NCSBN test bank Questions 16-30 correctly answered 2023

NCSBN test bank Questions 16-30 correctly answered 2023The 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 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 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. 00:22 01:39 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 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 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 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)." 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." 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 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: Around 2 months: Single vowel sounds such as ah, eh and uh By 3-4 months: Cooing, gurgling and laughing aloud By 6 months: Imitating sounds and combining syllables (e.g., "dada") A nurse is teaching a mother who will breast-feed for the first time. Which of these approaches is a priority? A. Show the mother films on the physiology of lactation B. Give the mother several illustrated pamphlets C. Give the mother privacy for the initial feeding D. Assist the mother to position the newborn at the breast D All of the approaches should be helpful in teaching. However, the priority is to place the infant to the breast as soon after birth as possible to establish contact and allow the newborn to begin to suck.