NCSBN PRACTICE EXAM - COMPLETE QUESTIONS
AND DETAILED SOLUTIONS LATEST UPDATE THIS
YEAR JUST RELEASED
Question 1: An external disaster has occurred in the town. The
triage nurse from the emergency department is transported to the
site and assigned to triage the injured. Which of these clients
would the nurse tag as "to be seen last" by the providers at the
scene?
A. An older adult person with a open fracture of the left arm
B. An infant with bilateral fractured lower legs with no active bleeding
C. A teenager with small amount of bright red blood dripping out of
the nose
D. A middle-aged person with deep abrasions that are over 90% of
the body
Answer:
A middle-aged person with deep abrasions that are over 90% of the body
Rationale: The clients that are least likely to survive are to be tagged as the "last to
be seen." Deep abrasions are usually treated as second or third degree burns
because the fluid loss is great.
Question 2: A child is treated with succimer for lead poisoning.
Which of these assessments should the nurse perform first?
A. Check serum potassium level
B. Check blood calcium level
C. Test deep tendon reflexes
D. Check complete blood count (CBC) with differential
,Answer:
Check complete blood count (CBC) with differential
Rationale: Succimer (Chemet) is used in the management of lead or other heavy
metal poisoning. Although it has generally well tolerated and has a relatively low
toxicity, it may cause neutropenia. Therapy should be withheld or discontinued if
the absolute neutrophil count (ANC) is below 1200/µ.
Question 3: The client with a T-2 spinal cord injury reports having a
"pounding" headache. Further assessment by the nurse reveals
excessive sweating, rash, pilomotor erection, facial flushing,
congested nasal passages and a heart rate of 50. What action
should the nurse take next?
A. Assist client with relaxation techniques
B. Measure the client's respirations, blood pressure, temperature and
pupillary responses
C. Check the client for bladder distention and the urinary catheter for
kinks
D. Place the client into the bed and administer the ordered PRN
analgesic
Answer:
Check the client for bladder distention and the urinary catheter for kinks
Rationale: These are findings of autonomic dysreflexia, also called hyperreflexia.
This response occurs in clients with a spinal cord injury above the T-6 level. It is
typically initiated by any noxious stimulus below the level of injury such as a full
bladder, an enema or bowel movement, fecal impaction, uterine contractions,
changing of the catheter and vaginal or rectal examinations. The stimulus creates
an exaggerated response of the sympathetic nervous system and can be a
life-threatening event. The BP is typically extremely high. The priority action of the
nurse is to identify and relieve the cause of the stimulus.
,Question 4: The client is diagnosed with cystic fibrosis (CF). The
nurse would expect the client to be treated with oral pancreatic
enzymes and which type of diet?
A. High fat, high-calorie
B. Gluten-free, low fiber
C. Dairy-free
D. Sodium-restricted
Answer:
High fat, high-calorie
Rationale: CF affects the cells that produce mucus, sweat and digestive juices.
Someone with CF needs a high-energy diet that includes high-fat and high-calorie
foods, extra fiber to prevent intestinal blockage and extra salt (especially during hot
weather.) People with CF are at risk for osteoporosis and need calcium and dairy
products. Someone with celiac disease or with a gluten intolerance, not CF, needs
a gluten-free diet.
Question 5: A client has a chest tube inserted immediately after
surgery for a left lower lobectomy. During the repositioning of the
client during the first postop check, the nurse notices 75 mL of a
dark, red fluid flowing into the collection chamber of the chest
drain system. What is the appropriate nursing action?
A. Continue to monitor the rate of drainage
B. Call the surgeon immediately
C. Check to see if the client has a type and cross match
D. Turn the client back to the original position
Answer:
Continue to monitor the rate of drainage
Rationale: It is not unusual for blood to collect in the chest and be released into the
chest drain when the client changes position this soon after surgery. The dark color
, of the blood indicates it is not active bleeding inside of the chest. Sanguinous
drainage should be expected within the initial 24 hours postop, progressing to
serosanguinous and then to a serous type. If the drainage exceeds 100 mL/hr, the
nurse should call the surgeon.
Question 6: A 67 year-old client is admitted with substernal chest
pressure that radiates to the jaw. The admitting diagnosis is acute
myocardial infarction (MI). What should be the priority nursing
diagnosis for this client during the first 24 hours?
A. Altered tissue perfusion
B. Activity intolerance
C. Anxiety
D. Risk for fluid volume excess
Answer:
Altered tissue perfusion
Rationale: In the immediate post MI period, altered tissue perfusion is priority, as
an area of myocardial tissue has been damaged by a lack of blood flow and
oxygenation. Interventions should be directed toward promoting tissue perfusion
and oxygenation. The other problems are also relevant, but tissue perfusion is the
priority.
Question 7: A client with a diagnosis of methicillin-resistant
Staphylococcus aureus (MRSA) has died. Which type of
precautions is appropriate to use when performing postmortem
care?
A. Contact precautions
B. Droplet precautions
C. Compromised host precautions
D. Airborne precautions
AND DETAILED SOLUTIONS LATEST UPDATE THIS
YEAR JUST RELEASED
Question 1: An external disaster has occurred in the town. The
triage nurse from the emergency department is transported to the
site and assigned to triage the injured. Which of these clients
would the nurse tag as "to be seen last" by the providers at the
scene?
A. An older adult person with a open fracture of the left arm
B. An infant with bilateral fractured lower legs with no active bleeding
C. A teenager with small amount of bright red blood dripping out of
the nose
D. A middle-aged person with deep abrasions that are over 90% of
the body
Answer:
A middle-aged person with deep abrasions that are over 90% of the body
Rationale: The clients that are least likely to survive are to be tagged as the "last to
be seen." Deep abrasions are usually treated as second or third degree burns
because the fluid loss is great.
Question 2: A child is treated with succimer for lead poisoning.
Which of these assessments should the nurse perform first?
A. Check serum potassium level
B. Check blood calcium level
C. Test deep tendon reflexes
D. Check complete blood count (CBC) with differential
,Answer:
Check complete blood count (CBC) with differential
Rationale: Succimer (Chemet) is used in the management of lead or other heavy
metal poisoning. Although it has generally well tolerated and has a relatively low
toxicity, it may cause neutropenia. Therapy should be withheld or discontinued if
the absolute neutrophil count (ANC) is below 1200/µ.
Question 3: The client with a T-2 spinal cord injury reports having a
"pounding" headache. Further assessment by the nurse reveals
excessive sweating, rash, pilomotor erection, facial flushing,
congested nasal passages and a heart rate of 50. What action
should the nurse take next?
A. Assist client with relaxation techniques
B. Measure the client's respirations, blood pressure, temperature and
pupillary responses
C. Check the client for bladder distention and the urinary catheter for
kinks
D. Place the client into the bed and administer the ordered PRN
analgesic
Answer:
Check the client for bladder distention and the urinary catheter for kinks
Rationale: These are findings of autonomic dysreflexia, also called hyperreflexia.
This response occurs in clients with a spinal cord injury above the T-6 level. It is
typically initiated by any noxious stimulus below the level of injury such as a full
bladder, an enema or bowel movement, fecal impaction, uterine contractions,
changing of the catheter and vaginal or rectal examinations. The stimulus creates
an exaggerated response of the sympathetic nervous system and can be a
life-threatening event. The BP is typically extremely high. The priority action of the
nurse is to identify and relieve the cause of the stimulus.
,Question 4: The client is diagnosed with cystic fibrosis (CF). The
nurse would expect the client to be treated with oral pancreatic
enzymes and which type of diet?
A. High fat, high-calorie
B. Gluten-free, low fiber
C. Dairy-free
D. Sodium-restricted
Answer:
High fat, high-calorie
Rationale: CF affects the cells that produce mucus, sweat and digestive juices.
Someone with CF needs a high-energy diet that includes high-fat and high-calorie
foods, extra fiber to prevent intestinal blockage and extra salt (especially during hot
weather.) People with CF are at risk for osteoporosis and need calcium and dairy
products. Someone with celiac disease or with a gluten intolerance, not CF, needs
a gluten-free diet.
Question 5: A client has a chest tube inserted immediately after
surgery for a left lower lobectomy. During the repositioning of the
client during the first postop check, the nurse notices 75 mL of a
dark, red fluid flowing into the collection chamber of the chest
drain system. What is the appropriate nursing action?
A. Continue to monitor the rate of drainage
B. Call the surgeon immediately
C. Check to see if the client has a type and cross match
D. Turn the client back to the original position
Answer:
Continue to monitor the rate of drainage
Rationale: It is not unusual for blood to collect in the chest and be released into the
chest drain when the client changes position this soon after surgery. The dark color
, of the blood indicates it is not active bleeding inside of the chest. Sanguinous
drainage should be expected within the initial 24 hours postop, progressing to
serosanguinous and then to a serous type. If the drainage exceeds 100 mL/hr, the
nurse should call the surgeon.
Question 6: A 67 year-old client is admitted with substernal chest
pressure that radiates to the jaw. The admitting diagnosis is acute
myocardial infarction (MI). What should be the priority nursing
diagnosis for this client during the first 24 hours?
A. Altered tissue perfusion
B. Activity intolerance
C. Anxiety
D. Risk for fluid volume excess
Answer:
Altered tissue perfusion
Rationale: In the immediate post MI period, altered tissue perfusion is priority, as
an area of myocardial tissue has been damaged by a lack of blood flow and
oxygenation. Interventions should be directed toward promoting tissue perfusion
and oxygenation. The other problems are also relevant, but tissue perfusion is the
priority.
Question 7: A client with a diagnosis of methicillin-resistant
Staphylococcus aureus (MRSA) has died. Which type of
precautions is appropriate to use when performing postmortem
care?
A. Contact precautions
B. Droplet precautions
C. Compromised host precautions
D. Airborne precautions
