NCSBN TEST BANK - for the NCLEX-RN & NCLEX-RN, UPDATED 2022/2023, COMPLETE Questions and Answers with ratio and RATIONALISED ANSWERS

Question 97 A client has been admitted with a fractured femur and has been placed in skeletal traction. Which of the following nursing interventions should receive PRIORITY? A) Maintaining proper body alignment B) Frequent neurovascular assessments of the affected leg C) Inspection of pin sites for evidence of drainage or inflammation D) Applying an over-bed trapeze to assist the client with movement in bed Review Information: The correct answer is:B) Frequent neurovascular assessments of the affected leg. The most important activity for the nurse is to assess neurovascular status. Compartment syndrome is a serious complication of fractures. Prompt recognition of this neurovascular problem and early intervention may prevent permanent limb damage. Question 98 The nurse is teaching a client newly diagnosed with asthma how to use the metered-dose inhaler (MDI). The client asks when they will know the canister is empty. The BEST response is A) Drop the canister in water to observe floating B) Estimate how many doses are usually in the canister C) Count the number of doses as the inhaler is used D) Shake the canister to detect any fluid movement Review Information: The correct answer is:A) Drop the canister in water to observe floating. Dropping the canister into a bowl of water assesses the amount of medications remaining in a metered-dose inhaler. The client should obtain a refill when the inhaler rises to the surface and begins to tip over. Question 99 While teaching the family of a child who will take phenytoin (Dilantin) regularly for seizure control, it is MOST important for the nurse to teach them to A) Maintain good oral hygiene and dental care B) Omit medication if the child is seizure free C) Administer acetaminophen to promote sleep D) Serve a diet that is high in iron Review Information: The correct answer is:A) Maintain good oral hygiene and dental care. Swollen and tender gums occur often with use of phenytoin. Oral hygiene and regular visits to the dentist should be emphasized. Question 100 A two year-old child has just been diagnosed with Cystic Fibrosis. The child's father asks the nurse "What are the chances that another child of ours will have Cystic Fibrosis?" Which of the following is the BEST response? A) "The probability of recurrence is unknown." B) "Cystic Fibrosis is more common in Asians." C) "Each of your children have a 25% chance of having Cystic Fibrosis." D) "The incidence of Cystic Fibrosis is approximately 1: 14,000 live births." Review Information: The correct answer is:C) "Each of your children have a 25% chance of having Cystic Fibrosis.". Cystic Fibrosis is an autosomal recessive disease. There is a 25% chance of each pregnancy of these parents resulting in a child with Cystic Fibrosis. Question 101 A 7 month pregnant woman is admitted with complaints of painless vaginal bleeding over several hours. The nurse should prepare the client for an immediate A) Non stress test B) Abdominal ultrasound C) Pelvic exam D) X-ray of abdomen Review Information: The correct answer is:B) Abdominal ultrasound. The standard for diagnosis of placenta previa, which is suggested in the client''s history, is abdominal ultrasound. Question 102 The nurse is assessing a 17 year-old female client with bulimia. Which of the following laboratory reports would the nurse anticipate? A) Increased serum glucose B) Decreased albumin C) Decreased potassium D) Increased sodium retention Review Information: The correct answer is:C) Decreased potassium. In bulimia, loss of electrolytes can occur in addition to signs and symptoms of starvation and dehydration. Question 103 An 80 year-old client on digitalis (Lanoxin) reports nausea, vomiting, abdominal cramps and halo vision. Which of the following laboratory results should the nurse analyze FIRST? A) Potassium levels B) Blood pH C) Magnesium levels D) Blood urea nitrogen Review Information: The correct answer is:A) Potassium levels. The most common cause of digitalis toxicity is a low potassium level. Clients must be taught that it is important to have adequate potassium intake while taking diuretics. Question 104 A mother telephones the clinic and tells the nurse she is concerned because her breastfed 1 month-old has soft, yellow stoolsafter each feeding. The nurse's BEST response would be based on the knowledge that A) This type of stool is normal for breast fed infants B) The stool should have turned to light brown by now C) Formula supplements will add bulk to the stools D) Water should be offered several times each day Review Information: The correct answer is:A) This type of stool is normal for breast fed infants. In breast-fed infants, stools are frequent and yellow to golden and vary from soft to thick liquid in consistency. No change in feedings is indicated. Question 105 The nurse caring for a 9 year-old child with a fractured femur is told that a medication error occurred. The child received twice the ordered dose of morphine an hour ago. Which of the following nursing diagnoses is a PRIORITY at this time? A) Risk for fluid volume deficit related to morphine overdose B) Decreased gastrointestinal mobility related to mucosal irritation C) Ineffective breathing patterns related to central nervous system depression D) Altered nutrition related to inability to control nausea and vomiting Review Information: The correct answer is:C) Ineffective breathing patterns related to central nervous system depression. Respiratory depression is a life-threatening risk in this overdose. Question 106 A pregnant client asks the nurse about the scheduled blood test for alpha-fetoprotein (AFP). The nurse's BEST explanation i A) "It tells us how far along your pregnancy is." B) "The results help determine if the baby is growing normally." C) "Placental exchange of oxygen is measured." D) "Possible neurological defects may be identified." Review Information: The correct answer is:D) "Possible neurological defects may be identified.". A fetus with neural tube defects loses alfa-fetoprotein (AFP) to the amniotic fluid and hence the maternal blood. High levels indicate the possibility of defects such as spina bifida and meningocele. Further assessments are indicated if a test is positive. Question 107 The nurse notes that a 2 year-old child recovering from a tonsillectomy has an temperature of 98.2 degrees F at 8:00 AM. At 10:00 AMthe child's mother reports that the child "feels very warm" to touch. The FIRST action by the nurse should be to A) Reassure the mother that this is normal B) Offer the child cold oral fluids C) Reassess the child's temperature D) Administer the prescribed acetaminophen Review Information: The correct answer is:C) Reassess the child''s temperature. A child''s temperature may have rapid fluctuations. The nurse should listen to and show respect for what parents say. Question 108 The nurse is assessing an eight month-old child. The nurse would anticipate that the child would be able to A) Say two words B) Pull up to stand C) Sit without support D) Use a spoon Review Information: The correct answer is:C) Sit without support. The age at which the normal child develops the ability to sit steadily without support is 8 months. Question 109 The nurse is teaching a newly diagnosed asthma client on how to use a peak flow meter. The nurse explains that this should be used to A) Determine oxygen saturation B) Measure forced expiratory volume C) Monitor atmosphere for presence of allergens D) Provide metered doses for inhaled bronchodilator Review Information: The correct answer is:B) Measure forced expiratory volume. The peak flow meter is used to measure peak expiratory flow volume. It provides useful information about the presence and/or severity of airway obstruction.