NCSBN Practice Questions 76-90
An 18 month-old weighing 22 pounds is admitted to the pediatric unit with a diagnosis of
dehydration. A replacement bolus of normal saline at 20 mL/kg is ordered to be
administered intravenously over 40 minutes.
In mL/hour, what will be the setting for the IV delivery system? ANSW - 300
Using ratio proportion:First, convert 22 pounds to kilograms (22/2.2) = 10 kg20 mL/kg =
20 x 10 kg = 200 mL200 mL/40 minutes = x mL/60 minutes (in an hour)200 x 60 =
12000/40 = 300 mL/hrUsing dimensional analysis:20 mL/kg x 1 kg/2.2 lb x 22 lb x 60
min/hr x 1/40 min = 300 mL/hr
The mother of a 2 month-old baby calls a pediatrician's nurse two days after the first
DTaP, inactivated polio vaccine (IPV), Hepatitis B and Haemophilus influenzae type B
(HIB) immunizations. She reports that the baby feels very warm, cries inconsolably for
as long as three hours, and has had several shaking spells. Which immunization would
the nurse expect to be primarily responsible with these findings?
A. DTaP
B. IPV
C. Hepatitis B
D. HIB ANSW - A
DTaP immunization is a vaccine that protects against diptheria, tetanus and pertussis
(whooping cough). The majority of reactions described in this question occur with the
administration of the DTaP vaccination. Contraindications to giving repeat DTaP
immunizations include the occurrence of severe side effects after a previous dose, as
well as signs of encephalopathy within seven days of the immunization.
A client diagnosed with angina has been instructed about the use of sublingual
nitroglycerin. Which statement made by the client is incorrect and indicates a need for
further teaching?
A. "I'll call the health care provider if pain continues after three tablets five minutes
apart."
B. "I will rest briefly right after taking one tablet."
C. "I understand that the medication should be kept in the dark bottle."
D. "I can swallow two or three tablets at once if I have severe pain." ANSW - D
Clients must understand that just one sublingual tablet should be taken at a time and
placed under the tongue. After rest and a five-minute interval, a second and then
eventually a third tablet may be necessary.
The nurse is working with victims of domestic abuse. The nurse should understand
which of these factors is a reason why domestic violence or emotional abuse remains
extensively undetected?
,A. The expenses due to police and court costs are prohibitive
B. Little knowledge is known about batterers and battering relationships
C. There are typically many series of minor, vague complaints
D. Few people who have been battered seek medical care ANSW - C
Signs of domestic violence or emotional abuse may not be clearly manifested and
include many series of a minor complaints such as headache, abdominal pain,
insomnia, back pain and dizziness. These may be covert indications of violence or
abuse that go undetected. These complaints may be vague and reflect ambivalence
about the disclosure of any violence or abuse.
The nurse is obtaining an aerobic wound culture from a client with stage two pressure
injury. The nurse first removes a gauze dressing and observes a moderate amount of
purulent drainage on the dressing and then the nurse performs hand hygiene. What is
the next correct step in the procedure?
A. Swab the gauze dressing that was removed from the wound
B. Irrigate the wound with normal saline
C. Obtain a culture by rotating a sterile swab in the open wound
D. Remove wound exudate from the wound edges with a cotton tip applicator ANSW -
B
After removing the dressing and performing hand hygiene, the wound needs to be
irrigated to remove surface pathogens before the nurse can obtain a wound culture.
Cultures are not obtained from wound exudate on the dressing or wounds that have not
been irrigated since the exudate may be contaminated with normal skin flora.
The nurse is caring for a client who is experiencing frightening hallucinations that are
markedly increased at night. The client's partner asks to stay a few hours beyond the
visiting time, in the client's private room. What would be the best response by the
nurse?
A. "Yes, staying with the client and orienting the client to the surroundings may
decrease any anxiety."
B. "No, your presence may cause the client to become more anxious."
C. "No, it would be best if you brought the client some reading material that the client
could read at night."
D. "Yes, would you like to spend the night when the client's behavior indicates that the
client is or will be frightened?" ANSW - A
Encouragement of a family member or a close friend to stay with the client in a quiet
surrounding cannot only help increase orientation, but can also minimize confusion and
anxiety. The visitor could also report to the nurse any unusual findings of the client. This
would be the most supportive approach for this client.
The RN, who is functioning as the charge nurse, needs to determine shift assignments.
How will the charge nurse determine which client assignments are appropriate for the
licensed practical nurse (LPN)?
,A. Ask the LPN about prior experience caring for clients with similar diagnoses
B. Determine how many nursing assistants are available to help the LPN with client care
C. Refer to the list of technical tasks LPNs are trained to perform
D. Review the procedure manual with the LPN prior to making an assignment ANSW -
A
The definition of assignment is the routine care, activities and procedures that are within
the authorized scope of practice of the RN or LPN/LVN. The RN must determine the
needs of the clients and make assignments not only based on scope of practice, but
also education, demonstrated competency and skill level. Regardless if the LPN
received education and training to perform specific skills, the RN needs to determine the
LPN's experience with caring for clients with similar diagnoses. While the RN is
responsible for ensuring an assignment given to a delegatee is carried out completely
and correctly, the LPN must be able to perform the skills or tasks independently.
The nurse is caring for a school-aged child with a diagnosis of secondary
hyperparathyroidism after treatment for chronic renal disease. Which serum lab data
should receive priority attention by the nurse?
A. Osmolality and sodium
B. Blood urea nitrogen and magnesium
C. Calcium and phosphorus
D. Glucose and potassium ANSW - C
The parathyroid regulates the calcium and phosphorus serum levels. Calcium and
phosphorous levels will be elevated in hyperfunction of this gland until the client is
stabilized. To recall this information think of a see-saw. Associate that calcium is first in
the alphabet and thus calcium follows the direction of the abnormality - hyper or hypo
function - of the parathyroid. Put the calcium on one side and the phosphorus on the
other side of the see-saw.
The nurse is caring for a client who just had a central venous catheter line inserted at
the bedside. Which of these assessments requires immediate attention by the nurse?
A. Pallor in the extremities
B. Increased temperature by one degree
C. Involuntary coughing spells
D. Dyspnea at rest ANSW - D
Complications of central catheter insertion include pneumothorax and hemothorax. Air
embolism is another potential complication. Dyspnea, shallow respirations, sudden
sharp chest pain that worsens with coughing or deep breathing are indications of
pneumothorax. Other potential complications of central catheters may include
thrombosis, local or systemic infection, or even cardiac tamponade (if the central line
perforates the heart). When considering the options listed, the client who is dyspneic
after central line insertion would be the greatest concern for the nurse.
, The nurse is providing preprocedural education to the client preparing for a barium
enema. What statement made by the client indicates a need for further education?
A. "I will need to drink plenty of fluids and eat foods high in fiber after the procedure."
B. "I will use the prescribed laxative before the procedure."
C. "I will not eat or drink anything after midnight before the procedure."
D. "A barium enema is used to examine the upper and lower GI tracts." ANSW - D
A barium enema involves filling the large intestine (lower GI tract) with diluted barium
liquid while x-ray images are taken. After the procedure, a small amount of barium will
be immediately expelled and the remainder will be excreted in the stool. Because
barium liquid may cause constipation, clients should eat foods high in fiber and drink
plenty of fluids to help expel the barium from the body.
A client admitted with heart failure is experiencing severe shortness of breath and
states, "I feel like something is terribly wrong!" The client is restless and begins to cough
up large amounts of pink frothy sputum. The client's skin is a dusky grayish color and
the oxygen saturation levels have decreased from 92% to 76% in the last hour. What is
the first action the nurse should take?
A. Check vital signs
B. Administer the PRN ordered oxygen
C. Call the health care provider
D. Place the bed in high Fowler's position ANSW - B
When dealing with a medical emergency, the rule is to assess airway first, then
breathing, and then circulation. Starting oxygen is the priority. The other actions should
also be implemented as quickly as possible, including activation of the rapid response
team. The client is experiencing an acute episode of fulminant pulmonary edema, likely
as a result of a new and severe cardiac event and possible cardiogenic shock.
Emergency assessment and intervention is indicated to prevent cardiac arrest and
possible death.
There is an order for a continuous lidocaine infusion at a rate of 4 mg/minute to treat
PVCs. The IV solution contains 2 grams of lidocaine in 500 mL of D5W. The infusion
pump delivers 60 microdrops/mL.
What rate in microdrops/minute would deliver 4 mg of lidocaine/minute? Report the
response using a whole number. ANSW - 60
Dimensional analysis (DA): Remember in DA, you always want to start your equation
with what's called for in the solution. In this case, you want to know
microdrops/minute.microdrops/minute = 4 mg/min X 1 g/1000 mg X 500 mL/2 g X 60
microdrops/mL = 4 X 500 X 60/1000 X 2 = 120000/2000 = 60 microdrops/mLAnother
way to solve for X:What you have: 2 grams (2000 mg) lidocaine in 500 mL AND you are
using a microdrip set (60 microdrops/mL)What you want/need: 4 mg lidocaine to
infuse/minute4 mg/min X 500 mL/2000 mg X 60 (microdrops)/min = 60
microdrops/minute
An 18 month-old weighing 22 pounds is admitted to the pediatric unit with a diagnosis of
dehydration. A replacement bolus of normal saline at 20 mL/kg is ordered to be
administered intravenously over 40 minutes.
In mL/hour, what will be the setting for the IV delivery system? ANSW - 300
Using ratio proportion:First, convert 22 pounds to kilograms (22/2.2) = 10 kg20 mL/kg =
20 x 10 kg = 200 mL200 mL/40 minutes = x mL/60 minutes (in an hour)200 x 60 =
12000/40 = 300 mL/hrUsing dimensional analysis:20 mL/kg x 1 kg/2.2 lb x 22 lb x 60
min/hr x 1/40 min = 300 mL/hr
The mother of a 2 month-old baby calls a pediatrician's nurse two days after the first
DTaP, inactivated polio vaccine (IPV), Hepatitis B and Haemophilus influenzae type B
(HIB) immunizations. She reports that the baby feels very warm, cries inconsolably for
as long as three hours, and has had several shaking spells. Which immunization would
the nurse expect to be primarily responsible with these findings?
A. DTaP
B. IPV
C. Hepatitis B
D. HIB ANSW - A
DTaP immunization is a vaccine that protects against diptheria, tetanus and pertussis
(whooping cough). The majority of reactions described in this question occur with the
administration of the DTaP vaccination. Contraindications to giving repeat DTaP
immunizations include the occurrence of severe side effects after a previous dose, as
well as signs of encephalopathy within seven days of the immunization.
A client diagnosed with angina has been instructed about the use of sublingual
nitroglycerin. Which statement made by the client is incorrect and indicates a need for
further teaching?
A. "I'll call the health care provider if pain continues after three tablets five minutes
apart."
B. "I will rest briefly right after taking one tablet."
C. "I understand that the medication should be kept in the dark bottle."
D. "I can swallow two or three tablets at once if I have severe pain." ANSW - D
Clients must understand that just one sublingual tablet should be taken at a time and
placed under the tongue. After rest and a five-minute interval, a second and then
eventually a third tablet may be necessary.
The nurse is working with victims of domestic abuse. The nurse should understand
which of these factors is a reason why domestic violence or emotional abuse remains
extensively undetected?
,A. The expenses due to police and court costs are prohibitive
B. Little knowledge is known about batterers and battering relationships
C. There are typically many series of minor, vague complaints
D. Few people who have been battered seek medical care ANSW - C
Signs of domestic violence or emotional abuse may not be clearly manifested and
include many series of a minor complaints such as headache, abdominal pain,
insomnia, back pain and dizziness. These may be covert indications of violence or
abuse that go undetected. These complaints may be vague and reflect ambivalence
about the disclosure of any violence or abuse.
The nurse is obtaining an aerobic wound culture from a client with stage two pressure
injury. The nurse first removes a gauze dressing and observes a moderate amount of
purulent drainage on the dressing and then the nurse performs hand hygiene. What is
the next correct step in the procedure?
A. Swab the gauze dressing that was removed from the wound
B. Irrigate the wound with normal saline
C. Obtain a culture by rotating a sterile swab in the open wound
D. Remove wound exudate from the wound edges with a cotton tip applicator ANSW -
B
After removing the dressing and performing hand hygiene, the wound needs to be
irrigated to remove surface pathogens before the nurse can obtain a wound culture.
Cultures are not obtained from wound exudate on the dressing or wounds that have not
been irrigated since the exudate may be contaminated with normal skin flora.
The nurse is caring for a client who is experiencing frightening hallucinations that are
markedly increased at night. The client's partner asks to stay a few hours beyond the
visiting time, in the client's private room. What would be the best response by the
nurse?
A. "Yes, staying with the client and orienting the client to the surroundings may
decrease any anxiety."
B. "No, your presence may cause the client to become more anxious."
C. "No, it would be best if you brought the client some reading material that the client
could read at night."
D. "Yes, would you like to spend the night when the client's behavior indicates that the
client is or will be frightened?" ANSW - A
Encouragement of a family member or a close friend to stay with the client in a quiet
surrounding cannot only help increase orientation, but can also minimize confusion and
anxiety. The visitor could also report to the nurse any unusual findings of the client. This
would be the most supportive approach for this client.
The RN, who is functioning as the charge nurse, needs to determine shift assignments.
How will the charge nurse determine which client assignments are appropriate for the
licensed practical nurse (LPN)?
,A. Ask the LPN about prior experience caring for clients with similar diagnoses
B. Determine how many nursing assistants are available to help the LPN with client care
C. Refer to the list of technical tasks LPNs are trained to perform
D. Review the procedure manual with the LPN prior to making an assignment ANSW -
A
The definition of assignment is the routine care, activities and procedures that are within
the authorized scope of practice of the RN or LPN/LVN. The RN must determine the
needs of the clients and make assignments not only based on scope of practice, but
also education, demonstrated competency and skill level. Regardless if the LPN
received education and training to perform specific skills, the RN needs to determine the
LPN's experience with caring for clients with similar diagnoses. While the RN is
responsible for ensuring an assignment given to a delegatee is carried out completely
and correctly, the LPN must be able to perform the skills or tasks independently.
The nurse is caring for a school-aged child with a diagnosis of secondary
hyperparathyroidism after treatment for chronic renal disease. Which serum lab data
should receive priority attention by the nurse?
A. Osmolality and sodium
B. Blood urea nitrogen and magnesium
C. Calcium and phosphorus
D. Glucose and potassium ANSW - C
The parathyroid regulates the calcium and phosphorus serum levels. Calcium and
phosphorous levels will be elevated in hyperfunction of this gland until the client is
stabilized. To recall this information think of a see-saw. Associate that calcium is first in
the alphabet and thus calcium follows the direction of the abnormality - hyper or hypo
function - of the parathyroid. Put the calcium on one side and the phosphorus on the
other side of the see-saw.
The nurse is caring for a client who just had a central venous catheter line inserted at
the bedside. Which of these assessments requires immediate attention by the nurse?
A. Pallor in the extremities
B. Increased temperature by one degree
C. Involuntary coughing spells
D. Dyspnea at rest ANSW - D
Complications of central catheter insertion include pneumothorax and hemothorax. Air
embolism is another potential complication. Dyspnea, shallow respirations, sudden
sharp chest pain that worsens with coughing or deep breathing are indications of
pneumothorax. Other potential complications of central catheters may include
thrombosis, local or systemic infection, or even cardiac tamponade (if the central line
perforates the heart). When considering the options listed, the client who is dyspneic
after central line insertion would be the greatest concern for the nurse.
, The nurse is providing preprocedural education to the client preparing for a barium
enema. What statement made by the client indicates a need for further education?
A. "I will need to drink plenty of fluids and eat foods high in fiber after the procedure."
B. "I will use the prescribed laxative before the procedure."
C. "I will not eat or drink anything after midnight before the procedure."
D. "A barium enema is used to examine the upper and lower GI tracts." ANSW - D
A barium enema involves filling the large intestine (lower GI tract) with diluted barium
liquid while x-ray images are taken. After the procedure, a small amount of barium will
be immediately expelled and the remainder will be excreted in the stool. Because
barium liquid may cause constipation, clients should eat foods high in fiber and drink
plenty of fluids to help expel the barium from the body.
A client admitted with heart failure is experiencing severe shortness of breath and
states, "I feel like something is terribly wrong!" The client is restless and begins to cough
up large amounts of pink frothy sputum. The client's skin is a dusky grayish color and
the oxygen saturation levels have decreased from 92% to 76% in the last hour. What is
the first action the nurse should take?
A. Check vital signs
B. Administer the PRN ordered oxygen
C. Call the health care provider
D. Place the bed in high Fowler's position ANSW - B
When dealing with a medical emergency, the rule is to assess airway first, then
breathing, and then circulation. Starting oxygen is the priority. The other actions should
also be implemented as quickly as possible, including activation of the rapid response
team. The client is experiencing an acute episode of fulminant pulmonary edema, likely
as a result of a new and severe cardiac event and possible cardiogenic shock.
Emergency assessment and intervention is indicated to prevent cardiac arrest and
possible death.
There is an order for a continuous lidocaine infusion at a rate of 4 mg/minute to treat
PVCs. The IV solution contains 2 grams of lidocaine in 500 mL of D5W. The infusion
pump delivers 60 microdrops/mL.
What rate in microdrops/minute would deliver 4 mg of lidocaine/minute? Report the
response using a whole number. ANSW - 60
Dimensional analysis (DA): Remember in DA, you always want to start your equation
with what's called for in the solution. In this case, you want to know
microdrops/minute.microdrops/minute = 4 mg/min X 1 g/1000 mg X 500 mL/2 g X 60
microdrops/mL = 4 X 500 X 60/1000 X 2 = 120000/2000 = 60 microdrops/mLAnother
way to solve for X:What you have: 2 grams (2000 mg) lidocaine in 500 mL AND you are
using a microdrip set (60 microdrops/mL)What you want/need: 4 mg lidocaine to
infuse/minute4 mg/min X 500 mL/2000 mg X 60 (microdrops)/min = 60
microdrops/minute
