NCSBN TEST BANK ON-LINE REVIEW EXAM-2022
1.A client has been hospitalized after an automobile accident. A full leg cast was
applied in the emergency room. The most important reason for the nurse to
elevatethe casted leg is to
A) Promote the client's comfort
B) Reduce the drying time
C) Decrease irritation to the skin
D) Improve venous return
D: Improve venous return. Elevating the leg both improves venous return and reduces
swelling. Client comfort will be improved as well.
2. The nurse is reviewing with a client how to collect a clean catch urine specimen.
What is the appropriate sequence to teach the client?
A) Clean the meatus, begin voiding, then catch urine stream
B) Void a little, clean the meatus, then collect specimen
C) Clean the meatus, then urinate into container
D) Void continuously and catch some of the urine
A: Clean the meatus, begin voiding, then catch urine stream. A clean catch urine is difficult to
obtain and requires clear directions. Instructing the client to carefully clean the meatus, then void
naturally with a steady stream prevents surface bacteria from contaminating the urine specimen. As
starting and stopping flow can be difficult, once the client begins voiding it’s best to just slip the
container into the stream.
Other responses do not reflect correct technique
3. Following change-of-shift report on an orthopedic unit, which client should the nurse see first?
A) 16 year-old who had an open reduction of a fractured wrist 10 hours ago
B) 20 year-old in skeletal traction for 2 weeks since a motor cycle accident
C) 72 year-old recovering from surgery after a hip replacement 2 hours ago
D)75 year-old who is in skin traction prior to planned hip pinning surgery.
C: Look for the client who has the most imminent risks and acute vulnerability. The client who
returned from surgery 2 hour sago is at risk for life threatening hemorrhage and should be seen
first. the16 year- old should be seen next because it is still the first post-op day. the75 year-old is
,potentially vulnerable to age-related physical and cognitive consequences in skin traction
should be seen next. The client who can safely be seen last is the20 year-old who is 2 weeks
post-injury.
4. A client with Guillain Barre is in a nonresponsive state, yet vital signs are stable and
breathing is independent. What should the nurse document to most accurately
describethe client's condition?
A) Comatose, breathing unlabored
B) Glascow Coma Scale 8, respirations regular
C) Appears to be sleeping, vital signs stable
D) Glascow Coma Scale 13, no ventilator required
B: Glascow Coma Scale 8, respirations regular. The Glascow Coma Scale provides a standard
reference for assessing or monitoring level of consciousness. Any score less than 13 indicates a
neurological impairment. Using the term comatose provides too much room for interpretation
andis not very precise.
5. When caring for a client receiving warfarin sodium (Coumadin), which lab test would
the nurse monitor to determine therapeutic response to the drug?
A) Bleeding time
B) Coagulation time
C) Prothrombin time
D)Partial thromboplastin time
C: Prothrombin time. Coumadin is ordered daily, based on the client's prothrombin time (PT).
This test evaluates the adequacy of the extrinsic system and common pathway in the clotting
cascade; Coumadin affects the Vitamin K dependent clotting factors.
6. A client with moderate persistent asthma is admitted for a minor surgical procedure. On
admission the peak flow meter is measured at 480 liters/minute. Post-operatively the client
iscomplaining of chest tightness. The peak flow has dropped to 200 liters/minute. What
shouldthe nurse do first?
A) Notify both the surgeon and provider
B) Administer the prn dose of albuterol
C) Apply oxygen at 2 liters per nasal cannula
D) Repeat the peak flow reading in 30 minutes
B: Administer the prn dose of albuterol. Peak flow monitoring during exacerbations of asthma is
, recommended for clients with moderate-to-severe persistent asthma to determine the severity of
1.A client has been hospitalized after an automobile accident. A full leg cast was
applied in the emergency room. The most important reason for the nurse to
elevatethe casted leg is to
A) Promote the client's comfort
B) Reduce the drying time
C) Decrease irritation to the skin
D) Improve venous return
D: Improve venous return. Elevating the leg both improves venous return and reduces
swelling. Client comfort will be improved as well.
2. The nurse is reviewing with a client how to collect a clean catch urine specimen.
What is the appropriate sequence to teach the client?
A) Clean the meatus, begin voiding, then catch urine stream
B) Void a little, clean the meatus, then collect specimen
C) Clean the meatus, then urinate into container
D) Void continuously and catch some of the urine
A: Clean the meatus, begin voiding, then catch urine stream. A clean catch urine is difficult to
obtain and requires clear directions. Instructing the client to carefully clean the meatus, then void
naturally with a steady stream prevents surface bacteria from contaminating the urine specimen. As
starting and stopping flow can be difficult, once the client begins voiding it’s best to just slip the
container into the stream.
Other responses do not reflect correct technique
3. Following change-of-shift report on an orthopedic unit, which client should the nurse see first?
A) 16 year-old who had an open reduction of a fractured wrist 10 hours ago
B) 20 year-old in skeletal traction for 2 weeks since a motor cycle accident
C) 72 year-old recovering from surgery after a hip replacement 2 hours ago
D)75 year-old who is in skin traction prior to planned hip pinning surgery.
C: Look for the client who has the most imminent risks and acute vulnerability. The client who
returned from surgery 2 hour sago is at risk for life threatening hemorrhage and should be seen
first. the16 year- old should be seen next because it is still the first post-op day. the75 year-old is
,potentially vulnerable to age-related physical and cognitive consequences in skin traction
should be seen next. The client who can safely be seen last is the20 year-old who is 2 weeks
post-injury.
4. A client with Guillain Barre is in a nonresponsive state, yet vital signs are stable and
breathing is independent. What should the nurse document to most accurately
describethe client's condition?
A) Comatose, breathing unlabored
B) Glascow Coma Scale 8, respirations regular
C) Appears to be sleeping, vital signs stable
D) Glascow Coma Scale 13, no ventilator required
B: Glascow Coma Scale 8, respirations regular. The Glascow Coma Scale provides a standard
reference for assessing or monitoring level of consciousness. Any score less than 13 indicates a
neurological impairment. Using the term comatose provides too much room for interpretation
andis not very precise.
5. When caring for a client receiving warfarin sodium (Coumadin), which lab test would
the nurse monitor to determine therapeutic response to the drug?
A) Bleeding time
B) Coagulation time
C) Prothrombin time
D)Partial thromboplastin time
C: Prothrombin time. Coumadin is ordered daily, based on the client's prothrombin time (PT).
This test evaluates the adequacy of the extrinsic system and common pathway in the clotting
cascade; Coumadin affects the Vitamin K dependent clotting factors.
6. A client with moderate persistent asthma is admitted for a minor surgical procedure. On
admission the peak flow meter is measured at 480 liters/minute. Post-operatively the client
iscomplaining of chest tightness. The peak flow has dropped to 200 liters/minute. What
shouldthe nurse do first?
A) Notify both the surgeon and provider
B) Administer the prn dose of albuterol
C) Apply oxygen at 2 liters per nasal cannula
D) Repeat the peak flow reading in 30 minutes
B: Administer the prn dose of albuterol. Peak flow monitoring during exacerbations of asthma is
, recommended for clients with moderate-to-severe persistent asthma to determine the severity of
