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NCSBN Practice Questions 76-90
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 - ✔✔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?
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. - ✔✔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
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. - ✔✔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."
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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
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
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 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.
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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
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 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."
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D. "Yes, would you like to spend the night when the client's behavior indicates that the client is or will
be frightened?"
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 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
C
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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
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
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 caring for a
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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
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. -
✔✔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."
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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. - ✔✔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
60
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