NCSBN Test bank 16-30 LATEST
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A nurse is teaching a mother who will breast-feed for the first time. Which of these approaches is a
priority?
,Give the mother privacy for the initial feeding
Assist the mother to position the newborn at the breast
Give the mother several illustrated pamphlets
Show the mother films on the physiology of lactation - correct ans:Assist the mother to position the
newborn at the breast
All of the approaches should be helpful in teaching. However, the priority is to place the infant to the
breast as soon after birth as possible to establish contact and allow the newborn to begin to suck.
The nurse in a long-term care facility is evaluating the plan of care for an older adult client with
advanced dementia. The client has had several falls out of bed. Which initial intervention should the
nurse implement?
Have the client sleep in a recliner at the nurse's station with a tray table across their lap
Put the bed in the lowest position with a thick pad or mat on the floor next to the bed
Correct!
Place the client in a bed with an enclosure mesh tent attached to the frame
Position all side rails of the bed up and move the bed close to the door - correct ans:Falls out of bed are
a common occurrence in the long-term care setting. Although it is nearly impossible to eliminate all falls,
the nurse can implement interventions to reduce the risk for injury related to a fall. The goal is to start
with the least invasive and restrictive intervention to preserve the client's rights, regardless of their level
of cognitive function. 'Low' beds and 'landing' mats to soften the fall should the client roll out of bed are
commonly used in long-term care settings and represent an appropriate, initial intervention to
implement for this client. The other interventions are much more restrictive and should be used only
after less restrictive interventions have been attempted.
,The nurse is developing a plan of care for a client who underwent total hip arthroplasty 24 hours ago.
Which interventions should the nurse include? Select all that apply.
1. Encourage the client to perform leg exercises while in bed
2. Remind the client to not bend the knee of the affected leg while seated
3. Encourage the use of an abduction pillow or splint between the legs
4. Provide a seat riser for the toilet or commode
5. Encourage the client to use the incentive spirometer every 2 hours
Assist the client with a clear liquid diet - correct ans:1,3,4,5
To prevent postoperative complications and complications related to immobility, the client should be up
in a chair as soon as possible after surgery. While seated, the client should bend the affected leg at the
knee. The nurse should reinforce teaching of simple leg exercises while in bed and the use of an
abduction pillow or foam wedge to prevent adduction. To prevent atelectasis and pneumonia the client
should be encouraged to use an incentive spirometer every 2 hours. Once the client is alert after surgery
and not experiencing nausea or vomiting, they can resume a regular diet.
A nurse is performing physical assessments on adolescents. What finding should the nurse anticipate
concerning female growth spurts?
Occur about two years earlier than for males
Begin about the same time for males
, Start just prior to the onset of puberty
Characterized by an increase in height of 4 inches each year - correct ans:Occur about two years earlier
than for males
A nurse is caring for a client following a Computed Tomography (CT) scan of the kidneys with contrast.
Which of these findings would require prompt intervention by the nurse?
Soreness reported at the IV site
Elevated serum creatinine above baseline
The client states that the urethra feels irritated and sore from the catheter
The client states they have felt mild nausea since the procedure - correct ans:2
A CT scan provides three-dimensional information about structures within the body. Oral or injected dye
(contrast) is generally used during this scan to provide detailed images. After the scan, the nurse should
monitor for complications associated with the contrast including anaphylaxis or contrast-induced
nephropathy. Contrast-induced nephropathy is defined as a 25% increase of the serum creatinine above
baseline within 48 hours of the procedure. While mild nausea and soreness at the IV site are problems
requiring intervention, they are not the immediate concern. A catheter is not required for this
procedure.
A client was admitted to the psychiatric unit after refusal to get out of the bed. Once admitted, the client
is observed talking to unseen people and voiding on the floor. The nurse should handle the problem of
voiding on the floor by which of these approaches?
Restrict the client's fluids throughout the day
Require the client to mop the floor after each incident
EXAM VERSION With Expected real
and comprehensive Questions and
Revised Correct Answers Guarantee
Pass A+
Professional Academic Assistance Services
Services Offered
Proctored Exam Assistance
Online Class Management (Full Course Support)
Exam Preparation & Study Materials
Assignments and Coursework Support
Essays and Research Papers
Discussion Posts and Replies
A nurse is teaching a mother who will breast-feed for the first time. Which of these approaches is a
priority?
,Give the mother privacy for the initial feeding
Assist the mother to position the newborn at the breast
Give the mother several illustrated pamphlets
Show the mother films on the physiology of lactation - correct ans:Assist the mother to position the
newborn at the breast
All of the approaches should be helpful in teaching. However, the priority is to place the infant to the
breast as soon after birth as possible to establish contact and allow the newborn to begin to suck.
The nurse in a long-term care facility is evaluating the plan of care for an older adult client with
advanced dementia. The client has had several falls out of bed. Which initial intervention should the
nurse implement?
Have the client sleep in a recliner at the nurse's station with a tray table across their lap
Put the bed in the lowest position with a thick pad or mat on the floor next to the bed
Correct!
Place the client in a bed with an enclosure mesh tent attached to the frame
Position all side rails of the bed up and move the bed close to the door - correct ans:Falls out of bed are
a common occurrence in the long-term care setting. Although it is nearly impossible to eliminate all falls,
the nurse can implement interventions to reduce the risk for injury related to a fall. The goal is to start
with the least invasive and restrictive intervention to preserve the client's rights, regardless of their level
of cognitive function. 'Low' beds and 'landing' mats to soften the fall should the client roll out of bed are
commonly used in long-term care settings and represent an appropriate, initial intervention to
implement for this client. The other interventions are much more restrictive and should be used only
after less restrictive interventions have been attempted.
,The nurse is developing a plan of care for a client who underwent total hip arthroplasty 24 hours ago.
Which interventions should the nurse include? Select all that apply.
1. Encourage the client to perform leg exercises while in bed
2. Remind the client to not bend the knee of the affected leg while seated
3. Encourage the use of an abduction pillow or splint between the legs
4. Provide a seat riser for the toilet or commode
5. Encourage the client to use the incentive spirometer every 2 hours
Assist the client with a clear liquid diet - correct ans:1,3,4,5
To prevent postoperative complications and complications related to immobility, the client should be up
in a chair as soon as possible after surgery. While seated, the client should bend the affected leg at the
knee. The nurse should reinforce teaching of simple leg exercises while in bed and the use of an
abduction pillow or foam wedge to prevent adduction. To prevent atelectasis and pneumonia the client
should be encouraged to use an incentive spirometer every 2 hours. Once the client is alert after surgery
and not experiencing nausea or vomiting, they can resume a regular diet.
A nurse is performing physical assessments on adolescents. What finding should the nurse anticipate
concerning female growth spurts?
Occur about two years earlier than for males
Begin about the same time for males
, Start just prior to the onset of puberty
Characterized by an increase in height of 4 inches each year - correct ans:Occur about two years earlier
than for males
A nurse is caring for a client following a Computed Tomography (CT) scan of the kidneys with contrast.
Which of these findings would require prompt intervention by the nurse?
Soreness reported at the IV site
Elevated serum creatinine above baseline
The client states that the urethra feels irritated and sore from the catheter
The client states they have felt mild nausea since the procedure - correct ans:2
A CT scan provides three-dimensional information about structures within the body. Oral or injected dye
(contrast) is generally used during this scan to provide detailed images. After the scan, the nurse should
monitor for complications associated with the contrast including anaphylaxis or contrast-induced
nephropathy. Contrast-induced nephropathy is defined as a 25% increase of the serum creatinine above
baseline within 48 hours of the procedure. While mild nausea and soreness at the IV site are problems
requiring intervention, they are not the immediate concern. A catheter is not required for this
procedure.
A client was admitted to the psychiatric unit after refusal to get out of the bed. Once admitted, the client
is observed talking to unseen people and voiding on the floor. The nurse should handle the problem of
voiding on the floor by which of these approaches?
Restrict the client's fluids throughout the day
Require the client to mop the floor after each incident
