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NCSBN Practice Questions 121-131 Exam Questions and answers ()
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NCSBN Practice Questions 121-131 Exam Questions and answers (202472025)It is the start of the shift and the nurse has just finished listening to a report on four
clients. Which client should the nurse assess first?
A. A client with a diagnosis of an acute traumatic brain injury who has a blood
pressure of 88/58
B. A client with a diagnosis of a concussion and who doesn't remember the motor
vehicle accident
C. A client diagnosed with viral meningitis and has signs of meningeal irritation
D. A client diagnosed with generalized seizures who complains of a headache
following an observed seizure - ✔✔A
Hypotension adversely affects cerebral perfusion following a traumatic brain
injury. Both hypotension and hypoxia are the greatest threats to functional
outcomes in brain injury and must be corrected early, taking priority over other
interventions for brain injury. Headache after a seizure is expected, amnesia is
common with a concussion, and meningeal irritation is an expected finding with
viral meningitis, making these clients a lower priority at this point.
The nurse discovers that a chest tube has become disconnected from the main
connection site of a closed chest drainage unit (CDU). What immediate action
should be taken by the nurse?
A. Cover the insertion site with a sterile petroleum gauze pad
B. Submerge the distal end of the tube in 2 - 4 centimeters of sterile water
C. Reconnect the drainage tube to the chest tube
D. Clamp the chest tube nearest to the client with a rubber-tipped hemostat - ✔✔B
If the tube becomes disconnected from the main connection site of a CDU, the
nurse should place the end of the chest tube in a bottle of sterile water (or saline
solution) while someone else prepares a new CDU setup. The health care provider
should be called (the nurse should expect an order for a chest X-ray.) To prevent
,the chest tube from coming apart, it's important to spiral-tape the main connection
site and not to let loops of tubing hang down the side of the bed. If there is an air
leak from the chest, do not clamp the chest tube as this will cause air to accumulate
in the pleural cavity, potentially leading to a collapsed lung or tension
pneumothorax. Only if the chest tube becomes dislodged from the client does the
nurse need to cover the insertion site with a sterile gauze dressing.
The client states to the nurse: "I am ready to stop all of these treatments. I just want
to go home and enjoy my family for the little bit of time I have left." Which action
is most appropriate?
A. Call in a referral to a social worker and explain that the request will need to be
discussed in more detail at a later time
B. Encourage the client to discuss this decision with the health care provider and
family
C. Tell the family members that the client's preference is to go home to die
D. No action is needed at this time unless the client repeats the statement to
another caregiver - ✔✔B
The client has the right to stop treatment and should be supported in clearly
communicating this decision with the health care provider and family. The nurse
needs to act as an advocate for the client. It is factually incorrect to wait until the
request is repeated; clients should not need to express their wishes repeatedly
before caregivers listen to them. The nurse should not be the one to share sensitive
information with the family; the client controls that information. Social services
may get involved but time is of the essence for those who are terminally ill.
A client who is newly diagnosed with hypertension is prescribed benazepril. What
is the most important point to make when teaching the client about this
medication?
A. "Notify the health care provider if there is a change in your voice."
,B. "Monitor your blood pressure and pulse regularly."
C. "Take medication as directed at the same time each day, even if you feel well."
D. "Call your health care provider if you develop a dry cough." - ✔✔A
Benazepril (Lotensin) is an angiotensin converting enzyme (ACE) inhibitor. Even
if you don't know this drug, remember that the spelling of ACE inhibitors usually
end with "pril." One of the side effects of ACE inhibitors is a dry cough;
sometimes the cough is severe enough to require discontinuation of the drug. But
the most important point to make is that if the client's voice changes or "sounds
funny" or there is any swelling of the lips, tongue or throat, the client should
contact the health care provider because this could indicate angioedema, a
potentially fatal condition.
A client's admission urinalysis shows the specific gravity value of 1.039. Which of
these findings would the nurse expect to find during the physical assessment of this
client?
A. Above normal heart rate
B. Moist mucous membranes
C. Poor skin turgor
D. Increased blood pressure - ✔✔C
The specific gravity value is high, which would indicate dehydration. Specific
gravity measures urine density and an average urine specific gravity value is
around 1.020. Poor skin turgor, as seen with tenting of the skin, is consistent with
this problem.
A male client is preparing for discharge after an acute myocardial infarction. The
client asks the nurse about sexual activity once the client is home. What should be
the nurse's initial approach?
A. Answer the questions accurately in a private environment
, B. Schedule a private, uninterrupted teaching session with both the client and the
partner
C. Assess the client's knowledge about the current health problems
D. Give the client written material from the American Heart Association about
sexual activity with heart disease - ✔✔C
The nursing process is continuous and cyclical in nature. When a client expresses a
specific concern, the nurse should perform a focused assessment to gather
additional data prior to planning and implementing nursing interventions.
A nurse is caring for a 2 year-old child who is being treated for lead poisoning by
chelation therapy. The nurse should be alert for which side effect of chelation
therapy?
A. Hepatomegaly
B. Ototoxicity
C. Neurotoxicity
D. Hypocalcemia - ✔✔D
Injections of ethylenediaminetetraacetic acid (EDTA) or other chemicals bind, or
chelate, to iron (and some other metals), which are then eliminated from the body.
Since chelation therapy removes minerals from the body, there is a risk of
developing low calcium levels (hypocalcemia) and bone damage.
After four electroconvulsive treatments over two weeks, a client is very upset and
states, "I am so confused. I lose my money. I just can't remember telephone
numbers." The most therapeutic response for the nurse to make is which of these
statements?
A. "Don't get upset. The confusion will clear up in a day or two."
B. "You were seriously ill and needed the treatments."
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