NCLEX RN PEARSON TEST BANK QUESTIONS, ANSWERS & RATIONALES 2023
The labor and delivery nurse would make it a priority to assess which of the following two newborn body systems
immediately after birth?
Gastrointestinal and hepatic
Urinary and hematologic
Neurologic and temperature control
Respiratory and cardiovascular
The mental health nurse working with children anticipates that unrealistic expectations or a sense of failure to
meet standards would cause a 10-year-old child to develop a sense of which of the following?
Shame
Guilt
Inferiority
Role confusion
The nurse is taking a nursing history from the mother of a child being admitted with flare-up of celiac disease.
What piece of information would the nurse expect the mother to report?
Steatorrhea
Increased appetite
Cheerful behavior
Soft, formed stools
During which of the following procedures should the labor and delivery nurse wear protective goggles in additionto
gloves?
Changing a soaked disposable bed pad
Assisting during an amniotomy
Starting an intravenous line
Washing dirty instruments
client with cancer has a calcium level of 11.8 mg/dL. Which of the following symptoms would indicate a needfor
the nurse to call the physician for treatment orders?
Increased gastric motility
Peaked T waves on 12-lead ECG
Muscle spasms
Muscle weakness
When evaluating the effectiveness of nursing care plans used for an anxious client, it is important to validate that
the client understands that:
Defense mechanisms should not be used.
Some anxiety can be helpful.
He should strive to never experience anxiety.
, He should try to avoid the fight or flight response.
nurse is discussing the home maintenance regimen with a client who has irritable bowel syndrome. Which ofthe
following statements indicates client understanding?
“I’ll take a walk after dinner each evening.”
“I’ll have a cigarette after meals to relax.”
“I’ll chew gum between meals to curb my appetite.”
“I’ll eat a lot of fresh vegetables and fruits.”
female client state that she will not undergo any invasive testing for her “stomach pain.” The nurse explains that
which of the following tests could be completed to assess the abdomen and still meet the client’s wishes?
Abdominal ultrasound
Barium swallow
Colonoscopy
CT scan with contrast
Certain that her stomach pain is a symptom of cancer, a female client with somatization disorder exhibits
pressured, rapid speech; elevated pulse and blood pressure; palpitations; and preoccupation with her pain, despite
negative results from a gastroscopy. The nurse formulates which of the following as the priority nursing diagnosis?
Pain
Anxiety
Hopelessness
Disturbed body image
The nurse suspects that hepatotoxicity is developing in a dark-skinned client who is on an antibiotic. In what areaof
the body should the nurse assess for jaundice?
Palms of the hands or soles of the feet
Hard palate of oral cavity
Sclera
Conjunctivae
primigravida client of 16 weeks gestation states that she has not yet felt fetal movement. The nurse’s best
response is:
“Your fetus will move any day now. Call me in a week if you don’t feel it.”
“Your fetus will begin moving at about 20 week’s gestation.”
“You should have been feeling the movement already.”
“Your fetus has been moving for the past 9 weeks without you feeling it. You will feel it within a
month.”
The mother of an infant who underwent surgery to repair hypospadias asks the nurse why the infant is diaperedas
shown. The nurse would respond that this method of diapering will help to:
Protect the urinary stent that has been put in place.
Adequately measure the urinary output.
Provide for maximum absorption of urine.
Provide optimal protection of perineal skin from infected urine.
,56-year-old client reports to the nurse that his sleep patterns are different than when he was younger. The nurse
anticipates that this client is likely to be experiencing which normal developmental pattern?
6 to 8 hours of sleep per night with about 20 to 25% of rapid eye movement (REM) sleep and a marked
decrease in Stage IV non-REM (NREM) sleep.
6 to 8 hours of sleep per night with about 20% REM sleep and a decrease in Stage IV NREM sleep.
Erratic sleep because of work schedule with about 30% of REM sleep and no marked decrease in Stage IV
NREM sleep.
Light sleep with equal amounts of REM sleep and NREM sleep.
While assessing the chest tube drainage system of a client, the nurse observes a slight rise and fall in the water
level in the water seal. The nurse should take which of the following actions?
Notify the physician immediately.
Have the client cough.
Continue to monitor the system.
Reposition the chest tube.
Which nutritional measure would help a client with gastroesophageal reflux disease (GERD) to minimize the riskof
symptoms?
Eating 3 large meals a day with no snacks
Using a lot of garlic to season food rather than salt
Limiting intake of coffee drinks to 2 or fewer cups a day
Using peppermint candies to take away the bitter taste in the mouth
A client who is 20 weeks gestation is concerned about how to tell her 3-year-old son about her pregnancy.
Which of the following would be the best statement when counseling this client?
“If he is not pleased with the news of a new baby, you should tell him that you are disappointed in him.”
“Tell him that he is going to have a lot of responsibilities in helping care for the baby.”
“Try to provide extra attention to him and include him in plans for the baby.”
“Tell him that he will have to stay with his grandparents when the baby is born because you will be busy with
the baby.”
An anxious client begins to yell and interrupt other clients. The client’s speech is rapid and pressured. What
action should the nurse take?
Ask the client to speak more slowly and softly.
Instruct the other clients to ignore this client’s behavior.
Point out to the client that the behavior is a sign of anxiety.
Remind the client of the need to use good manners when talking with other people.
He nurse concludes that teaching has been effective when the laboring client’s partner shouts, “She’s crowning!”as:
The nurse first starts to see a little of the baby’s head.
The baby’s head recedes upward between pushing contractions.
The perineum is thin and stretching around the occiput.
The mouth and nose are being suctioned.
, An 86-year-old client will be undergoing a surgical procedure. Which of the following changes would the nurse
make in the informed consent process for this elderly client?
Providing adequate time for the client to process the information
Encouraging the family members to make the decision for the client
Encouraging the client to sign immediately before the client forgets the purpose of the surgery
Providing the client with reading material about the surgery and the postoperative instructions
A 76-year-old woman visits the ambulatory clinic with reports of having difficulty reading and doing needlework
because of visual distortions with blurring of images directly in the line of vision. The peripheral visionassessment
by the nurse yields normal findings. The nurse suspects that this client is experiencing which of the following
visual problems?
Glaucoma
Detached retina
Cataracts
Macular degeneration
A client experiences severe nausea for up to 2 weeks following her chemotherapy treatment. Which statement
indicates a need for further instruction on management of nausea?
“I need to call my doctor if I lose more than 10 percent of my body weight.”
“I should try to eat bland, chilled foods, and drink liquids separate from my meals.”
“I need to lie down for an hour after each meal.”
“I should call the doctor if my nausea doesn’t go away, to see if a different anti-emetic could provide better
relief.”
The nurse is caring for the client who is recovering from partial thickness burns. Which of the following
breakfast options indicates client understanding of the recommended diet?
Two slices of toast with butter, orange juice, skim milk
Two poached eggs, hash brown potatoes, whole milk
Three pancakes with syrup, two slices of bacon, apple juice
One cup of oatmeal with skim milk, 1/2 grapefruit, coffee
A client questions the surgical nurse about the personnel in the operating room. Which of the following initial
responses by a nurse to the client’s concern is most therapeutic?
“The nurses are well-qualified for the job they do.”
“Have you had a bad experience in the OR?”
“You’re concerned about the personnel, but you have no need to worry.”
“Can you tell me about why you are interested in the personnel?”
The nurse is assigned to the care of a client receiving radiation therapy for cancer. Which of the following
activities needed in the care of a client receiving external beam radiation therapy could be safely delegated to an
unlicensed assistive person (UAP) working on the nursing unit? Select all that apply.
Observe the skin site following a treatment session.
Document intake from the meal trays.
Assess variations in level of fatigue during the shift.
The labor and delivery nurse would make it a priority to assess which of the following two newborn body systems
immediately after birth?
Gastrointestinal and hepatic
Urinary and hematologic
Neurologic and temperature control
Respiratory and cardiovascular
The mental health nurse working with children anticipates that unrealistic expectations or a sense of failure to
meet standards would cause a 10-year-old child to develop a sense of which of the following?
Shame
Guilt
Inferiority
Role confusion
The nurse is taking a nursing history from the mother of a child being admitted with flare-up of celiac disease.
What piece of information would the nurse expect the mother to report?
Steatorrhea
Increased appetite
Cheerful behavior
Soft, formed stools
During which of the following procedures should the labor and delivery nurse wear protective goggles in additionto
gloves?
Changing a soaked disposable bed pad
Assisting during an amniotomy
Starting an intravenous line
Washing dirty instruments
client with cancer has a calcium level of 11.8 mg/dL. Which of the following symptoms would indicate a needfor
the nurse to call the physician for treatment orders?
Increased gastric motility
Peaked T waves on 12-lead ECG
Muscle spasms
Muscle weakness
When evaluating the effectiveness of nursing care plans used for an anxious client, it is important to validate that
the client understands that:
Defense mechanisms should not be used.
Some anxiety can be helpful.
He should strive to never experience anxiety.
, He should try to avoid the fight or flight response.
nurse is discussing the home maintenance regimen with a client who has irritable bowel syndrome. Which ofthe
following statements indicates client understanding?
“I’ll take a walk after dinner each evening.”
“I’ll have a cigarette after meals to relax.”
“I’ll chew gum between meals to curb my appetite.”
“I’ll eat a lot of fresh vegetables and fruits.”
female client state that she will not undergo any invasive testing for her “stomach pain.” The nurse explains that
which of the following tests could be completed to assess the abdomen and still meet the client’s wishes?
Abdominal ultrasound
Barium swallow
Colonoscopy
CT scan with contrast
Certain that her stomach pain is a symptom of cancer, a female client with somatization disorder exhibits
pressured, rapid speech; elevated pulse and blood pressure; palpitations; and preoccupation with her pain, despite
negative results from a gastroscopy. The nurse formulates which of the following as the priority nursing diagnosis?
Pain
Anxiety
Hopelessness
Disturbed body image
The nurse suspects that hepatotoxicity is developing in a dark-skinned client who is on an antibiotic. In what areaof
the body should the nurse assess for jaundice?
Palms of the hands or soles of the feet
Hard palate of oral cavity
Sclera
Conjunctivae
primigravida client of 16 weeks gestation states that she has not yet felt fetal movement. The nurse’s best
response is:
“Your fetus will move any day now. Call me in a week if you don’t feel it.”
“Your fetus will begin moving at about 20 week’s gestation.”
“You should have been feeling the movement already.”
“Your fetus has been moving for the past 9 weeks without you feeling it. You will feel it within a
month.”
The mother of an infant who underwent surgery to repair hypospadias asks the nurse why the infant is diaperedas
shown. The nurse would respond that this method of diapering will help to:
Protect the urinary stent that has been put in place.
Adequately measure the urinary output.
Provide for maximum absorption of urine.
Provide optimal protection of perineal skin from infected urine.
,56-year-old client reports to the nurse that his sleep patterns are different than when he was younger. The nurse
anticipates that this client is likely to be experiencing which normal developmental pattern?
6 to 8 hours of sleep per night with about 20 to 25% of rapid eye movement (REM) sleep and a marked
decrease in Stage IV non-REM (NREM) sleep.
6 to 8 hours of sleep per night with about 20% REM sleep and a decrease in Stage IV NREM sleep.
Erratic sleep because of work schedule with about 30% of REM sleep and no marked decrease in Stage IV
NREM sleep.
Light sleep with equal amounts of REM sleep and NREM sleep.
While assessing the chest tube drainage system of a client, the nurse observes a slight rise and fall in the water
level in the water seal. The nurse should take which of the following actions?
Notify the physician immediately.
Have the client cough.
Continue to monitor the system.
Reposition the chest tube.
Which nutritional measure would help a client with gastroesophageal reflux disease (GERD) to minimize the riskof
symptoms?
Eating 3 large meals a day with no snacks
Using a lot of garlic to season food rather than salt
Limiting intake of coffee drinks to 2 or fewer cups a day
Using peppermint candies to take away the bitter taste in the mouth
A client who is 20 weeks gestation is concerned about how to tell her 3-year-old son about her pregnancy.
Which of the following would be the best statement when counseling this client?
“If he is not pleased with the news of a new baby, you should tell him that you are disappointed in him.”
“Tell him that he is going to have a lot of responsibilities in helping care for the baby.”
“Try to provide extra attention to him and include him in plans for the baby.”
“Tell him that he will have to stay with his grandparents when the baby is born because you will be busy with
the baby.”
An anxious client begins to yell and interrupt other clients. The client’s speech is rapid and pressured. What
action should the nurse take?
Ask the client to speak more slowly and softly.
Instruct the other clients to ignore this client’s behavior.
Point out to the client that the behavior is a sign of anxiety.
Remind the client of the need to use good manners when talking with other people.
He nurse concludes that teaching has been effective when the laboring client’s partner shouts, “She’s crowning!”as:
The nurse first starts to see a little of the baby’s head.
The baby’s head recedes upward between pushing contractions.
The perineum is thin and stretching around the occiput.
The mouth and nose are being suctioned.
, An 86-year-old client will be undergoing a surgical procedure. Which of the following changes would the nurse
make in the informed consent process for this elderly client?
Providing adequate time for the client to process the information
Encouraging the family members to make the decision for the client
Encouraging the client to sign immediately before the client forgets the purpose of the surgery
Providing the client with reading material about the surgery and the postoperative instructions
A 76-year-old woman visits the ambulatory clinic with reports of having difficulty reading and doing needlework
because of visual distortions with blurring of images directly in the line of vision. The peripheral visionassessment
by the nurse yields normal findings. The nurse suspects that this client is experiencing which of the following
visual problems?
Glaucoma
Detached retina
Cataracts
Macular degeneration
A client experiences severe nausea for up to 2 weeks following her chemotherapy treatment. Which statement
indicates a need for further instruction on management of nausea?
“I need to call my doctor if I lose more than 10 percent of my body weight.”
“I should try to eat bland, chilled foods, and drink liquids separate from my meals.”
“I need to lie down for an hour after each meal.”
“I should call the doctor if my nausea doesn’t go away, to see if a different anti-emetic could provide better
relief.”
The nurse is caring for the client who is recovering from partial thickness burns. Which of the following
breakfast options indicates client understanding of the recommended diet?
Two slices of toast with butter, orange juice, skim milk
Two poached eggs, hash brown potatoes, whole milk
Three pancakes with syrup, two slices of bacon, apple juice
One cup of oatmeal with skim milk, 1/2 grapefruit, coffee
A client questions the surgical nurse about the personnel in the operating room. Which of the following initial
responses by a nurse to the client’s concern is most therapeutic?
“The nurses are well-qualified for the job they do.”
“Have you had a bad experience in the OR?”
“You’re concerned about the personnel, but you have no need to worry.”
“Can you tell me about why you are interested in the personnel?”
The nurse is assigned to the care of a client receiving radiation therapy for cancer. Which of the following
activities needed in the care of a client receiving external beam radiation therapy could be safely delegated to an
unlicensed assistive person (UAP) working on the nursing unit? Select all that apply.
Observe the skin site following a treatment session.
Document intake from the meal trays.
Assess variations in level of fatigue during the shift.
