NCSBN Practice Questions 76-90
An 18 month-old weighing 22 pounds is admitted to the pediatric unit with a
diagnosis of A replacement bolus of normal saline at 20 mL/kg is
dehydration.
ordered to be intravenously over 40
administered
minutes.
In mL/hour, what will be the setting for the IV delivery system? Correct
answers
Using 300
ratio proportion:First, convert 22 pounds to kilograms (22/2.2) = 10
kg20
20 mL/kg
x 10 kg ==200 mL200 mL/40 minutes = x mL/60 minutes (in an
hour)200 x=60
12000/40 300= mL/hrUsing dimensional analysis:20 mL/kg x 1 kg/2.2 lb x
22 lb x x60
min/hr 1/40 min = 300
mL/hr
The mother of a 2 month-old baby calls a pediatrician's nurse two days
after the
DTaP, first
inactivated polio vaccine (IPV), Hepatitis B and Haemophilus
influenzae type B
(HIB) immunizations. She reports that the baby feels very warm, cries
inconsolably
as long as three for hours, and has had several shaking spells. Which
immunization
the nurse expect would
to be primarily responsible with these
findings?
A. DTaP
B. IPV
C. Hepatitis
B
D. HIB Correct
answers
DTaP A
immunization is a vaccine that protects against diptheria, tetanus
and pertussis
(whooping cough). The majority of reactions described in this question
occur with the of the DTaP vaccination. Contraindications to giving
administration
repeat DTaP
immunizations include the occurrence of severe side effects after a
previous
well dose,
as signs ofas
encephalopathy within seven days of the
immunization.
A client diagnosed with angina has been instructed about the use of
sublingual
nitroglycerin. Which statement made by the client is incorrect and indicates
a need for
further
teaching?
A. "I'll call the health care provider if pain continues after three tablets
five minutes
apart.
"B. "I will rest briefly right after taking one
tablet."
C. "I understand that the medication should be kept in the
dark
D. bottle."
"I can swallow two or three tablets at once if I have severe pain." Correct
answersmust
Clients D understand that just one sublingual tablet should be taken at
a time and
placed under the tongue. After rest and a five-minute interval, a
second andathen
eventually third tablet may be
necessary.
The nurse is working with victims of domestic abuse. The nurse should
understand
which of these factors is a reason why domestic violence or emotional
abuse remains
extensively
undetected?
,A. The expenses due to police and court costs are
prohibitive
B. Little knowledge is known about batterers and battering
relationships
C. There are typically many series of minor, vague
complaints
D. Few people who have been battered seek medical care Correct
answers
Signs C
of domestic violence or emotional abuse may not be clearly
manifested
include many andseries of a minor complaints such as headache,
abdominalback
insomnia, pain,pain and dizziness. These may be covert indications of
violence
abuse or go undetected. These complaints may be vague and reflect
that
ambivalence
about the disclosure of any violence or
abuse.
The nurse is obtaining an aerobic wound culture from a client with stage
two pressure
injury. The nurse first removes a gauze dressing and observes a moderate
amount of
purulent drainage on the dressing and then the nurse performs hand
hygiene. What is
A. Swab the gauze dressing that was removed from the
the next correct step in the
wound
B. Irrigate the wound with normal
procedure?
saline
C. Obtain a culture by rotating a sterile swab in the
open
D. woundwound exudate from the wound edges with a cotton tip
Remove
applicator Correct
answers
B
After removing the dressing and performing hand hygiene, the wound
needs to to
irrigated beremove surface pathogens before the nurse can obtain a
wound culture.
Cultures are not obtained from wound exudate on the dressing or wounds
that have
been not since the exudate may be contaminated with normal
irrigated
skin flora.
The nurse is caring for a client who is experiencing frightening
hallucinations
markedly increased that are
at night. The client's partner asks to stay a few hours
beyond time,
visiting the in the client's private room. What would be the best
response by the
nurse
?
A. "Yes, staying with the client and orienting the client to the
surroundings
decrease any may
anxiety."
B. "No, your presence may cause the client to become more
anxious."
C. "No, it would be best if you brought the client some reading material
that the
could readclient
at
D. "Yes, would you like to spend the night when the client's behavior
night."
indicates
client is orthat
willthe
be frightened?" Correct
answers A
Encouragement of a family member or a close friend to stay with the
client in a quiet
surrounding cannot only help increase orientation, but can also minimize
confusion
anxiety. and
The visitor could also report to the nurse any unusual findings of the
client. be
would Thisthe most supportive approach for this
client.
The RN, who is functioning as the charge nurse, needs to determine shift
assignments.
How will the charge nurse determine which client assignments are
appropriate
licensed for thenurse
practical
(LPN)?
,A. Ask the LPN about prior experience caring for clients with similar
diagnoses
B. Determine how many nursing assistants are available to help the LPN with
client
C. care
Refer to the list of technical tasks LPNs are trained to
perform
D. Review the procedure manual with the LPN prior to making an
assignment Correct
answers
A
The definition of assignment is the routine care, activities and procedures
thatauthorized
the are within scope of practice of the RN or LPN/LVN. The RN must
determine
needs of thethe
clients and make assignments not only based on scope of
practice,
also but
education, demonstrated competency and skill level. Regardless
if the LPNeducation and training to perform specific skills, the RN needs to
received
determine
LPN's the
experience with caring for clients with similar diagnoses. While
the RN is
responsible for ensuring an assignment given to a delegatee is carried out
completely
and correctly, the LPN must be able to perform the skills or tasks
independently.
The nurse is caring for a school-aged child with a diagnosis of
secondary
hyperparathyroidism after treatment for chronic renal disease. Which
serum lab
should datapriority attention by the
receive
nurse?
A. Osmolality and
sodium
B. Blood urea nitrogen and
magnesium
C. Calcium and
phosphorus
D. Glucose and potassium Correct
answers
The C
parathyroid regulates the calcium and phosphorus serum levels.
Calcium and levels will be elevated in hyperfunction of this gland until
phosphorous
the client isTo recall this information think of a see-saw. Associate that
stabilized.
calcium
the is first
alphabet in thus calcium follows the direction of the abnormality -
and
hyper or hypo
function - of the parathyroid. Put the calcium on one side and the
phosphorus
other side ofon thethesee-
saw.
The nurse is caring for a client who just had a central venous catheter line
inserted
the at Which of these assessments requires immediate attention by
bedside.
the nurse?
A. Pallor in the
extremities
B. Increased temperature by one
degree
C. Involuntary coughing
D. Dyspnea at rest Correct
spells
answers D
Complications of central catheter insertion include pneumothorax and
hemothorax.
embolism Air
is another potential complication. Dyspnea, shallow
respirations,
sharp sudden
chest pain that worsens with coughing or deep breathing are
indications of Other potential complications of central catheters
pneumothorax.
may include local or systemic infection, or even cardiac tamponade (if the
thrombosis,
central linethe heart). When considering the options listed, the client who
perforates
is dyspneic
after central line insertion would be the greatest concern for
the nurse.
, The nurse is providing preprocedural education to the client preparing
for a barium
enema. What statement made by the client indicates a need for further
education?
A. "I will need to drink plenty of fluids and eat foods high in fiber after the
procedure."
B. "I will use the prescribed laxative before the
procedure."
C. "I will not eat or drink anything after midnight before the
procedure."
D. "A barium enema is used to examine the upper and lower GI tracts."
Correct answers
D
A barium enema involves filling the large intestine (lower GI tract) with
dilutedwhile
liquid barium x-ray images are taken. After the procedure, a small amount of
barium
be will
immediately expelled and the remainder will be excreted in the
stool. Because
barium liquid may cause constipation, clients should eat foods high in
fiber and
plenty drink to help expel the barium from
of fluids
the body.
A client admitted with heart failure is experiencing severe shortness of
breath and
states, "I feel like something is terribly wrong!" The client is restless and
begins to cough of pink frothy sputum. The client's skin is a dusky
up large amounts
grayish
the oxygen color and
saturation levels have decreased from 92% to 76% in the last
hour.
the What
first is the nurse should
action
take?
A. Check vital
signs
B. Administer the PRN ordered
oxygen
C. Call the health care
provider
D. Place the bed in high Fowler's position Correct
answers
When B
dealing with a medical emergency, the rule is to assess airway
first, then and then circulation. Starting oxygen is the priority. The other
breathing,
actions
also be should
implemented as quickly as possible, including activation of the
rapid response
team. The client is experiencing an acute episode of fulminant pulmonary
edema,
as a resultlikely
of a new and severe cardiac event and possible
cardiogenic assessment
Emergency shock. and intervention is indicated to prevent cardiac
arrest and
possible
death.
There is an order for a continuous lidocaine infusion at a rate of 4
mg/minute
PVCs. The IV tosolution
treat contains 2 grams of lidocaine in 500 mL of D5W. The
infusion
pump delivers 60
microdrops/mL.
What rate in microdrops/minute would deliver 4 mg of lidocaine/minute?
Report theusing a whole number. Correct
response
answers 60 analysis (DA): Remember in DA, you always want to start your
Dimensional
equation
with what's called for in the solution. In this case, you want
to know
microdrops/minute.microdrops/minute = 4 mg/min X 1 g/1000 mg X 500
mL/2 g X 60
microdrops/mL = 4 X 500 X 60/1000 X 2 = 120000/2000 = 60
microdrops/mLAnother
way to solve for X:What you have: 2 grams (2000 mg) lidocaine in 500 mL
AND you
using are
a microdrip set (60 microdrops/mL)What you want/need: 4 mg
lidocaine to
infuse/minute4 mg/min X 500 mL/2000 mg X 60
(microdrops)/min = 60
microdrops/
minute
An 18 month-old weighing 22 pounds is admitted to the pediatric unit with a
diagnosis of A replacement bolus of normal saline at 20 mL/kg is
dehydration.
ordered to be intravenously over 40
administered
minutes.
In mL/hour, what will be the setting for the IV delivery system? Correct
answers
Using 300
ratio proportion:First, convert 22 pounds to kilograms (22/2.2) = 10
kg20
20 mL/kg
x 10 kg ==200 mL200 mL/40 minutes = x mL/60 minutes (in an
hour)200 x=60
12000/40 300= mL/hrUsing dimensional analysis:20 mL/kg x 1 kg/2.2 lb x
22 lb x x60
min/hr 1/40 min = 300
mL/hr
The mother of a 2 month-old baby calls a pediatrician's nurse two days
after the
DTaP, first
inactivated polio vaccine (IPV), Hepatitis B and Haemophilus
influenzae type B
(HIB) immunizations. She reports that the baby feels very warm, cries
inconsolably
as long as three for hours, and has had several shaking spells. Which
immunization
the nurse expect would
to be primarily responsible with these
findings?
A. DTaP
B. IPV
C. Hepatitis
B
D. HIB Correct
answers
DTaP A
immunization is a vaccine that protects against diptheria, tetanus
and pertussis
(whooping cough). The majority of reactions described in this question
occur with the of the DTaP vaccination. Contraindications to giving
administration
repeat DTaP
immunizations include the occurrence of severe side effects after a
previous
well dose,
as signs ofas
encephalopathy within seven days of the
immunization.
A client diagnosed with angina has been instructed about the use of
sublingual
nitroglycerin. Which statement made by the client is incorrect and indicates
a need for
further
teaching?
A. "I'll call the health care provider if pain continues after three tablets
five minutes
apart.
"B. "I will rest briefly right after taking one
tablet."
C. "I understand that the medication should be kept in the
dark
D. bottle."
"I can swallow two or three tablets at once if I have severe pain." Correct
answersmust
Clients D understand that just one sublingual tablet should be taken at
a time and
placed under the tongue. After rest and a five-minute interval, a
second andathen
eventually third tablet may be
necessary.
The nurse is working with victims of domestic abuse. The nurse should
understand
which of these factors is a reason why domestic violence or emotional
abuse remains
extensively
undetected?
,A. The expenses due to police and court costs are
prohibitive
B. Little knowledge is known about batterers and battering
relationships
C. There are typically many series of minor, vague
complaints
D. Few people who have been battered seek medical care Correct
answers
Signs C
of domestic violence or emotional abuse may not be clearly
manifested
include many andseries of a minor complaints such as headache,
abdominalback
insomnia, pain,pain and dizziness. These may be covert indications of
violence
abuse or go undetected. These complaints may be vague and reflect
that
ambivalence
about the disclosure of any violence or
abuse.
The nurse is obtaining an aerobic wound culture from a client with stage
two pressure
injury. The nurse first removes a gauze dressing and observes a moderate
amount of
purulent drainage on the dressing and then the nurse performs hand
hygiene. What is
A. Swab the gauze dressing that was removed from the
the next correct step in the
wound
B. Irrigate the wound with normal
procedure?
saline
C. Obtain a culture by rotating a sterile swab in the
open
D. woundwound exudate from the wound edges with a cotton tip
Remove
applicator Correct
answers
B
After removing the dressing and performing hand hygiene, the wound
needs to to
irrigated beremove surface pathogens before the nurse can obtain a
wound culture.
Cultures are not obtained from wound exudate on the dressing or wounds
that have
been not since the exudate may be contaminated with normal
irrigated
skin flora.
The nurse is caring for a client who is experiencing frightening
hallucinations
markedly increased that are
at night. The client's partner asks to stay a few hours
beyond time,
visiting the in the client's private room. What would be the best
response by the
nurse
?
A. "Yes, staying with the client and orienting the client to the
surroundings
decrease any may
anxiety."
B. "No, your presence may cause the client to become more
anxious."
C. "No, it would be best if you brought the client some reading material
that the
could readclient
at
D. "Yes, would you like to spend the night when the client's behavior
night."
indicates
client is orthat
willthe
be frightened?" Correct
answers A
Encouragement of a family member or a close friend to stay with the
client in a quiet
surrounding cannot only help increase orientation, but can also minimize
confusion
anxiety. and
The visitor could also report to the nurse any unusual findings of the
client. be
would Thisthe most supportive approach for this
client.
The RN, who is functioning as the charge nurse, needs to determine shift
assignments.
How will the charge nurse determine which client assignments are
appropriate
licensed for thenurse
practical
(LPN)?
,A. Ask the LPN about prior experience caring for clients with similar
diagnoses
B. Determine how many nursing assistants are available to help the LPN with
client
C. care
Refer to the list of technical tasks LPNs are trained to
perform
D. Review the procedure manual with the LPN prior to making an
assignment Correct
answers
A
The definition of assignment is the routine care, activities and procedures
thatauthorized
the are within scope of practice of the RN or LPN/LVN. The RN must
determine
needs of thethe
clients and make assignments not only based on scope of
practice,
also but
education, demonstrated competency and skill level. Regardless
if the LPNeducation and training to perform specific skills, the RN needs to
received
determine
LPN's the
experience with caring for clients with similar diagnoses. While
the RN is
responsible for ensuring an assignment given to a delegatee is carried out
completely
and correctly, the LPN must be able to perform the skills or tasks
independently.
The nurse is caring for a school-aged child with a diagnosis of
secondary
hyperparathyroidism after treatment for chronic renal disease. Which
serum lab
should datapriority attention by the
receive
nurse?
A. Osmolality and
sodium
B. Blood urea nitrogen and
magnesium
C. Calcium and
phosphorus
D. Glucose and potassium Correct
answers
The C
parathyroid regulates the calcium and phosphorus serum levels.
Calcium and levels will be elevated in hyperfunction of this gland until
phosphorous
the client isTo recall this information think of a see-saw. Associate that
stabilized.
calcium
the is first
alphabet in thus calcium follows the direction of the abnormality -
and
hyper or hypo
function - of the parathyroid. Put the calcium on one side and the
phosphorus
other side ofon thethesee-
saw.
The nurse is caring for a client who just had a central venous catheter line
inserted
the at Which of these assessments requires immediate attention by
bedside.
the nurse?
A. Pallor in the
extremities
B. Increased temperature by one
degree
C. Involuntary coughing
D. Dyspnea at rest Correct
spells
answers D
Complications of central catheter insertion include pneumothorax and
hemothorax.
embolism Air
is another potential complication. Dyspnea, shallow
respirations,
sharp sudden
chest pain that worsens with coughing or deep breathing are
indications of Other potential complications of central catheters
pneumothorax.
may include local or systemic infection, or even cardiac tamponade (if the
thrombosis,
central linethe heart). When considering the options listed, the client who
perforates
is dyspneic
after central line insertion would be the greatest concern for
the nurse.
, The nurse is providing preprocedural education to the client preparing
for a barium
enema. What statement made by the client indicates a need for further
education?
A. "I will need to drink plenty of fluids and eat foods high in fiber after the
procedure."
B. "I will use the prescribed laxative before the
procedure."
C. "I will not eat or drink anything after midnight before the
procedure."
D. "A barium enema is used to examine the upper and lower GI tracts."
Correct answers
D
A barium enema involves filling the large intestine (lower GI tract) with
dilutedwhile
liquid barium x-ray images are taken. After the procedure, a small amount of
barium
be will
immediately expelled and the remainder will be excreted in the
stool. Because
barium liquid may cause constipation, clients should eat foods high in
fiber and
plenty drink to help expel the barium from
of fluids
the body.
A client admitted with heart failure is experiencing severe shortness of
breath and
states, "I feel like something is terribly wrong!" The client is restless and
begins to cough of pink frothy sputum. The client's skin is a dusky
up large amounts
grayish
the oxygen color and
saturation levels have decreased from 92% to 76% in the last
hour.
the What
first is the nurse should
action
take?
A. Check vital
signs
B. Administer the PRN ordered
oxygen
C. Call the health care
provider
D. Place the bed in high Fowler's position Correct
answers
When B
dealing with a medical emergency, the rule is to assess airway
first, then and then circulation. Starting oxygen is the priority. The other
breathing,
actions
also be should
implemented as quickly as possible, including activation of the
rapid response
team. The client is experiencing an acute episode of fulminant pulmonary
edema,
as a resultlikely
of a new and severe cardiac event and possible
cardiogenic assessment
Emergency shock. and intervention is indicated to prevent cardiac
arrest and
possible
death.
There is an order for a continuous lidocaine infusion at a rate of 4
mg/minute
PVCs. The IV tosolution
treat contains 2 grams of lidocaine in 500 mL of D5W. The
infusion
pump delivers 60
microdrops/mL.
What rate in microdrops/minute would deliver 4 mg of lidocaine/minute?
Report theusing a whole number. Correct
response
answers 60 analysis (DA): Remember in DA, you always want to start your
Dimensional
equation
with what's called for in the solution. In this case, you want
to know
microdrops/minute.microdrops/minute = 4 mg/min X 1 g/1000 mg X 500
mL/2 g X 60
microdrops/mL = 4 X 500 X 60/1000 X 2 = 120000/2000 = 60
microdrops/mLAnother
way to solve for X:What you have: 2 grams (2000 mg) lidocaine in 500 mL
AND you
using are
a microdrip set (60 microdrops/mL)What you want/need: 4 mg
lidocaine to
infuse/minute4 mg/min X 500 mL/2000 mg X 60
(microdrops)/min = 60
microdrops/
minute
