NCSBN Practice Questions 1-15

NCSBN Practice Questions 1-15 A 3 year-old has just returned from surgery for application of a hip spica cast. What nursing action will be the priority? A. Drying the cast using a hair dryer set to "warm" B. Apply waterproof plastic tape to the cast around the genital area C. Use the crossbar to help turn the child from side to side D. Position the child flat in bed, repositioning from back to stomach every two to four hours Ans- B The most important aspects of caring for the cast is to keep it clean and dry. Shortly after returning from surgery, waterproof plastic tape will be applied around the genital area to prevent soiling. The child should be turned every two hours to help facilitate drying, from side to side and front to back, with the head elevated at all times. If a crossbar is used to stabilize the legs, it should not be used to turn the child (it may break off). After the cast has completely dried and it becomes damp, it can be either exposed to air or a hair dryer (set to cool) may be used to help dry the cast. A 15 year-old client has been placed in a Milwaukee brace. Which statement made by the client is incorrect and indicates a need for additional teaching? "I should inspect my skin under the brace every day" "The brace has to be worn all day and night." "I will only have to wear this for six months." "I can take it off when I shower or take a bath." Ans- C The brace must be worn long-term, during periods of growth, usually for one to two years. It is used to correct scoliosis, the lateral curvature of the spine. A 35 year-old female client talks to the nurse in her health care provider's office about her new diagnosis of uterine fibroids. What statement by the woman is incorrect and indicates that more teaching is needed? A. "Uterine fibroids are noncancerous tumors that grow slowly." B. "Fibroids occur more frequently in women my age but no one knows what causes them." C. "I sometimes experience pelvic pressure and pain, heavy menstrual bleeding, and I feel the need to urinate more often." D. "Even if the fibroids cause no problems, they will still need to be taken out." Ans- D Fibroids that cause no findings may require only "watchful waiting." The client may just need pelvic exams or ultrasounds every once in a while to monitor the fibroid's growth. Treatment for the symptoms of fibroids (such as painful menses and heavy periods) may include oral contraceptives, IUDs, iron supplements to prevent or treat anemia (due to heavy periods), NSAIDs for cramps or pain or even short-term hormonal therapy to help shrink the fibroids. Surgical removal using myomectomy or hysterectomy is usually reserved as a final alternative after other treatment options have failed to provide adequate relief. In addition, concerns about loss of fertility with this diagnosis and its treatment may be important to this client who is still in her childbearing years. A 67 year-old client is admitted with substernal chest pressure that radiates to the jaw. The admitting diagnosis is acute myocardial infarction (MI). What should be the priority nursing diagnosis for this client during the first 24 hours? A. Altered tissue perfusion B. Activity intolerance C. Anxiety D. Risk for fluid volume excess Ans- A In the immediate post MI period, altered tissue perfusion is priority, as an area of myocardial tissue has been damaged by a lack of blood flow and oxygenation. Interventions should be directed toward promoting tissue perfusion and oxygenation. The other problems are also relevant, but tissue perfusion is the priority. A child is treated with succimer for lead poisoning. Which of these assessments should the nurse perform first? A. Check serum potassium level B. Check blood calcium level C. Test deep tendon reflexes D. Check complete blood count (CBC) with differential Ans- D Succimer (Chemet) is used in the management of lead or other heavy metal poisoning. Although it has generally well tolerated and has a relatively low toxicity, it may cause neutropenia. Therapy should be withheld or discontinued if the absolute neutrophil count (ANC) is below 1200/µ. A client asks the nurse to call the police and states: "I need to report that I am being abused by a nurse." The nurse should take which action? A. Assist with the report of the client's complaint to the police B. Obtain more details of the client's claim of abuse by a nurse C. Document the statement on the client's chart with a report to the manager D. Focus on reality orientation to time, place and person Ans- B The advocacy role of the professional nurse, as well as the legal duty of the reasonable prudent nurse, requires the investigation of claims of abuse or violation of rights. The nurse is legally accountable for actions delegated to others. The application of the nursing process requires that the nurse gather more information, assessment before interventions and before documenting or reporting the complaint. A client diagnosed with testicular cancer has undergone a unilateral orchiectomy. The client expresses fears about his prognosis prior to discharge. What information would the nurse want to include when helping the client better understand this type of cancer? A. With early intervention, the cure rate for teticular cancer is about 50% B. This surgery causes impotence and infertility C. Testicular cancer has a five-year survival rate of 95% with early diagnosis and treatment D. Intensive chemotherapy is the treatment of choice following surgery Ans- C With aggressive treatment and early detection/diagnosis the cure rate is 90%. The other options are incorrect information. After unilateral orchiectomy, the remaining testicle can produce adequate sperm for fertility and impotence is unlikely. In bilateral orchiectomy, fertility is lost, so sperm banking prior to surgery is recommended. Dissection of lymph nodes for surgical cancer treatment may cause nerve injury, which would increase the risk of impotence. A client expresses anger when a call light is not answered within five minutes. The client demanded a blanket. How should the nurse respond? A. "I see this is frustrating for you. I have a few minutes so let's talk." B. "I am surprised that you are upset. The request could have waited a few more minutes." C. "Let's talk. Why are you upset about this?" D. "I apologize for the delay. I was involved in an emergency." Ans- A This is the best response because it gives credence to the client's feelings and then concerns. To say "let's talk" and ask a why question is not a therapeutic approach because it does not acknowledge or validate the client's feelings. To apologize and not notice the client's feelings is inappropriate. To say it could have waited a few minutes is rude and non-accepting of the client's verbalized needs. A client has a chest tube inserted immediately after surgery for a left lower lobectomy. During the repositioning of the client during the first postop check, the nurse notices 75 mL of a dark, red fluid flowing into the collection chamber of the chest drain system. What is the appropriate nursing action? A. Continue to monitor the rate of drainage B. Call the surgeon immediately C. Check to see if the client has a type and cross match D. Turn the client back to the original position Ans- A It is not unusual for blood to collect in the chest and be released into the chest drain when the client changes position this soon after surgery. The dark color of the blood indicates it is not active bleeding inside of the chest. Sanguinous drainage should be expected within the initial 24 hours postop, progressing to serosanguinous and then to a serous type. If the drainage exceeds 100 mL/hr, the nurse should call the surgeon. A client has been prescribed dexamethasone by mouth daily for transplant rejection prophylaxis. The client asks the nurse for more information about the medication. What information should the nurse include? (Select all that apply) A. "Take the medication with food" B. "Take acetaminophen for minor pain or aches." C. "You might experience an increase in weight." D. "Avoid dairy products" E. "Do not stop taking the drug abruptly." Ans- A,B,C,E Adverse effects (ADEs) of long-term corticosteroid therapy include: behavioral/psychological changes, eye changes such as cataracts and glaucoma, and increased susceptibility to infections, hyperglycemia, hypocalcemia, fluid retention, HTN, edema, myopathy, muscle wasting, osteoporosis and peptic ulcers.To reduce the aforementioned ADEs, it is recommended to take the drug with food, avoid using NSAIDs for pain and increase dietary intake of calcium, found in dairy products.To prevent or avoid adrenal atrophy and acute adrenal insufficiency, discontinue corticosteroids gradually. Never discontinue corticosteroids abruptly! A client has had a positive reaction to purified protein derivative (PPD). When the client asks, "What does this mean?" the nurse should respond with which statement? A. "You have been exposed to the organism Mycobacterium tuberculosis." B. "This means you have never had or been around someone with tuberculosis." C. "You are mostly likely have a natural immunity to the bacteria." D. "You most likely have a resistant form of active tuberculosis." Ans- A The PPD skin test is used to determine the presence of tuberculosis antibodies. In an otherwise healthy person, an induration greater than or equal to 15 mm is considered a positive skin test. This indicates that the client has been exposed to the organism Mycobacterium tuberculosis. Additional tests such as a chest x-ray and sputum culture will be needed to determine if active tuberculosis is present. The sputum cytology test is the only definitive test to confirm a diagnosis of active TB. A client has just received an extracorporeal shock-wave lithotripsy (ESWL) procedure. What is the priority information the nurse should teach ? A. "Restrict milk and dairy products for one to two months." B. "Drink 3,000 to 4,000 mL of fluid each day for one month." C. "Increase intake of citrus fruits to three servings per day for two months." D. "Limit fluid intake to 1,000 mL each day for two months." Ans- B Drinking three to four quarts (3,000 to 4,000 mL) of fluid each day will aid passage of fragments of the broken up renal calculi and help prevent formation of new calculi. A client has just returned to the medical-surgical unit postop for a segmental lung resection. After assessing the client, which is the first action the nurse should take? A. Apply the pulse oximeter and monitor oxygen saturation B. Administer the PRN pain medication C. Suction excessive tracheobronchial secretions D. Assist the client to turn, deep breathe and cough Ans- C This type of surgery involves removing a bronchovascular segment of a lobe. It is typically used to remove small, peripheral lung tumors. Surgical manipulation during this procedure, along with anesthesia, can increase mucus production and lead to airway obstruction, which is why the nurse may need to suction the client if there are excessive secretions. Since this client just returned from surgery, it is not the time to ask the client to cough and deep breathe. Vital signs and oxygen saturation would have been measured during the assessment. The client would probably be on a PCA, or have a intrathecal or intrapleural catheter for pain relief. A client has received two units of whole blood today after an episode of gastrointestinal bleeding. Which laboratory report should the nurse be sure to monitor closely? A. White blood cells B. Hemoglobin and hematocrit C. Platelets D. Bleeding time Ans- B The post-transfusion hematocrit provides immediate information about red cell replacement and if there is any continued blood loss; the follow-up hematocrit should be checked around 4 to 6 hours after the infusion is completed. A client has returned from a cardiac catheterization that was two hours ago. Which finding would indicate that the client has a potential complication from the procedure? A. No pulse in the affected extremity B. Increased blood pressure C. Increased heart rate D. Decreased urine output Ans- A Loss of the pulse in the extremity would indicate a potential severe spasm of the artery or clot formation to the extent of an occlusion below the site of insertion. It is not uncommon that initially the pulse may be intermittently weaker from the baseline. However, a total loss of the pulse is a nursing emergency. The health care provider needs immediate notification. A client is about to have an intravenous pyelogram (IVP). After the contrast material is injected, which client reaction should be acted upon immediately by a nurse? A. Hives with severe itching over the body B. Excessive salty taste in the mouth C. Face turning a deep ruddy red color D. Feeling of excessive warmth Ans- A Hives over the body with severe itching is a sign of anaphylaxis and should be acted upon with the administration of epinephrine (adrenaline) immediately. The other reactions are considered normal after the dye injection. Prior to any dye injection procedure clients should be informed that these symptoms may occur. A client is admitted for first- and second-degree burns on the face, neck, anterior chest and hands. What should be the nurse's priority action? A. Administer pain medication B. Initiate intravenous therapy C. Cover the areas with dry sterile dressing