NCSBN Real Exam Questions And Answers|Well Structured|100% Pass
QUESTIONS ANSWERS
300
An 18 month-old weighing 22 pounds
Using ratio proportion:First, convert 22
is admitted to the pediatric unit with a
pounds to kilograms (22/2.2) = 10 kg20
diagnosis of dehydration. A replacement
mL/kg = 20 x 10 kg = 200 mL200
bolus of normal saline at 20 mL/kg is or-
mL/40 minutes = x mL/60 minutes
dered to be administered intravenously
(in an hour)200 x 60 = 12000/40 =
over 40 minutes.
300 mL/hrUsing dimensional analysis:20
In mL/hour, what will be the setting for
mL/kg x 1 kg/2.2 lb x 22 lb x 60 min/hr x
the IV delivery system?
1/40 min = 300 mL/hr
The mother of a 2 month-old baby calls
a pediatrician's nurse two days after
the first DTaP, inactivated polio vaccine A
(IPV), Hepatitis B and Haemophilus in- DTaP immunization is a vaccine that pro-
fluenzae type B (HIB) immunizations. tects against diptheria, tetanus and per-
She reports that the baby feels very tussis (whooping cough). The majority of
warm, cries inconsolably for as long as reactions described in this question oc-
three hours, and has had several shak- cur with the administration of the DTaP
ing spells.Which immunization would the vaccination. Contraindications to giving
nurse expect to be primarily responsible repeat DTaP immunizations include the
with these findings? occurrence of severe side effects after a
previous dose, as well as signs of en-
A. DTaP cephalopathy within seven days of the
B. IPV immunization.
C. Hepatitis B
D. HIB
A client diagnosed with angina has been
instructed about the use of sublingual
nitroglycerin. Which statement made by
the client is incorrect and indicates a D
need for further teaching? Clients must understand that just one
sublingual tablet should be taken at a
A. "I'll call the health care provider if pain time and placed under the tongue. After
continues after three tablets five minutes rest and a five-minute interval, a second
apart." and then eventually a third tablet may be
B. "I will rest briefly right after taking one necessary.
tablet."
C. "I understand that the medication
should be kept in the dark bottle."
, NCSBN Real Exam Questions And Answers|Well Structured|100% Pass
QUESTIONS ANSWERS
D. "I can swallow two or three tablets at
once if I have severe pain."
The nurse is working with victims of do-
mestic abuse. The nurse should under-
C
stand which of these factors is a rea-
Signs of domestic violence or emotion-
son why domestic violence or emotional
al abuse may not be clearly manifest-
abuse remains extensively undetected?
ed and include many series of a minor
complaints such as headache, abdomi-
A. The expenses due to police and court
nal pain, insomnia, back pain and dizzi-
costs are prohibitive
ness. These may be covert indications
B. Little knowledge is known about bat-
of violence or abuse that go undetected.
terers and battering relationships
These complaints may be vague and re-
C. There are typically many series of mi-
flect ambivalence about the disclosure of
nor, vague complaints
any violence or abuse.
D. Few people who have been battered
seek medical care
The nurse is obtaining an aerobic wound
culture from a client with stage two pres-
sure injury. The nurse first removes a
gauze dressing and observes a moder- B
ate amount of purulent drainage on the After removing the dressing and perform-
dressing and then the nurse performs ing hand hygiene, the wound needs to
hand hygiene. What is the next correct be irrigated to remove surface pathogens
step in the procedure? before the nurse can obtain a wound
culture. Cultures are not obtained from
A. Swab the gauze dressing that was wound exudate on the dressing or
removed from the wound wounds that have not been irrigated
B. Irrigate the wound with normal saline since the exudate may be contaminated
C. Obtain a culture by rotating a sterile with normal skin flora.
swab in the open wound
D. Remove wound exudate from the
wound edges with a cotton tip applicator
The nurse is caring for a client who
is experiencing frightening hallucinations
that are markedly increased at night. The
client's partner asks to stay a few hours
beyond the visiting time, in the client's
private room. What would be the best
, NCSBN Real Exam Questions And Answers|Well Structured|100% Pass
QUESTIONS ANSWERS
response by the nurse?
A. "Yes, staying with the client and ori- A
enting the client to the surroundings may Encouragement of a family member or
decrease any anxiety." a close friend to stay with the client in
B. "No, your presence may cause the a quiet surrounding cannot only help in-
client to become more anxious." crease orientation, but can also minimize
C. "No, it would be best if you brought confusion and anxiety. The visitor could
the client some reading material that the also report to the nurse any unusual find-
client could read at night." ings of the client. This would be the most
D."Yes, would you like to spend the night supportive approach for this client.
when the client's behavior indicates that
the client is or will be frightened?"
A
The definition of assignment is the rou-
The RN, who is functioning as the charge
tine care, activities and procedures that
nurse, needs to determine shift assign-
are within the authorized scope of prac-
ments. How will the charge nurse deter-
tice of the RN or LPN/LVN. The RN must
mine which client assignments are ap-
determine the needs of the clients and
propriate for the licensed practical nurse
make assignments not only based on
(LPN)?
scope of practice, but also education,
demonstrated competency and skill lev-
A. Ask the LPN about prior experience
el. Regardless if the LPN received ed-
caring for clients with similar diagnoses
ucation and training to perform specific
B. Determine how many nursing assis-
skills, the RN needs to determine the
tants are available to help the LPN with
LPN's experience with caring for clients
client care
with similar diagnoses. While the RN is
C. Refer to the list of technical tasks
responsible for ensuring an assignment
LPNs are trained to perform
given to a delegatee is carried out com-
D.Review the procedure manual with the
pletely and correctly, the LPN must be
LPN prior to making an assignment
able to perform the skills or tasks inde-
pendently.
C
The nurse is caring for a school-aged
The parathyroid regulates the calcium
child with a diagnosis of secondary
and phosphorus serum levels. Calcium
hyperparathyroidism after treatment for
and phosphorous levels will be elevated
chronic renal disease. Which serum lab
in hyperfunction of this gland until the
data should receive priority attention by
client is stabilized. To recall this informa-
, NCSBN Real Exam Questions And Answers|Well Structured|100% Pass
QUESTIONS ANSWERS
tion think of a see-saw. Associate that
the nurse?
calcium is first in the alphabet and thus
calcium follows the direction of the ab-
A. Osmolality and sodium
normality - hyper or hypo function - of the
B. Blood urea nitrogen and magnesium
parathyroid. Put the calcium on one side
C. Calcium and phosphorus
and the phosphorus on the other side of
D. Glucose and potassium
the see-saw.
D
Complications of central catheter inser-
tion include pneumothorax and hemoth-
The nurse is caring for a client who just orax. Air embolism is another potential
had a central venous catheter line insert- complication. Dyspnea, shallow respira-
ed at the bedside. Which of these as- tions, sudden sharp chest pain that wors-
sessments requires immediate attention ens with coughing or deep breathing are
by the nurse? indications of pneumothorax. Other po-
tential complications of central catheters
A. Pallor in the extremities may include thrombosis, local or sys-
B. Increased temperature by one degree temic infection, or even cardiac tampon-
C. Involuntary coughing spells ade (if the central line perforates the
D. Dyspnea at rest heart). When considering the options list-
ed, the client who is dyspneic after cen-
tral line insertion would be the greatest
concern for the nurse.
The nurse is providing preprocedural ed-
ucation to the client preparing for a bari- D
um enema. What statement made by the
A barium enema involves filling the large
client indicates a need for further educa-
intestine (lower GI tract) with diluted bar-
tion?
ium liquid while x-ray images are tak-
en. After the procedure, a small amount
A. "I will need to drink plenty of fluids and
of barium will be immediately expelled
eat foods high in fiber after the proce-
and the remainder will be excreted in
dure."
the stool. Because barium liquid may
B. "I will use the prescribed laxative be-
cause constipation, clients should eat
fore the procedure."
foods high in fiber and drink plenty of
C. "I will not eat or drink anything after
fluids to help expel the barium from the
midnight before the procedure."
body.
D. "A barium enema is used to examine
the upper and lower GI tracts."
QUESTIONS ANSWERS
300
An 18 month-old weighing 22 pounds
Using ratio proportion:First, convert 22
is admitted to the pediatric unit with a
pounds to kilograms (22/2.2) = 10 kg20
diagnosis of dehydration. A replacement
mL/kg = 20 x 10 kg = 200 mL200
bolus of normal saline at 20 mL/kg is or-
mL/40 minutes = x mL/60 minutes
dered to be administered intravenously
(in an hour)200 x 60 = 12000/40 =
over 40 minutes.
300 mL/hrUsing dimensional analysis:20
In mL/hour, what will be the setting for
mL/kg x 1 kg/2.2 lb x 22 lb x 60 min/hr x
the IV delivery system?
1/40 min = 300 mL/hr
The mother of a 2 month-old baby calls
a pediatrician's nurse two days after
the first DTaP, inactivated polio vaccine A
(IPV), Hepatitis B and Haemophilus in- DTaP immunization is a vaccine that pro-
fluenzae type B (HIB) immunizations. tects against diptheria, tetanus and per-
She reports that the baby feels very tussis (whooping cough). The majority of
warm, cries inconsolably for as long as reactions described in this question oc-
three hours, and has had several shak- cur with the administration of the DTaP
ing spells.Which immunization would the vaccination. Contraindications to giving
nurse expect to be primarily responsible repeat DTaP immunizations include the
with these findings? occurrence of severe side effects after a
previous dose, as well as signs of en-
A. DTaP cephalopathy within seven days of the
B. IPV immunization.
C. Hepatitis B
D. HIB
A client diagnosed with angina has been
instructed about the use of sublingual
nitroglycerin. Which statement made by
the client is incorrect and indicates a D
need for further teaching? Clients must understand that just one
sublingual tablet should be taken at a
A. "I'll call the health care provider if pain time and placed under the tongue. After
continues after three tablets five minutes rest and a five-minute interval, a second
apart." and then eventually a third tablet may be
B. "I will rest briefly right after taking one necessary.
tablet."
C. "I understand that the medication
should be kept in the dark bottle."
, NCSBN Real Exam Questions And Answers|Well Structured|100% Pass
QUESTIONS ANSWERS
D. "I can swallow two or three tablets at
once if I have severe pain."
The nurse is working with victims of do-
mestic abuse. The nurse should under-
C
stand which of these factors is a rea-
Signs of domestic violence or emotion-
son why domestic violence or emotional
al abuse may not be clearly manifest-
abuse remains extensively undetected?
ed and include many series of a minor
complaints such as headache, abdomi-
A. The expenses due to police and court
nal pain, insomnia, back pain and dizzi-
costs are prohibitive
ness. These may be covert indications
B. Little knowledge is known about bat-
of violence or abuse that go undetected.
terers and battering relationships
These complaints may be vague and re-
C. There are typically many series of mi-
flect ambivalence about the disclosure of
nor, vague complaints
any violence or abuse.
D. Few people who have been battered
seek medical care
The nurse is obtaining an aerobic wound
culture from a client with stage two pres-
sure injury. The nurse first removes a
gauze dressing and observes a moder- B
ate amount of purulent drainage on the After removing the dressing and perform-
dressing and then the nurse performs ing hand hygiene, the wound needs to
hand hygiene. What is the next correct be irrigated to remove surface pathogens
step in the procedure? before the nurse can obtain a wound
culture. Cultures are not obtained from
A. Swab the gauze dressing that was wound exudate on the dressing or
removed from the wound wounds that have not been irrigated
B. Irrigate the wound with normal saline since the exudate may be contaminated
C. Obtain a culture by rotating a sterile with normal skin flora.
swab in the open wound
D. Remove wound exudate from the
wound edges with a cotton tip applicator
The nurse is caring for a client who
is experiencing frightening hallucinations
that are markedly increased at night. The
client's partner asks to stay a few hours
beyond the visiting time, in the client's
private room. What would be the best
, NCSBN Real Exam Questions And Answers|Well Structured|100% Pass
QUESTIONS ANSWERS
response by the nurse?
A. "Yes, staying with the client and ori- A
enting the client to the surroundings may Encouragement of a family member or
decrease any anxiety." a close friend to stay with the client in
B. "No, your presence may cause the a quiet surrounding cannot only help in-
client to become more anxious." crease orientation, but can also minimize
C. "No, it would be best if you brought confusion and anxiety. The visitor could
the client some reading material that the also report to the nurse any unusual find-
client could read at night." ings of the client. This would be the most
D."Yes, would you like to spend the night supportive approach for this client.
when the client's behavior indicates that
the client is or will be frightened?"
A
The definition of assignment is the rou-
The RN, who is functioning as the charge
tine care, activities and procedures that
nurse, needs to determine shift assign-
are within the authorized scope of prac-
ments. How will the charge nurse deter-
tice of the RN or LPN/LVN. The RN must
mine which client assignments are ap-
determine the needs of the clients and
propriate for the licensed practical nurse
make assignments not only based on
(LPN)?
scope of practice, but also education,
demonstrated competency and skill lev-
A. Ask the LPN about prior experience
el. Regardless if the LPN received ed-
caring for clients with similar diagnoses
ucation and training to perform specific
B. Determine how many nursing assis-
skills, the RN needs to determine the
tants are available to help the LPN with
LPN's experience with caring for clients
client care
with similar diagnoses. While the RN is
C. Refer to the list of technical tasks
responsible for ensuring an assignment
LPNs are trained to perform
given to a delegatee is carried out com-
D.Review the procedure manual with the
pletely and correctly, the LPN must be
LPN prior to making an assignment
able to perform the skills or tasks inde-
pendently.
C
The nurse is caring for a school-aged
The parathyroid regulates the calcium
child with a diagnosis of secondary
and phosphorus serum levels. Calcium
hyperparathyroidism after treatment for
and phosphorous levels will be elevated
chronic renal disease. Which serum lab
in hyperfunction of this gland until the
data should receive priority attention by
client is stabilized. To recall this informa-
, NCSBN Real Exam Questions And Answers|Well Structured|100% Pass
QUESTIONS ANSWERS
tion think of a see-saw. Associate that
the nurse?
calcium is first in the alphabet and thus
calcium follows the direction of the ab-
A. Osmolality and sodium
normality - hyper or hypo function - of the
B. Blood urea nitrogen and magnesium
parathyroid. Put the calcium on one side
C. Calcium and phosphorus
and the phosphorus on the other side of
D. Glucose and potassium
the see-saw.
D
Complications of central catheter inser-
tion include pneumothorax and hemoth-
The nurse is caring for a client who just orax. Air embolism is another potential
had a central venous catheter line insert- complication. Dyspnea, shallow respira-
ed at the bedside. Which of these as- tions, sudden sharp chest pain that wors-
sessments requires immediate attention ens with coughing or deep breathing are
by the nurse? indications of pneumothorax. Other po-
tential complications of central catheters
A. Pallor in the extremities may include thrombosis, local or sys-
B. Increased temperature by one degree temic infection, or even cardiac tampon-
C. Involuntary coughing spells ade (if the central line perforates the
D. Dyspnea at rest heart). When considering the options list-
ed, the client who is dyspneic after cen-
tral line insertion would be the greatest
concern for the nurse.
The nurse is providing preprocedural ed-
ucation to the client preparing for a bari- D
um enema. What statement made by the
A barium enema involves filling the large
client indicates a need for further educa-
intestine (lower GI tract) with diluted bar-
tion?
ium liquid while x-ray images are tak-
en. After the procedure, a small amount
A. "I will need to drink plenty of fluids and
of barium will be immediately expelled
eat foods high in fiber after the proce-
and the remainder will be excreted in
dure."
the stool. Because barium liquid may
B. "I will use the prescribed laxative be-
cause constipation, clients should eat
fore the procedure."
foods high in fiber and drink plenty of
C. "I will not eat or drink anything after
fluids to help expel the barium from the
midnight before the procedure."
body.
D. "A barium enema is used to examine
the upper and lower GI tracts."
