NCSBN ON-LINE REVIEW 1
126. The nurse is planning discharge for a 90-year-old client with musculoskeletal weakness. Which intervention should be included
in the plan that would be most effective for the prevention of falls?
A) Place nightlights in the bedroom
B) Wear eyeglasses at all times
C) Install grab bars in the bathroom
D) Teach muscle strengthening exercises
Place nightlights in the bedroom. Because more falls occur in the bedroom than any other location, begin there. However,
work in partnership with the client and family so they are willing to move furniture, lamp cords, and storage areas, add lighting,
remove throw rugs, and eliminate other environmental hazards.
131. A female client is admitted for a breast biopsy. She says, tearfully to the nurse, "If this turns out to be cancer and I have to have my breast removed, my partner will never come near me." The nurse's best response would be which of these statements?
A) "I hear you saying that you have a fear for the loss of love."
B) "You sound concerned that your partner will reject you."
C) "Are you wondering about the effects on your sexuality?"
D) "Are you worried that the surgery will lead to changes?"
"Are you worried that the surgery will lead to changes?". This is a general lead in type of response that encourages further discussion without focusing on an area that the nurse, but possibly not the client, feels is a problem.
A client has an order for 1000 ml of D5W over an 8 hour period. The nurse discovers that 800 ml has been infused after 4 hours. What is the priority nursing action?
A) Ask the client if there are any breathing problems
B) Have the client void as much as possible
C) Check the vital signs
D) Auscultate the lungs
Auscultate the lungs. All of the options would be part of the evaluation for the effects of the large amount of fluid in a short
period of time. However the worst result is heart failure with lung congestion so the auscultation of the lungs is the priority
action. The sequence of actions would be D, A, C, B.
141. A parent brings her 3 month-old into the clinic, reporting that the child seems to be spitting up all the time and has a lot of gas. The nurse expects to find which of the following on the initial history and physical assessment?
A) increased temperature and lethargy
B) restlessness and increased mucus production
C) increased sleeping and listlessness
D) diarrhea and poor skin turgor
restlessness and increased mucus production. This infant could be experiencing gastroesophageal reflux, or could be allergic to the formula. Restlessness, irritability and increased mucus production can develop if an allergy is present. Soy based formula is often recommended.
The nurse is caring for a client who is post-op following a thoracotomy. The client has 2 chest tubes in place, connected to 1 chest drain. The nursing assessment reveals bubbling in the water seal chamber when the client coughs. What is the most appropriate nursing action?
A) Clamp the chest tube
B) Call the surgeon immediately
C) Continue to monitor the client to see if the bubbling increases
D) Instruct the client to try to avoid coughing
Continue to monitor the client to see if the bubbling increases. Bubbling associated with coughing after lung surgery is to be expected as small amounts of air escape the pleural space when pressures inside the chest increase with coughing. Monitoring is the only nursing action required at this time.
127. An 8-year-old child is hospitalized during the edema phase of minimal change nephrotic syndrome. The nurse is assisting in choosing the lunch menu. Which menu is the best choice?
A) Bologna sandwich, pudding, milk
B) Frankfurter, baked potato, milk
C) Chicken strips, corn on the cob, milk
D) Grilled cheese sandwich, apple, milk
Chicken strips, corn on the cob, milk. This menu is lowest in sodium. Ideally, low fat milk would be available.
A client is admitted for treatment of a right upper lobe infiltrate and to rule out tuberculosis. Which of these would be the most appropriate self-protective action by the nurse?
A) Provide negative room ventilation
B) Wear a face mask with shield
C) Wear a particulate respirator mask
D) Institute airborne precautions
Wear a particulate respirator mask. Tight-fitting, high-efficiency masks are required when caring for clients who have a suspected communicable disease of the airborne variety.
A nurse observes a family member administer a rectal suppository by having the client lie on the left side for the administration. The family member pushed the suppository until the finger went up to the second knuckle. After 10 minutes the client was told by the family member to turn to the right side and the client did this. What is the appropriate comment for the nurse to make?
A) Why don’t we now have the client turn back to the left side.
B) That was done correctly. Did you have any problems with the insertion?
C) Let’s check to see if the suppository is in far enough.
D) Did you feel any stool in the intestinal tract?
That was done correctly. Did you have any problems with the insertion?. Left side-lying position is the optimal position for the client receiving rectal medications. Due to the position of the descending colon, left side-lying allows the medication to be inserted and move along the natural curve of the intestine and facilitates retention of the medication. After a short time it will nothurt the client to turn in any manner. The suppository should be somewhat melted after 10 to 15 minutes. The other responses are incorrect since no data are in the stem to support such comments.
The nurse manager hears a provider loudly criticize one of the staff nurses within the hearing range of others. The nurse manager's next action should be to
A) Walk up to the provider and quietly state: "Stop this unacceptable behavior."
B) Allow the staff nurse to handle this situation without interference
C) Notify the of the other administrative persons of a breech of professional conduct
D) Request an immediate private meeting with the provider and staff nurse
Request an immediate private meeting with the provider and staff nurse. Assertive communication respects the needs of all parties to express themselves, but not at the expense of others. The nurse manager needs first to protect clients and other staff from this display and come to the assistance of the nurse employee.
A newly admitted elderly client is severely dehydrated. When planning care for this client, which task is appropriate to assign to an unlicensed assistive personnel (UAP)?
A) Converse with the client to determine if the mucous membranes are impaired
B) Report hourly outputs of less than 30 ml/hr
C) Monitor client's ability for movement in the bed
D) Check skin turgor every 4 hours
Report hourly outputs of less than 30 ml/hr. When directing a UAP, the nurse must communicate clearly about each delegated
task with specific instructions on what must be reported. Because the RN is responsible for all care-related decisions, only
implementation tasks should be assigned because they do not require independent judgment.
128. The nurse is teaching a client with non-insulin-dependent diabetes mellitus about the prescribed diet. The nurse should teach the client to
A) maintain previous calorie intake
B) keep a candy bar available at all times
C) reduce carbohydrates intake to 25% of total calories
D) keep a regular schedule of meals and snacks
Keep a regular schedule of meals and snacks. Currently, calorie-controlled diets with strict meal plans are rarely suggested for clients who have diabetes. Try to incorporate schedule or food changes into clients'' existing dietary patterns. Help clients learn to read labels and identify specific canned foods, frozen entrees, or other foods that are acceptable and those which should be avoided.
The charge nurse has a health care team that consists of 1 practical nurse (PN), 1 unlicensed assistive personnel (UAP) and 1 PN nursing student. Which assignment should be questioned by the nurse manager?
A) An admission at the change of shifts with atrial fibrillation and heart failure - PN
B) Client who had a major stroke 6 days ago - PN nursing student
C) A child with burns who has packed cells and albumin IV running - charge nurse
D) An elderly client who had a myocardial infarction a week ago – UAP
An admission at the change of shifts with atrial fibrillation and heart failure - PN. The care for a new admissions should be performed by an RN. Since the client was admitted at the change of shifts, the stability of the client would not have been established. The charge nurse should take this client. The PN could monitor the IV fluids in option C. Tasks that do not require independent judgment should be delegated. The nurse may delegate the care for a stable client to a UAP.
As the nurse observes the student nurse during the administration of a narcotic analgesic IM injection, the nurse notes that the student begins to give the medication without first aspirating. What should the nurse do?
A) Ask the student: "What did you forget to do?”
B) Stop. Tell me why aspiration is needed.
C) Loudly state: “You forgot to aspirate.
D) Walk up and whisper in the student’s ear “Stop. Aspirate. Then inject.”
Walk up and whisper in the student’s ear “Stop. Aspirate. Then inject.”. This action is a direct threat to the client if the medication enters into the bloodstream instead of the muscle. The purpose of aspiration with IM injections is to prevent the injection of the drug directly into the bloodstream. Option 4 protects the client and is the most professional.
143. The charge nurse is planning assignments on a medical unit. The client with should be assigned to the unlicensed assistive personnel (UAP).
A) difficulty swallowing after a mild stroke
B) an order of enemas until clear prior to colonoscopy
C) an order for a post-op abdominal dressing change
D) transfer orders to a long term facility
an order of enemas until clear prior to colonoscopy. The UAP can be assigned routine tasks which have predictable outcomes.
Which statement best describes time management strategies applied to the role of a nurse manager?
A) Schedule staff efficiently to cover the anticipated needs on the managed unit
B) Assume a fair share of direct client care as a role model
C) Set daily goals with a prioritization of the work
D) Delegate tasks to reduce workload associated with direct care and meetings
Set daily goals with a prioritization of the work. Time management strategies include setting goals and prioritization. This is similar to time management of direct care for clients
129. A depressed client in an assisted living facility tells the nurse that "life isn't worth living anymore." What is the best response to this statement?
A) "Come on, it is not that bad."
B) "Have you thought about hurting yourself?"
C) "Did you tell that to your family?"
D) "Think of the many positive things in life."
"Have you thought about hurting yourself?". It is appropriate and necessary to determine if someone who has voiced thoughts about death is considering a suicidal act. This response is most therapeutic in the circumstances. Options A and D deny the validity of the client’s statement, and the purpose of option C is unclear and it lacks client focus.
The nurse is teaching an elderly client how to use MDI's (multi-dose inhalers). The nurse is concerned that the client is unable to coordinate the release of the medication with the inhalation phase. What is the nurse's best recommendation to improve delivery of the medication?
A) Nebulized treatments for home care
B) Adding a spacer device to the MDI canister
C) Asking a family member to assist the client with the MDI
D) Request a visiting nurse to follow the client at home
Adding a spacer device to the MDI canister. If the client is not using the MDI properly, the medication can get trapped in the upper airway, resulting in dry mouth and throat irritation. Using a spacer will allow more drug to be deposited in the lungs and less in the mouth. It is especially useful in the elderly because it allows more time to inhale and requires less eye-hand coordination.
An adult client is found to be unresponsive on morning rounds. After checking for responsiveness and calling for help, the next action that should be taken by the nurse is to:
A) check the carotid pulse
B) deliver 5 abdominal thrusts
C) give 2 rescue breaths
D) ensure an open airway
ensure an open airway. According to the ABCs of CPR the first step in rescuing an unresponsive victim after checking responsiveness and calling for help is to open the victims airway. The airway must be opened appropriately before the need for rescue breaths can be determined. The pulse is assessed, after breathing is evaluated. The need for abdominal thrusts is determined by inability to achieve chest rise when ventilation is attempted.
144. The nurse manager has been using a block scheduling plan to staff the nursing unit. However, staff have asked for many changes and exceptions to the schedule over the past few months. The manager considers self-scheduling knowing that this method will
A) Improve the quality of care
B) Decrease staff turnover
C) Minimize the amount of overtime payouts
D) Improve team morale
Improve team morale. Nurses are more satisfied when opportunities exist for autonomy and control. The nurse manager becomes the facilitator of scheduling rather than the decision-maker of the schedule when self-scheduling exists.
The charge nurse on the night shift at an urgent care center has to deal with admitting clients of a higher acuity than usual because of a large fire in the area. Which style of leadership and decision-making would be best in this circumstance?
A) Assume a decision-making role
B) Seek input from staff
C) Use a non-directive approach
D) Shared decision-making with others
Assume a decision-making role. Authoritarian leadership assumes that decision-making is the role of the leader with little
input by subordinates. This style is best used in emergency situations or as a triage nurse.
130. The nurse is observing a client with an obsessive-compulsive disorder in an inpatient setting. Which behavior is consistent with this diagnosis?
A) Repeatedly checking that the door is locked
B) Verbalized suspicions about thefts
C) Preference for consistent caregivers
D) Repetitive, involuntary movements
Repeatedly checking that the door is locked. Behaviors that are repeated are symptomatic of obsessive-compulsive disorders. These behaviors, performed to reduced feelings of anxiety, often interfere with normal function and employment.
The nurse is teaching a client newly diagnosed with asthma how to use the metered-dose inhaler (MDI). The client asks when they will know the canister is empty. The best response is
A) Drop the canister in water to observe floating
B) Estimate how many doses are usually in the canister
C) Count the number of doses as the inhaler is used
D) Shake the canister to detect any fluid movement
Drop the canister in water to observe floating. Dropping the canister into a bowl of water assesses the amount of medications
remaining in a metered-dose inhaler. The client should obtain a refill when the inhaler rises to the surface and begins to tip over.
Some of the newer canisters have counters.
A practical nurse (PN) is assigned to care for a newborn with a neural tube defect. Which dressing, if applied by the PN, would need no further intervention by the charge nurse?
A) Telfa dressing with antibiotic ointment
B) Moist sterile nonadherent dressing
C) Dry sterile dressing that is occlusive
D) Sterile occlusive pressure dressing
Moist sterile nonadherent dressing. Before surgical closure, the sac is prevented from drying by the application of a sterile, moist, nonadherent dressing over the defect. Dressings are changed frequently to keep them moist.
145. A client is admitted to a voluntary hospital mental health unit due to suicidal ideation. The client has been on the unit for 2 days and now states “I demand to be released now!” The appropriate from the nurse is
A) You cannot be released because you are still suicidal.
B) You can be released only if you sign a no suicide contract.
C) Let’s discuss your decision to leave and then we can prepare you for discharge.
D) You have a right to sign out as soon as we get the provider's discharge order.
Let’s discuss your decision to leave and then we can prepare you for discharge. Clients voluntarily admitted to the hospital have a right to demand and obtain release. Discussing the decision initially allows an opportunity for other interventions.
150. Which activity can the RN ask an unlicensed assistive personnel (UAP) to perform?
A) Take a history on a newly admitted client
B) Adjust the rate of a gastric tube feeding
C) Check the blood pressure of a 2 hours post operative client
D) Check on a client receiving chemotherapy
Check the blood pressure of a 2 hours post operative client. UAPs must be assigned tasks that require no nursing judgment or decision making situations. Vital signs on stable clients are commonly assigned to unlicensed staff.