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2025 - 2026 NCSBN ACTUAL EXAM STUDY
TEST WITH COMPLETE QUESTIONS AND
CORRECT ANSWERS RATED A+
A client who is 12 hours postop becomes confused and says: "Giant sharks are swimming across the ceiling." Which assessment is necessary by the nurse to adequately identify the source of this client's behavior? A. Peripheral glucose stick B. Cardiac rhythm strip C. Pupillary response D. Pulse oximetry Correct Answer D A sudden change in mental status in any postop client should trigger a nursing intervention directed toward evaluation of the client's respiratory status. Pulse oximetry would be the initial assessment. If available, arterial blood gases would be better. Acute respiratory failure is the sudden inability of the respiratory system to maintain adequate gas exchange, which may result in hypercapnia and/or hypoxemia. Clinical findings of hypoxemia include these finding, which are listed in order of initial to later findings: restlessness, irritability, agitation, dyspnea, disorientation, confusion, delirium, hallucinations, and loss of consciousness. While there may be other factors influencing the client's behavior, the first nursing action should be
directed toward maintaining oxygenation. Once respiratory or oxygenation issues are ruled out, then significant changes in glucose would be evaluated. A client continuously calls out to the nursing staff when anyone passes the client's door and asks them to do something in the room. The charge nurse should take which approach for this client? A. Reassure the client that a staff person will check frequently to see if the client needs anything B. Arrange for each staff member to go into the client's room to check on needs every hour on the hour C. Keep the client's room door cracked to minimize the distractions of people passing by the room D. Assign a nursing staff member to visit the client at regular intervals Correct Answer D Regular, frequent, planned contact by a designated staff member is the best approach to provide a continuity of care and communicate to the client that care will be available as needed. A nurse working at a clinic is reviewing a client's blood sugar log and recognizes that the client is not consistently monitoring blood sugar. Which of the following diagnostic tests would assist the nurse in evaluating the client's overall management of diabetes?
such as dry mouth and nasal congestion, dilated pupils and urinary retention. Although promethazine is a sedative, the nurse should understand that it can cause some people to have heart palpitations and to feel restless and unable to sleep. The nurse suspects that the client is in cardiogenic shock. Which of the following findings supports this information? A. Bradycardia B. Increased cardiac output C. Decreased or muffled heart sounds D. Bounding pulses Correct Answer C Cardiogenic shock involves decreased cardiac output and evidence of tissue hypoxia in the presence of adequate intravascular volume; it is the leading cause of death in acute MI. Findings of cardiogenic shock include hypotension, rapid and faint peripheral pulses, distant-sounding heart sounds, cool and mottled skin, oliguria and altered mental status. The client is admitted with a pressure ulcer that's two inches in diameter with no tunneling. It is a shallow open ulcer with loss of dermis and a red/pink wound bed. The nurse observes some serous drainage. What intervention does the nurse anticipate will be ordered to treat this wound?
A. Hydrogel dressing B. Whirlpool treatment and debridement C. Alginate dressing with silver added D. Alternating pressure pad overlay for the bed Correct Answer A This ulcer is a partial thickness wound. These types of wounds heal by tissue regeneration, which is why the nurse would expect a gel dressing to be ordered. This dressing will keep the wound moist, provide protection from infection and promote healing; also, the cool sensation provided by the gel offers pain relief. Pink/red wound edges are considered normal in the inflammatory stage of healing; the wound does not require debridement. There is nothing to indicate that there's an infection, which is why the alginate with silver is not needed; also, alginate dressings are better for wounds with moderate-to-heavy drainage and are good for filling cavities or tracts. An alternating pressure pad overlay would not treat the wound. The nurse is evaluating a stage III pressure ulcer while performing a dressing change. Which wound assessment findings indicate that the prescribed treatment is appropriate to support wound healing? (Select all that apply.) A. The wound base is moderately moist, shiny and red B. Clumps of soft yellow tissue adhere to the wound bed C. The size of the wound is decreasing
client should not take the medication with antacids, dairy products, coffee or tea because these will decrease the effectiveness of the medicine. The client should not lie down for at least 10 minutes after taking the medicine. A client has been given a prescription for alendronate. Which of the following statements indicate the client understands how to safely take this medication? (Select all that apply.) A. "I will notify the health care provider if I have any difficulty swallowing." B. "I will take the pill immediately preceding weight-bearing exercise." C. "I will swallow it with 8 ounces of water." D. "I will stand or sit quietly for 30 minutes after taking it." E. "I will always eat breakfast before taking it." Correct Answer A,C,D Alendronate (Fosamax) can cause esophagitis or esophageal ulcers unless precautions are followed. The client must be able to sit upright or stand for at least 30 minutes after taking the tablet. The client should take the tablet first thing in the morning, with a full glass of water, at least 30 minutes before eating or drinking anything or taking any other medication. A nurse, who is assigned for five days to a client who has exhibited manipulative behaviors, becomes aware of feeling
reluctance to interact with the client. The nurse should take what action next? A. Discuss the feelings of reluctance with an objective peer or supervisor within the next 24 hours B. Develop a behavior modification plan for the client that will promote more functional behavior within the next week C. Limit contacts with the client to avoid reinforcement of the manipulative behavior during the work times D. Talk with the client about the negative effects of manipulative behaviors on other clients and staff within the next few days Correct Answer A The nurse who experiences stress in a therapeutic relationship can gain objectivity through discussion with other professionals. The nurse may wish to have a peer observe the nurse-client interactions with this client for a shift and then have a debriefing of positive and negative actions. The nurse must attempt to discover attitudes and feelings in the self that influence the nurse-client relationship in positive and negative ways. A nurse is reviewing the nutritional needs for a child diagnosed with cystic fibrosis. The nurse should anticipate that this client would be deficient in which vitamins? A. B12, D and K
obstructed. If suction equipment is not at the bedside, request that someone else get it for you, rather than leaving the client. Do not place anything in the client's mouth. For safety, do not leave the client unattended. A cardiac arrest should only be announced if pulse or respirations are absent after the seizure. In response to a call for assistance by a client in labor, the nurse notes that a loop of the umbilical cord is protruding from the vagina. What is the priority action? A. Put the client into a knee-chest position B. Apply oxygen by mask C. Check for a fetal heart beat D. Call the health care provider Correct Answer A Immediate action is needed to relieve pressure on the cord to prevent the risk of fetal hypoxia. A Trendelenburg or knee- chest position accomplishes this. The exposed cord should be covered with saline soaked gauze and not reinserted. The fetal heart rate should be checked rapidly, the health care provider should be called immediately and the client should be prepared for immediate vaginal or C-section birth. A prolapsed umbilical cord is a medical emergency, which can result in brain damage or death to the fetus if not treated promptly and properly.
A client is admitted directly from surgery in skeletal traction for a fractured femur. Which of these nursing interventions should be the priority? A. Maintain proper body alignment B. Apply an overhead trapeze to assist with movement in bed C. Inspect the pin sites for evidence of drainage or inflammation D. Perform frequent neurovascular assessments of the affected leg Correct Answer D The priority postoperative action is to assess the neurovascular status of the leg after a fracture. Nursing management of a client in skeletal traction also includes assessing and caring for pin sites, and educating the client and family about skeletal traction. The overhead trapeze helps the client move in bed and proper body alignment is important, but these are not the priority. If a client is stated to have a dual diagnosis. The nurse should understand that this indicates a substance abuse problem as well as what other type of problem? A. Medical problem B. Mental disorder C. Disorder of any type D. Cross addiction Correct Answer B
D. Eye splashes Correct Answer B The greatest risk for young children is from oral ingestion. While children under age six may come in contact with other poisons or inhale toxic fumes, these are not as common. A 2-year-old child has just been diagnosed with cystic fibrosis. The child's parent asks the nurse what the most important concerns are at this time. Which is the appropriate response from the nurse? A. "Thick, sticky secretions from the lungs are a constant challenge." B. "Cystic fibrosis results in nutritional concerns that can be dealt with." C. "You will work with a team of experts and have access to a support group." D. "There is a high probability of life-long complications." Correct Answer A The primary factor, and the one responsible for many of the clinical manifestations of cystic fibrosis, is mechanical obstruction caused by the increased viscosity of mucous gland secretions.Because of the increased viscosity of bronchial mucus, there is greater resistance to ciliary action (probably secondary to infection and ciliary destruction), a slower flow rate of mucus and incomplete expectoration, which also contributes to the mucus obstruction. This retained mucus serves as an excellent medium for bacterial growth. Reduced oxygen-carbon dioxide exchange
causes variable degrees of hypoxia, hypercapnia and acidosis.In severe cases, progressive lung involvement, compression of pulmonary blood vessels and progressive lung dysfunction frequently lead to pulmonary hypertension, cor pulmonale, respiratory failure and death. Pulmonary complications are present in almost all children with cystic fibrosis, but the onset and extent of involvement are variable. A nursing assistant is taking care of a 2 year-old child with Wilm's tumor. The assistant asks the nurse why there is a sign above the bed that says DO NOT PALPATE THE ABDOMEN. Which statement by the nurse would be the best response? A. "Touching the abdomen could cause cancer cells to spread." B. "Pushing on the stomach might contribute to a bowel obstruction." C. "Examining the area would be painful." D. "Placing any pressure on the abdomen may cause the tumor to rupture." Correct Answer A Manipulation of the abdomen can lead to dissemination of cancer cells to nearby and distant areas. Bathing and turning the child should be done carefully. The nurse manager identifies that time spent charting is excessive. The nurse manager states that "staff will form a task force to investigate and develop potential solutions to the problem
The client had an open reduction and internal fixation (ORIF) of a femur fracture. During a routine assessment 36 hours after surgery, the nurse finds the client disoriented, short of breath and warm to the touch. The client's temperature is 102.4 F (39 C). What assessment should the nurse perform next? A. Measure oxygen saturation using a pulse oximeter B. Assess orientation to time, person and place C. Remove the splint and inspect the incision D. Perform a neurologic check of bilateral distal extremities Correct Answer A Based on the client's history and assessment findings, the nurse should suspect fat embolism syndrome (FES). Neurologic changes and respiratory distress are two of the classic findings of FES (the third finding is a characteristic petechial rash.) The nurse should activate the rapid response team. While waiting for the team, the nurse will measure the client's SpO2, as well as pulse and blood pressure, and auscultate the lungs. The nurse will also administer supplemental oxygen and ensure venous access. A hospitalized child has a seizure while the family is visiting. The nurse notes the child's whole body is rigid, followed generalized jerking movements of the extremities. The child vomits immediately after the seizure. What is a priority nursing diagnosis for the child at this time?
A. Risk for airway obstruction related to aspiration B. Fluid volume deficit related to vomiting C. Risk for infection related to vomiting D. Altered family processes related to chronic illness and hospitalization Correct Answer A The tonic-clonic seizure appears suddenly and often leads to brief loss of consciousness. The greatest risk for this child is from airway obstruction due to aspiration of the vomit. A nurse is caring for a client with left ventricular heart failure with an ejection fraction (EF) of 40%. Which assessment finding is an early indication of inadequate tissue perfusion? A. Use of accessory muscles B. Crackles in the lungs C. Distended jugular veins D. Confusion and restlessness Correct Answer D Neurological changes, including impaired mental status, are early signs of inadequate tissue perfusion and decreased oxygenation of the brain tissues. Other signs of low EF are shortness of breath, dependent edema and arrhythmias. The low EF indicates that this client has severe damage to the left ventricle (normal EF is about 55-70%).
(evil eye). You should make the association between the words "looking" and "seeing"(eye). Also note that the answer needs to refer to the newborn, not the parents ("give the newborn the evil eye"). To only look at the parents is an unrealistic approach. The client returns from the post anesthesia care unit (PACU) in stable condition following abdominal surgery. While planning immediate postoperative care, the nurse identifies the nursing diagnoses listed below. Prioritize these diagnoses by placing them in order of importance (with 1 being the most important). A. Impaired mobility related to invasive equipment B. Acute pain related to surgical procedure C. Risk for ineffective airway clearance related to anesthesia D. Risk for imbalanced nutrition: less than body requirements related to NPO satus Correct Answer C,B,A,D Airway is the highest priority, especially in the immediate postoperative period. Pain control is the next priority because this client will most likely experience significant pain. Although impaired mobility is expected, it does increase the client's risk for postoperative complications. The client's risk for nutrition imbalance is the lowest priority and is to be expected for a client who has had abdominal surgery; hydration is provided intravenously.
The nurse who is caring for clients over the age of 70, implements a teaching plan about diet. Using knowledge based on age- related changes, the nurse will emphasize which of the following factors? A. Add high protein supplements to your diet B. Make at least half your grains whole grain C. Follow the DASH eating plan D. Look for foods fortified with iron and other minerals Correct Answer B Anyone, regardless of age, should eat a balanced diet of nutrient- packed foods. However, the diet of the older adult without other chronic health issues should include an increase of fiber and whole grains. The DASH diet is recommended to reduce blood pressure, but there is nothing to indicate this client is hypertensive. Older adults should eat lean proteins but don't necessarily need protein supplements. They should also look for foods fortified with vitamins B12 and D, as well as calcium. A newborn born prematurely is to be fed breast milk through a nasogastric tube. Why is breast milk preferred over formula for premature infants? A. Is higher in calories/ounce B. Contains less lactose C. Provides antibodies
