NCSBN QBANK

NCSBN QBANK COMPLETE ANSWERS The nurse is reviewing the laboratory results for several clients. Which of the laboratory result indicates a client with partly compensated metabolic acidosis? Chloride 100 mEq/L (100 mmol/L) Sodium 130 mEq/L (130 mmol/L) Hemoglobin 15 g/dL (150 g//L) PaCO2 30 mm Hg Ans- PaCO2 30 mm Hg The client is admitted to an ambulatory surgery center and undergoes a right inguinal orchiectomy. Which option is the priority before the client can be discharged to home? Able to ambulate in the hallway with assistance Post-operative pain is managed Correct response Able to tolerate a regular diet Psychological counseling is scheduled Ans- Post-operative pain is managed A child is treated with succimer for lead poisoning. Which of these assessments should the nurse perform first? Test deep tendon reflexes Check blood calcium level Check complete blood count (CBC) with differential Check serum potassium level Ans- Check complete blood count (CBC) with differential 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. The client with a T-2 spinal cord injury reports having a "pounding" headache. Further assessment by the nurse reveals excessive sweating, rash, pilomotor erection, facial flushing, congested nasal passages and a heart rate of 50. What action should the nurse take next? Place the client into the bed and administer the ordered PRN analgesic Measure the client's respirations, blood pressure, temperature and pupillary responses Check the client for bladder distention and the urinary catheter for kinks Assist client with relaxation techniques Ans- Check the client for bladder distention and the urinary catheter for kinks These are findings of autonomic dysreflexia, also called hyperreflexia. This response occurs in clients with a spinal cord injury above the T-6 level. It is typically initiated by any noxious stimulus below the level of injury such as a full bladder, an enema or bowel movement, fecal impaction, uterine contractions, changing of the catheter and vaginal or rectal examinations. The stimulus creates an exaggerated response of the sympathetic nervous system and can be a life-threatening event. The BP is typically extremely high. The priority action of the nurse is to identify and relieve the cause of the stimulus. The nurse is assessing a 4 year-old child who is in skeletal traction 24 hours after surgical repair of a fractured femur. The child is crying and reports having severe pain. The right foot is pale and there is no palpable pulse. What action should the nurse take first? Administer the ordered PRN medication Reassess the extremity in 15 minutes Readjust the traction for comfort Notify the health care provider Ans- Notify the health care provider Pain and absence of a pulse within 48-72 hours after a severe injury to an extremity suggests acute compartment syndrome. This condition occurs when there's a build up of pressure within the muscles; this pressure decreases blood flow and can cause muscle and nerve damage. Acute compartment syndrome is a medical emergency. Surgery is needed immediately; delaying surgery can lead to permanent damage to the extremity. The nurse is examining a 2 year-old child with a tentative diagnosis of Wilm's tumor. The nurse would be most concerned about which statement by the mother? "My child has lost three pounds in the last month." "The child prefers some salty foods more than others." "All the pants have become tight around the waist." "Urinary output seems to be less over the past two days." Ans- "Urinary output seems to be less over the past two days." Wilm's tumor is a malignant tumor of the kidney that can lead to kidney dysfunction; therefore, a recent decrease in urinary output should be investigated further as it may be a sign of renal dysfunction. Increasing abdominal girth is a common finding in Wilm's tumor, but does not require immediate intervention by the nurse. A client with a diagnosis of methicillin-resistant Staphylococcus aureus (MRSA) has died. Which type of precautions is appropriate to use when performing postmortem care? Compromised host precautions Airborne precautions Contact precautions Droplet precautions Ans- Contact precautions The resistant bacteria remain alive for up to three days after the client dies. Therefore, contact precautions must still be used. The body should also be labeled as MRSA-contaminated so that the funeral home staff can protect themselves as well. Gown and gloves are required. The client is diagnosed with cystic fibrosis (CF). The nurse would expect the client to be treated with oral pancreatic enzymes and which type of diet? Sodium-restricted Dairy-free High fat, high-calorie Gluten-free, low fiber Ans- High fat, high-calorie CF affects the cells that produce mucus, sweat and digestive juices. Someone with CF needs a highenergy diet that includes high-fat and high-calorie foods, extra fiber to prevent intestinal blockage and extra salt (especially during hot weather.) People with CF are at risk for osteoporosis and need calcium and dairy products. Someone with celiac disease or with a gluten intolerance, not CF, needs a glutenfree diet. During assessment of orthostatic vital signs on a client with cardiomyopathy, the nurse finds that the systolic blood pressure (BP) decreased from 145 to 110 mm Hg between the supine and upright positions while the heart rate (HR) rose from 72 to 96 beats per minute. In addition, the client reports feeling lightheaded when standing up. The nurse should implement which of the following actions? Increase fluids that are high in protein Instruct the client to increase fluid intake for the next two days Restrict fluids for the next few hours Instruct client to increase fluid intake for several hours Ans- Instruct client to increase fluid intake for several hours This client is experiencing postural hypotension, a decrease in systolic