NCSBN Practice Questions 76-90
Exam with 100% Solution
An 18 month-old weighing 22 pounds is admitted to the pediatric unit
with a diagnosis of dehydration. A replacement bolus of normal saline
at 20 mL/kg is ordered to be administered intravenously over 40
minutes.
In mL/hour, what will be the setting for the IV delivery system? -
CORRECT ANSWERS ✔✔300
Using ratio proportion:First, convert 22 pounds to kilograms (22/2.2) =
10 kg20 mL/kg = 20 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 60 min/hr x 1/40 min = 300
mL/hr
The mother of a 2 month-old baby calls a pediatrician's nurse two days
after the first DTaP, inactivated polio vaccine (IPV), Hepatitis B and
Haemophilus influenzae type B (HIB) immunizations. She reports that
the baby feels very warm, cries inconsolably for as long as three hours,
and has had several shaking spells. Which immunization would the
nurse expect to be primarily responsible with these findings?
A. DTaP
B. IPV
C. Hepatitis B
D. HIB - CORRECT ANSWERS ✔✔A
DTaP immunization is a vaccine that protects against diptheria, tetanus
and pertussis (whooping cough). The majority of reactions described in
,NCSBN Practice Questions 76-90
Exam with 100% Solution
this question occur with the administration of the DTaP vaccination.
Contraindications to giving repeat DTaP immunizations include the
occurrence of severe side effects after a previous dose, as well as signs
of 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 bottle."
D. "I can swallow two or three tablets at once if I have severe pain." -
CORRECT ANSWERS ✔✔D
Clients must 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 and then eventually a 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
,NCSBN Practice Questions 76-90
Exam with 100% Solution
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 ✔✔C
Signs of domestic violence or emotional abuse may not be clearly
manifested and include many series of a minor complaints such as
headache, abdominal pain, insomnia, back pain and dizziness. These
may be covert indications of violence or abuse that go undetected.
These complaints may be vague and reflect 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 the next correct step in
the procedure?
A. Swab the gauze dressing that was removed from the wound
B. Irrigate the wound with normal saline
C. Obtain a culture by rotating a sterile swab in the open wound
D. Remove wound exudate from the wound edges with a cotton tip
applicator - CORRECT ANSWERS ✔✔B
After removing the dressing and performing hand hygiene, the wound
needs to be irrigated to remove surface pathogens before the nurse
can obtain a wound culture. Cultures are not obtained from wound
, NCSBN Practice Questions 76-90
Exam with 100% Solution
exudate on the dressing or wounds that have not been irrigated since
the exudate may be contaminated with normal skin flora.
The nurse is caring for a client who is experiencing frightening
hallucinations that are markedly increased at night. The client's partner
asks to stay a few hours beyond the visiting time, 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 may decrease any 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 client could read at night."
D. "Yes, would you like to spend the night when the client's behavior
indicates that the client is or will 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 and anxiety. The visitor could also report
to the nurse any unusual findings of the client. This would be the 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 for the licensed practical nurse (LPN)?
Exam with 100% Solution
An 18 month-old weighing 22 pounds is admitted to the pediatric unit
with a diagnosis of dehydration. A replacement bolus of normal saline
at 20 mL/kg is ordered to be administered intravenously over 40
minutes.
In mL/hour, what will be the setting for the IV delivery system? -
CORRECT ANSWERS ✔✔300
Using ratio proportion:First, convert 22 pounds to kilograms (22/2.2) =
10 kg20 mL/kg = 20 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 60 min/hr x 1/40 min = 300
mL/hr
The mother of a 2 month-old baby calls a pediatrician's nurse two days
after the first DTaP, inactivated polio vaccine (IPV), Hepatitis B and
Haemophilus influenzae type B (HIB) immunizations. She reports that
the baby feels very warm, cries inconsolably for as long as three hours,
and has had several shaking spells. Which immunization would the
nurse expect to be primarily responsible with these findings?
A. DTaP
B. IPV
C. Hepatitis B
D. HIB - CORRECT ANSWERS ✔✔A
DTaP immunization is a vaccine that protects against diptheria, tetanus
and pertussis (whooping cough). The majority of reactions described in
,NCSBN Practice Questions 76-90
Exam with 100% Solution
this question occur with the administration of the DTaP vaccination.
Contraindications to giving repeat DTaP immunizations include the
occurrence of severe side effects after a previous dose, as well as signs
of 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 bottle."
D. "I can swallow two or three tablets at once if I have severe pain." -
CORRECT ANSWERS ✔✔D
Clients must 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 and then eventually a 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
,NCSBN Practice Questions 76-90
Exam with 100% Solution
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 ✔✔C
Signs of domestic violence or emotional abuse may not be clearly
manifested and include many series of a minor complaints such as
headache, abdominal pain, insomnia, back pain and dizziness. These
may be covert indications of violence or abuse that go undetected.
These complaints may be vague and reflect 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 the next correct step in
the procedure?
A. Swab the gauze dressing that was removed from the wound
B. Irrigate the wound with normal saline
C. Obtain a culture by rotating a sterile swab in the open wound
D. Remove wound exudate from the wound edges with a cotton tip
applicator - CORRECT ANSWERS ✔✔B
After removing the dressing and performing hand hygiene, the wound
needs to be irrigated to remove surface pathogens before the nurse
can obtain a wound culture. Cultures are not obtained from wound
, NCSBN Practice Questions 76-90
Exam with 100% Solution
exudate on the dressing or wounds that have not been irrigated since
the exudate may be contaminated with normal skin flora.
The nurse is caring for a client who is experiencing frightening
hallucinations that are markedly increased at night. The client's partner
asks to stay a few hours beyond the visiting time, 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 may decrease any 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 client could read at night."
D. "Yes, would you like to spend the night when the client's behavior
indicates that the client is or will 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 and anxiety. The visitor could also report
to the nurse any unusual findings of the client. This would be the 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 for the licensed practical nurse (LPN)?
