NCSBN TEST BANK - for the NCLEX-RN and NCLEX-
PN, Updated 2021, Complete Questions and
Answers
SECTION I: MANAGEMENT OF CARE (Questions 1–20)
1. A nurse is caring for a client who is scheduled for surgery in 2 hours. The client tells the nurse,
"I don't think I want to go through with this." Which of the following actions should the nurse
take first?
A. Notify the surgeon immediately
B. Document the client's statement in the medical record
C. Explore the client's concerns about the procedure
D. Obtain a signed informed consent form
Correct Answer: C
Rationale: The nurse should first explore the client's concerns to understand the reason for
hesitation. This allows the nurse to address any misconceptions or fears. Notifying the surgeon
(A) may be appropriate but is not the first action. Documentation (B) is important but should
occur after assessment. Obtaining consent (D) would be inappropriate if the client is expressing
doubt.
2. A nurse is delegating tasks to an unlicensed assistive personnel (UAP). Which of the following
tasks is appropriate for the nurse to delegate?
Select all that apply.
A. Ambulating a stable client who had surgery 2 days ago
B. Administering oral pain medication
C. Measuring intake and output
D. Performing a sterile dressing change
E. Obtaining a blood glucose reading via fingerstick
F. Teaching a client about a new medication
Correct Answers: A, C, E
Rationale: UAPs can perform tasks that do not require nursing judgment, such as
ambulating stable clients (A), measuring I&O (C), and obtaining fingerstick blood glucose
,readings (E). Administering medications (B), performing sterile dressing changes (D), and client
teaching (F) require the skill and judgment of a licensed nurse and cannot be delegated to UAP.
3. A nurse is serving on a committee to develop a disaster preparedness plan. Which of the
following should the nurse identify as the priority during the mitigation phase?
A. Providing emergency shelter for displaced persons
B. Conducting community education on disaster preparedness
C. Triaging victims at the scene of the disaster
D. Distributing food and water to affected individuals
Correct Answer: B
Rationale: The mitigation phase focuses on preventing or reducing the impact of a disaster
before it occurs. Community education (B) is a key mitigation strategy. Providing shelter (A) and
distributing supplies (D) occur during the response phase. Triaging victims (C) also occurs during
the response phase.
4. A nurse is reviewing a client's advance directives. The client has a living will stating no
extraordinary measures. The client is now unresponsive and in respiratory distress. The
healthcare provider orders intubation. Which of the following actions should the nurse take?
A. Follow the healthcare provider's order for intubation
B. Refuse to follow the order and document the refusal
C. Inform the healthcare provider of the living will and advocate for the client's wishes
D. Ask the family to make the decision
Correct Answer: C
Rationale: The nurse is obligated to advocate for the client's wishes as stated in the living
will. Informing the healthcare provider (C) is the appropriate action. Following the order (A)
would violate the client's advance directive. Refusing without discussion (B) is not collaborative.
Asking the family (D) may be appropriate for clarification, but the living will takes precedence.
5. A nurse is caring for a client who speaks limited English. Which of the following actions
should the nurse take to ensure effective communication?
,A. Ask the client's family member to interpret
B. Use a certified medical interpreter
C. Speak loudly and use simple words
D. Provide written materials in English
Correct Answer: B
Rationale: Using a certified medical interpreter (B) ensures accurate and confidential
communication. Family members (A) may not be competent to interpret medical information
and may filter information. Speaking loudly (C) does not address the language barrier. Written
materials in English (D) would not be helpful if the client cannot read English.
6. A charge nurse is making assignments for the upcoming shift. Which of the following clients
should be assigned to the most experienced nurse?
A. A client who is 1 day postoperative following a total hip replacement
B. A client with chronic obstructive pulmonary disease receiving oxygen
C. A client with acute myocardial infarction receiving thrombolytic therapy
D. A client with diabetes who is learning to administer insulin
Correct Answer: C
Rationale: The client receiving thrombolytic therapy (C) is at high risk for bleeding and
requires close monitoring and assessment by an experienced nurse. The other clients (A, B, D)
are more stable and can be assigned to less experienced nurses with appropriate supervision.
7. A nurse is preparing to administer medications to a group of clients. Which of the following
prescriptions should the nurse question?
A. Morphine sulfate 4 mg IV every 4 hours PRN for pain
B. Digoxin 0.25 mg PO daily for heart failure
C. Heparin 5,000 units subcutaneous every 12 hours for DVT prophylaxis
D. Regular insulin 10 units IV push for blood glucose of 180 mg/dL
Correct Answer: D
Rationale: Regular insulin is administered subcutaneously or via continuous IV infusion, not
IV push (D). IV push insulin can cause severe hypoglycemia. The other prescriptions (A, B, C) are
within standard guidelines.
, 8. A nurse manager is reviewing incident reports. Which of the following situations requires
immediate follow-up?
A. A client fell in the bathroom but was not injured
B. A nurse administered the wrong dose of a medication but the client was not harmed
C. A client's family member verbally threatened a nurse
D. A nurse forgot to document a dressing change
Correct Answer: C
Rationale: A verbal threat (C) poses an immediate safety risk to staff and requires
immediate intervention. While the other incidents (A, B, D) are important, they do not pose an
immediate threat to safety.
9. A nurse is participating in a quality improvement project. Which of the following is the first
step in the quality improvement process?
A. Implement a change
B. Identify a problem or opportunity for improvement
C. Collect data
D. Evaluate the effectiveness of the change
Correct Answer: B
Rationale: The first step in the quality improvement process is to identify a problem or
opportunity for improvement (B). Data collection (C) follows problem identification.
Implementation (A) and evaluation (D) occur later in the process.
10. A nurse is caring for a client who is being discharged home. Which of the following referrals
should the nurse make for a client who needs assistance with bathing and dressing?
A. Physical therapist
B. Occupational therapist
C. Home health aide
D. Social worker
Correct Answer: C
PN, Updated 2021, Complete Questions and
Answers
SECTION I: MANAGEMENT OF CARE (Questions 1–20)
1. A nurse is caring for a client who is scheduled for surgery in 2 hours. The client tells the nurse,
"I don't think I want to go through with this." Which of the following actions should the nurse
take first?
A. Notify the surgeon immediately
B. Document the client's statement in the medical record
C. Explore the client's concerns about the procedure
D. Obtain a signed informed consent form
Correct Answer: C
Rationale: The nurse should first explore the client's concerns to understand the reason for
hesitation. This allows the nurse to address any misconceptions or fears. Notifying the surgeon
(A) may be appropriate but is not the first action. Documentation (B) is important but should
occur after assessment. Obtaining consent (D) would be inappropriate if the client is expressing
doubt.
2. A nurse is delegating tasks to an unlicensed assistive personnel (UAP). Which of the following
tasks is appropriate for the nurse to delegate?
Select all that apply.
A. Ambulating a stable client who had surgery 2 days ago
B. Administering oral pain medication
C. Measuring intake and output
D. Performing a sterile dressing change
E. Obtaining a blood glucose reading via fingerstick
F. Teaching a client about a new medication
Correct Answers: A, C, E
Rationale: UAPs can perform tasks that do not require nursing judgment, such as
ambulating stable clients (A), measuring I&O (C), and obtaining fingerstick blood glucose
,readings (E). Administering medications (B), performing sterile dressing changes (D), and client
teaching (F) require the skill and judgment of a licensed nurse and cannot be delegated to UAP.
3. A nurse is serving on a committee to develop a disaster preparedness plan. Which of the
following should the nurse identify as the priority during the mitigation phase?
A. Providing emergency shelter for displaced persons
B. Conducting community education on disaster preparedness
C. Triaging victims at the scene of the disaster
D. Distributing food and water to affected individuals
Correct Answer: B
Rationale: The mitigation phase focuses on preventing or reducing the impact of a disaster
before it occurs. Community education (B) is a key mitigation strategy. Providing shelter (A) and
distributing supplies (D) occur during the response phase. Triaging victims (C) also occurs during
the response phase.
4. A nurse is reviewing a client's advance directives. The client has a living will stating no
extraordinary measures. The client is now unresponsive and in respiratory distress. The
healthcare provider orders intubation. Which of the following actions should the nurse take?
A. Follow the healthcare provider's order for intubation
B. Refuse to follow the order and document the refusal
C. Inform the healthcare provider of the living will and advocate for the client's wishes
D. Ask the family to make the decision
Correct Answer: C
Rationale: The nurse is obligated to advocate for the client's wishes as stated in the living
will. Informing the healthcare provider (C) is the appropriate action. Following the order (A)
would violate the client's advance directive. Refusing without discussion (B) is not collaborative.
Asking the family (D) may be appropriate for clarification, but the living will takes precedence.
5. A nurse is caring for a client who speaks limited English. Which of the following actions
should the nurse take to ensure effective communication?
,A. Ask the client's family member to interpret
B. Use a certified medical interpreter
C. Speak loudly and use simple words
D. Provide written materials in English
Correct Answer: B
Rationale: Using a certified medical interpreter (B) ensures accurate and confidential
communication. Family members (A) may not be competent to interpret medical information
and may filter information. Speaking loudly (C) does not address the language barrier. Written
materials in English (D) would not be helpful if the client cannot read English.
6. A charge nurse is making assignments for the upcoming shift. Which of the following clients
should be assigned to the most experienced nurse?
A. A client who is 1 day postoperative following a total hip replacement
B. A client with chronic obstructive pulmonary disease receiving oxygen
C. A client with acute myocardial infarction receiving thrombolytic therapy
D. A client with diabetes who is learning to administer insulin
Correct Answer: C
Rationale: The client receiving thrombolytic therapy (C) is at high risk for bleeding and
requires close monitoring and assessment by an experienced nurse. The other clients (A, B, D)
are more stable and can be assigned to less experienced nurses with appropriate supervision.
7. A nurse is preparing to administer medications to a group of clients. Which of the following
prescriptions should the nurse question?
A. Morphine sulfate 4 mg IV every 4 hours PRN for pain
B. Digoxin 0.25 mg PO daily for heart failure
C. Heparin 5,000 units subcutaneous every 12 hours for DVT prophylaxis
D. Regular insulin 10 units IV push for blood glucose of 180 mg/dL
Correct Answer: D
Rationale: Regular insulin is administered subcutaneously or via continuous IV infusion, not
IV push (D). IV push insulin can cause severe hypoglycemia. The other prescriptions (A, B, C) are
within standard guidelines.
, 8. A nurse manager is reviewing incident reports. Which of the following situations requires
immediate follow-up?
A. A client fell in the bathroom but was not injured
B. A nurse administered the wrong dose of a medication but the client was not harmed
C. A client's family member verbally threatened a nurse
D. A nurse forgot to document a dressing change
Correct Answer: C
Rationale: A verbal threat (C) poses an immediate safety risk to staff and requires
immediate intervention. While the other incidents (A, B, D) are important, they do not pose an
immediate threat to safety.
9. A nurse is participating in a quality improvement project. Which of the following is the first
step in the quality improvement process?
A. Implement a change
B. Identify a problem or opportunity for improvement
C. Collect data
D. Evaluate the effectiveness of the change
Correct Answer: B
Rationale: The first step in the quality improvement process is to identify a problem or
opportunity for improvement (B). Data collection (C) follows problem identification.
Implementation (A) and evaluation (D) occur later in the process.
10. A nurse is caring for a client who is being discharged home. Which of the following referrals
should the nurse make for a client who needs assistance with bathing and dressing?
A. Physical therapist
B. Occupational therapist
C. Home health aide
D. Social worker
Correct Answer: C
