NCSBN TEST BANK - for the NCLEX-RN and NCLEX-
PN, Updated 2021, Complete Questions and
Answers
1. A charge nurse is making client assignments for the oncoming shift. Which client should the
nurse assign to a newly licensed RN who has been on the unit for three months?
A. A client with a new tracheostomy requiring frequent suctioning
B. A client scheduled for a cardiac catheterization in one hour
C. A client with pneumonia receiving IV antibiotics
D. A client with an arterial line requiring continuous monitoring
Correct Answer: C
Rationale: A client with pneumonia receiving IV antibiotics is stable and requires routine
nursing care, making this the most appropriate assignment for a newly licensed nurse.
Options A, B, and D require advanced assessment skills, frequent monitoring, and experience
with complex equipment. The nurse should assign more complex clients to experienced staff.
2. A nurse is preparing to delegate tasks to a nursing assistant. Which task is appropriate for
delegation? (Select All That Apply)
A. Measuring vital signs on a stable postoperative client
B. Administering oral pain medication
C. Assisting a client with ambulation
D. Performing a sterile dressing change
E. Recording intake and output
F. Teaching a client about a new medication
Correct Answers: A, C, E
Rationale: Vital signs on stable clients, ambulation assistance, and intake/output
recording are within the scope of a nursing assistant. Medication administration (B), sterile
dressing changes (D), and client teaching (F) require the assessment, judgment, and skill of a
licensed nurse and cannot be delegated to unlicensed assistive personnel.
3. A nurse is caring for four clients. Which client should the nurse assess FIRST?
,A. A client requesting pain medication for chronic back pain rated 6/10
B. A client who had a thyroidectomy 8 hours ago and reports neck swelling
C. A client with a urinary tract infection who has a temperature of 100.2°F
D. A client scheduled for discharge who needs paperwork completed
Correct Answer: B
Rationale: Neck swelling following a thyroidectomy may indicate a hematoma, which can
rapidly compress the airway and cause life-threatening respiratory compromise. This is the
priority. The other clients have less urgent needs. Using Maslow's hierarchy and the ABCs
(Airway, Breathing, Circulation), airway compromise is always the priority.
4. A nurse is reviewing an informed consent form signed by a client scheduled for surgery. The
client tells the nurse, "I don't really understand what the surgeon is going to do." What is the
nurse's BEST action?
A. Explain the surgical procedure in detail to the client
B. Have the client sign a new consent form
C. Notify the surgeon that the client has questions about the procedure
D. Document the client's statement and proceed with surgery preparation
Correct Answer: C
Rationale: Informed consent requires that the client understands the procedure. The
nurse's role is to witness the signature and ensure the client understands; the surgeon is
responsible for explaining the procedure. If the client has questions, the nurse must notify the
surgeon. The nurse should not explain the procedure (A) as this is the provider's
responsibility.
5. A nurse manager is implementing a change in the unit's shift report process. Which action
should the nurse take FIRST?
A. Implement the change immediately
B. Identify the problem and gather data
C. Notify administration of the change
D. Evaluate the effectiveness of the change
Correct Answer: B
, Rationale: Using the nursing process as a framework for change, the first step is
assessment—identifying the problem and gathering data. This allows for informed decision-
making. Implementing immediately (A) without assessment is premature. Notifying
administration (C) and evaluating (D) come later in the change process.
6. An RN is working with an LPN/LVN and a nursing assistant. Which client should the RN
assign to the LPN/LVN?
A. A client requiring discharge teaching after a myocardial infarction
B. A client with a new colostomy who needs stoma care and reinforcement of teaching
C. A client requiring initial assessment upon admission
D. A client with an unstable cardiac rhythm requiring continuous monitoring
Correct Answer: B
Rationale: LPNs/LVNs can perform stoma care and reinforce teaching that has already
been initiated by the RN. Discharge teaching (A) and initial assessments (C) are RN
responsibilities. Unstable cardiac clients (D) require RN assessment and monitoring.
7. A nurse is documenting in a client's medical record. Which entry is most appropriate?
A. "Client seems depressed today."
B. "Client is being difficult and refuses medication."
C. "Client states, 'I feel sad and don't want to get out of bed.' Vital signs: BP 118/72, HR 88, RR
18, T 98.6°F."
D. "Client is noncompliant with care."
Correct Answer: C
Rationale: Documentation should be objective, specific, and include direct client quotes.
Subjective terms like "seems depressed" (A), "difficult" (B), and "noncompliant" (D) are
judgmental and not appropriate for legal documentation. Option C provides objective data
and a direct client quote.
8. A nurse is preparing to administer medications when another nurse says, "I already
checked those medications for you." What is the nurse's BEST action?
, A. Administer the medications since they were double-checked
B. Verify the medications independently before administration
C. Ask the other nurse to administer the medications
D. Document that the medications were double-checked by another nurse
Correct Answer: B
Rationale: The nurse who administers the medication is ultimately responsible for
verifying the "rights" of medication administration. Even if another nurse checked, the
administering nurse must independently verify the medication, dose, client, route, and time.
This ensures client safety and maintains accountability.
9. A nurse is caring for a client who speaks limited English. Which action should the nurse take
to ensure effective communication?
A. Ask a family member to interpret
B. Use a trained medical interpreter
C. Speak loudly and slowly in English
D. Provide written materials in English
Correct Answer: B
Rationale: Using a trained medical interpreter ensures accurate communication and is
required by law (Title VI of the Civil Rights Act). Family members (A) may not interpret
accurately and may filter information. Speaking loudly (C) does not address language barriers.
Written materials in English (D) are not helpful if the client cannot read English.
10. A nurse is reviewing a client's advance directive. The client has a living will stating no
heroic measures. The client's condition deteriorates, and the family requests full
resuscitation. What should the nurse do?
A. Follow the family's wishes since they are the decision-makers
B. Follow the living will as it represents the client's wishes
C. Ask the family to sign a waiver
D. Call the ethics committee immediately
Correct Answer: B
Rationale: A living will is a legal document that expresses the client's wishes regarding
medical treatment. The nurse is legally and ethically obligated to follow the client's
PN, Updated 2021, Complete Questions and
Answers
1. A charge nurse is making client assignments for the oncoming shift. Which client should the
nurse assign to a newly licensed RN who has been on the unit for three months?
A. A client with a new tracheostomy requiring frequent suctioning
B. A client scheduled for a cardiac catheterization in one hour
C. A client with pneumonia receiving IV antibiotics
D. A client with an arterial line requiring continuous monitoring
Correct Answer: C
Rationale: A client with pneumonia receiving IV antibiotics is stable and requires routine
nursing care, making this the most appropriate assignment for a newly licensed nurse.
Options A, B, and D require advanced assessment skills, frequent monitoring, and experience
with complex equipment. The nurse should assign more complex clients to experienced staff.
2. A nurse is preparing to delegate tasks to a nursing assistant. Which task is appropriate for
delegation? (Select All That Apply)
A. Measuring vital signs on a stable postoperative client
B. Administering oral pain medication
C. Assisting a client with ambulation
D. Performing a sterile dressing change
E. Recording intake and output
F. Teaching a client about a new medication
Correct Answers: A, C, E
Rationale: Vital signs on stable clients, ambulation assistance, and intake/output
recording are within the scope of a nursing assistant. Medication administration (B), sterile
dressing changes (D), and client teaching (F) require the assessment, judgment, and skill of a
licensed nurse and cannot be delegated to unlicensed assistive personnel.
3. A nurse is caring for four clients. Which client should the nurse assess FIRST?
,A. A client requesting pain medication for chronic back pain rated 6/10
B. A client who had a thyroidectomy 8 hours ago and reports neck swelling
C. A client with a urinary tract infection who has a temperature of 100.2°F
D. A client scheduled for discharge who needs paperwork completed
Correct Answer: B
Rationale: Neck swelling following a thyroidectomy may indicate a hematoma, which can
rapidly compress the airway and cause life-threatening respiratory compromise. This is the
priority. The other clients have less urgent needs. Using Maslow's hierarchy and the ABCs
(Airway, Breathing, Circulation), airway compromise is always the priority.
4. A nurse is reviewing an informed consent form signed by a client scheduled for surgery. The
client tells the nurse, "I don't really understand what the surgeon is going to do." What is the
nurse's BEST action?
A. Explain the surgical procedure in detail to the client
B. Have the client sign a new consent form
C. Notify the surgeon that the client has questions about the procedure
D. Document the client's statement and proceed with surgery preparation
Correct Answer: C
Rationale: Informed consent requires that the client understands the procedure. The
nurse's role is to witness the signature and ensure the client understands; the surgeon is
responsible for explaining the procedure. If the client has questions, the nurse must notify the
surgeon. The nurse should not explain the procedure (A) as this is the provider's
responsibility.
5. A nurse manager is implementing a change in the unit's shift report process. Which action
should the nurse take FIRST?
A. Implement the change immediately
B. Identify the problem and gather data
C. Notify administration of the change
D. Evaluate the effectiveness of the change
Correct Answer: B
, Rationale: Using the nursing process as a framework for change, the first step is
assessment—identifying the problem and gathering data. This allows for informed decision-
making. Implementing immediately (A) without assessment is premature. Notifying
administration (C) and evaluating (D) come later in the change process.
6. An RN is working with an LPN/LVN and a nursing assistant. Which client should the RN
assign to the LPN/LVN?
A. A client requiring discharge teaching after a myocardial infarction
B. A client with a new colostomy who needs stoma care and reinforcement of teaching
C. A client requiring initial assessment upon admission
D. A client with an unstable cardiac rhythm requiring continuous monitoring
Correct Answer: B
Rationale: LPNs/LVNs can perform stoma care and reinforce teaching that has already
been initiated by the RN. Discharge teaching (A) and initial assessments (C) are RN
responsibilities. Unstable cardiac clients (D) require RN assessment and monitoring.
7. A nurse is documenting in a client's medical record. Which entry is most appropriate?
A. "Client seems depressed today."
B. "Client is being difficult and refuses medication."
C. "Client states, 'I feel sad and don't want to get out of bed.' Vital signs: BP 118/72, HR 88, RR
18, T 98.6°F."
D. "Client is noncompliant with care."
Correct Answer: C
Rationale: Documentation should be objective, specific, and include direct client quotes.
Subjective terms like "seems depressed" (A), "difficult" (B), and "noncompliant" (D) are
judgmental and not appropriate for legal documentation. Option C provides objective data
and a direct client quote.
8. A nurse is preparing to administer medications when another nurse says, "I already
checked those medications for you." What is the nurse's BEST action?
, A. Administer the medications since they were double-checked
B. Verify the medications independently before administration
C. Ask the other nurse to administer the medications
D. Document that the medications were double-checked by another nurse
Correct Answer: B
Rationale: The nurse who administers the medication is ultimately responsible for
verifying the "rights" of medication administration. Even if another nurse checked, the
administering nurse must independently verify the medication, dose, client, route, and time.
This ensures client safety and maintains accountability.
9. A nurse is caring for a client who speaks limited English. Which action should the nurse take
to ensure effective communication?
A. Ask a family member to interpret
B. Use a trained medical interpreter
C. Speak loudly and slowly in English
D. Provide written materials in English
Correct Answer: B
Rationale: Using a trained medical interpreter ensures accurate communication and is
required by law (Title VI of the Civil Rights Act). Family members (A) may not interpret
accurately and may filter information. Speaking loudly (C) does not address language barriers.
Written materials in English (D) are not helpful if the client cannot read English.
10. A nurse is reviewing a client's advance directive. The client has a living will stating no
heroic measures. The client's condition deteriorates, and the family requests full
resuscitation. What should the nurse do?
A. Follow the family's wishes since they are the decision-makers
B. Follow the living will as it represents the client's wishes
C. Ask the family to sign a waiver
D. Call the ethics committee immediately
Correct Answer: B
Rationale: A living will is a legal document that expresses the client's wishes regarding
medical treatment. The nurse is legally and ethically obligated to follow the client's
