker from the baseline. However, a total loss of the pulse is a nursing emergency. The health care provider needs immediate notification. The nurse is evaluating a developmentally challenged 2 year-old child. During the evaluation, what goal should the nurse stress when talking to the child's mother? A. Help the family decide on long-term care B. Prepare for independent toileting C. Teach the child self-care skills D. Promote the child's optimal development Correct Answer-D The primary goal of nursing care for a developmentally challenged child is to promote the child's optimal development. The client with cancer is being treated with a biological response modifier. Which of the following side effects does the nurse anticipate with biologic therapy? A. ConstipationB. Hematuria C. Photophobia and sun sensitivity D. Chills and fever Correct Answer-D Biological response modifier cancer therapy agents (for example, interferons and interleukins) are drugs that stimulate the body's own defense mechanisms to fight cancer cells. Flu-like findings such as chills, fever and nausea, are common side effects of this type of therapy. The other assessment findings are not what you would expect when the body is fighting pathogens. A client is admitted with severe injuries resulting from an auto accident. The client's vital signs are BP 120/50, pulse rate 110, and respiratory rate of 28. What should be the initial nursing intervention? A. Administer oxygen as ordered B. Initiate continuous blood pressure monitoring C. Initiate the ordered intravenous therapy D. Institute continuous cardiac monitoring Correct Answer-A Early findings of shock are associated with hypoxia and manifested by a rapid heart rate and rapid respirations. Therefore, oxygen is the most critical initial intervention; the other interventions are secondary to oxygen therapy. A newborn who is delivered at home and without a birth attendant is admitted to the hospital for observation. The initial temperature is 95 F (35 C) axillary. The nurse should recognize that cold stress may lead to what complication? A. Hyperglycemia B. Reduced partial pressure of oxygen in arterial blood (PaO2) C.Metabolic alkalosis D. Lowered basal metabolic rate Correct Answer-B Hypothermia and cold stress cause a variety of physiologic stresses including increased oxygen consumption, metabolic acidosis, hypoglycemia, tachypnea and decreased cardiac output. The baby delivered in such circumstances needs careful monitoring. In this situation, the newborn must be warmed immediately to increase its temperature to at least 97 F (36 C). Normal core body temperature for newborns is 97.7 F to 99.3 F (36.5 C to 37.3 C).Two members of the interdisciplinary team are arguing about the plan of care for a client. Which action could any one of the members of the team use as a de-escalation strategy? A. Interrupt, apologize for interruption, and change the subject B. Adjourn the meeting and reschedule when everyone has calmed down C. Tell the violators they must calm down and be reasonable D. Bring the communication focus back to the client Correct Answer-D Bringing the subject of the communication back to the client refocuses attention on the client's care, instead of the manner of communication. It is the most effective strategy because it is an example of collaboration. The other options are non-productive and may even make matters worse. A nurse is teaching a class on human immunodeficiency virus (HIV) prevention. Which activity should be cautioned against since it is shown to increase the risk of HIV? A. Donation of blood to the state agencies B. Physical touch of a person with autoimmune deficiency syndrome (AIDS) C. Use of public bathrooms in any city D. Engaging in unprotected sexual encounters Correct Answer-D Because HIV is spread through exposure to bodily fluids, unprotected intercourse and shared drug paraphernalia remain the highest risks for this infection. The other actions are not at risk behaviors for HIV. The nurse is providing discharge teaching to a client who has had a total hip prosthesis implanted. During teaching, the nurse should include which content in the instructions for home care? A. Do not cross your legs at the ankles or knees B. Ambulate using crutches only C. Sleep only on your back and not on your side D. Avoid climbing stairs for three months Correct Answer-A These clients should avoid the bringing of the knees together. Clients are to use a pillow between their legs when lying down and can lie on the back or side. Crossing the legs or bringing the knees together results in a strain on the hip joint. This increases the risk of a malfunction of the prosthesis where theball may pop out. A walker or crutches may be used as assistive devices. These and other precautions are minimally followed for six weeks postoperative and sometimes longer as indicated. The charge nurse is making assignments for the shift. Which of these clients would be appropriate to assign to a licensed practical nurse (LPN)? A. A confused client whose family complains about the nursing care two days after the client's surgery B. An older adult client diagnosed with cystitis and has an indwelling urethral catheter C. A client admitted with the diagnosis of possible transient ischemic attack with unstable neurological signs D. A trauma victim with multiple lacerations that require complex dressing changes Correct Answer-B The most stable client is the one diagnosed with cystitis. Care for this client has predictable outcomes and there is only a minimal risk for complications. The other clients require more complex care and independent, specialized nursing knowledge, skill or judgment that only an RN can provide. A nurse is teaching adolescents about sexually transmitted diseases. What should the nurse emphasize is the most common infection? A. Herpes B. Chlamydia C. Gonorrhea D. Human immunodeficiency virus (HIV) Correct Answer-B Chlamydia is the most frequently reported bacterial sexually transmitted disease in the United States. Prevention is similar to safe sex practices taught to prevent any sexually transmitted disease, such as abstinence, and the use of a condom and spermicide for protection during intercourse. This infection has subtle findings so the infected persons are less likely to pursue medical attention. The respiratory technician arrives to draw blood for arterial blood gas (ABG) analysis. What should the nurse understand about the procedure? A.Supplemental oxygen should be turned off 30 minutes prior to collecting the sample B. Firm pressure is applied over the puncture site for at least five minutes after the sample is drawnC. The blood sample must be kept at room temperature and delivered to the lab as soon as possible D. The femoral artery is the preferred sample site Correct Answer-B The radial artery is preferred; the second choice is the brachia [Show More]

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