NCSBN TEST BANK for NCLEX-RN Examination
Updated 2021, Complete Questions and Answers
Section 1: Management of Care
1. A nurse is caring for four clients on a medical-surgical unit. Which client should the nurse
assess first?
A. A client with a new prescription for antihypertensive medication
B. A client with stable vital signs 6 hours post-surgery
C. A client reporting chest pain rated 8/10
D. A client requesting assistance with ambulation
Correct Answer: C
Rationale: Chest pain rated 8/10 indicates a potential cardiac emergency requiring
immediate assessment and intervention. Using the ABC (Airway, Breathing, Circulation)
framework and Maslow's hierarchy, physiological needs that are life-threatening take priority
over stable clients or those with non-urgent requests. The client with new antihypertensive
prescription requires assessment but is not the priority. The post-surgical client with stable vital
signs and the client requesting ambulation are both stable.
2. A nurse is delegating tasks to an unlicensed assistive personnel (UAP). Which task is most
appropriate for the nurse to delegate?
A. Assessing a client who reports new-onset shortness of breath
B. Measuring vital signs for a stable postoperative client
C. Administering a PRN oral analgesic to a client reporting pain
D. Evaluating the effectiveness of patient education
Correct Answer: B
Rationale: Measuring vital signs for a stable client falls within the UAP's scope of practice as
it does not require nursing judgment, assessment, or evaluation. Under the NCSBN Five Rights
of Delegation, tasks involving assessment, medication administration, and evaluation cannot be
delegated to UAP. The RN remains accountable for all delegated tasks.
,3. A nurse is serving as a team leader with one LPN and one nursing assistant. To whom is it
appropriate to assign complete care for a newly admitted client requiring a comprehensive
assessment?
A. Yourself (the RN)
B. The nursing student
C. The LPN
D. The nursing assistant
Correct Answer: A
Rationale: While the RN may delegate a bed bath for a stable client, comprehensive
assessment and complete care for a new admission should be performed by the RN. Only tasks
that do not require independent judgment should be delegated. New admissions require
assessment, care planning, and clinical judgment that falls within the RN scope of practice.
4. A nurse is prioritizing care for four clients. Which client should be seen first?
A. A client requesting pain medication for chronic back pain rated 5/10
B. A client with new-onset chest pain rated 8/10
C. A client awaiting discharge instructions
D. A client needing a routine dressing change
Correct Answer: B
Rationale: New-onset chest pain may indicate a life-threatening condition such as
myocardial infarction and requires immediate assessment and intervention. Prioritization
frameworks dictate that actual or potential threats to physiologic stability are addressed before
stable or self-care requests. The other clients have predictable, non-urgent needs.
5. A nurse is reviewing advance directives with a newly admitted client. Which statements by
the client reflect an accurate understanding of advance directives? Select all that apply.
A. "I can name my daughter as my health care proxy in a durable power of attorney."
B. "My living will guides my care only when I cannot communicate my own wishes."
C. "Once my advance directive is signed, it can never be changed."
D. "My health care proxy can make decisions for me only when I am unable to make them
myself."
,E. "The hospital will decide my end-of-life care if I do not complete these documents."
F. "I should give copies of my advance directive to my provider and my family."
Correct Answers: A, B, D, F
Rationale: A durable power of attorney for health care designates a surrogate decision-
maker. The living will applies when the client cannot communicate. The proxy's authority
activates only in the event of incapacity. Copies should be distributed so documents are
available when needed. Client self-determination is protected under the Patient Self-
Determination Act. An advance directive may be revised or revoked at any time, making
statement C incorrect. Hospitals must ask clients about advance directives but do not substitute
their own decisions, making E incorrect.
6. A nurse observes a coworker diverting a narcotic pain medication for personal use. What is
the priority action?
A. Confront the coworker directly in front of other staff
B. Document the observation in the client's medical record
C. Report the behavior to the nurse manager or supervisor immediately
D. Call the local police immediately
Correct Answer: C
Rationale: The nurse has a legal and ethical duty to report impaired practice to a supervisor
or manager. This protects clients and initiates the proper investigation process. Confrontation
may lead to conflict and does not ensure client safety. The incident should never be
documented in the client's medical record as this violates confidentiality and is not the
appropriate reporting mechanism. Law enforcement notification follows institutional protocol
and is not the nurse's first action.
7. A nurse is preparing to administer a blood transfusion. Which action is most important before
starting the transfusion?
A. Checking the client's temperature
B. Verifying the blood type and client identification with another nurse
C. Administering an antihistamine prophylactically
D. Flushing the IV line with dextrose 5% in water
Correct Answer: B
, Rationale: Verifying blood type and client identification with another nurse is the most
critical safety step to prevent transfusion reactions due to mismatched blood. This is a required
two-nurse verification. Temperature should be assessed but is not the priority over correct
identification. Antihistamines are not routinely administered prophylactically. Blood products
must be primed with 0.9% normal saline, not dextrose solutions, as dextrose causes hemolysis.
8. A nurse is reviewing client assignments. Which assignment violates scope of practice?
A. CNA taking vital signs for a stable client
B. LPN administering a blood transfusion
C. RN performing a comprehensive assessment
D. CNA assisting with ambulation of a stable client
Correct Answer: B
Rationale: Administering blood transfusions is an RN-level task that requires advanced
assessment and monitoring for transfusion reactions. LPNs can administer some medications
but not blood products. Vital signs and ambulation assistance are appropriate tasks for CNAs.
Comprehensive assessment is within RN scope.
9. A nurse is preparing to insert a urinary catheter. What is the first step?
A. Apply sterile gloves
B. Perform hand hygiene
C. Position the client
D. Open the catheter kit
Correct Answer: B
Rationale: Hand hygiene is the first step in any procedure to prevent infection, per CDC
guidelines. This precedes applying gloves, positioning, and opening equipment. Proper hand
hygiene is the most effective method of infection prevention.
10. A charge nurse is making assignments for the medical-surgical unit. Which client should be
assigned to the most experienced registered nurse?
A. A client with newly diagnosed type 2 diabetes who requires diet teaching
B. A client with cirrhosis whose blood pressure has dropped from 120/80 to 90/60 mm Hg over
Updated 2021, Complete Questions and Answers
Section 1: Management of Care
1. A nurse is caring for four clients on a medical-surgical unit. Which client should the nurse
assess first?
A. A client with a new prescription for antihypertensive medication
B. A client with stable vital signs 6 hours post-surgery
C. A client reporting chest pain rated 8/10
D. A client requesting assistance with ambulation
Correct Answer: C
Rationale: Chest pain rated 8/10 indicates a potential cardiac emergency requiring
immediate assessment and intervention. Using the ABC (Airway, Breathing, Circulation)
framework and Maslow's hierarchy, physiological needs that are life-threatening take priority
over stable clients or those with non-urgent requests. The client with new antihypertensive
prescription requires assessment but is not the priority. The post-surgical client with stable vital
signs and the client requesting ambulation are both stable.
2. A nurse is delegating tasks to an unlicensed assistive personnel (UAP). Which task is most
appropriate for the nurse to delegate?
A. Assessing a client who reports new-onset shortness of breath
B. Measuring vital signs for a stable postoperative client
C. Administering a PRN oral analgesic to a client reporting pain
D. Evaluating the effectiveness of patient education
Correct Answer: B
Rationale: Measuring vital signs for a stable client falls within the UAP's scope of practice as
it does not require nursing judgment, assessment, or evaluation. Under the NCSBN Five Rights
of Delegation, tasks involving assessment, medication administration, and evaluation cannot be
delegated to UAP. The RN remains accountable for all delegated tasks.
,3. A nurse is serving as a team leader with one LPN and one nursing assistant. To whom is it
appropriate to assign complete care for a newly admitted client requiring a comprehensive
assessment?
A. Yourself (the RN)
B. The nursing student
C. The LPN
D. The nursing assistant
Correct Answer: A
Rationale: While the RN may delegate a bed bath for a stable client, comprehensive
assessment and complete care for a new admission should be performed by the RN. Only tasks
that do not require independent judgment should be delegated. New admissions require
assessment, care planning, and clinical judgment that falls within the RN scope of practice.
4. A nurse is prioritizing care for four clients. Which client should be seen first?
A. A client requesting pain medication for chronic back pain rated 5/10
B. A client with new-onset chest pain rated 8/10
C. A client awaiting discharge instructions
D. A client needing a routine dressing change
Correct Answer: B
Rationale: New-onset chest pain may indicate a life-threatening condition such as
myocardial infarction and requires immediate assessment and intervention. Prioritization
frameworks dictate that actual or potential threats to physiologic stability are addressed before
stable or self-care requests. The other clients have predictable, non-urgent needs.
5. A nurse is reviewing advance directives with a newly admitted client. Which statements by
the client reflect an accurate understanding of advance directives? Select all that apply.
A. "I can name my daughter as my health care proxy in a durable power of attorney."
B. "My living will guides my care only when I cannot communicate my own wishes."
C. "Once my advance directive is signed, it can never be changed."
D. "My health care proxy can make decisions for me only when I am unable to make them
myself."
,E. "The hospital will decide my end-of-life care if I do not complete these documents."
F. "I should give copies of my advance directive to my provider and my family."
Correct Answers: A, B, D, F
Rationale: A durable power of attorney for health care designates a surrogate decision-
maker. The living will applies when the client cannot communicate. The proxy's authority
activates only in the event of incapacity. Copies should be distributed so documents are
available when needed. Client self-determination is protected under the Patient Self-
Determination Act. An advance directive may be revised or revoked at any time, making
statement C incorrect. Hospitals must ask clients about advance directives but do not substitute
their own decisions, making E incorrect.
6. A nurse observes a coworker diverting a narcotic pain medication for personal use. What is
the priority action?
A. Confront the coworker directly in front of other staff
B. Document the observation in the client's medical record
C. Report the behavior to the nurse manager or supervisor immediately
D. Call the local police immediately
Correct Answer: C
Rationale: The nurse has a legal and ethical duty to report impaired practice to a supervisor
or manager. This protects clients and initiates the proper investigation process. Confrontation
may lead to conflict and does not ensure client safety. The incident should never be
documented in the client's medical record as this violates confidentiality and is not the
appropriate reporting mechanism. Law enforcement notification follows institutional protocol
and is not the nurse's first action.
7. A nurse is preparing to administer a blood transfusion. Which action is most important before
starting the transfusion?
A. Checking the client's temperature
B. Verifying the blood type and client identification with another nurse
C. Administering an antihistamine prophylactically
D. Flushing the IV line with dextrose 5% in water
Correct Answer: B
, Rationale: Verifying blood type and client identification with another nurse is the most
critical safety step to prevent transfusion reactions due to mismatched blood. This is a required
two-nurse verification. Temperature should be assessed but is not the priority over correct
identification. Antihistamines are not routinely administered prophylactically. Blood products
must be primed with 0.9% normal saline, not dextrose solutions, as dextrose causes hemolysis.
8. A nurse is reviewing client assignments. Which assignment violates scope of practice?
A. CNA taking vital signs for a stable client
B. LPN administering a blood transfusion
C. RN performing a comprehensive assessment
D. CNA assisting with ambulation of a stable client
Correct Answer: B
Rationale: Administering blood transfusions is an RN-level task that requires advanced
assessment and monitoring for transfusion reactions. LPNs can administer some medications
but not blood products. Vital signs and ambulation assistance are appropriate tasks for CNAs.
Comprehensive assessment is within RN scope.
9. A nurse is preparing to insert a urinary catheter. What is the first step?
A. Apply sterile gloves
B. Perform hand hygiene
C. Position the client
D. Open the catheter kit
Correct Answer: B
Rationale: Hand hygiene is the first step in any procedure to prevent infection, per CDC
guidelines. This precedes applying gloves, positioning, and opening equipment. Proper hand
hygiene is the most effective method of infection prevention.
10. A charge nurse is making assignments for the medical-surgical unit. Which client should be
assigned to the most experienced registered nurse?
A. A client with newly diagnosed type 2 diabetes who requires diet teaching
B. A client with cirrhosis whose blood pressure has dropped from 120/80 to 90/60 mm Hg over
