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NCSBN TEST BANK - for the NCLEX-RN & NCLEX-PN UPDATED Question and Answers

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Question 1 A c. What document should be in guiding the care of this client? A) Client Self Determination Act B) Physician's treatment orders C) Advance Directives. D) Clinical Pathway protocols Review Information: The correct answer is: C) Advance Directives. This document specifies the client's wishes Question 2 You are the of a health care team that consists of one licensed practical/vocational nurse, one nursing assistant, a nursing student and yourself. To whom is it appropriate to assign complete care for A) Yourself B) The nursing student C) The licensed vocational nurse D) The nursing assistant Review Information: The correct answer is:A) Yourself. While the nurse may delegate a bed bath for a stable client, this care should be performed by an RN for a new admission. Only tasks that do not require independent judgment should be delegated. Question 3 A mother brings her the clinic, complaining that the child seems to be .The nurse expects to find which of the following on the initial history and physical assessment? A) Increased temperature and lethargy B) Rash and restlessness C) Increased sleeping and listlessness D) Diarrhea and poor skin turgor Review Information: The correct answer is: B) Rash and restlessness. Question 4 As the nurse takes a history of a 3 year-old with neuroblastoma, what comments by the parents require follow-up and are consistent with the diagnosis? A) "The child has been listless and has lost weight." B) "Her urine is dark yellow and small in amounts." C) "Clothes are becoming tighter across her abdomen." D+) "We notice muscle weakness and some unsteadiness." Review Information: The correct answer is:C) "Clothes are becoming tighter across her abdomen.". One of the most common signs of neuroblastoma is increasing abdominal girth. The parents'' report that clothing is tight is significant, and should be followed by additional assessments. Question 5 A 16 year-old presents to the emergency department. The triage nurse finds that this teenager is legally married and signed the consent form for treatment. What would be the appropriate INITIAL action by the nurse? A) Refuse to see the client until a parent or legal guardian can be contacted B) Withhold treatment until telephone consent can be obtained from the spouse C) Refer the client to a community pediatric hospital emergency room D) Assess and treat in the same manner as any adult client Review Information: The correct answer is:D) Assess and treat in the same manner as any adult client. Minors may become known as an "emancipated minor" through marriage, pregnancy, high school graduation, independent living or service in the military. Therefore, this client, who is married, has the legal capacity of an adult. Question 6 A newly admitted elderly client is severely dehydrated. When planning care for this client, which one of the following is an appropriate task for an Unlicensed Assistive Personnel (UAP)? A) Obtain a history of fluid loss B) Report output of less than 30 ml/hr C) Monitor response to IV fluids D) Check skin turgor every four hours Review Information: The correct answer is:B) Report output of less than 30 ml/hr. When directing a UAP, the nurse must communicate clearly about each delegated task with specific instructions on what must be reported. Because the RN is responsible for all care-related decisions,only implementation tasks should be assigned because they do not require independent judgment. Question 7 The nurse is assessing a 4 year-old for possible rheumatic fever. Which of the following would the nurse suspect is related to this diagnosis? A) Diagnosis of chickenpox six months ago B) Exposure to strep throat in daycare last month

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Uploaded on
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Written in
2024/2025
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Exam (elaborations)
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Questions & answers

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NCSBN TEST BANK - for the NCLEX-RN &
NCLEX-PN UPDATED Question and
Answers
Question 1

A c. What document should be in guiding the care of this client?

A) Client Self Determination Act

B) Physician's treatment orders

C) Advance Directives.

D) Clinical Pathway protocols

Review Information: The correct answer is: C) Advance Directives. This document
specifies the client's wishes



Question 2

You are the of a health care team that consists of one licensed practical/vocational nurse,
one nursing assistant, a nursing student and yourself. To whom is it appropriate to assign
complete care for

A) Yourself

B) The nursing student

C) The licensed vocational nurse

D) The nursing assistant

Review Information: The correct answer is:A) Yourself.

While the nurse may delegate a bed bath for a stable client, this care should be performed
by an RN for a new admission. Only tasks that do not require independent judgment
should be delegated.



Question 3

,A mother brings her the clinic, complaining that the child seems to be .The nurse expects
to find which of the following on the initial history and physical assessment?

A) Increased temperature and lethargy

B) Rash and restlessness

C) Increased sleeping and listlessness

D) Diarrhea and poor skin turgor

Review Information: The correct answer is: B) Rash and restlessness.




Question 4

As the nurse takes a history of a 3 year-old with neuroblastoma, what comments by the
parents require follow-up and are consistent with the diagnosis?

A) "The child has been listless and has lost weight."

B) "Her urine is dark yellow and small in amounts."

C) "Clothes are becoming tighter across her abdomen."

D+) "We notice muscle weakness and some unsteadiness."

Review Information: The correct answer is:C) "Clothes are becoming tighter across her
abdomen.".

One of the most common signs of neuroblastoma is increasing abdominal girth. The
parents'' report that clothing is tight is significant, and should be followed by additional
assessments.



Question 5

A 16 year-old presents to the emergency department. The triage nurse finds that this
teenager is legally married and signed the consent form for treatment. What would be the
appropriate INITIAL action by the nurse?

A) Refuse to see the client until a parent or legal guardian can be contacted

,B) Withhold treatment until telephone consent can be obtained from the spouse

C) Refer the client to a community pediatric hospital emergency room

D) Assess and treat in the same manner as any adult client

Review Information: The correct answer is:D) Assess and treat in the same manner as
any adult client.

Minors may become known as an "emancipated minor" through marriage, pregnancy,
high school graduation, independent living or service in the military. Therefore, this
client, who is married, has the legal capacity of an adult.



Question 6

A newly admitted elderly client is severely dehydrated. When planning care for this
client, which one of the following is an appropriate task for an Unlicensed Assistive
Personnel (UAP)?

A) Obtain a history of fluid loss

B) Report output of less than 30 ml/hr

C) Monitor response to IV fluids

D) Check skin turgor every four hours

Review Information: The correct answer is:B) Report output of less than 30 ml/hr.

When directing a UAP, the nurse must communicate clearly about each delegated task
with specific instructions on what must be reported. Because the RN is responsible for all
care-related decisions,only implementation tasks should be assigned because they do not
require independent judgment.



Question 7

The nurse is assessing a 4 year-old for possible rheumatic fever. Which of the following
would the nurse suspect is related to this diagnosis?

A) Diagnosis of chickenpox six months ago

B) Exposure to strep throat in daycare last month

, C) Treatment for ear infection two months ago

D) Episode of fungal skin infection last week

Review Information: The correct answer is:B) Exposure to strep throat in daycare last
month.

Evidence supports a strong relationship between infection with Group A streptococci and
subsequent rheumatic fever (usually within 2-6 weeks). Therefore, the history of
playmates recovering from strep throat would indicate that the child diagnosed with
rheumatic fever most likely also had strep throat. Sometimes, such an infection has no
clinical symptoms.



Question 8

When the nurse becomes aware of feeling reluctant to interact with a manipulative client,
the BEST action by the nurse is to

A) Discuss the feeling of reluctance with an objective peer or supervisor

B) Limit contacts with the client to avoid reinforcing the manipulative behavior

C) Confront the client regarding the negative effects of his/her behavior on others

D) Develop a behavior modification plan that will promote more functional behavior

Review Information: The correct answer is:A) Discuss the feeling of reluctance with an
objective peer or supervisor.

The nurse who is experiencing stress in the therapeutic relationship can gain objectivity
through supervision. The nurse must attempt to discover attitudes and feelings in the self
that influence the nurse-client relationship.



Question 9

A client is being treated for paranoid schizophrenia. When the client became loud and
boisterous, the nurse immediately placed him in seclusion as a precautionary measure.
The client willingly complied. The nurse's action

A) May result in charges of unlawful seclusion and restraint

B) Leaves the nurse vulnerable for charges of assault and battery
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