NCSBN Practice Questions 1-15 with
Complete Solutions69
Two hours after receiving the first does of lithium, the client reports fine hand tremors. What is
the nurse's best explanation for these findings?
A. "Reducing dietary intake of sodium and fluids should minimize any side effects."
B. "Taking lithium on an empty stomach should help minimize these symptoms."
C. "These are common and expected side effects and should subside in a few days."
D. "You are probably having an allergic reaction. The medication should be discontinued." -
ANSWERS-C
Tremors are common side effects that usually subside quickly. Informing clients of these
possible reactions can help them tolerate these initial difficulties, while continuing to take the
drug and obtaining therapeutic effects.
The nurse is caring for a toddler who is diagnosed with an infection and whose temperature is
103 F (39.4 C). Which intervention would be most effective in lowering the client's temperature
and promoting comfort?
A. Immerse the child in a tub containing cool water
B. Give a tepid sponge bath prior to giving an antipyretic medication
C. Apply extra layers of clothing to prevent shivering
D. Administer the prescribed antipyretic medication - ANSWERS-D
Fever is not the primary illness; it is a physiologic mechanism the body uses to fight an infection.
Although tepid sponge baths can lower the body temperature, they can distress febrile children
(as evidenced by crying, shivering and goosebumps.) Antipyretics can not only reduce the fever
in the child, but they can also improve comfort and decrease irritability.
,Which individual is at greatest risk for the development of hypertension?
A. 40 year-old Caucasian nurse
B. 60 year-old Asian-American shop owner
C. 45 year-old African-American attorney
D. 55 year-old Hispanic teacher - ANSWERS-C
The incidence of hypertension is greater among African-Americans than other groups in the
United States. The incidence among the Hispanic population is rising.
A woman, who delivered five days ago and who had been diagnosed with pregnancy induced
hypertension (PIH), calls a hospital triage nurse hotline to ask for advice. She states, "I have had
the worst headache for the past two days. It pounds and by the middle of the afternoon
everything I look at looks wavy. Nothing I have taken helps." What should the nurse do next?
A. Advise the client to have someone bring her to the emergency room as soon as possible
B. Ask the client to explain what she has taken and how often, and then evaluate other specific
complaints
C. Advise the client that the swings in her hormones may be the problem; suggest that she call
her health care provider
D. Ask the client to stay on the line, get the address, and send an ambulance to the home -
ANSWERS-D
The woman is at risk for seizure activity. The ambulance needs to bring the woman to the
hospital for evaluation and treatment. For at-risk clients, PIH may progress to preeclampsia and
eclampsia prior to, during, or after delivery; this may occur up to 10 days after delivery.
There's a new medication order that reads: "administer 1 gtt ciprofloxacin solution OD Q 4 h"
What action should the nurse take?
A. Squeeze one drop of the medication in the left eye every 4 hours
,B. Apply one drop in the right ear every 4 hours
C. Call the prescriber to clarify and rewrite the order
D. Ask other nurses for their interpretation of the order - ANSWERS-C
Abbreviations, symbols and dose designations can be misinterpreted and lead to medication
errors. "OD" can mean "right eye" (oculus dexter) or "once daily"; it should never be used when
communicating medical information. The abbreviation "Q" should be written out as "every."
Although "gtt" is not on the official "Do Not Use List", it's best to use "drop" instead. Asking
other nurses to interpret an order is a potentially dangerous "workaround." The nurse should
call the health care provider who prescribed the medication and clarify the order.
A client expresses anger when a call light is not answered within five minutes. The client
demanded a blanket. How should the nurse respond?
A. "I see this is frustrating for you. I have a few minutes so let's talk."
B. "I am surprised that you are upset. The request could have waited a few more minutes."
C. "Let's talk. Why are you upset about this?"
D. "I apologize for the delay. I was involved in an emergency." - ANSWERS-A
This is the best response because it gives credence to the client's feelings and then concerns. To
say "let's talk" and ask a why question is not a therapeutic approach because it does not
acknowledge or validate the client's feelings. To apologize and not notice the client's feelings is
inappropriate. To say it could have waited a few minutes is rude and non-accepting of the
client's verbalized needs.
The clinic nurse is assisting with medical billing. The nurse uses the DRG (Diagnosis Related
Group) manual for which purpose?
A. Determine reimbursement for a medical diagnosis
B. Identify findings related to a medical diagnosis
C. Classify nursing diagnoses from the client's health history
, D. Implement nursing care based on case management protocol - ANSWERS-DRGs are the basis
of prospective payment plans for reimbursement for Medicare clients. Other insurance
companies often use it as a standard for determining payment.
A nurse is planning care for a 2 year-old hospitalized child. Which issue will produce the most
stress at this age?
A. Fear of pain
B. Separation anxiety
C. Loss of control
D. Bodily injury - ANSWERS-B
While a toddler will experience all of the stresses, separation from parents is the major stressor.
Separation anxiety peaks in the toddler years.
The nurse receives a client from the post anesthesia care unit following a left femoral-popliteal
bypass graft procedure. Which of the following assessments requires immediate notification of
the health care provider?
A. Left foot is cool to the touch
B. Absent left pedal pulse using Doppler analysis
C. Inability to palpate the left pedal pulse
D. Acute pain in the left lower leg - ANSWERS-B
Although the inability to palpate the left pedal pulse, a cool extremity, and increased pain in the
left lower leg are important findings, they all require additional nursing assessment prior to
contacting the health care provider. In clients without palpable pedal pulses, the next step in
the assessment is to perform a Doppler analysis. The inability to locate the left pedal pulse using
the Doppler analysis requires immediately notifying the health care provider.
The nurse is reviewing the laboratory results for several clients. Which of the laboratory result
indicates a client with partly compensated metabolic acidosis?
Complete Solutions69
Two hours after receiving the first does of lithium, the client reports fine hand tremors. What is
the nurse's best explanation for these findings?
A. "Reducing dietary intake of sodium and fluids should minimize any side effects."
B. "Taking lithium on an empty stomach should help minimize these symptoms."
C. "These are common and expected side effects and should subside in a few days."
D. "You are probably having an allergic reaction. The medication should be discontinued." -
ANSWERS-C
Tremors are common side effects that usually subside quickly. Informing clients of these
possible reactions can help them tolerate these initial difficulties, while continuing to take the
drug and obtaining therapeutic effects.
The nurse is caring for a toddler who is diagnosed with an infection and whose temperature is
103 F (39.4 C). Which intervention would be most effective in lowering the client's temperature
and promoting comfort?
A. Immerse the child in a tub containing cool water
B. Give a tepid sponge bath prior to giving an antipyretic medication
C. Apply extra layers of clothing to prevent shivering
D. Administer the prescribed antipyretic medication - ANSWERS-D
Fever is not the primary illness; it is a physiologic mechanism the body uses to fight an infection.
Although tepid sponge baths can lower the body temperature, they can distress febrile children
(as evidenced by crying, shivering and goosebumps.) Antipyretics can not only reduce the fever
in the child, but they can also improve comfort and decrease irritability.
,Which individual is at greatest risk for the development of hypertension?
A. 40 year-old Caucasian nurse
B. 60 year-old Asian-American shop owner
C. 45 year-old African-American attorney
D. 55 year-old Hispanic teacher - ANSWERS-C
The incidence of hypertension is greater among African-Americans than other groups in the
United States. The incidence among the Hispanic population is rising.
A woman, who delivered five days ago and who had been diagnosed with pregnancy induced
hypertension (PIH), calls a hospital triage nurse hotline to ask for advice. She states, "I have had
the worst headache for the past two days. It pounds and by the middle of the afternoon
everything I look at looks wavy. Nothing I have taken helps." What should the nurse do next?
A. Advise the client to have someone bring her to the emergency room as soon as possible
B. Ask the client to explain what she has taken and how often, and then evaluate other specific
complaints
C. Advise the client that the swings in her hormones may be the problem; suggest that she call
her health care provider
D. Ask the client to stay on the line, get the address, and send an ambulance to the home -
ANSWERS-D
The woman is at risk for seizure activity. The ambulance needs to bring the woman to the
hospital for evaluation and treatment. For at-risk clients, PIH may progress to preeclampsia and
eclampsia prior to, during, or after delivery; this may occur up to 10 days after delivery.
There's a new medication order that reads: "administer 1 gtt ciprofloxacin solution OD Q 4 h"
What action should the nurse take?
A. Squeeze one drop of the medication in the left eye every 4 hours
,B. Apply one drop in the right ear every 4 hours
C. Call the prescriber to clarify and rewrite the order
D. Ask other nurses for their interpretation of the order - ANSWERS-C
Abbreviations, symbols and dose designations can be misinterpreted and lead to medication
errors. "OD" can mean "right eye" (oculus dexter) or "once daily"; it should never be used when
communicating medical information. The abbreviation "Q" should be written out as "every."
Although "gtt" is not on the official "Do Not Use List", it's best to use "drop" instead. Asking
other nurses to interpret an order is a potentially dangerous "workaround." The nurse should
call the health care provider who prescribed the medication and clarify the order.
A client expresses anger when a call light is not answered within five minutes. The client
demanded a blanket. How should the nurse respond?
A. "I see this is frustrating for you. I have a few minutes so let's talk."
B. "I am surprised that you are upset. The request could have waited a few more minutes."
C. "Let's talk. Why are you upset about this?"
D. "I apologize for the delay. I was involved in an emergency." - ANSWERS-A
This is the best response because it gives credence to the client's feelings and then concerns. To
say "let's talk" and ask a why question is not a therapeutic approach because it does not
acknowledge or validate the client's feelings. To apologize and not notice the client's feelings is
inappropriate. To say it could have waited a few minutes is rude and non-accepting of the
client's verbalized needs.
The clinic nurse is assisting with medical billing. The nurse uses the DRG (Diagnosis Related
Group) manual for which purpose?
A. Determine reimbursement for a medical diagnosis
B. Identify findings related to a medical diagnosis
C. Classify nursing diagnoses from the client's health history
, D. Implement nursing care based on case management protocol - ANSWERS-DRGs are the basis
of prospective payment plans for reimbursement for Medicare clients. Other insurance
companies often use it as a standard for determining payment.
A nurse is planning care for a 2 year-old hospitalized child. Which issue will produce the most
stress at this age?
A. Fear of pain
B. Separation anxiety
C. Loss of control
D. Bodily injury - ANSWERS-B
While a toddler will experience all of the stresses, separation from parents is the major stressor.
Separation anxiety peaks in the toddler years.
The nurse receives a client from the post anesthesia care unit following a left femoral-popliteal
bypass graft procedure. Which of the following assessments requires immediate notification of
the health care provider?
A. Left foot is cool to the touch
B. Absent left pedal pulse using Doppler analysis
C. Inability to palpate the left pedal pulse
D. Acute pain in the left lower leg - ANSWERS-B
Although the inability to palpate the left pedal pulse, a cool extremity, and increased pain in the
left lower leg are important findings, they all require additional nursing assessment prior to
contacting the health care provider. In clients without palpable pedal pulses, the next step in
the assessment is to perform a Doppler analysis. The inability to locate the left pedal pulse using
the Doppler analysis requires immediately notifying the health care provider.
The nurse is reviewing the laboratory results for several clients. Which of the laboratory result
indicates a client with partly compensated metabolic acidosis?
