NCSBN Practice Questions 46-60. Accurately ANSWERED With Rationales 2022

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The nurse is providing discharge teaching for a client with a long leg cast. During instructions, the nurse should recommend which of these exercises for the affected extremity? A. Aerobic B. Rang... e of motion C. Isometric D. Isotonic - Ans-C A nurse should instruct the client on isometric exercises for the muscles of the casted extremity. This means the client should be instructed to alternately contract and relax muscles without moving the affected part. The client should also be instructed to do active range of motion exercises for every joint that is not immobilized at regular and frequent intervals of at least every four hours. The nurse is caring for a client with chronic renal failure who is undergoing peritoneal dialysis. The nurse notes that the dialysate solution is instilling very slowly. Which of the following actions would be appropriate for the nurse to implement? (Select all that apply.) A. Reposition the client B. Assess for headache and hypertension C. Assess for bruit or vibration D. Check tubing and catheter for kinks - Ans-A,D Slow dialysate instillation may be due to a partially obstructed tube or catheter. Checking for kinks and repositioning may facilitate improved instillation of this fluid. Assessment for bruit or headache and hypertension are appropriate for hemodialysis situations, not peritoneal dialysis. A client exhibiting confusion has been placed in physical restraints by order of the health care provider. Which task could be assigned to an unlicensed assistive person (UAP)? A. Assist the client with activities of daily living B. Document mental status and muscle strength C. Monitor the client's physical safety D. Document client's status every two hours - Ans-A The person to whom the activity is delegated must be capable of performing it. The UAP is capable of assisting clients with basic needs and routine tasks. Only the nurse can monitor and evaluate the client's condition. The nurse is reviewing medications with a client diagnosed with heart failure. The client asks the nurse how much longer he has to take the prescribed diuretic. Which is the best response by the nurse? A. "Please talk to your health care provider about medications and treatments." B. "You will have to take this medication for about a year." C. "The medication must be continued as long as the fluid problem needs to be controlled." D. "As you urinate more, you will need less medication to control fluid." - Ans-C The most therapeutic response is the one that addresses the client's health condition and gives the client accurate information, which is that he will take the medication for as long as needed to treat his medical condition. The nurse should determine if the client understands why he is taking this and any other medications and to reinforce teaching on possible side effects or adverse effects and when to notify the health care provider. The charge nurse is making assignment for the health care team. Which of these tasks can be safely delegated to the licensed practical nurse (LPN)? A. Provide stoma care for a client with a well-functioning ostomy B. Care for a recent complicated double barrel colostomy C. Teach the initial ostomy care to a client and family members D. Assess the function of a newly created ileostomy - Ans-A The care of a mature stoma and the application of an ostomy appliance may be delegated to a LPN. The condition of this client is stable, there's a low likelihood of any emergency and care of this client is not too complex. The other options require higher level care by the RN. The RN is the manager of care and is responsible for any initial teaching; the LPN can reinforce information once it has been introduced by the RN. A couple attempting to conceive asks the nurse when ovulation occurs. The woman reports a regular 32-day cycle. Which response by the nurse is correct? A. Days 11-13 B. Days 7-10 C. Days 14-16 D. Days 17-19 - Ans-D Ovulation occurs 14 days prior to menses. Considering that the woman's cycle is 32 days, subtracting 14 from 32 suggests ovulation is at about the 18th day. The nurse is teaching the client scheduled for a thyroidectomy about taking potassium iodide (SSKI, ThyroShield) drops. What information shall the nurse include? A. Mix the medication with juice or milk. B. Take the medication on an empty stomach. C. Store the medication in the refrigerator. D. The medication will enlarge the thyroid gland. - Ans-A This medication is used preoperatively, 10-14 days before surgery, to reduce the size and vascularity of the thyroid gland, not enlarge it. Potassium iodide drops should be mixed with water, fruit juice, milk, broth or even formula. The client can use a straw to drink the mixture. To minimize gastrointestinal irritation, it can be given after meals or with food. It should be stored at room temperature. An 8 year-old child is hospitalized with minimal-change disease (MCD). The nurse assists the child to select a lunch menu. Which menu selection is the best choice? A. Grilled chicken strips, corn on the cob with 1 pat of butter, skim milk B. Bologna and cheese sandwich with mustard, vanilla pudding snack, skim milk C. Peanut butter and sliced banana sandwich, apple, skim chocolate milk D. Frankfurter on bun (plain), strawberry gelatin dessert, skim chocolate milk - Ans-A MCD is a kidney disease in which large amounts of protein are lost in the urine. Corticosteroids are used to treat the disease; ACE inhibitors and diuretics are used to treat the edema. Treatment also includes eating a healthy, low-sodium diet with high-quality protein. Of the given choices, grilled chicken strips, corn on the cob and a glass of skim milk has the smallest total sodium content (less than 500 mg) and is the healthiest diet. Since nearly every layer of a sandwich is loaded with salt, the bologna and cheese sandwich (with around 1260 mg sodium) and the frankfurter on the bun (717) are not the best choices. However, the peanut butter and sliced banana sandwich, apple and milk option is a close second (about 650 mg sodium.) A parent of a 14 month-old is sharing concerns with the nurse. Which statement by a parent would alert a nurse to assess for iron-deficiency anemia in the toddler? A. "My child doesn't like many fruits and vegetables, but really loves milk." B. "I can't understand why my child is not eating as much as four months ago." C. "My child doesn't drink a whole glass of juice or water at one time." D. "I know there is a problem since my baby is always constipated." - Ans-A About two to three cups of milk a day are sufficient for the young child's needs. Sometimes excess milk intake, a habit carried over from infancy, may exclude many solid foods from the diet. As a result, the child may lack iron and develop a so-called milk anemia. Although the majority of infants with iron deficiency are underweight, many are overweight because of excessive milk ingestion. The nurse needs to make frequent detailed client assessments for pressure sore risk. Which client has the highest risk for developing a pressure sore? A. A 40 year-old wearing a controlled ankle motion walker following surgical repair of a ruptured tendon B. A 75 year-old diagnosed with peripheral vascular disease and needs assistance to walk C. A 68 year-old with left-sided paresthesia who is incontinent of urine D. A 55 year-old in balanced-skeletal traction for a fractured femur - Ans-C According to the Braden Scale, the risk for developing pressure sores is rated on a scale of 1 to 4 for each of these factors: sensory perception, moisture, activity, mobility, nutrition, and friction and shear; a score of 12 or lower represents a high risk. With all other risk factors being equal, the 68 year-old client with paresthesia and who is incontinent of urine has the greatest risk for developing a pressure sore. A nurse is assigned to triage clients who are brought to the emergency department after a bus accident. Which client would be cared for first? A. The 9 year-old with dilated pupils and cessation of breathing 10 minutes ago B. The 18 year-old who is diaphoretic and tachycardic and has a board-like abdomen C. The 35 year-old with an abrasion on the right anterior and lateral side of the chest D. The 56 year-old with external rotation and shortening of the left lower extremity - Ans-B Triage categories used during a mass casualty incident often use color-coding to prioritize care. The person in greatest need of immediate care (category - red) is the person with a board-like abdomen because this would indicate internal bleeding. The next person requiring urgent care (category - yellow) would be the individual with the shortened leg that is externally rotated, indicating a probable broken hip. The person with the chest abrasions is not currently having any difficulty breathing and can have treatment delayed for hours or even days (category - green). The individual who stopped breathing 10 minutes ago and whose pupils are fixed and dilated would not be treated because this person has already died (category - black). The client is confirmed to have a diagnosis of cerebral vascular accident. What serum lab value should the nurse check prior to administration of alteplase (TPA)? A. Arterial blood gases and [Show More]

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