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NCSBN ON-LINE REVIEW
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NCLEX RN, NCSBN ON-LINE REVIEW 2021-2022
1.A client has been hospitalized after an automobile accident. A full leg cast was applied in the emergency room. The most
important reason for the nurse to elevate the casted leg is to
Promote the client's comfort
Reduce the drying time
Decrease irritation to the skin
Improve venous return
D: Improve venous return. Elevating the leg both improves venous return and reduces swelling. Client comfort will be
improved as well.
The nurse is reviewing with a client how to collect a clean catch urine specimen. What is the appropriate sequence to teach
the client?
Clean the meatus, begin voiding, then catch urine stream
Void a little, clean the meatus, then collect specimen
Clean the meatus, then urinate into container
Void continuously and catch some of the urine
A: Clean the meatus, begin voiding, then catch urine stream. A clean catch urine is difficult to obtain and requires clear
directions. Instructing the client to carefully clean the meatus, then void naturally with a steady stream prevents surface
bacteria from contaminating the urine specimen. As starting and stopping flow can be difficult, once the client begins
voiding it’s best to just slip the container into the stream. Other responses do not reflect correct technique
Following change-of-shift report on an orthopedic unit, which client should the nurse see first?
16 year-old who had an open reduction of a fractured wrist 10 hours ago
20 year-old in skeletal traction for 2 weeks since a motor cycle accident
72 year-old recovering from surgery after a hip replacement 2 hours ago
75 year-old who is in skin traction prior to planned hip pinning surgery.
C: Look for the client who has the most imminent risks and acute vulnerability. The client who returned from surgery 2
hours ago is at risk for life threatening hemorrhage and should be seen first. The 16 year- old should be seen next because it
is still the first post-op day. The 75 year- old is potentially vulnerable to age-related physical and cognitive consequences in
skin traction should be seen next. The client who can safely be seen last is the 20 year-old who is 2 weeks post-injury.
A client with Guillain Barre is in a nonresponsive state, yet vital signs are stable and breathing is independent. What should
the nurse document to most accurately describe the client's condition?
Comatose, breathing unlabored
Glascow Coma Scale 8, respirations regular
Appears to be sleeping, vital signs stable
Glascow Coma Scale 13, no ventilator required
B: Glascow Coma Scale 8, respirations regular. The Glascow Coma Scale provides a standard reference for assessing or
monitoring level of consciousness. Any score less than 13 indicates a neurological impairment. Using the term comatose
provides too much room for interpretation and is not very precise.
When caring for a client receiving warfarin sodium (Coumadin), which lab test would the nurse monitor to determine
therapeutic response to the drug?
Bleeding time
Coagulation time
Prothrombin time
Partial thromboplastin time
C: Prothrombin time. Coumadin is ordered daily, based on the client''s prothrombin time (PT). This test evaluates the
adequacy of the extrinsic system and common pathway in the clotting cascade; Coumadin affects the Vitamin K dependent
clotting factors.
client with moderate persistent asthma is admitted for a minor surgical procedure. On admission the peak flow meter is
measured at 480 liters/minute. Post-operatively the client is complaining of chest tightness. The peak flow has dropped to
200 liters/minute. What should the nurse do first?
Notify both the surgeon and provider
Administer the prn dose of albuterol
Apply oxygen at 2 litD
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Repeat the peak flow reaDdisintrgibiuntio30no mf itnhuistedsocument is illegal
, A) The client lost 2 pounds in 24 hours
The client’s potassium level is 4 mEq/liter.
The client’s urine output was 1500 cc in 5 hours
The client is to receive another dose of Lasix at 10 PM
C: The client’s urine output was 1500 cc in 5 hours. Although all of these may be correct information to include in report,
the essential piece would be the urine output.
8.A client has been tentatively diagnosed with Graves' disease (hyperthyroidism). Which of these findings noted on the initial
nursing assessment requires quick intervention by the nurse?
a report of 10 pounds weight loss in the last month
a comment by the client "I just can't sit still."
the appearance of eyeballs that appear to "pop" out of the client's eye sockets
a report of the sudden onset of irritability in the past 2 weeks
C: the appearance of eyeballs that appear to "pop" out of the client''s eye sockets. Exophthalmos or protruding eyeballs is
a distinctive characteristic of Graves'' Disease. It can result in corneal abrasions with severe eye pain or damage when the
eyelid is unable to blink down over the protruding eyeball. Eye drops or ointment may be needed.
The nurse has performed the initial assessments of 4 clients admitted with an acute episode of asthma. Which
assessment finding would cause the nurse to call the provider immediately?
prolonged inspiration with each breath
expiratory wheezes that are suddenly absent in 1 lobe
expectoration of large amounts of purulent mucous
appearance of the use of abdominal muscles for breathing
B: expiratory wheezes that are suddenly absent in 1 lobe. Acute asthma is characterized by expiratory wheezes caused by
obstruction of the airways. Wheezes are a high pitched musical sounds produced by air moving through narrowed airways.
Clients often associate wheezes with the feeling of tightness in the chest. However, sudden cessation of wheezing is an
ominous or bad sign that indicates an emergency -- the small airways are now collapsed.
10. During the initial home visit, a nurse is discussing the care of a client newly diagnosed with Alzheimer's disease with family
members. Which of these interventions would be most helpful at this time?
leave a book about relaxation techniques
write out a daily exercise routine for them to assist the client to do
list actions to improve the client's daily nutritional intake
suggest communication strategies
D: suggest communication strategies. Alzheimer''s disease, a progressive chronic illness, greatly challenges caregivers. The
nurse can be of greatest assistance in helping the family to use communication strategies to enhance their ability to relate
to the client. By use of select verbal and nonverbal communication strategies the family can best support the client’s
strengths and cope with any aberrant behavior.
11. An 80 year-old client admitted with a diagnosis of possible cerebral vascular accident has had a blood pressure from 160/100
to 180/110 over the past 2 hours. The nurse has also noted increased lethargy. Which assessment finding should the nurse
report immediately to the provider?
Slurred speech
Incontinence
Muscle weakness
Rapid pulse
A: Slurred speech. Changes in speech patterns and level of conscious can be indicators of continued intracranial bleeding or
extension of the stroke. Further diagnostic testing may be indicated.
A school-aged child has had a long leg (hip to ankle) synthetic cast applied 4 hours ago. Which statement from the parent
indicates that teaching has been inadequate?
"I will keep the cast uncovered for the next day to prevent burning of the skin."
"I can apply an ice pack over the area to relieve itching inside the cast."
"The cast should be propped on at least 2 pillows when my child is lying down."
"I think I remember that my child should not stand until after 72 hours."
D: "I think I remember that my child should not stand until after 72 hours.". Synthetic casts will typically set up in 30
minutes and dry in a few hours. Thus, the client may stand within the initial 24 hours. With plaster casts, the set up and
drying time, especially in a long leg cast which is thicker than an arm cast, can take up to 72 hours. Both types of casts give
, off a lot of heat when drying and it is preferable to keep the cast uncovered for the first 24 hours. Clients may complain of a
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chill from the wet cast and therefore can simply be covered lightly with a sheet or blanket. Applying ice is a safe method of
relieving the itching.
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