NCSBN Practice Questions 61-75 with
Complete Solutions69
A nurse detects fluid leaking from the nose and ears of a client admitted for head trauma.
Which is the appropriate nursing action?
A. Pack the nose and ears with sterile gauze
B. Raise the head of the bed so the client is sitting upright
C. Position an ice pack on the back of the neck
D. Place loose dressings below the nostril and ear - ANSWERS-D
Drainage from the nose and ear in a client with head trauma may be caused by leakage of
cerebrospinal fluid (CSF). Applying a loose dressing to the nose and ears permits the fluid to
drain and provides a visual reference to assess the type and amount of drainage. The nose and
ear should not be packed if CSF leakage is suspected. If the drainage contains blood, look for the
halo sign: a ring formed when protein in the CSF migrates to the edge of the wet spot as the
gauze dries. If the drainage is clear, the nurse should check it for glucose. The head of the bed
should be elevated 15 to 30 degrees to facilitate the drainage and decrease intracranial
pressure.
A client had a full leg plaster cast applied during surgery. What is the priority reason for the
nurse to elevate the casted leg postoperatively?
A. Improve venous return
B. Reduce the drying time
C. Promote the client's comfort
D. Decrease irritation to the skin - ANSWERS-A
Elevating the leg on one or two pillows will improve venous return, which will reduce the
amount of swelling in the extremity. Ice may be ordered to also help prevent or reduce swelling.
,Elevating the leg will have little effect on drying time. Skin irritation can be decreased by
handling the wet cast with the palms of the hands.
The nurse is caring for a client newly diagnosed with atrial fibrillation. The atrial heart rate is
250 and the ventricular rate is controlled at 75. Which finding is a cause for the most concern?
A. Difficulty speaking
B. Diminished bowel sounds
C. Tachypnea with movement
D. Loss of appetite - ANSWERS-A
Anticoagulant therapy is usually given to patients with atrial fibrillation to prevent blood clots
and stroke. A new finding of difficulty speaking may indicate that the client has suffered a
stroke. The nurse should assess for any other cognitive changes, assess lung function, and
immediately contact the provider and possibly the stroke team. The atrial rate of 250 is normal
for atrial fibrillation and is of no concern; the ventricular rate of 75 indicates that the cardiac
rate is well-controlled (a ventricular rate above 100 would not be adequately controlled,
necessitating additional rate control medications such as a beta blocker, calcium channel blocker
or digoxin).
The nurse is coordinating care for a postpartum client and her newborn with the unlicensed
assistive personnel (UAP). The mother is human immunodeficiency virus (HIV) positive. The
nurse would recognize the need to educate the UAP, who is observed doing which of the
following actions?
A. Assist the mother who is attempting to breastfeed her baby
B. Place the infant on his or her back in the bassinet
C. Wear gloves while changing the newborn's soiled diaper
D. Assist the mother to walk to the bathroom - ANSWERS-A
In the United States, it is current practice to counsel a mother who is HIV positive, or has AIDS,
against breast feeding; breast feeding can transmit the virus through the breast milk to the
infant. It is correct to place an infant on his or her back to prevent sudden infant death
,syndrome. Standard precautions should be followed when caring for any client; health care
providers should wear gloves when they anticipate contact with body secretions (changing a
soiled diaper).
The nurse is teaching a client about precautions while taking warfarin. The nurse should instruct
the client to avoid foods with excessive amounts of which nutrient?
A. Calcium
B. Vitamin E
C. Iron
D. Vitamin K - ANSWERS-D
Vitamin K is an essential vitamin required for blood clotting. Eating foods with excessive
amounts of Vitamin K may alter anticoagulant effects. Foods highest in vitamin K include (dried
and fresh) herbs, dark leafy greens, scallions, brussel sprouts, broccoli, chili powder, prunes,
asparagus and cabbage.
A newly admitted client reports gaining 5 pounds (2.27 kg) the past week even though he has
hasn't been very hungry. The nurse observes swelling of the feet and ankles. What is the most
likely explanation for the weight gain?
A. Hyperthyroidism
B. Malnutrition
C. Congestive heart failure
D. Acromegaly - ANSWERS-C
The unexplained rapid weight gain is probably due to fluid retention. Clients who gain as little as
two pounds (0.9 kg) in a week may require hospitalization due to worsening heart failure. The
lack of appetite (or a feeling of being full) and edema are also signs of worsening heart failure.
Hypothyroidism, and not hyperthyroidism, can lead to low body temperature, which causes
fluid retention or bloating. Low protein levels in the blood caused by malnutrition can cause
edema. However, there's not enough information given in the question to know if this client is
, malnourished or not. Acromegaly is characterized by overgrowth of body tissues, not edema,
and is caused by excessive secretion of growth hormone.
A nurse is caring for a client with acute renal failure who has a subclavian vascular access port
for hemodialysis. Which of these findings necessitates immediate action by the nurse?
A. Elevated temperature
B. Dry, hacking cough
C. Chronic fatigue
D. Pruritic rash - ANSWERS-A
An elevated temperature in this client would indicate a possible central line infection. This
finding should be reported to the provider who should order wound and blood cultures. If a line
infection is suspected, the line will need to be removed, necessitating alternate line placement
for hemodialysis. Interventions to prevention line infection through maintenance of line sterility
and stabilization of the site are a priority in any client with a central line. The other findings
should be reported to the health care provider but a febrile reaction is the priority.
The parent of a 2 year-old reports the child has experienced mild diarrhea for the past two days.
Which statement by the nurse provides the best nutritional information for the child?
A. Clear liquids and gelatin for 24 hours
B. NPO for 24 hours, then rehydrate with milk and water
C. Continue with the regular diet and include oral rehydration fluids
D. Offer bananas, apples, rice and toast as tolerated - ANSWERS-C
Current recommendations for mild to moderate diarrhea are to maintain a normal diet with
fluids to rehydrate. If the diarrhea was severe then the BRAT (for bananas, apples, rice and
toast) diet may be appropriate.
An important goal in the development of a therapeutic inpatient milieu is which of these items?
Complete Solutions69
A nurse detects fluid leaking from the nose and ears of a client admitted for head trauma.
Which is the appropriate nursing action?
A. Pack the nose and ears with sterile gauze
B. Raise the head of the bed so the client is sitting upright
C. Position an ice pack on the back of the neck
D. Place loose dressings below the nostril and ear - ANSWERS-D
Drainage from the nose and ear in a client with head trauma may be caused by leakage of
cerebrospinal fluid (CSF). Applying a loose dressing to the nose and ears permits the fluid to
drain and provides a visual reference to assess the type and amount of drainage. The nose and
ear should not be packed if CSF leakage is suspected. If the drainage contains blood, look for the
halo sign: a ring formed when protein in the CSF migrates to the edge of the wet spot as the
gauze dries. If the drainage is clear, the nurse should check it for glucose. The head of the bed
should be elevated 15 to 30 degrees to facilitate the drainage and decrease intracranial
pressure.
A client had a full leg plaster cast applied during surgery. What is the priority reason for the
nurse to elevate the casted leg postoperatively?
A. Improve venous return
B. Reduce the drying time
C. Promote the client's comfort
D. Decrease irritation to the skin - ANSWERS-A
Elevating the leg on one or two pillows will improve venous return, which will reduce the
amount of swelling in the extremity. Ice may be ordered to also help prevent or reduce swelling.
,Elevating the leg will have little effect on drying time. Skin irritation can be decreased by
handling the wet cast with the palms of the hands.
The nurse is caring for a client newly diagnosed with atrial fibrillation. The atrial heart rate is
250 and the ventricular rate is controlled at 75. Which finding is a cause for the most concern?
A. Difficulty speaking
B. Diminished bowel sounds
C. Tachypnea with movement
D. Loss of appetite - ANSWERS-A
Anticoagulant therapy is usually given to patients with atrial fibrillation to prevent blood clots
and stroke. A new finding of difficulty speaking may indicate that the client has suffered a
stroke. The nurse should assess for any other cognitive changes, assess lung function, and
immediately contact the provider and possibly the stroke team. The atrial rate of 250 is normal
for atrial fibrillation and is of no concern; the ventricular rate of 75 indicates that the cardiac
rate is well-controlled (a ventricular rate above 100 would not be adequately controlled,
necessitating additional rate control medications such as a beta blocker, calcium channel blocker
or digoxin).
The nurse is coordinating care for a postpartum client and her newborn with the unlicensed
assistive personnel (UAP). The mother is human immunodeficiency virus (HIV) positive. The
nurse would recognize the need to educate the UAP, who is observed doing which of the
following actions?
A. Assist the mother who is attempting to breastfeed her baby
B. Place the infant on his or her back in the bassinet
C. Wear gloves while changing the newborn's soiled diaper
D. Assist the mother to walk to the bathroom - ANSWERS-A
In the United States, it is current practice to counsel a mother who is HIV positive, or has AIDS,
against breast feeding; breast feeding can transmit the virus through the breast milk to the
infant. It is correct to place an infant on his or her back to prevent sudden infant death
,syndrome. Standard precautions should be followed when caring for any client; health care
providers should wear gloves when they anticipate contact with body secretions (changing a
soiled diaper).
The nurse is teaching a client about precautions while taking warfarin. The nurse should instruct
the client to avoid foods with excessive amounts of which nutrient?
A. Calcium
B. Vitamin E
C. Iron
D. Vitamin K - ANSWERS-D
Vitamin K is an essential vitamin required for blood clotting. Eating foods with excessive
amounts of Vitamin K may alter anticoagulant effects. Foods highest in vitamin K include (dried
and fresh) herbs, dark leafy greens, scallions, brussel sprouts, broccoli, chili powder, prunes,
asparagus and cabbage.
A newly admitted client reports gaining 5 pounds (2.27 kg) the past week even though he has
hasn't been very hungry. The nurse observes swelling of the feet and ankles. What is the most
likely explanation for the weight gain?
A. Hyperthyroidism
B. Malnutrition
C. Congestive heart failure
D. Acromegaly - ANSWERS-C
The unexplained rapid weight gain is probably due to fluid retention. Clients who gain as little as
two pounds (0.9 kg) in a week may require hospitalization due to worsening heart failure. The
lack of appetite (or a feeling of being full) and edema are also signs of worsening heart failure.
Hypothyroidism, and not hyperthyroidism, can lead to low body temperature, which causes
fluid retention or bloating. Low protein levels in the blood caused by malnutrition can cause
edema. However, there's not enough information given in the question to know if this client is
, malnourished or not. Acromegaly is characterized by overgrowth of body tissues, not edema,
and is caused by excessive secretion of growth hormone.
A nurse is caring for a client with acute renal failure who has a subclavian vascular access port
for hemodialysis. Which of these findings necessitates immediate action by the nurse?
A. Elevated temperature
B. Dry, hacking cough
C. Chronic fatigue
D. Pruritic rash - ANSWERS-A
An elevated temperature in this client would indicate a possible central line infection. This
finding should be reported to the provider who should order wound and blood cultures. If a line
infection is suspected, the line will need to be removed, necessitating alternate line placement
for hemodialysis. Interventions to prevention line infection through maintenance of line sterility
and stabilization of the site are a priority in any client with a central line. The other findings
should be reported to the health care provider but a febrile reaction is the priority.
The parent of a 2 year-old reports the child has experienced mild diarrhea for the past two days.
Which statement by the nurse provides the best nutritional information for the child?
A. Clear liquids and gelatin for 24 hours
B. NPO for 24 hours, then rehydrate with milk and water
C. Continue with the regular diet and include oral rehydration fluids
D. Offer bananas, apples, rice and toast as tolerated - ANSWERS-C
Current recommendations for mild to moderate diarrhea are to maintain a normal diet with
fluids to rehydrate. If the diarrhea was severe then the BRAT (for bananas, apples, rice and
toast) diet may be appropriate.
An important goal in the development of a therapeutic inpatient milieu is which of these items?
