NCSBN Practice Questions 121-131
with Verified Solutions56
The family of a client diagnosed with schizophrenia is upset to learn that there is an order to
transfer the client from a locked inpatient facility to a community group home setting. The
family tells the nurse that they need the client stay to stay in the locked facility. Which response
by the nurse is most appropriate?
A. It violates the principle of least restrictive environment if the client, who qualifies for
community placement, is kept in a locked facility
B. In keeping with the principle of beneficence, the health care provider decides on which
placement is best for the client
C. Due to confidentiality issues, you will need to take your concerns directly to the health care
provider
D. If the client agrees to stay, I will submit a request for voluntary commitment to protect the
client's right of self-determination - ANSWERS-A
Clients have the right to be treated in the least restrictive environment. Additionally, a client
cannot be restrained or locked in a facility when less restrictive options are available. A health
care provider and nursing team assess a client's ability to function in a less restrictive setting
and initiate transfer when appropriate. Ethical principles of beneficence, confidentiality and
self-determination are important, but are not the overriding principles in the decision to move a
client from a locked facility to a less restrictive, community facility.
A nurse is assigned to care for four clients. After listening to change-of-shift report, how would
the nurse prioritize care for the following clients? (Drag the responses into the correct order.)
A. The client with a tracheostomy
B. The client scheduled for a colonoscopy
C. The postoperative client who has an order to be discharged to home
,D. The client who is in skeletal traction - ANSWERS-A,B,D,C
The nurse will check on the client with a tracheostomy (airway) first. The nurse would then
check on the client who is to undergo a procedure (to ensure the prep was completed and the
results of the bowel movements are clear). Next, the nurse would check on the client in skeletal
traction, and finally the nurse would prepare the client who is ready for discharge.
A client frequently admitted to the locked psychiatric unit repeatedly compliments and then
invites one of the nurses to go out on a date. The nurse should take which of these approaches?
A. Ask to not be assigned to this client or request to work on another unit
B. Discuss the boundaries of a therapeutic relationship with the client
C. Tell the client that such behavior is inappropriate and unethical
D. Inform the client that the hospital policy prohibits staff to date clients - ANSWERS-B
The nurse-client relationship is one with professional not social boundaries. Consistent
adherence to the limits of the professional relationship builds trust. The client may need to be
educated about the interactions in a therapeutic relationship.
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 - ANSWERS-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 - ANSWERS-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.
The client states to the nurse: "I am ready to stop all of these treatments. I just want to go home
and enjoy my family for the little bit of time I have left." Which action is most appropriate?
A. Call in a referral to a social worker and explain that the request will need to be discussed in
more detail at a later time
B. Encourage the client to discuss this decision with the health care provider and family
C. Tell the family members that the client's preference is to go home to die
D. No action is needed at this time unless the client repeats the statement to another caregiver
- ANSWERS-B
The client has the right to stop treatment and should be supported in clearly communicating
this decision with the health care provider and family. The nurse needs to act as an advocate for
, the client. It is factually incorrect to wait until the request is repeated; clients should not need
to express their wishes repeatedly before caregivers listen to them. The nurse should not be the
one to share sensitive information with the family; the client controls that information. Social
services may get involved but time is of the essence for those who are terminally ill.
A client who is newly diagnosed with hypertension is prescribed benazepril. What is the most
important point to make when teaching the client about this medication?
A. "Notify the health care provider if there is a change in your voice."
B. "Monitor your blood pressure and pulse regularly."
C. "Take medication as directed at the same time each day, even if you feel well."
D. "Call your health care provider if you develop a dry cough." - ANSWERS-A
Benazepril (Lotensin) is an angiotensin converting enzyme (ACE) inhibitor. Even if you don't
know this drug, remember that the spelling of ACE inhibitors usually end with "pril." One of the
side effects of ACE inhibitors is a dry cough; sometimes the cough is severe enough to require
discontinuation of the drug. But the most important point to make is that if the client's voice
changes or "sounds funny" or there is any swelling of the lips, tongue or throat, the client
should contact the health care provider because this could indicate angioedema, a potentially
fatal condition.
A client's admission urinalysis shows the specific gravity value of 1.039. Which of these findings
would the nurse expect to find during the physical assessment of this client?
A. Above normal heart rate
B. Moist mucous membranes
C. Poor skin turgor
D. Increased blood pressure - ANSWERS-C
The specific gravity value is high, which would indicate dehydration. Specific gravity measures
urine density and an average urine specific gravity value is around 1.020. Poor skin turgor, as
seen with tenting of the skin, is consistent with this problem.
with Verified Solutions56
The family of a client diagnosed with schizophrenia is upset to learn that there is an order to
transfer the client from a locked inpatient facility to a community group home setting. The
family tells the nurse that they need the client stay to stay in the locked facility. Which response
by the nurse is most appropriate?
A. It violates the principle of least restrictive environment if the client, who qualifies for
community placement, is kept in a locked facility
B. In keeping with the principle of beneficence, the health care provider decides on which
placement is best for the client
C. Due to confidentiality issues, you will need to take your concerns directly to the health care
provider
D. If the client agrees to stay, I will submit a request for voluntary commitment to protect the
client's right of self-determination - ANSWERS-A
Clients have the right to be treated in the least restrictive environment. Additionally, a client
cannot be restrained or locked in a facility when less restrictive options are available. A health
care provider and nursing team assess a client's ability to function in a less restrictive setting
and initiate transfer when appropriate. Ethical principles of beneficence, confidentiality and
self-determination are important, but are not the overriding principles in the decision to move a
client from a locked facility to a less restrictive, community facility.
A nurse is assigned to care for four clients. After listening to change-of-shift report, how would
the nurse prioritize care for the following clients? (Drag the responses into the correct order.)
A. The client with a tracheostomy
B. The client scheduled for a colonoscopy
C. The postoperative client who has an order to be discharged to home
,D. The client who is in skeletal traction - ANSWERS-A,B,D,C
The nurse will check on the client with a tracheostomy (airway) first. The nurse would then
check on the client who is to undergo a procedure (to ensure the prep was completed and the
results of the bowel movements are clear). Next, the nurse would check on the client in skeletal
traction, and finally the nurse would prepare the client who is ready for discharge.
A client frequently admitted to the locked psychiatric unit repeatedly compliments and then
invites one of the nurses to go out on a date. The nurse should take which of these approaches?
A. Ask to not be assigned to this client or request to work on another unit
B. Discuss the boundaries of a therapeutic relationship with the client
C. Tell the client that such behavior is inappropriate and unethical
D. Inform the client that the hospital policy prohibits staff to date clients - ANSWERS-B
The nurse-client relationship is one with professional not social boundaries. Consistent
adherence to the limits of the professional relationship builds trust. The client may need to be
educated about the interactions in a therapeutic relationship.
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 - ANSWERS-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 - ANSWERS-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.
The client states to the nurse: "I am ready to stop all of these treatments. I just want to go home
and enjoy my family for the little bit of time I have left." Which action is most appropriate?
A. Call in a referral to a social worker and explain that the request will need to be discussed in
more detail at a later time
B. Encourage the client to discuss this decision with the health care provider and family
C. Tell the family members that the client's preference is to go home to die
D. No action is needed at this time unless the client repeats the statement to another caregiver
- ANSWERS-B
The client has the right to stop treatment and should be supported in clearly communicating
this decision with the health care provider and family. The nurse needs to act as an advocate for
, the client. It is factually incorrect to wait until the request is repeated; clients should not need
to express their wishes repeatedly before caregivers listen to them. The nurse should not be the
one to share sensitive information with the family; the client controls that information. Social
services may get involved but time is of the essence for those who are terminally ill.
A client who is newly diagnosed with hypertension is prescribed benazepril. What is the most
important point to make when teaching the client about this medication?
A. "Notify the health care provider if there is a change in your voice."
B. "Monitor your blood pressure and pulse regularly."
C. "Take medication as directed at the same time each day, even if you feel well."
D. "Call your health care provider if you develop a dry cough." - ANSWERS-A
Benazepril (Lotensin) is an angiotensin converting enzyme (ACE) inhibitor. Even if you don't
know this drug, remember that the spelling of ACE inhibitors usually end with "pril." One of the
side effects of ACE inhibitors is a dry cough; sometimes the cough is severe enough to require
discontinuation of the drug. But the most important point to make is that if the client's voice
changes or "sounds funny" or there is any swelling of the lips, tongue or throat, the client
should contact the health care provider because this could indicate angioedema, a potentially
fatal condition.
A client's admission urinalysis shows the specific gravity value of 1.039. Which of these findings
would the nurse expect to find during the physical assessment of this client?
A. Above normal heart rate
B. Moist mucous membranes
C. Poor skin turgor
D. Increased blood pressure - ANSWERS-C
The specific gravity value is high, which would indicate dehydration. Specific gravity measures
urine density and an average urine specific gravity value is around 1.020. Poor skin turgor, as
seen with tenting of the skin, is consistent with this problem.
