NCSBN Practice Questions 91-
105(answered and well explained)
Quiz:> 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
{{Answer}} ( 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.)
Quiz:> 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
{{Answer}} ( 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.)
Quiz:> 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
{{Answer}} ( 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.)
Quiz:> 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
{{Answer}} ( 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.)
Quiz:> 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
{{Answer}} ( 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.)
Quiz:> 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
{{Answer}} ( 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.)
Quiz:> 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
D. Check the pulse
{{Answer}} ( B
Place the client in a side-lying position to maintain an open airway, drain secretions, and
prevent aspiration if vomiting occurs. After that, any ordered medication should be
given.)
Quiz:> A 16 year-old adolescent is admitted for Ewing's sarcoma of the tibia. In
discussing the care with the parents, the nurse should understand that the initial
treatment for this diagnosis usually includes which approach?
A. Surgical excision of the mass
B. Radiation with adjunctive chemotherapy
C. Amputation above the tumor
D. Bone marrow graft in the affected leg
{{Answer}} ( B
The initial approach for the treatment of Ewing's sarcoma is usually a combination of
radiation and chemotherapy to reduce the size of the tumor.)
Quiz:> A 2 day-old child with spina bifida and meningomyelocele is in the intensive care
unit after the initial surgery. As the nurse accompanies the grandparents for a first visit,
which response should the nurse anticipate of the grandparents?
A. Disbelief
B. Anger
C. Frustration
D. Depression
{{Answer}} ( A
The first phase of the grieving process is shock, denial or disbelief. Then follows anger,
bargaining, depression and acceptance. Each stage can take any amount of time to
work through. Clients often go back and forth between the stages until acceptance is
, achieved. Some clients may get stuck in any one or two of the stages to never achieve
acceptance.)
Quiz:> A client has a serum glucose of 385 mg/dL (21.4 mmol/L). Which of these verbal
orders would be a priority for the nurse to question and call back the health care
provider for a revision?
A. Repeat glycosolated hemoglobin in 24 hours
B. IV fluids of 0.9% normal saline at 125 mL per hour
C. Document peripheral glucose sticks every four hours
D. Humulin N 20 units IV push over 10 minutes
{{Answer}} ( D
Short-acting insulin, such as regular or semilente insulin, is the only insulin that can be
given by the intravenous route. Humulin insulin IV is the order to question. Repeating
the glycohemoglobin should also be questioned, although it is not a priority because the
client would not be harmed by this action. This lab test gives the average glucose on the
hemoglobin molecule for the past two to three months; there would be no need to
repeat it at this time. A fasting glucose in the morning would be a more appropriate
assessment. The other orders are within expected actions in this situation.)
Quiz:> While discussing issues with colleagues on the unit, the novice nurse seems
surprised when the other nurses state that the manager makes all decisions and rarely
asks for staff input. What is the best description of the nurse manager's management
style?
A. Ultraliberal or communicative
B. Laissez-faire or permissive
C. Autocratic or authoritarian
D. Participative or democratic
{{Answer}} ( C
Autocratic leadership style is suggested in this situation. It is appropriate for groups with
little education and experience who need strong direction. A Participative or democratic
style is usually more successful on nursing units with a mix of staff of differing
experience.)
Quiz:> An 89 year-old with impaired mental status is transferred from a nursing home to
the hospital for surgery. When assisting the client with a clear liquid diet postoperatively,
the client begins to cough forcefully. What action by the nurse is indicated?
A. Refer the client for a swallowing assessment
B. Add a thickening agent to the fluids
C. Order a soft diet
D. Call the nursing home for more information
{{Answer}} ( A
The nurse should contact the health care provider to request a swallowing assessment
for this client. Older adults with impaired mental status are at greater risk for aspiration
105(answered and well explained)
Quiz:> 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
{{Answer}} ( 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.)
Quiz:> 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
{{Answer}} ( 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.)
Quiz:> 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
{{Answer}} ( 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.)
Quiz:> 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
{{Answer}} ( 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.)
Quiz:> 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
{{Answer}} ( 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.)
Quiz:> 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
{{Answer}} ( 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.)
Quiz:> 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
D. Check the pulse
{{Answer}} ( B
Place the client in a side-lying position to maintain an open airway, drain secretions, and
prevent aspiration if vomiting occurs. After that, any ordered medication should be
given.)
Quiz:> A 16 year-old adolescent is admitted for Ewing's sarcoma of the tibia. In
discussing the care with the parents, the nurse should understand that the initial
treatment for this diagnosis usually includes which approach?
A. Surgical excision of the mass
B. Radiation with adjunctive chemotherapy
C. Amputation above the tumor
D. Bone marrow graft in the affected leg
{{Answer}} ( B
The initial approach for the treatment of Ewing's sarcoma is usually a combination of
radiation and chemotherapy to reduce the size of the tumor.)
Quiz:> A 2 day-old child with spina bifida and meningomyelocele is in the intensive care
unit after the initial surgery. As the nurse accompanies the grandparents for a first visit,
which response should the nurse anticipate of the grandparents?
A. Disbelief
B. Anger
C. Frustration
D. Depression
{{Answer}} ( A
The first phase of the grieving process is shock, denial or disbelief. Then follows anger,
bargaining, depression and acceptance. Each stage can take any amount of time to
work through. Clients often go back and forth between the stages until acceptance is
, achieved. Some clients may get stuck in any one or two of the stages to never achieve
acceptance.)
Quiz:> A client has a serum glucose of 385 mg/dL (21.4 mmol/L). Which of these verbal
orders would be a priority for the nurse to question and call back the health care
provider for a revision?
A. Repeat glycosolated hemoglobin in 24 hours
B. IV fluids of 0.9% normal saline at 125 mL per hour
C. Document peripheral glucose sticks every four hours
D. Humulin N 20 units IV push over 10 minutes
{{Answer}} ( D
Short-acting insulin, such as regular or semilente insulin, is the only insulin that can be
given by the intravenous route. Humulin insulin IV is the order to question. Repeating
the glycohemoglobin should also be questioned, although it is not a priority because the
client would not be harmed by this action. This lab test gives the average glucose on the
hemoglobin molecule for the past two to three months; there would be no need to
repeat it at this time. A fasting glucose in the morning would be a more appropriate
assessment. The other orders are within expected actions in this situation.)
Quiz:> While discussing issues with colleagues on the unit, the novice nurse seems
surprised when the other nurses state that the manager makes all decisions and rarely
asks for staff input. What is the best description of the nurse manager's management
style?
A. Ultraliberal or communicative
B. Laissez-faire or permissive
C. Autocratic or authoritarian
D. Participative or democratic
{{Answer}} ( C
Autocratic leadership style is suggested in this situation. It is appropriate for groups with
little education and experience who need strong direction. A Participative or democratic
style is usually more successful on nursing units with a mix of staff of differing
experience.)
Quiz:> An 89 year-old with impaired mental status is transferred from a nursing home to
the hospital for surgery. When assisting the client with a clear liquid diet postoperatively,
the client begins to cough forcefully. What action by the nurse is indicated?
A. Refer the client for a swallowing assessment
B. Add a thickening agent to the fluids
C. Order a soft diet
D. Call the nursing home for more information
{{Answer}} ( A
The nurse should contact the health care provider to request a swallowing assessment
for this client. Older adults with impaired mental status are at greater risk for aspiration
