NCSBN Practice 149Questions 76-90 and
answers correctly verified latest update
2024/2025 best exam for nursing
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? - CORRECT
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?
A. DTaP
B. IPV
C. Hepatitis B
D. HIB - CORRECT ANSWERS A
DTaP immunization is a vaccine that protects against diptheria, tetanus and
pertussis (whooping cough). The majority of reactions described in this question
occur with the administration of the DTaP vaccination. Contraindications to giving
repeat DTaP immunizations include the occurrence of severe side effects after a
previous dose, as well as signs of encephalopathy within seven days of the
immunization.
A client diagnosed with angina has been instructed about the use of sublingual
nitroglycerin. Which statement made by the client is incorrect and indicates a need
for further teaching?
A. "I'll call the health care provider if pain continues after three tablets five minutes
apart."
,NCSBN Practice 149Questions 76-90 and
answers correctly verified latest update
2024/2025 best exam for nursing
B. "I will rest briefly right after taking one tablet."
C. "I understand that the medication should be kept in the dark bottle."
D. "I can swallow two or three tablets at once if I have severe pain." - CORRECT
ANSWERS D
Clients must understand that just one sublingual tablet should be taken at a time
and placed under the tongue. After rest and a five-minute interval, a second and
then eventually a third tablet may be necessary.
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 - CORRECT 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 -
CORRECT ANSWERS B
,NCSBN Practice 149Questions 76-90 and
answers correctly verified latest update
2024/2025 best exam for nursing
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?" - CORRECT 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 -
CORRECT 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
, NCSBN Practice 149Questions 76-90 and
answers correctly verified latest update
2024/2025 best exam for nursing
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 - CORRECT 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 - CORRECT 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
The benefits of buying summaries with Stuvia:
Guaranteed quality through customer reviews
Stuvia customers have reviewed more than 700,000 summaries. This how you know that you are buying the best documents.
Quick and easy check-out
You can quickly pay through credit card or Stuvia-credit for the summaries. There is no membership needed.
Focus on what matters
Your fellow students write the study notes themselves, which is why the documents are always reliable and up-to-date. This ensures you quickly get to the core!
Frequently asked questions
What do I get when I buy this document?
You get a PDF, available immediately after your purchase. The purchased document is accessible anytime, anywhere and indefinitely through your profile.
Satisfaction guarantee: how does it work?
Our satisfaction guarantee ensures that you always find a study document that suits you well. You fill out a form, and our customer service team takes care of the rest.
Who am I buying these notes from?
Stuvia is a marketplace, so you are not buying this document from us, but from seller NURSINGGRADER2012. Stuvia facilitates payment to the seller.
Will I be stuck with a subscription?
No, you only buy these notes for $18.99. You're not tied to anything after your purchase.
