NCSBN Practice Questions 76-90
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,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 ans: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 ans:A
DTaP immunization is a vaccine that protects against diptheria, tetanus and pertussis (whooping cough).
The majority of reactions described in 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 ans: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
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 ans: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 ans: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
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 ans: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)?
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 care
C. 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 ans:A
The definition of assignment is the routine care, activities and procedures that are within the authorized
scope of practice of the RN or LPN/LVN. The RN must determine the needs of the clients and make
assignments not only based on scope of practice, but also education, demonstrated competency and
skill level. Regardless if the LPN received education and training to perform specific skills, the RN needs
to determine the LPN's 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 data should receive priority attention by the
nurse?
A. Osmolality and sodium
B. Blood urea nitrogen and magnesium
C. Calcium and phosphorus
D. Glucose and potassium - correct ans:C
The parathyroid regulates the calcium and phosphorus serum levels. Calcium and phosphorous levels
will be elevated in hyperfunction of this gland until the client is stabilized. To recall this information
think of a see-saw. Associate that calcium is first in the alphabet and thus calcium follows the direction
of the abnormality - hyper or hypo function - of the parathyroid. Put the calcium on one side and the
phosphorus on the other side of the see-saw.
LATEST EXAM VERSION With
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Revised Correct Answers Guarantee
Pass A+
Professional Academic Assistance Services
Services Offered
Proctored Exam Assistance
Online Class Management (Full Course Support)
Exam Preparation & Study Materials
Assignments and Coursework Support
Essays and Research Papers
Discussion Posts and Replies
,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 ans: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 ans:A
DTaP immunization is a vaccine that protects against diptheria, tetanus and pertussis (whooping cough).
The majority of reactions described in 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 ans: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
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 ans: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 ans: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
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 ans: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)?
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 care
C. 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 ans:A
The definition of assignment is the routine care, activities and procedures that are within the authorized
scope of practice of the RN or LPN/LVN. The RN must determine the needs of the clients and make
assignments not only based on scope of practice, but also education, demonstrated competency and
skill level. Regardless if the LPN received education and training to perform specific skills, the RN needs
to determine the LPN's 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 data should receive priority attention by the
nurse?
A. Osmolality and sodium
B. Blood urea nitrogen and magnesium
C. Calcium and phosphorus
D. Glucose and potassium - correct ans:C
The parathyroid regulates the calcium and phosphorus serum levels. Calcium and phosphorous levels
will be elevated in hyperfunction of this gland until the client is stabilized. To recall this information
think of a see-saw. Associate that calcium is first in the alphabet and thus calcium follows the direction
of the abnormality - hyper or hypo function - of the parathyroid. Put the calcium on one side and the
phosphorus on the other side of the see-saw.
