NCSBN Practice exam 2024 with 100% correct answers

It is the start of the shift and the nurse has just finished listening to a report on four clients. Which client should the nurse assess first? A. A client with a diagnosis of an acute traumatic brain injury who has a blood pressure of 88/58 B. A client with a diagnosis of a concussion and who doesn't remember the motor vehicle accident C. A client diagnosed with viral meningitis and has signs of meningeal irritation D. A client diagnosed with generalized seizures who complains of a headache following an observed seizure - correct answer A Hypotension adversely affects cerebral perfusion following a traumatic brain injury. Both hypotension and hypoxia are the greatest threats to functional outcomes in brain injury and must be corrected early, taking priority over other interventions for brain injury. Headache after a seizure is expected, amnesia is common with a concussion, and meningeal irritation is an expected finding with viral meningitis, making these clients a lower priority at this point. The nurse discovers that a chest tube has become disconnected from the main connection site of a closed chest drainage unit (CDU). What immediate action should be taken by the nurse? A. Cover the insertion site with a sterile petroleum gauze pad B. Submerge the distal end of the tube in 2 - 4 centimeters of sterile water C. Reconnect the drainage tube to the chest tube D. Clamp the chest tube nearest to the client with a rubber-tipped hemostat - correct answer B If the tube becomes disconnected from the main connection site of a CDU, the nurse should place the end of the chest tube in a bottle of sterile water (or saline solution) while someone else prepares a new CDU setup. The health care provider should be called (the nurse should expect an order for a chest X-ray.) To prevent the chest tube from coming apart, it's important to spiral-tape the main connection site and not to let loops of tubing hang down the side of the bed. If there is an air leak from the chest, do not clamp the chest tube as this will cause air to accumulate in the pleural cavity, potentially leading to a collapsed lung or tension pneumothorax. Only if the chest tube becomes dislodged from the client does the nurse need to cover the insertion site with a sterile gauze dressing.