NCSBN Practice Questions 76-90 with
Complete Solutions67
The nurse is working with victims of domestic abuse. The nurse should understand which of
these factors is a reason why domestic violence or emotional abuse remains extensively
undetected?
A. The expenses due to police and court costs are prohibitive
B. Little knowledge is known about batterers and battering relationships
C. There are typically many series of minor, vague complaints
D. Few people who have been battered seek medical care - ANSWERS-C
Signs of domestic violence or emotional abuse may not be clearly manifested and include many
series of a minor complaints such as headache, abdominal pain, insomnia, back pain and
dizziness. These may be covert indications of violence or abuse that go undetected. These
complaints may be vague and reflect ambivalence about the disclosure of any violence or
abuse.
The nurse is obtaining an aerobic wound culture from a client with stage two pressure injury.
The nurse first removes a gauze dressing and observes a moderate amount of purulent drainage
on the dressing and then the nurse performs hand hygiene. What is the next correct step in the
procedure?
A. Swab the gauze dressing that was removed from the wound
B. Irrigate the wound with normal saline
C. Obtain a culture by rotating a sterile swab in the open wound
D. Remove wound exudate from the wound edges with a cotton tip applicator - ANSWERS-B
After removing the dressing and performing hand hygiene, the wound needs to be irrigated to
remove surface pathogens before the nurse can obtain a wound culture. Cultures are not
,obtained from wound exudate on the dressing or wounds that have not been irrigated since the
exudate may be contaminated with normal skin flora.
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 response by the nurse?
A. "Yes, staying with the client and orienting the client to the surroundings may decrease any
anxiety."
B. "No, your presence may cause the client to become more anxious."
C. "No, it would be best if you brought the client some reading material that the client could
read at night."
D. "Yes, would you like to spend the night when the client's behavior indicates that the client is
or will be frightened?" - ANSWERS-A
Encouragement of a family member or a close friend to stay with the client in a quiet
surrounding cannot only help increase orientation, but can also minimize confusion and anxiety.
The visitor could also report to the nurse any unusual findings of the client. This would be the
most supportive approach for this client.
The RN, who is functioning as the charge nurse, needs to determine shift assignments. How will
the charge nurse determine which client assignments are appropriate for the licensed practical
nurse (LPN)?
A. Ask the LPN about prior experience caring for clients with similar diagnoses
B. Determine how many nursing assistants are available to help the LPN with client care
C. Refer to the list of technical tasks LPNs are trained to perform
D. Review the procedure manual with the LPN prior to making an assignment - ANSWERS-A
The definition of assignment is the routine care, activities and procedures that are within the
authorized scope of practice of the RN or LPN/LVN. The RN must determine the needs of the
clients and make assignments not only based on scope of practice, but also education,
demonstrated competency and skill level. Regardless if the LPN received education and training
,to perform specific skills, the RN needs to determine the LPN's experience with caring for clients
with similar diagnoses. While the RN is responsible for ensuring an assignment given to a
delegatee is carried out completely and correctly, the LPN must be able to perform the skills or
tasks independently.
The nurse is caring for a school-aged child with a diagnosis of secondary hyperparathyroidism
after treatment for chronic renal disease. Which serum lab data should receive priority
attention by the nurse?
A. Osmolality and sodium
B. Blood urea nitrogen and magnesium
C. Calcium and phosphorus
D. Glucose and potassium - ANSWERS-C
The parathyroid regulates the calcium and phosphorus serum levels. Calcium and phosphorous
levels will be elevated in hyperfunction of this gland until the client is stabilized. To recall this
information think of a see-saw. Associate that calcium is first in the alphabet and thus calcium
follows the direction of the abnormality - hyper or hypo function - of the parathyroid. Put the
calcium on one side and the phosphorus on the other side of the see-saw.
The nurse is caring for a client who just had a central venous catheter line inserted at the
bedside. Which of these assessments requires immediate attention by the nurse?
A. Pallor in the extremities
B. Increased temperature by one degree
C. Involuntary coughing spells
D. Dyspnea at rest - ANSWERS-D
Complications of central catheter insertion include pneumothorax and hemothorax. Air
embolism is another potential complication. Dyspnea, shallow respirations, sudden sharp chest
pain that worsens with coughing or deep breathing are indications of pneumothorax. Other
potential complications of central catheters may include thrombosis, local or systemic infection,
or even cardiac tamponade (if the central line perforates the heart). When considering the
, options listed, the client who is dyspneic after central line insertion would be the greatest
concern for the nurse.
The nurse is providing preprocedural education to the client preparing for a barium enema.
What statement made by the client indicates a need for further education?
A. "I will need to drink plenty of fluids and eat foods high in fiber after the procedure."
B. "I will use the prescribed laxative before the procedure."
C. "I will not eat or drink anything after midnight before the procedure."
D. "A barium enema is used to examine the upper and lower GI tracts." - ANSWERS-D
A barium enema involves filling the large intestine (lower GI tract) with diluted barium liquid
while x-ray images are taken. After the procedure, a small amount of barium will be
immediately expelled and the remainder will be excreted in the stool. Because barium liquid
may cause constipation, clients should eat foods high in fiber and drink plenty of fluids to help
expel the barium from the body.
An 18 month-old weighing 22 pounds is admitted to the pediatric unit with a diagnosis of
dehydration. A replacement bolus of normal saline at 20 mL/kg is ordered to be administered
intravenously over 40 minutes.
In mL/hour, what will be the setting for the IV delivery system? - ANSWERS-300
Using ratio proportion:First, convert 22 pounds to kilograms (22/2.2) = 10 kg20 mL/kg = 20 x 10
kg = 200 mL200 mL/40 minutes = x mL/60 minutes (in an hour)200 x 60 = 12000/40 = 300
mL/hrUsing dimensional analysis:20 mL/kg x 1 kg/2.2 lb x 22 lb x 60 min/hr x 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 (IPV), Hepatitis B and Haemophilus influenzae type B (HIB)
immunizations. She reports that the baby feels very warm, cries inconsolably for as long as
three hours, and has had several shaking spells. Which immunization would the nurse expect to
be primarily responsible with these findings?
Complete Solutions67
The nurse is working with victims of domestic abuse. The nurse should understand which of
these factors is a reason why domestic violence or emotional abuse remains extensively
undetected?
A. The expenses due to police and court costs are prohibitive
B. Little knowledge is known about batterers and battering relationships
C. There are typically many series of minor, vague complaints
D. Few people who have been battered seek medical care - ANSWERS-C
Signs of domestic violence or emotional abuse may not be clearly manifested and include many
series of a minor complaints such as headache, abdominal pain, insomnia, back pain and
dizziness. These may be covert indications of violence or abuse that go undetected. These
complaints may be vague and reflect ambivalence about the disclosure of any violence or
abuse.
The nurse is obtaining an aerobic wound culture from a client with stage two pressure injury.
The nurse first removes a gauze dressing and observes a moderate amount of purulent drainage
on the dressing and then the nurse performs hand hygiene. What is the next correct step in the
procedure?
A. Swab the gauze dressing that was removed from the wound
B. Irrigate the wound with normal saline
C. Obtain a culture by rotating a sterile swab in the open wound
D. Remove wound exudate from the wound edges with a cotton tip applicator - ANSWERS-B
After removing the dressing and performing hand hygiene, the wound needs to be irrigated to
remove surface pathogens before the nurse can obtain a wound culture. Cultures are not
,obtained from wound exudate on the dressing or wounds that have not been irrigated since the
exudate may be contaminated with normal skin flora.
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 response by the nurse?
A. "Yes, staying with the client and orienting the client to the surroundings may decrease any
anxiety."
B. "No, your presence may cause the client to become more anxious."
C. "No, it would be best if you brought the client some reading material that the client could
read at night."
D. "Yes, would you like to spend the night when the client's behavior indicates that the client is
or will be frightened?" - ANSWERS-A
Encouragement of a family member or a close friend to stay with the client in a quiet
surrounding cannot only help increase orientation, but can also minimize confusion and anxiety.
The visitor could also report to the nurse any unusual findings of the client. This would be the
most supportive approach for this client.
The RN, who is functioning as the charge nurse, needs to determine shift assignments. How will
the charge nurse determine which client assignments are appropriate for the licensed practical
nurse (LPN)?
A. Ask the LPN about prior experience caring for clients with similar diagnoses
B. Determine how many nursing assistants are available to help the LPN with client care
C. Refer to the list of technical tasks LPNs are trained to perform
D. Review the procedure manual with the LPN prior to making an assignment - ANSWERS-A
The definition of assignment is the routine care, activities and procedures that are within the
authorized scope of practice of the RN or LPN/LVN. The RN must determine the needs of the
clients and make assignments not only based on scope of practice, but also education,
demonstrated competency and skill level. Regardless if the LPN received education and training
,to perform specific skills, the RN needs to determine the LPN's experience with caring for clients
with similar diagnoses. While the RN is responsible for ensuring an assignment given to a
delegatee is carried out completely and correctly, the LPN must be able to perform the skills or
tasks independently.
The nurse is caring for a school-aged child with a diagnosis of secondary hyperparathyroidism
after treatment for chronic renal disease. Which serum lab data should receive priority
attention by the nurse?
A. Osmolality and sodium
B. Blood urea nitrogen and magnesium
C. Calcium and phosphorus
D. Glucose and potassium - ANSWERS-C
The parathyroid regulates the calcium and phosphorus serum levels. Calcium and phosphorous
levels will be elevated in hyperfunction of this gland until the client is stabilized. To recall this
information think of a see-saw. Associate that calcium is first in the alphabet and thus calcium
follows the direction of the abnormality - hyper or hypo function - of the parathyroid. Put the
calcium on one side and the phosphorus on the other side of the see-saw.
The nurse is caring for a client who just had a central venous catheter line inserted at the
bedside. Which of these assessments requires immediate attention by the nurse?
A. Pallor in the extremities
B. Increased temperature by one degree
C. Involuntary coughing spells
D. Dyspnea at rest - ANSWERS-D
Complications of central catheter insertion include pneumothorax and hemothorax. Air
embolism is another potential complication. Dyspnea, shallow respirations, sudden sharp chest
pain that worsens with coughing or deep breathing are indications of pneumothorax. Other
potential complications of central catheters may include thrombosis, local or systemic infection,
or even cardiac tamponade (if the central line perforates the heart). When considering the
, options listed, the client who is dyspneic after central line insertion would be the greatest
concern for the nurse.
The nurse is providing preprocedural education to the client preparing for a barium enema.
What statement made by the client indicates a need for further education?
A. "I will need to drink plenty of fluids and eat foods high in fiber after the procedure."
B. "I will use the prescribed laxative before the procedure."
C. "I will not eat or drink anything after midnight before the procedure."
D. "A barium enema is used to examine the upper and lower GI tracts." - ANSWERS-D
A barium enema involves filling the large intestine (lower GI tract) with diluted barium liquid
while x-ray images are taken. After the procedure, a small amount of barium will be
immediately expelled and the remainder will be excreted in the stool. Because barium liquid
may cause constipation, clients should eat foods high in fiber and drink plenty of fluids to help
expel the barium from the body.
An 18 month-old weighing 22 pounds is admitted to the pediatric unit with a diagnosis of
dehydration. A replacement bolus of normal saline at 20 mL/kg is ordered to be administered
intravenously over 40 minutes.
In mL/hour, what will be the setting for the IV delivery system? - ANSWERS-300
Using ratio proportion:First, convert 22 pounds to kilograms (22/2.2) = 10 kg20 mL/kg = 20 x 10
kg = 200 mL200 mL/40 minutes = x mL/60 minutes (in an hour)200 x 60 = 12000/40 = 300
mL/hrUsing dimensional analysis:20 mL/kg x 1 kg/2.2 lb x 22 lb x 60 min/hr x 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 (IPV), Hepatitis B and Haemophilus influenzae type B (HIB)
immunizations. She reports that the baby feels very warm, cries inconsolably for as long as
three hours, and has had several shaking spells. Which immunization would the nurse expect to
be primarily responsible with these findings?
