BSC 2085 NCSBN TEST BANK - NCLEX-RN & NCLEX PN,
2025 LATEST UPDATE| 200 QUESTIONS AND ANSWERS
100%
A nurse is caring for a client following a Computed Tomography (CT) scan of the
kidneys with contrast. Which of these findings would require prompt intervention by the
nurse?
Soreness reported at the IV site
Elevated serum creatinine above baseline
The client states that the urethra feels irritated and sore from the catheter
The client states they have felt mild nausea since the procedure - __100% correct
answer as 2
A CT scan provides three-dimensional information about structures within the body.
Oral or injected dye (contrast) is generally used during this scan to provide detailed
images. After the scan, the nurse should monitor for complications associated with the
contrast including anaphylaxis or contrast-induced nephropathy. Contrast-induced
nephropathy is defined as a 25% increase of the serum creatinine above baseline within
A nurse is teaching a mother who will breast-feed for the first time. Which of these
approaches is a priority?
Give the mother privacy for the initial feeding
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 - __100% correct answer as
Assist the mother to position the newborn at the breast
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 in a long-term care facility is evaluating the plan of care for an older adult
client with advanced dementia. The client has had several falls out of bed. Which initial
intervention should the nurse implement?
Have the client sleep in a recliner at the nurse's station with a tray table across their lap
Put the bed in the lowest position with a thick pad or mat on the floor next to the bed
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 - __100%
correct answer as Falls out of bed are a common occurrence in the long-term care
setting. Although it is nearly impossible to eliminate all falls, the nurse can implement
interventions to reduce the risk for injury related to a fall. The goal is to start with the
least invasive and restrictive intervention to preserve the client's rights, regardless of
their level of cognitive function. 'Low' beds and 'landing' mats to soften the fall should
the client roll out of bed are commonly used in long-term care settings and represent an
appropriate, initial intervention to implement for this client. The other interventions are
much more restrictive and should be used only after less restrictive interventions have
been attempted.
The nurse is developing a plan of care for a client who underwent total hip arthroplasty
24 hours ago. Which interventions should the nurse include? Select all that apply.
1. Encourage the client to perform leg exercises while in bed
2. Remind the client to not bend the knee of the affected leg while seated
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 - __100% correct answer as 1,3,4,5
To prevent postoperative complications and complications related to 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 should reinforce teaching of simple
leg exercises while in bed and the use of an abduction pillow or foam wedge to prevent
adduction. To prevent atelectasis and pneumonia the client should be encouraged to
use an incentive spirometer every 2 hours. Once the client is alert after surgery and not
experiencing nausea or vomiting, they can resume a regular diet.
,A nurse is performing physical assessments on 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 - __100% correct answer
as Occur about two years earlier than for males
48 hours of the procedure. While mild nausea and soreness at the IV site are problems
requiring intervention, they are not the immediate concern. A catheter is not required for
this procedure.
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?
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 - __100% correct answer as Toilet the
client more frequently with supervision
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.
The nurse is caring for a client who is experiencing alcohol withdrawal. The client is
experiencing tremors and nausea. The client's vital signs are within normal limits, but
the client is sweating profusely. Which nursing intervention is a priority for this client?
Assess the client's vital signs every 6 hours
Monitor for agitation or hallucinations
Update the client regularly on their progress
, Ask the family to leave the bedside to provide privacy - __100% correct answer as
Monitor for agitation or hallucinations
During alcohol withdrawal, the client may experience many clinical manifestations. Six
to eight hours after alcohol cessation, the client may experience tremors, nausea and
agitation. After eight to ten hours, the client may experience increasing perceptual
changes such as hallucinations, unconsciousness, seizures, or delirium. This is a
medical emergency and the nurse should anticipate administration of lorazepam or
chlordiazepoxide. After twelve to twenty-four hours, the client may experience tonic-
clonic seizures and diazepam may be administered. Monitoring the client for 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 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 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?
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 - __100% correct answer as Pulse
oximetry of 86% saturation
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?
Avoiding passive smoke
Limiting alcohol use
Learning relaxation techniques
Eat smaller meals - __100% correct answer as Learning relaxation techniques
2025 LATEST UPDATE| 200 QUESTIONS AND ANSWERS
100%
A nurse is caring for a client following a Computed Tomography (CT) scan of the
kidneys with contrast. Which of these findings would require prompt intervention by the
nurse?
Soreness reported at the IV site
Elevated serum creatinine above baseline
The client states that the urethra feels irritated and sore from the catheter
The client states they have felt mild nausea since the procedure - __100% correct
answer as 2
A CT scan provides three-dimensional information about structures within the body.
Oral or injected dye (contrast) is generally used during this scan to provide detailed
images. After the scan, the nurse should monitor for complications associated with the
contrast including anaphylaxis or contrast-induced nephropathy. Contrast-induced
nephropathy is defined as a 25% increase of the serum creatinine above baseline within
A nurse is teaching a mother who will breast-feed for the first time. Which of these
approaches is a priority?
Give the mother privacy for the initial feeding
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 - __100% correct answer as
Assist the mother to position the newborn at the breast
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 in a long-term care facility is evaluating the plan of care for an older adult
client with advanced dementia. The client has had several falls out of bed. Which initial
intervention should the nurse implement?
Have the client sleep in a recliner at the nurse's station with a tray table across their lap
Put the bed in the lowest position with a thick pad or mat on the floor next to the bed
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 - __100%
correct answer as Falls out of bed are a common occurrence in the long-term care
setting. Although it is nearly impossible to eliminate all falls, the nurse can implement
interventions to reduce the risk for injury related to a fall. The goal is to start with the
least invasive and restrictive intervention to preserve the client's rights, regardless of
their level of cognitive function. 'Low' beds and 'landing' mats to soften the fall should
the client roll out of bed are commonly used in long-term care settings and represent an
appropriate, initial intervention to implement for this client. The other interventions are
much more restrictive and should be used only after less restrictive interventions have
been attempted.
The nurse is developing a plan of care for a client who underwent total hip arthroplasty
24 hours ago. Which interventions should the nurse include? Select all that apply.
1. Encourage the client to perform leg exercises while in bed
2. Remind the client to not bend the knee of the affected leg while seated
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 - __100% correct answer as 1,3,4,5
To prevent postoperative complications and complications related to 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 should reinforce teaching of simple
leg exercises while in bed and the use of an abduction pillow or foam wedge to prevent
adduction. To prevent atelectasis and pneumonia the client should be encouraged to
use an incentive spirometer every 2 hours. Once the client is alert after surgery and not
experiencing nausea or vomiting, they can resume a regular diet.
,A nurse is performing physical assessments on 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 - __100% correct answer
as Occur about two years earlier than for males
48 hours of the procedure. While mild nausea and soreness at the IV site are problems
requiring intervention, they are not the immediate concern. A catheter is not required for
this procedure.
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?
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 - __100% correct answer as Toilet the
client more frequently with supervision
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.
The nurse is caring for a client who is experiencing alcohol withdrawal. The client is
experiencing tremors and nausea. The client's vital signs are within normal limits, but
the client is sweating profusely. Which nursing intervention is a priority for this client?
Assess the client's vital signs every 6 hours
Monitor for agitation or hallucinations
Update the client regularly on their progress
, Ask the family to leave the bedside to provide privacy - __100% correct answer as
Monitor for agitation or hallucinations
During alcohol withdrawal, the client may experience many clinical manifestations. Six
to eight hours after alcohol cessation, the client may experience tremors, nausea and
agitation. After eight to ten hours, the client may experience increasing perceptual
changes such as hallucinations, unconsciousness, seizures, or delirium. This is a
medical emergency and the nurse should anticipate administration of lorazepam or
chlordiazepoxide. After twelve to twenty-four hours, the client may experience tonic-
clonic seizures and diazepam may be administered. Monitoring the client for 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 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 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?
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 - __100% correct answer as Pulse
oximetry of 86% saturation
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?
Avoiding passive smoke
Limiting alcohol use
Learning relaxation techniques
Eat smaller meals - __100% correct answer as Learning relaxation techniques
