NCSBN Practice Questions And Correct Answers Latest Updates

NCSBN Practice Questions 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 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. 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. The nurse is collecting data from an adolescent client. Which of the following issues should the nurse address? (Select all that apply.) A. "Where are you currently living?" B. "How are things going at home?" C. "Have you decided what you are going to do after high school?" D. "Are you currently having conflicts with someone close to you?" E. "How many sexual partners have you had in the past six months?" F. "Have you gotten in any trouble lately?" - A,B,D,E Several professional organizations have published guidelines aimed at improving and maintaining health care for adolescents and young adults. The American Academy of Pediatrics, American Academy of Family Physicians, American Medical Association and U.S. Preventive Services Task Force have similar guidelines for health supervision of adolescents. These guidelines emphasize the need to provide health services to adolescents that meet their physical and emotional needs. Bright Futures (American Academy of Pediatrics, 2017) emphasizes that the following issues should be addressed with adolescents at each health visit: Physical growth and development (physical and dental health, body image, healthy nutrition, physical activity) Social and academic competence (relationships with peers and family, school performance, interpersonal relationships) Emotional well-being (mental health, sexuality) Risk reduction (tobacco, alcohol, other drugs, pregnancy, STIs) Violence and injury prevention Closed-ended questions about the client's plans after high school and if they have been in trouble are non-therapeutic and not appropriate in this situation. A 16 year-old client is admitted to a psychiatric unit with a diagnosis of attempted suicide. The nurse should understand that a more frequent cause for suicide in adolescents is which factor? A. Feelings of anger or hostility with others B. Reunion wish or fantasy of the supernatural C. Progressive failure to adapt socially D. Feelings of alienation or isolation from peers - D The isolation from peers may occur gradually to result in a loss of all meaningful social contacts. Isolation can be self-imposed or can occur as a result of the inability to express feelings to peers or family members. During adolescence, an important benchmark is to achieve a sense of identity and peer acceptance. The nurse is caring for a child diagnosed with seizures. While teaching the family and the child about the medication phenytoin, what information should the nurse emphasize? A. Omit the medication if the child is seizure-free B. Serve a diet that is high in iron C. Administer acetaminophen to promote sleep D. Maintain good oral hygiene and dental care - D Swollen and tender gums occur often with use of phenytoin. Good oral hygiene and regular visits to the dentist should be emphasized. The medication should never be stopped, even if the child is seizure-free; sudden discontinuation could result in status epilepticus. Acetaminophen is not a sleep-aid and iron interferes with phenytoin absorption. The nurse is performing an assessment on an infant with severe airway obstruction. Which assessment finding would the nurse anticipate? A. Rapid, shallow respirations B. Nasal flaring C. Chest pain aggravated by respiratory movement D. Cyanosis and mottling of the skin - B When the trachea or bronchioles become partially blocked, air flow is restricted. Nasal flaring is an exaggerated opening and closing of the nostrils with breathing, and is considered a subtle but important sign of acute respiratory distress in an infant. This is an emergency and requires rapid medical intervention. Several hours after a gastrectomy, the nasogastric tube (NGT) stops draining. After referring to the standing gastrectomy postoperative orders, what order will the nurse implement first? A. Notify the surgeon B. Increase the amount of suction C. Gently irrigate the tube with sterile normal saline D. Reposition the tube until it begins to drain - C The nurse will assess the position and patency of the NGT, as well as the color and amount of gastric drainage. The nurse can gently irrigate the NG tube with sterile normal saline if it becomes clogged. But if that does not resolve the issue or repositioning the tube is needed, the nurse must call the surgeon. The NGT inserted in surgery should not be repositioned by the nurse because of the risk of disrupting any internal sutures. The NGT should be connected to low suction; it would be contraindicated to increase the suction. A nurse notes that a 2 year-old child recovering from a tonsillectomy has a temperature of 98.2 F (36.7 C) at 11:00 am. At 1:00 pm the child's parent reports that the child "feels very warm" to touch. What should the nurse do first? A. Administer the prescribed acetaminophen B. Reassure the parent that this is normal C. Offer the child cold oral fluids D. Reassess the child's temperature - D The nurse should listen to and show respect for what the parent is saying, because the parent is more sensitive to the variations in the child's condition. However, the nurse knows that a low-grade fever (99-101 F or 37.2-38.3 C) is common after surgery, which is why the nurse should first reassess the temperature before implementing any intervention. Usually the surgeon is contacted if the temperature is higher than 101.5 F (38.6 C).