NCSBN Practice Questions 16-30
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,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?
A. Client is unable to speak
B. Mist is visible in the T-Piece of the ventilator circuit
C. Pulse oximetry of 86% saturation
D. Breath sounds are heard bilaterally - correct ans:C
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?
A. Eat smaller meals
B. Limiting alcohol use
C. Avoiding passive smoke
D. Learning relaxation techniques - correct ans:D
The only factor that can enhance the client's response to pain medication for angina is reduction of
anxiety through relaxation methods. Anxiety may increase intensity to a point where pain medication
outcomes are totally ineffective.
The clinic nurse is counseling a postpartum client who has a substance-abuse problem and is at risk for
continued cocaine use. In order to provide continuity of care, which nursing diagnosis should be a
priority?
A. Altered parenting
B. Social isolation
C. Ineffective coping
D. Sexual dysfunction - correct ans:A
,The mother who abuses cocaine puts her newborn and any other children at risk for neglect and abuse.
The continued use of drugs has the potential to impact parenting behaviors. Social service referrals are
indicated for evaluation and follow-up.
A nurse is caring for a client with end-stage heart failure. The family members are distressed about the
client's impending death. Which intervention should the nurse take first?
A. Assess the family's patterns for dealing with death
B. Ask about their present religious affiliations
C. Explain the stages of death and dying to the family
D. Recommend an easy-to-read book on grief - correct ans:A
When a new problem is identified, it is important for the nurse to first collect accurate information. This
is crucial to ensure that the client and the family's needs are adequately identified in order to plan and
implement nursing care. Once the situation has been assessed and a plan has been established, the
nurse can focus on teaching or referral to other resources.
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?
A. Require the client to mop the floor after each incident
B. Restrict the client's fluids throughout the day
C. Toilet the client more frequently with supervision
D. Withhold privileges each time the voiding occurs - correct ans:C
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.
A client on warfarin therapy after coronary artery stent placement calls the clinic to ask: "Can I take
Alka-Seltzer for an upset stomach?" What is the best response by the nurse?
A. "Use about half the recommended dose of Alka-Seltzer."
B. "Select another antacid that does not inactivate warfarin (Coumadin)."
, C. "Avoid Alka-Seltzer because it contains aspirin."
D. "Take Alka-Seltzer at a different time of day than you take the warfarin (Coumadin)." - correct ans:C
Alka-Seltzer is an over-the-counter aspirin-antacid combination. Aspirin is an antiplatelet drug and
taking this with warfarin will potentiate the anticoagulant effects of warfarin (Coumadin), which may
increase the risk of bleeding.
At a well-child checkup, the nurse is assessing a 1 year-old who was born prematurely and is being
evaluated for cerebral palsy (CP). Which information provided by the parents would support this
diagnosis?
A. "Our child isn't talking yet."
B. "We think our child seems smaller than other babies this age."
C. "Mealtime is so messy when he tries to feed himself."
D. "He crawls by pushing off with one hand and leg while dragging the opposite hand and leg." - correct
ans:D
Cerebral palsy refers to a group of conditions that affect movement, balance and posture. Prematurity,
infections during pregnancy, and asphyxia during labor and delivery are risk factors for CP. Some
children with CP may have delays in learning to roll over, sit, crawl or walk. Because this child was born
prematurely, it would be expected that he would be smaller than other babies. At this age, most
children can say a few words (like "mama"), but they are not talking, and mealtime can get pretty messy.
The parent of an 8-month-old infant asks the nurse if the child's language development is normal for this
age. Which sounds should the nurse expect at this age? (Select all that apply.)
A. Single vowel sounds such as ah, eh and uh
B. Combining syllables (e.g., "dada")
C. Cooing, gurgling and laughing aloud
D. Imitating sounds
E. Crying for 1-1 1/2 hours per day - correct ans:B,D
In the first few weeks of life, crying has a reflexive quality and is mostly related to the child's physiologic
needs. Infants cry for 1-1 1/2 hours per day until up to 3 weeks of age and then build up to 2 hours and
even 4 hours by 6 weeks of age. Crying tends to decrease by 12 weeks.
Normal infant language development milestones:
LATEST EXAM VERSION With
Expected real and comprehensive
Questions and 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
,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?
A. Client is unable to speak
B. Mist is visible in the T-Piece of the ventilator circuit
C. Pulse oximetry of 86% saturation
D. Breath sounds are heard bilaterally - correct ans:C
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?
A. Eat smaller meals
B. Limiting alcohol use
C. Avoiding passive smoke
D. Learning relaxation techniques - correct ans:D
The only factor that can enhance the client's response to pain medication for angina is reduction of
anxiety through relaxation methods. Anxiety may increase intensity to a point where pain medication
outcomes are totally ineffective.
The clinic nurse is counseling a postpartum client who has a substance-abuse problem and is at risk for
continued cocaine use. In order to provide continuity of care, which nursing diagnosis should be a
priority?
A. Altered parenting
B. Social isolation
C. Ineffective coping
D. Sexual dysfunction - correct ans:A
,The mother who abuses cocaine puts her newborn and any other children at risk for neglect and abuse.
The continued use of drugs has the potential to impact parenting behaviors. Social service referrals are
indicated for evaluation and follow-up.
A nurse is caring for a client with end-stage heart failure. The family members are distressed about the
client's impending death. Which intervention should the nurse take first?
A. Assess the family's patterns for dealing with death
B. Ask about their present religious affiliations
C. Explain the stages of death and dying to the family
D. Recommend an easy-to-read book on grief - correct ans:A
When a new problem is identified, it is important for the nurse to first collect accurate information. This
is crucial to ensure that the client and the family's needs are adequately identified in order to plan and
implement nursing care. Once the situation has been assessed and a plan has been established, the
nurse can focus on teaching or referral to other resources.
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?
A. Require the client to mop the floor after each incident
B. Restrict the client's fluids throughout the day
C. Toilet the client more frequently with supervision
D. Withhold privileges each time the voiding occurs - correct ans:C
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.
A client on warfarin therapy after coronary artery stent placement calls the clinic to ask: "Can I take
Alka-Seltzer for an upset stomach?" What is the best response by the nurse?
A. "Use about half the recommended dose of Alka-Seltzer."
B. "Select another antacid that does not inactivate warfarin (Coumadin)."
, C. "Avoid Alka-Seltzer because it contains aspirin."
D. "Take Alka-Seltzer at a different time of day than you take the warfarin (Coumadin)." - correct ans:C
Alka-Seltzer is an over-the-counter aspirin-antacid combination. Aspirin is an antiplatelet drug and
taking this with warfarin will potentiate the anticoagulant effects of warfarin (Coumadin), which may
increase the risk of bleeding.
At a well-child checkup, the nurse is assessing a 1 year-old who was born prematurely and is being
evaluated for cerebral palsy (CP). Which information provided by the parents would support this
diagnosis?
A. "Our child isn't talking yet."
B. "We think our child seems smaller than other babies this age."
C. "Mealtime is so messy when he tries to feed himself."
D. "He crawls by pushing off with one hand and leg while dragging the opposite hand and leg." - correct
ans:D
Cerebral palsy refers to a group of conditions that affect movement, balance and posture. Prematurity,
infections during pregnancy, and asphyxia during labor and delivery are risk factors for CP. Some
children with CP may have delays in learning to roll over, sit, crawl or walk. Because this child was born
prematurely, it would be expected that he would be smaller than other babies. At this age, most
children can say a few words (like "mama"), but they are not talking, and mealtime can get pretty messy.
The parent of an 8-month-old infant asks the nurse if the child's language development is normal for this
age. Which sounds should the nurse expect at this age? (Select all that apply.)
A. Single vowel sounds such as ah, eh and uh
B. Combining syllables (e.g., "dada")
C. Cooing, gurgling and laughing aloud
D. Imitating sounds
E. Crying for 1-1 1/2 hours per day - correct ans:B,D
In the first few weeks of life, crying has a reflexive quality and is mostly related to the child's physiologic
needs. Infants cry for 1-1 1/2 hours per day until up to 3 weeks of age and then build up to 2 hours and
even 4 hours by 6 weeks of age. Crying tends to decrease by 12 weeks.
Normal infant language development milestones:
