Page 1 of 70
“NCSBN EXAM 2 2025 “ NEWEST UPDATED EXAM 2025 – 2026 SOLVED
QUESTIONS & ANSWERS VERIFIED 100% GRADED A+ (LATEST VERSION) WELL
REVISED AND HIGHLY RECOMMENDALE
A nurse is caring for a client who is being evaluated for a possible myocardial
infarction. The nurse notes what appears to be ventricular tachycardia on the
cardiac monitor. Which action is a priority for the nurse?
Assess airway, breathing and circulation
The nurse must treat the client, not the cardiac monitor. Always assess the client to
determine the next step. This focused assessment includes checking the client's
airway, breathing, and circulation (ABCs) and for signs of low cardiac output. Signs
of low cardiac output include chest pain, dyspnea, hypotension and an altered level
of consciousness. These clinical manifestations would indicate a need for
cardioversion and other emergency interventions. The other options would be
appropriate after the nurse has assessed the client.
The nurse is caring for a client who was diagnosed with a deep vein
thrombosis (DVT). The client reports sudden shortness of breath and the
oxygen saturation decreases to 87% on room air. Which intervention is a
priority action by the nurse?
Administer oxygen to maintain a saturation of 92%
An acute onset of dyspnea and hypoxia is a classic finding of pulmonary embolism
(PE). A client with a DVT has a risk for part of the clot breaking off and traveling to
the lungs. The administration of oxygen to correct hypoxia is the highest priority.
After administering oxygen, the HCP would need to be notified and the nurse should
anticipate orders for diagnostic tests (Pulmonary Angiogram, d-dimer, CT scan).
Albuterol nebulization is a standard treatment for respiratory distress related to
asthma, COPD and anaphylaxis. However, it is not used for dyspnea due to a PE.
, Page 2 of 70
The nurse is providing pre-operative care for a 2-month-old diagnosed with a
congenital heart defect. Which intervention is best for meeting the child's
nutrition and health needs?
Support the mother who breastfeeds
Infants with congenital heart defects have increased nutrition needs and tend to tire
quickly during feeding. Breastmilk offers the optimal nutrition and requires less effort
from the infant when compared to bottle feeding. Infants with congenital heart
disease usually do better when fed more often and on demand. This is usually 8 to
12 times a day. The nurse should support the mother's efforts to breastfeed. The
infant should not be given water since there are no calories or vitamins in water.
Medication should never be mixed with milk or formula.
While assessing a client's blood pressure (BP), the nurse cannot hear the
sounds through the stethoscope. However, the nurse is able to palpate the
systolic pressure reading. Which action should the nurse take first?
Check to ensure the diaphragm of the stethoscope is being used
If a BP can be palpated for the systolic reading but nothing is heard on auscultation,
the first action is to check to see if the stethoscope is turned to the bell side (a
peripheral BP is taken using the diaphragm side of the stethoscope.) Then the nurse
would wait two minutes between readings of a BP in the same arm to allow the
vessels to recover from being squeezed. The electronic cuff would also require a two
minute wait. The nurse should also be aware that the electronic cuff may not read
pressures below 80 mm Hg.
The nurse is assessing a client who takes a prescribed antipsychotic
medication. Which findings require immediate discontinuation of this
medication?
Hyperthermia and severe muscle rigidity
Hyperthermia, severe muscle rigidity and malignant hypertension are findings
associated with neuroleptic malignant syndrome (NMS). NMS is a serious
complication associated with the use of antipsychotic drugs. Repetitive, involuntary
movements of the face or body may be a sign of tardive dyskinesia related to
antipsychotic use. This is a serious concern, but not an emergency. Tardive
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dyskinesia may be irreversible, even after the medication has been discontinued.
Agitation and being in a constant state of motion are most likely related to the illness
being treated, such as bipolar disorder or schizophrenia.
The nurse is educating a pregnant woman who was advised to increase the
intake of protein and vitamin C to meet the needs of the growing fetus. Which
food choice best satisfies these dietary recommendations?
Baked chicken and fresh strawberries
The food choice that best satisfies an increased protein and Vitamin C intake is
baked chicken (protein) and fresh strawberries (vitamin C). The other choices might
contain some protein and vitamin C as well but are also high in carbohydrates or
fats, making them a less nutritious choice.
The nurse is preparing a presentation focusing on the prevention of Lyme
disease. Which statement by a participant would require further clarification by
the nurse?
"Lyme disease is caused by a virus similar to the flu."
While the symptoms of Lyme disease are similar to influenza, Lyme disease is not
caused by a virus. Lyme disease is caused by the spirochete, Borrelia burgdorferi,
which is transmitted to humans by deer ticks. Because the ticks are so small, it is
easier to see them on light-colored clothing. Long pants and long-sleeved shirts help
protect individuals from insect bites. After being outdoors, individuals should assess
their body for any ticks or rashes. Parents should be instructed to check children for
ticks and rashes. There may be a "bull's eye" rash at the site of the tick bite. Without
antibiotics, the disease can spread to the brain, heart and joints of the body.
The oncology nurse is caring for a female client who is being treated for
metastatic breast cancer. The client is scheduled to receive their first dose of
trastuzumab. Which assessment finding is most important to notify the health
care provider of?
Irregular apical pulse
Trastuzumab is a monoclonal antibody used as anticancer therapy for women with
HER2-positive breast cancer. The main concern in administering trastuzumab is
cardiotoxicity, manifesting as ventricular dysfunction and congestive heart failure.
, Page 4 of 70
Therefore, the irregular apical pulse is the most important assessment findings. An
ejection fraction is obtained as a baseline before treatment and may be monitored
every few months while the client is receiving this medication. The other findings are
to be expected, normal or near normal and not as important as the irregular apical
pulse.
The nurse is caring for an 83-year-old client who is experiencing a sudden
onset of confusion. Which medication most likely contributed to this change?
Antihistamine
Older adults are more susceptible to the side effects of anticholinergic medications,
such as antihistamines. Antihistamines often cause confusion in the older adult,
especially at high doses. Cardiac glycosides, anticoagulants and antacids are not
associated with confusion or mental status changes in the older adult.
The nurse is preparing to assess a 3-year-old using the Denver II
Developmental Test. The child's mother asks the nurse to explain the purpose
of the test. Which statement by the nurse is correct?
"It assesses a child's development in several categories."
The Denver II Developmental Test is a screening test to assess children from birth
through six years of age in personal/social, fine motor adaptive, language and gross
motor development. This screening test determines the highest level of functioning in
these areas at the time of the examination. The screening is quick and inexpensive,
but any low scores will need to be evaluated by more precise exams. The screening
does not include psychological responses to stimuli or intelligence levels. It does not
solely test for the development of motor function.
While caring for a newborn, the nurse notes a high-pitched cry, irritability and
lack of interest in feeding. The nurse suspects the newborn is experiencing
neonatal abstinence syndrome. Which intervention is most appropriate for this
newborn?
Dim the lights and reduce the noise in the room.
A high-pitched cry, irritability, poor feeding, increased respiratory rate, fever, vomiting
and diarrhea are all clinical manifestations of neonatal abstinence syndrome (NAS).
NAS is a term used to describe the behaviors exhibited by the infant exposed to
“NCSBN EXAM 2 2025 “ NEWEST UPDATED EXAM 2025 – 2026 SOLVED
QUESTIONS & ANSWERS VERIFIED 100% GRADED A+ (LATEST VERSION) WELL
REVISED AND HIGHLY RECOMMENDALE
A nurse is caring for a client who is being evaluated for a possible myocardial
infarction. The nurse notes what appears to be ventricular tachycardia on the
cardiac monitor. Which action is a priority for the nurse?
Assess airway, breathing and circulation
The nurse must treat the client, not the cardiac monitor. Always assess the client to
determine the next step. This focused assessment includes checking the client's
airway, breathing, and circulation (ABCs) and for signs of low cardiac output. Signs
of low cardiac output include chest pain, dyspnea, hypotension and an altered level
of consciousness. These clinical manifestations would indicate a need for
cardioversion and other emergency interventions. The other options would be
appropriate after the nurse has assessed the client.
The nurse is caring for a client who was diagnosed with a deep vein
thrombosis (DVT). The client reports sudden shortness of breath and the
oxygen saturation decreases to 87% on room air. Which intervention is a
priority action by the nurse?
Administer oxygen to maintain a saturation of 92%
An acute onset of dyspnea and hypoxia is a classic finding of pulmonary embolism
(PE). A client with a DVT has a risk for part of the clot breaking off and traveling to
the lungs. The administration of oxygen to correct hypoxia is the highest priority.
After administering oxygen, the HCP would need to be notified and the nurse should
anticipate orders for diagnostic tests (Pulmonary Angiogram, d-dimer, CT scan).
Albuterol nebulization is a standard treatment for respiratory distress related to
asthma, COPD and anaphylaxis. However, it is not used for dyspnea due to a PE.
, Page 2 of 70
The nurse is providing pre-operative care for a 2-month-old diagnosed with a
congenital heart defect. Which intervention is best for meeting the child's
nutrition and health needs?
Support the mother who breastfeeds
Infants with congenital heart defects have increased nutrition needs and tend to tire
quickly during feeding. Breastmilk offers the optimal nutrition and requires less effort
from the infant when compared to bottle feeding. Infants with congenital heart
disease usually do better when fed more often and on demand. This is usually 8 to
12 times a day. The nurse should support the mother's efforts to breastfeed. The
infant should not be given water since there are no calories or vitamins in water.
Medication should never be mixed with milk or formula.
While assessing a client's blood pressure (BP), the nurse cannot hear the
sounds through the stethoscope. However, the nurse is able to palpate the
systolic pressure reading. Which action should the nurse take first?
Check to ensure the diaphragm of the stethoscope is being used
If a BP can be palpated for the systolic reading but nothing is heard on auscultation,
the first action is to check to see if the stethoscope is turned to the bell side (a
peripheral BP is taken using the diaphragm side of the stethoscope.) Then the nurse
would wait two minutes between readings of a BP in the same arm to allow the
vessels to recover from being squeezed. The electronic cuff would also require a two
minute wait. The nurse should also be aware that the electronic cuff may not read
pressures below 80 mm Hg.
The nurse is assessing a client who takes a prescribed antipsychotic
medication. Which findings require immediate discontinuation of this
medication?
Hyperthermia and severe muscle rigidity
Hyperthermia, severe muscle rigidity and malignant hypertension are findings
associated with neuroleptic malignant syndrome (NMS). NMS is a serious
complication associated with the use of antipsychotic drugs. Repetitive, involuntary
movements of the face or body may be a sign of tardive dyskinesia related to
antipsychotic use. This is a serious concern, but not an emergency. Tardive
, Page 3 of 70
dyskinesia may be irreversible, even after the medication has been discontinued.
Agitation and being in a constant state of motion are most likely related to the illness
being treated, such as bipolar disorder or schizophrenia.
The nurse is educating a pregnant woman who was advised to increase the
intake of protein and vitamin C to meet the needs of the growing fetus. Which
food choice best satisfies these dietary recommendations?
Baked chicken and fresh strawberries
The food choice that best satisfies an increased protein and Vitamin C intake is
baked chicken (protein) and fresh strawberries (vitamin C). The other choices might
contain some protein and vitamin C as well but are also high in carbohydrates or
fats, making them a less nutritious choice.
The nurse is preparing a presentation focusing on the prevention of Lyme
disease. Which statement by a participant would require further clarification by
the nurse?
"Lyme disease is caused by a virus similar to the flu."
While the symptoms of Lyme disease are similar to influenza, Lyme disease is not
caused by a virus. Lyme disease is caused by the spirochete, Borrelia burgdorferi,
which is transmitted to humans by deer ticks. Because the ticks are so small, it is
easier to see them on light-colored clothing. Long pants and long-sleeved shirts help
protect individuals from insect bites. After being outdoors, individuals should assess
their body for any ticks or rashes. Parents should be instructed to check children for
ticks and rashes. There may be a "bull's eye" rash at the site of the tick bite. Without
antibiotics, the disease can spread to the brain, heart and joints of the body.
The oncology nurse is caring for a female client who is being treated for
metastatic breast cancer. The client is scheduled to receive their first dose of
trastuzumab. Which assessment finding is most important to notify the health
care provider of?
Irregular apical pulse
Trastuzumab is a monoclonal antibody used as anticancer therapy for women with
HER2-positive breast cancer. The main concern in administering trastuzumab is
cardiotoxicity, manifesting as ventricular dysfunction and congestive heart failure.
, Page 4 of 70
Therefore, the irregular apical pulse is the most important assessment findings. An
ejection fraction is obtained as a baseline before treatment and may be monitored
every few months while the client is receiving this medication. The other findings are
to be expected, normal or near normal and not as important as the irregular apical
pulse.
The nurse is caring for an 83-year-old client who is experiencing a sudden
onset of confusion. Which medication most likely contributed to this change?
Antihistamine
Older adults are more susceptible to the side effects of anticholinergic medications,
such as antihistamines. Antihistamines often cause confusion in the older adult,
especially at high doses. Cardiac glycosides, anticoagulants and antacids are not
associated with confusion or mental status changes in the older adult.
The nurse is preparing to assess a 3-year-old using the Denver II
Developmental Test. The child's mother asks the nurse to explain the purpose
of the test. Which statement by the nurse is correct?
"It assesses a child's development in several categories."
The Denver II Developmental Test is a screening test to assess children from birth
through six years of age in personal/social, fine motor adaptive, language and gross
motor development. This screening test determines the highest level of functioning in
these areas at the time of the examination. The screening is quick and inexpensive,
but any low scores will need to be evaluated by more precise exams. The screening
does not include psychological responses to stimuli or intelligence levels. It does not
solely test for the development of motor function.
While caring for a newborn, the nurse notes a high-pitched cry, irritability and
lack of interest in feeding. The nurse suspects the newborn is experiencing
neonatal abstinence syndrome. Which intervention is most appropriate for this
newborn?
Dim the lights and reduce the noise in the room.
A high-pitched cry, irritability, poor feeding, increased respiratory rate, fever, vomiting
and diarrhea are all clinical manifestations of neonatal abstinence syndrome (NAS).
NAS is a term used to describe the behaviors exhibited by the infant exposed to
