Answers and explanations for the nursing 11456 NCSBN test bank review questions
1. The nurse is reviewing with a client how to collect a clean catch urine specimen. What is the appropriate sequence to teach the clien
a) Void a little, clean the meatus, then collect specimen
b) Clean the meatus, then urinate into container
c) Clean the meatus, begin voiding, and then catch the urine stream
d) Void continuously and catch some of the urine.
Answer. C, Clean the meatus, begin voiding and then catch the urine stream.
Explanation. Client should carefully clean the meatus and then void naturally with a steady stream as this prevents surface bacteria from contaminating the urine specimen. Since its difficult to stopping flow of urine at once client start voiding, it’s advisable to slip the container into the stream.
2. A client has been hospitalized after an automobile accident. A full leg cast applied while inside the emergency room. The most important reason for the nurse to elevate the casted leg is to:
a) Reduce the drying time
b) Improve venous return
c) Promote the client's comfort
d) Decrease irritation to the skin
Answer is B. Improve venous return
Explanation. When the casted leg is elevated, it improves venous return and reduces swelling which happens after cast is applied and also it improves comfort.
3. A nurse who works on the orthopedic unit has just received the change-of-shift report. Which patient should the nurse assess first?
a) Patient who reports foot pain after hammertoe surgery
b) Patient who has not voided 10 hours after having a laminectomy
c) Patient with low back pain and a positive straight-leg-raise test
d) Patient with osteomyelitis who has a temperature of 100.5 F (38.1 C)
Answer. B. Patient who has not voided 10 hours after having a laminectomyd.
Explanation. Damage to the spinal nerves may make a patient not to void and it should be assessed and reported to the surgeon immediately. The other information does not need immediate intervention as they are consistent with their diagnoses. However, the nurse will need to assess them as quickly as possible.
4. Which actions will the nurse include in the plan of care when caring for a patient with metastatic bone cancer of the left femur (select all that apply)?
a) Teach about the need for strict bed rest.
b) Support family as they discuss the prognosis of patient
c) Support the left leg when repositioning the patient.
d) Avoid use of sustained-release opioids for pain.
e) Monitor serum calcium level.
Answer: B, C, E
Explanation. Bone decalcification causes hypercalcemia and nurse will need to monitor. Support of the leg helps reduce the risk for pathologic fractures. Activity is important to maintain function, though the patient may be reluctant to exercise since exercise prevents complications associated with immobility. For the severe pain that is frequently associated with bone cancer, adequate pain medication, including sustained release and rapidly acting opioids is needed. Patient and family need to be supported as they deal with the reality of the diagnosis for metastatic bone cancer. Answers and explanations for the nursing 11456 NCSBN test bank review questions.
5. Which information will the nurse include when teaching a patient with acute low back pain (select all that apply)?
a) Avoid activities that require twisting of the back or prolonged sitting.
b) Sleep in a prone position with the legs extended
c) Symptoms of acute low back pain frequently improve in a few weeks.
d) Ibuprofen (Motrin, Advil) or acetaminophen (Tylenol) can be used to relieve pain.
e) Keep the knees straight when leaning forward to pick something up.
Answer. A, C, D.
Explanation. Within two weeks acute back pain starts to improve. For the time being, the patient should use medications such as acetaminophen or nonsteroidal anti-inflammatory drugs (NSAIDs) to manage pain and avoid activities that stress the back. The patient should also avoid sleeping in a prone position and keeping the knees straight when leaning forward as this will place stress on the back.
6.When caring for a patient warfarin sodium (coumadin) which lab test would the nurse monitor to determine therapeutic response to the drug?
a) Prothrombin time
b) Bleeding time
c) Coagulation time
d) Partial thromboplastin time
Answer. A, Prothrombin time
Explanation. Based on client’s prothrombin time (PT), coumadin is ordered daily. Coumadin affects the vitamin K dependent clotting factors and this test evaluates the adequacy of the extrinsic system and common pathway in the clotting cascade.
7. A client with moderate persistent asthma is admitted for a minor surgical procedure. On admission the peak flow meter is measured at 480 liters/minute. Post-operatively the client is complaining of chest tightness. The peak flow has dropped to 200 liters/minute. What should the nurse do first?
a) Notify both the surgeon and provider
b) Apply oxygen at 2 liters per nasal cannula
c) Repeat the peak flow reading in 30 minutes
d) Administer the prn dose of albuterol
Answer. D, Administer the prn dose of albuterol
Explanation. You are required to administer the prn dose of albuterol. During exacerbations of asthma peak flow monitoring is recommended to determine the severity of the exacerbation for clients with moderate-to-severe persistent asthma and to guide the treatment. If peak flow reading is less than 50% of the client's baseline reading is a medical alert condition and a short-acting beta-agonist must be taken immediately.
8. A client has been tentatively diagnosed with Graves’ disease (hyperthyroidism). Which of the finding noted on the initial nursing assessment require quick intervention by the nurse?
a) A report of 10 pounds weight loss in the last month.
b) The appearance of eyeballs that appear to “pop” out of the client’s eye sockets.
c) A comment by the client “I just can’t sit still”
d) A report of the sudden onset of irritability in the past 2 weeks.
Answer. B. The appearance of eyeballs that appear to “pop” out of the client’s eye sockets.
Explanation. Distinctive characteristic of Graves’ disease is exophthalmos or protruding eyeballs and can result in corneal abrasions with severe eye pain or damage when the eyelid is unable to blink down over the protruding eyeball. Eye drops or ointment may be needed. Answers and explanations for the nursing 11456 NCSBN test bank review questions.
9. The nurse has performed the initial assessments of 4 clients admitted with an acute episode of asthma. Which assessment finding would cause the nurse to call the provider immediately?
a) Prolonged inspiration with each breath
b) Expectoration of large amounts of purulent mucous
c) Expiratory wheezes that are suddenly absent in 1 lobe
d) Appearance of the use of abdominal muscles for breathing
Answer. C: Expiratory wheezes that are suddenly absent in 1 lobe.
Explanation. Expiratory wheezes characterize acute asthma which is caused by obstruction of the airways. Wheezes are associated with the feeling of tightness in the chest is a high-pitched musical sound produced by air moving through narrowed airways. A sudden cessation of wheezing is threatening or bad sign that indicates an emergency since the small airways have collapsed
10. During the initial home visit, a nurse is discussing the care of a client newly diagnosed with Alzheimer’s disease with family members. Which of the interventions would be most helpful at this time?
a) Leave a book about relaxations techniques
b) Suggest communications strategy
c) Write about daily exercise routine for them to assist the client to do
d) List actions to improve the client’s daily nutritional intake
Answer. B. Suggest communications strategy
Explanation.
* Alzheimer's is a brain disorder disease that slowly destroys thinking skills and memory. Ultimately affects the ability to carry out the simplest tasks.
* Alzheimer’s disease greatly challenges caregivers being a progressive chronic illness. The family will need assistance from the nurse on communication strategy for the ability to communicate to the client.
11. An 80-year-old client admitted with a diagnosis of possible cerebral vascular accident has had a blood pressure from 160/100 to 180/110 over the past 2 hours. The nurse has also noted increased lethargy.
a) Incontinence
b) Muscle weakness
c) Slurred speech
d) Rapid pulse
Answer. C. Slurred speech.
Explanation. When speech changes patterns with levels of conscious can be the indicators of continued intracranial bleeding or extension of stroke which may require further diagnosis.
12. A school aged child has had a long leg (hip to ankle) synthetic cast applied 4 hours ago. Which statement from the parent indicates that teaching has been inadequate?
a) I will keep the cast uncovered for the next day to prevent burning of the skin.
b) I can apply an ice pack over the area to relieve itching inside the cast.
c) I think I remember that my child should not stand until after 72 hours.
d) The cast should be propped on at least 2 pillows when my child is lying down.
Answer. C. I think I remember that my child should not stand until after 72 hours. Answers and explanations for the nursing 11456 NCSBN test bank review questions.
Explanation. It will take about 30 minutes to set up synthetic cast and a few hours to dry up. Therefore, client can stand within initial 24 hours. Plaster cast will take about 72 hours for set up and drying especially in a long leg cast which is thicker than arm. It’s also the keep the cast uncovered for the first 24 hours since both casts give off a lot of heat when drying. Client can also be covered lightly with a sheet or blanket as he may complain of chill from wet cast. Additionally, another safe method of relieving itching is by applying ice.