NCSBN EXAM
GUIDE
High-Yield Qs & Answers with Rationales
This Exam Description:
High-Yield Qs
Answers with Rationales
100% Guaranteed Pass
Multiple –Choices (A-D)
1
,1. 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 attects 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.
2. 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
2
,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 spiraltape 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.
3. 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.
4. 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 ettects of ACE inhibitors is
4
GUIDE
High-Yield Qs & Answers with Rationales
This Exam Description:
High-Yield Qs
Answers with Rationales
100% Guaranteed Pass
Multiple –Choices (A-D)
1
,1. 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 attects 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.
2. 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
2
,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 spiraltape 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.
3. 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.
4. 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 ettects of ACE inhibitors is
4
