NCSBN QBANK QUESTIONS AND ANSWERS LATEST UPDATE WITH COMPLETE SOLUTION

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The nurse is reviewing the laboratory results for several clients. Which of the laboratory result indicates a client with partly compensated metabolic acidosis? Chloride 100 mEq/L (100 mmol/L) Sod... ium 130 mEq/L (130 mmol/L) Hemoglobin 15 g/dL (150 g//L) PaCO2 30 mm Hg Correct Answer-PaCO2 30 mm Hg The client is admitted to an ambulatory surgery center and undergoes a right inguinal orchiectomy. Which option is the priority before the client can be discharged to home? Able to ambulate in the hallway with assistance Post-operative pain is managed Correct response Able to tolerate a regular diet Psychological counseling is scheduled Correct Answer-Post-operative pain is managed A child is treated with succimer for lead poisoning. Which of these assessments should the nurse perform first? Test deep tendon reflexes Check blood calcium level Check complete blood count (CBC) with differential Check serum potassium level Correct Answer-Check complete blood count (CBC) with differential Succimer (Chemet) is used in the management of lead or other heavy metal poisoning. Although it has generally well tolerated and has a relatively low toxicity, it may cause neutropenia. Therapy should be withheld or discontinued if the absolute neutrophil count (ANC) is below 1200/µ. The client with a T-2 spinal cord injury reports having a "pounding" headache. Further assessment by the nurse reveals excessive sweating, rash, pilomotor erection, facial flushing, congested nasal passages and a heart rate of 50. What action should the nurse take next? Place the client into the bed and administer the ordered PRN analgesic Measure the client's respirations, blood pressure, temperature and pupillary responses Check the client for bladder distention and the urinary catheter for kinks Assist client with relaxation techniques Correct Answer-Check the client for bladder distention and the urinary catheter for kinks These are findings of autonomic dysreflexia, also called hyperreflexia. This response occurs in clients with a spinal cord injury above the T-6 level. It is typically initiated by any noxious stimulus below the level of injury such as a full bladder, an enema or bowel movement, fecal impaction, uterine contractions, changing of the catheter and vaginal or rectal examinations. The stimulus creates an exaggerated response of the sympathetic nervous system and can be a life-threatening event. The BP is typically extremely high. The priority action of the nurse is to identify and relieve the cause of the stimulus. The nurse is assessing a 4 year-old child who is in skeletal traction 24 hours after surgical repair of a fractured femur. The child is crying and reports having severe pain. The right foot is pale and there is no palpable pulse. What action should the nurse take first? Administer the ordered PRN medication Reassess the extremity in 15 minutes Readjust the traction for comfort Notify the health care provider Correct Answer-Notify the health care provider Pain and absence of a pulse within 48-72 hours after a severe injury to an extremity suggests acute compartment syndrome. This condition occurs when there's a build up of pressure within the muscles; this pressure decreases blood flow and can cause muscle and nerve damage. Acute compartment syndrome is a medical emergency. Surgery is needed immediately; delaying surgery can lead to permanent damage to the extremity. The nurse is examining a 2 year-old child with a tentative diagnosis of Wilm's tumor. The nurse would be most concerned about which statement by the mother? "My child has lost three pounds in the last month." "The child prefers some salty foods more than others." "All the pants have become tight around the waist." "Urinary output seems to be less over the past two days." Correct Answer-"Urinary output seems to be less over the past two days." [Show More]

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