NCSBN Practice Questions 91-105
with Complete Solutions66
The nurse is caring for a client, who is the mother of a close friend. The friend asks the nurse for
an update about her mother's condition on a social networking website. How should the nurse
respond?
A. Do not respond to the friend on the social networking website
B. Answer the question on the social networking website because only trusted contacts can
access the information
C. Do not use the social networking website to answer the question; call the friend instead
D. Respond on the social networking website, directing the friend to ask the question in person -
ANSWERS-A
A nurse cannot disclose information about a client except to those who are directly involved in
the care of the client. Also, clients must be informed about how their personal health
information will be used and given the opportunity to object to or restrict the use or release of
information. Nurses cannot use social networking websites, like Facebook, to disclose patient
information, even with the use of privacy settings or when no names are used. Each health care
organization has strict policies prohibiting the disclosure of protected health information.
A client who is recovering from alcoholism asks a nurse, "What can I do when I start to
recognize relapse triggers within myself?" How might the nurse respond?
A. "Exercise daily and get involved in activities that will cause you not to think about drinking."
B. "When you have an impulse to stop in a bar, contact sober friends and talk with them."
C. "Let's talk about possible options you have when you recognize these relapse triggers in
yourself."
D. "Go to an AA meeting that week when you feel the urge to drink." - ANSWERS-C
,This option encourages the process of self-evaluation and problem solving and provides an
avoidance of telling the client what to do. Encouraging the client to brainstorm about response
to relapse trigger options validates the nurse's belief in the client's personal competency. These
behaviors reinforce a coping strategy that will be needed when the nurse is not available to
offer solutions.
A client is admitted with low T3 and T4 levels and an elevated thyroid stimulating hormone
(TSH) level. On initial assessment, the nurse should anticipate which of these findings?
A. Lethargy
B. Diarrhea
C. Heat intolerance
D. Skin eruptions - ANSWERS-A
In hypothyroidism the metabolic activity of all cells of the body decreases, reducing oxygen
consumption, decreasing oxidation of nutrients for energy, and producing less body heat.
Therefore, the nurse can expect the client to report being constipated, tired and unable to get
warm.
A neonate born 12 hours ago to a methadone-maintained woman is exhibiting a hyperactive
Moro reflex and slight tremors. The newborn passed one loose, watery stool. Which of these
actions is a nursing priority?
A. Hold the infant at frequent intervals
B. Offer fluids to prevent dehydration
C. Administer paregoric to stop diarrhea
D. Assess for neonatal withdrawal syndrome - ANSWERS-D
Neonatal withdrawal syndrome is a cluster of findings that signal the withdrawal of the infant
from the opiates. The findings seen in methadone withdrawal are often more severe than for
other substances. Initial signs are central nervous system hyperirritability and gastrointestinal
symptoms. If withdrawal signs are severe, there is an increased mortality risk. Scoring the infant
ensures proper treatment during the periods of withdrawal.
,Nurse colleagues are discussing their nursing practice during lunch. Which statement is correct?
A. Each state has specific regulations for licensed registered nurses (RNs) and licensed practical
nurses (LPNs)
B. The employing agency is ultimately responsible to provide practice guidelines for licensed
nurses
C. The federal government ensures the safety of clients by defining the scope of nursing practice
D. National nurses' associations work collaboratively to update the social policy statement for
nursing - ANSWERS-A
Boards of nursing are state governmental agencies that are responsible for licensing nurses in
each state/jurisdiction and enforcing the rules and regulations of the nurse practice act (NPA).
The NPA is enacted by the state legislature. The NPA and rules define the scope of practice and
responsibilities for nurses. The scope of practice for nurses, especially LPN/VNs, varies from
state to state.
An infant who has recently been diagnosed with cystic fibrosis (CF) is being assessed by the
nurse. Which finding of this disease would the nurse not expect to see at this time?
A. Bulky, greasy stools
B. Positive sweat test
C. Moist, productive cough
D. Meconium ileus - ANSWERS-C
Moist and productive cough is a later sign in CF. Noisy respirations and a dry nonproductive
cough are commonly the first respiratory signs to appear in a newly diagnosed client with CF.
The other options are the earlier findings. CF is an inherited (genetic) condition affecting the
cells that produce mucus, sweat, saliva and digestive juices. Normally, these secretions are thin
and slippery, but in CF a defective gene causes the secretions to become thick and sticky.
Instead of acting as a lubricant, the secretions plug up tubes, ducts and passageways, especially
in the pancreas and lungs. Respiratory failure is the most dangerous consequence of CF.
, The nurse is caring for a client with orders for complete bed rest. Which action by the nurse is
most important in the prevention of the formation of deep vein thrombosis (DVT)?
A. Prevent pressure at back of the knees
B. Elevate the foot of the bed
C. Encourage isometric leg muscle exercises
D. Apply knee high support stockings - ANSWERS-A
Prevention of popliteal pressure will minimize venous stasis and deep vein thrombosis. The
other actions would also be implemented for clients with orders for bed rest. However, the
correct option is the one action directly associated with DVT.
The nurse is assessing a client with portal hypertension. Which findings should the nurse expect
during the assessment?
A. Expiratory wheezes
B. Blurred vision
C. Dilated pupils
D. Ascites - ANSWERS-D
Portal hypertension can occur in a client with right-sided heart failure or cirrhosis of the liver.
Portal hypertension can lead to ascites from the increased portal pressure as well as a lowered
colloid osmotic pressure because of low albumin. When liver functioning deteriorates, protein
metabolism is decreased with the result of a low serum albumin.
The nurse finds a client unconscious, following a tonic-clonic seizure. What should a nurse do
first?
A. Administer the ordered Ativan
B. Place the client in a side-lying position
C. Prepare for suctioning
with Complete Solutions66
The nurse is caring for a client, who is the mother of a close friend. The friend asks the nurse for
an update about her mother's condition on a social networking website. How should the nurse
respond?
A. Do not respond to the friend on the social networking website
B. Answer the question on the social networking website because only trusted contacts can
access the information
C. Do not use the social networking website to answer the question; call the friend instead
D. Respond on the social networking website, directing the friend to ask the question in person -
ANSWERS-A
A nurse cannot disclose information about a client except to those who are directly involved in
the care of the client. Also, clients must be informed about how their personal health
information will be used and given the opportunity to object to or restrict the use or release of
information. Nurses cannot use social networking websites, like Facebook, to disclose patient
information, even with the use of privacy settings or when no names are used. Each health care
organization has strict policies prohibiting the disclosure of protected health information.
A client who is recovering from alcoholism asks a nurse, "What can I do when I start to
recognize relapse triggers within myself?" How might the nurse respond?
A. "Exercise daily and get involved in activities that will cause you not to think about drinking."
B. "When you have an impulse to stop in a bar, contact sober friends and talk with them."
C. "Let's talk about possible options you have when you recognize these relapse triggers in
yourself."
D. "Go to an AA meeting that week when you feel the urge to drink." - ANSWERS-C
,This option encourages the process of self-evaluation and problem solving and provides an
avoidance of telling the client what to do. Encouraging the client to brainstorm about response
to relapse trigger options validates the nurse's belief in the client's personal competency. These
behaviors reinforce a coping strategy that will be needed when the nurse is not available to
offer solutions.
A client is admitted with low T3 and T4 levels and an elevated thyroid stimulating hormone
(TSH) level. On initial assessment, the nurse should anticipate which of these findings?
A. Lethargy
B. Diarrhea
C. Heat intolerance
D. Skin eruptions - ANSWERS-A
In hypothyroidism the metabolic activity of all cells of the body decreases, reducing oxygen
consumption, decreasing oxidation of nutrients for energy, and producing less body heat.
Therefore, the nurse can expect the client to report being constipated, tired and unable to get
warm.
A neonate born 12 hours ago to a methadone-maintained woman is exhibiting a hyperactive
Moro reflex and slight tremors. The newborn passed one loose, watery stool. Which of these
actions is a nursing priority?
A. Hold the infant at frequent intervals
B. Offer fluids to prevent dehydration
C. Administer paregoric to stop diarrhea
D. Assess for neonatal withdrawal syndrome - ANSWERS-D
Neonatal withdrawal syndrome is a cluster of findings that signal the withdrawal of the infant
from the opiates. The findings seen in methadone withdrawal are often more severe than for
other substances. Initial signs are central nervous system hyperirritability and gastrointestinal
symptoms. If withdrawal signs are severe, there is an increased mortality risk. Scoring the infant
ensures proper treatment during the periods of withdrawal.
,Nurse colleagues are discussing their nursing practice during lunch. Which statement is correct?
A. Each state has specific regulations for licensed registered nurses (RNs) and licensed practical
nurses (LPNs)
B. The employing agency is ultimately responsible to provide practice guidelines for licensed
nurses
C. The federal government ensures the safety of clients by defining the scope of nursing practice
D. National nurses' associations work collaboratively to update the social policy statement for
nursing - ANSWERS-A
Boards of nursing are state governmental agencies that are responsible for licensing nurses in
each state/jurisdiction and enforcing the rules and regulations of the nurse practice act (NPA).
The NPA is enacted by the state legislature. The NPA and rules define the scope of practice and
responsibilities for nurses. The scope of practice for nurses, especially LPN/VNs, varies from
state to state.
An infant who has recently been diagnosed with cystic fibrosis (CF) is being assessed by the
nurse. Which finding of this disease would the nurse not expect to see at this time?
A. Bulky, greasy stools
B. Positive sweat test
C. Moist, productive cough
D. Meconium ileus - ANSWERS-C
Moist and productive cough is a later sign in CF. Noisy respirations and a dry nonproductive
cough are commonly the first respiratory signs to appear in a newly diagnosed client with CF.
The other options are the earlier findings. CF is an inherited (genetic) condition affecting the
cells that produce mucus, sweat, saliva and digestive juices. Normally, these secretions are thin
and slippery, but in CF a defective gene causes the secretions to become thick and sticky.
Instead of acting as a lubricant, the secretions plug up tubes, ducts and passageways, especially
in the pancreas and lungs. Respiratory failure is the most dangerous consequence of CF.
, The nurse is caring for a client with orders for complete bed rest. Which action by the nurse is
most important in the prevention of the formation of deep vein thrombosis (DVT)?
A. Prevent pressure at back of the knees
B. Elevate the foot of the bed
C. Encourage isometric leg muscle exercises
D. Apply knee high support stockings - ANSWERS-A
Prevention of popliteal pressure will minimize venous stasis and deep vein thrombosis. The
other actions would also be implemented for clients with orders for bed rest. However, the
correct option is the one action directly associated with DVT.
The nurse is assessing a client with portal hypertension. Which findings should the nurse expect
during the assessment?
A. Expiratory wheezes
B. Blurred vision
C. Dilated pupils
D. Ascites - ANSWERS-D
Portal hypertension can occur in a client with right-sided heart failure or cirrhosis of the liver.
Portal hypertension can lead to ascites from the increased portal pressure as well as a lowered
colloid osmotic pressure because of low albumin. When liver functioning deteriorates, protein
metabolism is decreased with the result of a low serum albumin.
The nurse finds a client unconscious, following a tonic-clonic seizure. What should a nurse do
first?
A. Administer the ordered Ativan
B. Place the client in a side-lying position
C. Prepare for suctioning
