NCSBN TEST BANK - for the NCLEX- RN & NCLEX-PN,
UPDATED EDITION,
Complete Questions & Answers with rationale
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.
3Question 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
UPDATED EDITION,
Complete Questions & Answers with rationale
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.
3Question 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
