NCSBN Practice Questions with Correct Detailed Verified

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NCSBN Practice Questions with Correct Detailed Verified Answers/ New Update 2024 – Rated A+

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?

• DTaP

B. IPV

• Hepatitis B
• HIB - Correct Answer - 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 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?

• The expenses due to police and court costs are prohibitive
• Little knowledge is known about batterers and battering relationships
• There are typically many series of minor, vague complaints
• Few people who have been battered seek medical care - Correct Answer - 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 1 / 4

pg. 2 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?

• Swab the gauze dressing that was removed from the wound
• Irrigate the wound with normal saline
• Obtain a culture by rotating a sterile swab in the open wound
• Remove wound exudate from the wound edges with a cotton tip applicator - Correct Answer - 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?

• "Yes, staying with the client and orienting the client to the surroundings may decrease any anxiety."
• "No, your presence may cause the client to become more anxious."
• "No, it would be best if you brought the client some reading material that the client could read at

night."

• "Yes, would you like to spend the night when the client's behavior indicates that the client is or will be

frightened?" - Correct Answer - 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)?

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• Ask the LPN about prior experience caring for clients with similar diagnoses
• Determine how many nursing assistants are available to help the LPN with client care
• Refer to the list of technical tasks LPNs are trained to perform
• Review the procedure manual with the LPN prior to making an assignment - Correct Answer - 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 to review the topic of caring for clients with Guillain-Barré syndrome with other staff members at a monthly meeting. Which of these findings should the nurse include in the discussion?(Select all that apply.)

• Weakness, tingling or loss of sensation in legs and feet occur first
• Rapidly progressive ascending paralysis of the legs, arms, respiratory muscles and face
• Difficulty with bladder control or intestinal functions
• Hypertension
• Difficulty with eye movement, facial movement, speaking, chewing or swallowing
• Numbness, tingling, prickling sensation or moderate pain throughout the body - Correct Answer -

A,B,C,E,F

Guillian-Barré is an autoimmune disease. The symptoms of weakness or tingling sensation begins in the legs and progresses to the arms and upper body, resulting in almost complete paralysis. The client is often put on a ventilator during the worst part of the disease to assist breathing. The client may have low blood pressure or poor blood pressure control.

A 1 year-old child is receiving temporary total parental nutrition (TPN) through a central venous line. This is the first day of TPN therapy. Although all of the following nursing actions must be included in the plan of care of this child, which one would be a priority at this time?

• Use aseptic technique during dressing changes
• Check results of liver enzyme tests 3 / 4

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• Maintain central line catheter integrity
• Monitor serum glucose levels - Correct Answer - D

Hyperglycemia may occur during the first day or two as the child adapts to the high-glucose load of the TPN solution. Thus, a priority nursing responsibility is blood glucose testing.

The nurse is teaching diet restrictions to a client diagnosed with Addison's disease. The client indicates an understanding of the dietary restrictions when making which of these statements?

• "I will increase fluids and restrict sodium and potassium."
• "I will increase sodium and fluids and restrict potassium."
• "I will increase sodium, potassium and fluids."
• "I will increase potassium and sodium and restrict fluids." - Correct Answer - B

The manifestations of Addison's disease (also called adrenal insufficiency or hypocortisolism) are due to mineralocorticoid deficiency that results in renal sodium wasting and potassium retention. Other findings are dehydration, hypotension, hyponatremia, hyperkalemia and metabolic acidosis.

A nurse is working in an inpatient psychiatric setting. The nurse understands what reason touching clients should be limited to a quick handshake?

• A handshake allows the use of therapeutic touch while maintaining boundaries.
• Touching a client, other than a handshake, can set off a violent episode.
• Refraining from touching signals the termination of the nurse-client relationship.
• A handshake will not be misinterpreted as an invitation to more sexual behavior. - Correct Answer - A

The therapeutic use of touch is a basic part of the nurse-client relationship. However, in a psychiatric setting, the extent of physical contact should be limited to handshakes. Some facilities may even have a no-touch policy, especially when working with clients who have a history of sexual trauma. Even reassuring touching can be misinterpreted by the client.

Upon completion of the admission documents, the nurse identifies that an elderly client does not have an advance directive. What action should the nurse take?

• Document this information on the chart
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