Test Bank NCSSBV NCLEX 2024:2027
Question 1
What document should be in guiding the care of this client?
Advance Directives
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
Yourself
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?
"Clothes are becoming tighter across her abdomen."
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?
Assess and treat in the same manner as any adult client
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)?
Report output of less than 30 ml/hr
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?
Exposure to strep throat in daycare last month
Question 8
When the nurse becomes aware of feeling reluctant to interact with a manipulative client, the BEST action by the
nurse is to
Discuss the feeling of reluctance with an objective peer or supervisor
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
May result in charges of unlawful seclusion and restraint
,Question 10
A client has been admitted to the Coronary Care Unit with a Myocardial Infarction. Which of the following nursing
diagnosis should have PRIORITY?
Pain related to ischemia
Question 11
The nurse manager who is responsible for hiring professional nursing staff is required to comply with the Americans
with Disabilities Act. The provisions of the law require the nurse manager to
Provide reasonable accommodations for disabled individuals
Question 12
The mother of a school-aged child in a long leg cast asks the nurse how to relieve itching inside the cast. Which of
the following is appropriate for the nurse to suggest as a remedy?
Applying an ice pack over the area of the cast that is affected
Question 13
Which of the following BEST describes the application of time management strategies in the role of the nurse
manager?
Setting daily goals to prioritize work
Question 14
The clinic nurse assesses a toddler with a tentative diagnosis of neuroblastoma. Symptoms the nurse observes that
suggest this problem include
Abdominal mass and weakness
Question 15
A fifteen-year-old client has been placed in a Milwaukee Brace. Which one of the following statements from the client indicates the
need for additional teaching?
"I will only have to wear this for six months."
Question 16
The nurse manager has been using a decentralized block scheduling plan to staff the nursing unit. However, staff have asked for
many changes and exceptions to the schedule over the past few months. The manager considers self-scheduling knowing that
Team morale will improve
Question 17
A client is admitted to the emergency room following an acute asthma attack. Which of the following assessments
would be expected by the nurse?
Diffuse expiratory wheezing
Question 18
,The nurse manager hears a physician loudly criticizing one of the staff nurses in the hearing of others. The
employee does not respond to the physician's complaints. The nurse manager's FIRST action should be
Request an immediate private meeting with the physician and staff nurse
Question 19
A client voluntarily admits herself to the hospital due to suicidal ideation. The client has been on the unit for two
days and is now demanding to be released. The MOST appropriate action is for the nurse to
Discuss with the client the decision to leave and prepare for her discharge
Question 20
A client is admitted with infective endocarditis (IE). Which symptom would alert the nurse to a complication of this
condition?
Heart murmur
Question 21
A nurse admits a premature infant who has respiratory distress syndrome. In planning care, nursing actions are
based on the fact that the MOST likely cause of this problem stems from the infant's inability to
Maintain alveolar surface tension
Question 22
An 18-year-old client is admitted to intensive care from the emergency room following a diving accident. The injury
is suspected to be at the level of the 2nd cervical vertebrae. The nurse's PRIORITY assessment should be
Respiratory function
Question 23
The nurse is caring for a client who was successfully resuscitated from a pulseless dysrhythmia. Which of the
following assessments is CRITICAL for the nurse to include in the plan of care?
Hourly urine output
Question 24
The nurse admitting a 5-month-old who vomited nine times in the past six hours should observe for signs of
Metabolic alkalosis
Question 25
A child is injured on the school playground and appears to have a fractured leg. The FIRST action the school nurse
should take is
Assess the child and the extent of the injury
Question 26
As the nurse interviews the parents of a child with asthma, it is a PRIORITY to ask about
Household pets
, Question 27
An 80-year-old client was admitted with a diagnosis of possible cerebral vascular accident. Blood pressure has
ranged from 180/110 to 160/100. Over the past several hours, the nurse noted increasing lethargy. Which of
the following assessments should the nurse report IMMEDIATELY to the physician?
Slurred speech
Question 28
A 3-year-old child is brought to the clinic by his grandmother to be seen for " scratching his bottom and wetting the
bed at night." Based on these complaints, the nurse would INITIALLY assess for
Pinworms
Question 29
A 72-year-old client with osteomyelitis requires a six-week course of intravenous antibiotics. In planning for home
care, the MOST important action by the nurse is
Assessing the client's ability to participate in self-care and/or the reliability of a caregiver
Question 30
The mother of a child with a neural tube defect asks the nurse what she can do to decrease the chances of having
another baby with a neural tube defect. The BEST response by the nurse is
"Folic acid should be taken before and after conception."
Question 31
The nurse is caring for a newborn with a neural tube defect. The BEST covering for the lesion is
Moist sterile nonadherent dressing
Question 32
A nurse is providing a parenting class to individuals living in a community of older homes. In discussing formula
preparation, which of the following is most important to prevent lead poisoning?
Let tap water run for 2 minutes before adding to concentrate
Question 33
A client is admitted to the rehabilitation unit following a CVA and mild dysphagia. The MOST appropriate
intervention for this client is
Position client in upright position while eating
Question 34
The nurse explains an autograft to a client scheduled for excision of a skin tumor. The nurse knows the client
understands the procedure when the client says,
"I will receive tissue from my thigh.”
Question 35
Question 1
What document should be in guiding the care of this client?
Advance Directives
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
Yourself
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?
"Clothes are becoming tighter across her abdomen."
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?
Assess and treat in the same manner as any adult client
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)?
Report output of less than 30 ml/hr
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?
Exposure to strep throat in daycare last month
Question 8
When the nurse becomes aware of feeling reluctant to interact with a manipulative client, the BEST action by the
nurse is to
Discuss the feeling of reluctance with an objective peer or supervisor
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
May result in charges of unlawful seclusion and restraint
,Question 10
A client has been admitted to the Coronary Care Unit with a Myocardial Infarction. Which of the following nursing
diagnosis should have PRIORITY?
Pain related to ischemia
Question 11
The nurse manager who is responsible for hiring professional nursing staff is required to comply with the Americans
with Disabilities Act. The provisions of the law require the nurse manager to
Provide reasonable accommodations for disabled individuals
Question 12
The mother of a school-aged child in a long leg cast asks the nurse how to relieve itching inside the cast. Which of
the following is appropriate for the nurse to suggest as a remedy?
Applying an ice pack over the area of the cast that is affected
Question 13
Which of the following BEST describes the application of time management strategies in the role of the nurse
manager?
Setting daily goals to prioritize work
Question 14
The clinic nurse assesses a toddler with a tentative diagnosis of neuroblastoma. Symptoms the nurse observes that
suggest this problem include
Abdominal mass and weakness
Question 15
A fifteen-year-old client has been placed in a Milwaukee Brace. Which one of the following statements from the client indicates the
need for additional teaching?
"I will only have to wear this for six months."
Question 16
The nurse manager has been using a decentralized block scheduling plan to staff the nursing unit. However, staff have asked for
many changes and exceptions to the schedule over the past few months. The manager considers self-scheduling knowing that
Team morale will improve
Question 17
A client is admitted to the emergency room following an acute asthma attack. Which of the following assessments
would be expected by the nurse?
Diffuse expiratory wheezing
Question 18
,The nurse manager hears a physician loudly criticizing one of the staff nurses in the hearing of others. The
employee does not respond to the physician's complaints. The nurse manager's FIRST action should be
Request an immediate private meeting with the physician and staff nurse
Question 19
A client voluntarily admits herself to the hospital due to suicidal ideation. The client has been on the unit for two
days and is now demanding to be released. The MOST appropriate action is for the nurse to
Discuss with the client the decision to leave and prepare for her discharge
Question 20
A client is admitted with infective endocarditis (IE). Which symptom would alert the nurse to a complication of this
condition?
Heart murmur
Question 21
A nurse admits a premature infant who has respiratory distress syndrome. In planning care, nursing actions are
based on the fact that the MOST likely cause of this problem stems from the infant's inability to
Maintain alveolar surface tension
Question 22
An 18-year-old client is admitted to intensive care from the emergency room following a diving accident. The injury
is suspected to be at the level of the 2nd cervical vertebrae. The nurse's PRIORITY assessment should be
Respiratory function
Question 23
The nurse is caring for a client who was successfully resuscitated from a pulseless dysrhythmia. Which of the
following assessments is CRITICAL for the nurse to include in the plan of care?
Hourly urine output
Question 24
The nurse admitting a 5-month-old who vomited nine times in the past six hours should observe for signs of
Metabolic alkalosis
Question 25
A child is injured on the school playground and appears to have a fractured leg. The FIRST action the school nurse
should take is
Assess the child and the extent of the injury
Question 26
As the nurse interviews the parents of a child with asthma, it is a PRIORITY to ask about
Household pets
, Question 27
An 80-year-old client was admitted with a diagnosis of possible cerebral vascular accident. Blood pressure has
ranged from 180/110 to 160/100. Over the past several hours, the nurse noted increasing lethargy. Which of
the following assessments should the nurse report IMMEDIATELY to the physician?
Slurred speech
Question 28
A 3-year-old child is brought to the clinic by his grandmother to be seen for " scratching his bottom and wetting the
bed at night." Based on these complaints, the nurse would INITIALLY assess for
Pinworms
Question 29
A 72-year-old client with osteomyelitis requires a six-week course of intravenous antibiotics. In planning for home
care, the MOST important action by the nurse is
Assessing the client's ability to participate in self-care and/or the reliability of a caregiver
Question 30
The mother of a child with a neural tube defect asks the nurse what she can do to decrease the chances of having
another baby with a neural tube defect. The BEST response by the nurse is
"Folic acid should be taken before and after conception."
Question 31
The nurse is caring for a newborn with a neural tube defect. The BEST covering for the lesion is
Moist sterile nonadherent dressing
Question 32
A nurse is providing a parenting class to individuals living in a community of older homes. In discussing formula
preparation, which of the following is most important to prevent lead poisoning?
Let tap water run for 2 minutes before adding to concentrate
Question 33
A client is admitted to the rehabilitation unit following a CVA and mild dysphagia. The MOST appropriate
intervention for this client is
Position client in upright position while eating
Question 34
The nurse explains an autograft to a client scheduled for excision of a skin tumor. The nurse knows the client
understands the procedure when the client says,
"I will receive tissue from my thigh.”
Question 35
