NCSBN Test bank 16-30 update|comprehensive questions
and verified answers (complete solutions) Exam|GRADE
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Save
Terms in this set (200)
A nurse is teaching a mother who will breast-feed for Assist the mother to position the newborn at the breast
the first time. Which of these approaches is a priority?
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
Give the mother privacy for the initial feeding contact and allow the newborn to begin to suck.
Assist the mother to position the newborn at the breast
Give the mother several illustrated pamphlets
Show the mother films on the physiology of lactation
The nurse in a long-term care facility is evaluating the Falls out of bed are a common occurrence in the long-term care setting.
plan of care for an older adult client with advanced Although it is nearly impossible to eliminate all falls, the nurse can implement
dementia. The client has had several falls out of bed. interventions to reduce the risk for injury related to a fall. The goal is to start
Which initial intervention should the nurse implement? with the least invasive and restrictive intervention to preserve the client's
rights, regardless of their level of cognitive function. 'Low' beds and 'landing'
Have the client sleep in a recliner at the nurse's station mats to soften the fall should the client roll out of bed are commonly used in
with a tray table across their lap long-term care settings and represent an appropriate, initial intervention to
implement for this client. The other interventions are much more restrictive
Put the bed in the lowest position with a thick pad or and should be used only after less restrictive interventions have been
mat on the floor next to the bed attempted.
Correct!
Place the client in a bed with an enclosure mesh tent
attached to the frame
Position all side rails of the bed up and move the bed
close to the door
,The nurse is developing a plan of care for a client who 1,3,4,5
underwent total hip arthroplasty 24 hours ago. Which
interventions should the nurse include? Select all that To prevent postoperative complications and complications related to
apply. immobility, the client should be up in a chair as soon as possible after surgery.
While seated, the client should bend the affected leg at the knee. The nurse
1. Encourage the client to perform leg exercises while should reinforce teaching of simple leg exercises while in bed and the use of
in bed an abduction pillow or foam wedge to prevent adduction. To prevent
atelectasis and pneumonia the client should be encouraged to use an
2. Remind the client to not bend the knee of the incentive spirometer every 2 hours. Once the client is alert after surgery and
affected leg while seated not experiencing nausea or vomiting, they can resume a regular diet.
3. Encourage the use of an abduction pillow or splint
between the legs
4. Provide a seat riser for the toilet or commode
5. Encourage the client to use the incentive spirometer
every 2 hours
Assist the client with a clear liquid diet
A nurse is performing physical assessments on Occur about two years earlier than for males
adolescents. What finding should the nurse anticipate
concerning female growth spurts?
Occur about two years earlier than for males
Begin about the same time for males
Start just prior to the onset of puberty
Characterized by an increase in height of 4 inches
each year
A nurse is caring for a client following a Computed 2
Tomography (CT) scan of the kidneys with contrast. A CT scan provides three-dimensional information about structures within the
Which of these findings would require prompt body. Oral or injected dye (contrast) is generally used during this scan to
intervention by the nurse? provide detailed images. After the scan, the nurse should monitor for
complications associated with the contrast including anaphylaxis or contrast-
Soreness reported at the IV site induced nephropathy. Contrast-induced nephropathy is defined as a 25%
increase of the serum creatinine above baseline within 48 hours of the
Elevated serum creatinine above baseline procedure. While mild nausea and soreness at the IV site are problems
requiring intervention, they are not the immediate concern. A catheter is not
The client states that the urethra feels irritated and sore required for this procedure.
from the catheter
The client states they have felt mild nausea since the
procedure
,A client was admitted to the psychiatric unit after Toilet the client more frequently with supervision
refusal to get out of the bed. Once admitted, the client
is observed talking to unseen people and voiding on With a client that has altered thought processes, the appropriate nursing
the floor. The nurse should handle the problem of approach to change behaviors is to take an active role in attending to the
voiding on the floor by which of these approaches? physical needs of the client. The other options are incorrect approaches.
Restrict the client's fluids throughout the day
Require the client to mop the floor after each incident
Toilet the client more frequently with supervision
Withhold privileges each time the voiding occurs
The nurse is caring for a client who is experiencing Monitor for agitation or hallucinations
alcohol withdrawal. The client is experiencing tremors
and nausea. The client's vital signs are within normal During alcohol withdrawal, the client may experience many clinical
limits, but the client is sweating profusely. Which manifestations. Six to eight hours after alcohol cessation, the client may
nursing intervention is a priority for this client? experience tremors, nausea and agitation. After eight to ten hours, the client
may experience increasing perceptual changes such as hallucinations,
Assess the client's vital signs every 6 hours unconsciousness, seizures, or delirium. This is a medical emergency and the
nurse should anticipate administration of lorazepam or chlordiazepoxide.
Monitor for agitation or hallucinations After twelve to twenty-four hours, the client may experience tonic-clonic
seizures and diazepam may be administered. Monitoring the client for
Update the client regularly on their progress Delirium tremens (DTs) is a nursing priority. DTs are a medical emergency and
if left untreated have a significant risk of death. Vital signs and monitoring for
Ask the family to leave the bedside to provide privacy clinical manifestations of DTs should be done more often than every 6 hours.
During this time, regularly updating the client on their progress may cause
frustration with the client. Additionally, if the client wants the family at the
bedside, privacy is not needed.
The nurse is performing a physical assessment on a Pulse oximetry of 86% saturation
client who just had an endotracheal tube (ET) inserted
with a connection to a ventilator. Which finding should Pulse oximetry should not be lower than 90% saturation. Breath sounds are
prompt the nurse to take immediate action to resolve heard bilaterally so the placement of an ET is most likely in proper position.
the issue? 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.
Pulse oximetry of 86% saturation
Client is unable to speak
Breath sounds are heard bilaterally
Mist is visible in the T-Piece of the ventilator circuit
, In order to enhance a client's response to medication Learning relaxation techniques
for chest pain from acute angina, the nurse should
emphasize which approach? 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
Avoiding passive smoke ineffective.
Limiting alcohol use
Learning relaxation techniques
Eat smaller meals
The home health nurse is developing a plan of care for Treat muscle spasms
a 3-year-old client diagnosed with cerebral palsy (CP).
Which goals are the priority for this client? Select all Promote locomotion
that apply.
Prevent seizures
Arrange for genetic counseling
Cerebral palsy (CP) is defined as a disorder of posture and movement from
Treat muscle spasms static brain injury perinatally or postnatally, which limits activity. In addition to
motor disorders, the condition often involves disturbances of sensation,
Promote locomotion perception, communication, cognition, and behavior. Some of the disabilities
associated with CP are visual impairment, hearing impairment, behavioral
Prevent seizures problems, communication and speech difficulties, seizures, and intellectual
impairment. The priority goals at this age should include the prevention of
Select appropriate school environment seizure activity and correction of any associated physical defects and
physical/occupational therapy to promote mobility and movement or the
ability to move from one place to another (locomotion). Children with CP
often suffer from muscle spasms and seizures and typically require
pharmacotherapy for both. The other interventions are not appropriate at this
age. CP is not a genetic disease.
At a well-child checkup, the nurse is assessing a 1 year- "He crawls by pushing off with one hand and leg while dragging the opposite
old who was born prematurely and is being evaluated hand and leg."
for cerebral palsy (CP). Which information provided by
the parents would support this diagnosis? 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
"He crawls by pushing off with one hand and leg while delays in learning to roll over, sit, crawl or walk. Because this child was born
dragging the opposite hand and leg." 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
"Our child isn't talking yet." talking, and mealtime can get pretty messy.
"Mealtime is so messy when he tries to feed himself."
"We think our child seems smaller than other babies
this age."
and verified answers (complete solutions) Exam|GRADE
A+!!
Save
Terms in this set (200)
A nurse is teaching a mother who will breast-feed for Assist the mother to position the newborn at the breast
the first time. Which of these approaches is a priority?
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
Give the mother privacy for the initial feeding contact and allow the newborn to begin to suck.
Assist the mother to position the newborn at the breast
Give the mother several illustrated pamphlets
Show the mother films on the physiology of lactation
The nurse in a long-term care facility is evaluating the Falls out of bed are a common occurrence in the long-term care setting.
plan of care for an older adult client with advanced Although it is nearly impossible to eliminate all falls, the nurse can implement
dementia. The client has had several falls out of bed. interventions to reduce the risk for injury related to a fall. The goal is to start
Which initial intervention should the nurse implement? with the least invasive and restrictive intervention to preserve the client's
rights, regardless of their level of cognitive function. 'Low' beds and 'landing'
Have the client sleep in a recliner at the nurse's station mats to soften the fall should the client roll out of bed are commonly used in
with a tray table across their lap long-term care settings and represent an appropriate, initial intervention to
implement for this client. The other interventions are much more restrictive
Put the bed in the lowest position with a thick pad or and should be used only after less restrictive interventions have been
mat on the floor next to the bed attempted.
Correct!
Place the client in a bed with an enclosure mesh tent
attached to the frame
Position all side rails of the bed up and move the bed
close to the door
,The nurse is developing a plan of care for a client who 1,3,4,5
underwent total hip arthroplasty 24 hours ago. Which
interventions should the nurse include? Select all that To prevent postoperative complications and complications related to
apply. immobility, the client should be up in a chair as soon as possible after surgery.
While seated, the client should bend the affected leg at the knee. The nurse
1. Encourage the client to perform leg exercises while should reinforce teaching of simple leg exercises while in bed and the use of
in bed an abduction pillow or foam wedge to prevent adduction. To prevent
atelectasis and pneumonia the client should be encouraged to use an
2. Remind the client to not bend the knee of the incentive spirometer every 2 hours. Once the client is alert after surgery and
affected leg while seated not experiencing nausea or vomiting, they can resume a regular diet.
3. Encourage the use of an abduction pillow or splint
between the legs
4. Provide a seat riser for the toilet or commode
5. Encourage the client to use the incentive spirometer
every 2 hours
Assist the client with a clear liquid diet
A nurse is performing physical assessments on Occur about two years earlier than for males
adolescents. What finding should the nurse anticipate
concerning female growth spurts?
Occur about two years earlier than for males
Begin about the same time for males
Start just prior to the onset of puberty
Characterized by an increase in height of 4 inches
each year
A nurse is caring for a client following a Computed 2
Tomography (CT) scan of the kidneys with contrast. A CT scan provides three-dimensional information about structures within the
Which of these findings would require prompt body. Oral or injected dye (contrast) is generally used during this scan to
intervention by the nurse? provide detailed images. After the scan, the nurse should monitor for
complications associated with the contrast including anaphylaxis or contrast-
Soreness reported at the IV site induced nephropathy. Contrast-induced nephropathy is defined as a 25%
increase of the serum creatinine above baseline within 48 hours of the
Elevated serum creatinine above baseline procedure. While mild nausea and soreness at the IV site are problems
requiring intervention, they are not the immediate concern. A catheter is not
The client states that the urethra feels irritated and sore required for this procedure.
from the catheter
The client states they have felt mild nausea since the
procedure
,A client was admitted to the psychiatric unit after Toilet the client more frequently with supervision
refusal to get out of the bed. Once admitted, the client
is observed talking to unseen people and voiding on With a client that has altered thought processes, the appropriate nursing
the floor. The nurse should handle the problem of approach to change behaviors is to take an active role in attending to the
voiding on the floor by which of these approaches? physical needs of the client. The other options are incorrect approaches.
Restrict the client's fluids throughout the day
Require the client to mop the floor after each incident
Toilet the client more frequently with supervision
Withhold privileges each time the voiding occurs
The nurse is caring for a client who is experiencing Monitor for agitation or hallucinations
alcohol withdrawal. The client is experiencing tremors
and nausea. The client's vital signs are within normal During alcohol withdrawal, the client may experience many clinical
limits, but the client is sweating profusely. Which manifestations. Six to eight hours after alcohol cessation, the client may
nursing intervention is a priority for this client? experience tremors, nausea and agitation. After eight to ten hours, the client
may experience increasing perceptual changes such as hallucinations,
Assess the client's vital signs every 6 hours unconsciousness, seizures, or delirium. This is a medical emergency and the
nurse should anticipate administration of lorazepam or chlordiazepoxide.
Monitor for agitation or hallucinations After twelve to twenty-four hours, the client may experience tonic-clonic
seizures and diazepam may be administered. Monitoring the client for
Update the client regularly on their progress Delirium tremens (DTs) is a nursing priority. DTs are a medical emergency and
if left untreated have a significant risk of death. Vital signs and monitoring for
Ask the family to leave the bedside to provide privacy clinical manifestations of DTs should be done more often than every 6 hours.
During this time, regularly updating the client on their progress may cause
frustration with the client. Additionally, if the client wants the family at the
bedside, privacy is not needed.
The nurse is performing a physical assessment on a Pulse oximetry of 86% saturation
client who just had an endotracheal tube (ET) inserted
with a connection to a ventilator. Which finding should Pulse oximetry should not be lower than 90% saturation. Breath sounds are
prompt the nurse to take immediate action to resolve heard bilaterally so the placement of an ET is most likely in proper position.
the issue? 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.
Pulse oximetry of 86% saturation
Client is unable to speak
Breath sounds are heard bilaterally
Mist is visible in the T-Piece of the ventilator circuit
, In order to enhance a client's response to medication Learning relaxation techniques
for chest pain from acute angina, the nurse should
emphasize which approach? 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
Avoiding passive smoke ineffective.
Limiting alcohol use
Learning relaxation techniques
Eat smaller meals
The home health nurse is developing a plan of care for Treat muscle spasms
a 3-year-old client diagnosed with cerebral palsy (CP).
Which goals are the priority for this client? Select all Promote locomotion
that apply.
Prevent seizures
Arrange for genetic counseling
Cerebral palsy (CP) is defined as a disorder of posture and movement from
Treat muscle spasms static brain injury perinatally or postnatally, which limits activity. In addition to
motor disorders, the condition often involves disturbances of sensation,
Promote locomotion perception, communication, cognition, and behavior. Some of the disabilities
associated with CP are visual impairment, hearing impairment, behavioral
Prevent seizures problems, communication and speech difficulties, seizures, and intellectual
impairment. The priority goals at this age should include the prevention of
Select appropriate school environment seizure activity and correction of any associated physical defects and
physical/occupational therapy to promote mobility and movement or the
ability to move from one place to another (locomotion). Children with CP
often suffer from muscle spasms and seizures and typically require
pharmacotherapy for both. The other interventions are not appropriate at this
age. CP is not a genetic disease.
At a well-child checkup, the nurse is assessing a 1 year- "He crawls by pushing off with one hand and leg while dragging the opposite
old who was born prematurely and is being evaluated hand and leg."
for cerebral palsy (CP). Which information provided by
the parents would support this diagnosis? 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
"He crawls by pushing off with one hand and leg while delays in learning to roll over, sit, crawl or walk. Because this child was born
dragging the opposite hand and leg." 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
"Our child isn't talking yet." talking, and mealtime can get pretty messy.
"Mealtime is so messy when he tries to feed himself."
"We think our child seems smaller than other babies
this age."
