NCSBN TEST BANK
1. A 43-year-old African American male is admitted with sickle cell anemia. The nurse plans to assess
circulation in the lower extremities every two hours. Which of the following outcome criteria?
❍ A. Body temperature of 99°F or less
❍ B. Toes moved in active range of motion
❍ C. Sensation reported when soles of feet are touched
❍ D. Capillary refill of < 3 seconds
2. A 30-year-old male from Haiti is brought to the emergency department in sickle cell crisis. What is
the best position for this client?
❍ A. Side-lying with knees flexed
❍ B. Knee-chest
❍ C. High Fowler’s with knees flexed
❍ D. Semi-Fowler’s with legs extended on the bed
3. A 25-year-old male is admitted in sickle cell crisis. Which of the following interventions would be of
highest priority for this client?
❍ A. Taking hourly blood pressures with mechanical cuff
❍ B. Encouraging fluid intake of at least 200mL per hour
❍ C. Position in high Fowler’s with knee gatch raised
❍ D. Administering Tylenol as ordered
4. Which of the following foods would the nurse encourage the client in sickle cell crisis to eat?
❍ A. Steak
❍ B. Cottage cheese
❍ C. Popsicle
❍ D. Lima beans
5. A newly admitted client has sickle cell crisis. He is complaining of pain in his feet and hands. The
nurse’s assessment finding include a pulse oximetry of 92. Assuming that all the following
interventions are ordered, which should be done first?
❍ A. Adjust the room temperature
❍ B. Give a bolus of IV fluids
❍ C. Start O 2
❍ D. Administer meperidine (Demerol) 75mg IV push
6. The nurse is instructing a client with iron-deficiency anemia. Which of the following meal plans
would the nurse expect the client to select?
❍ A. Roast beef, gelatin salad, green beans, and peach pie
❍ B. Chicken salad sandwich, coleslaw, French fries, ice cream
❍ C. Egg salad on wheat bread, carrot sticks, lettuce salad, raisin pie
❍ D. Pork chop, creamed potatoes, corn, and coconut cake
7. Clients with sickle cell anemia are taught to avoid activities that cause hypoxia and hypoxemia.
Which of the following activities would the nurse recommend?
❍ A. A family vacation in the Rocky Mountains
❍ B. Chaperoning the local boys club on a snow-skiing trip
❍ C. Traveling by airplane for business trips
❍ D. A bus trip to the Museum of Natural History
1
, NCSBN TEST BANK
8. The nurse is conducting an admission assessment of a client with Vitamin B12 deficiency. Which
finding reinforces the diagnosis of B12 deficiency?
❍ A. Enlarged spleen
❍ B. Elevated blood pressure
❍ C. Bradycardia
❍ D. Beefy tongue
9. The body part that would most likely display jaundice in the dark skinned individual is the:
❍ A. Conjunctiva of the eye
❍ B. Soles of the feet
❍ C. Roof of the mouth
❍ D. Shins
10. The nurse is conducting a physical assessment on a client with anemia. Which of the following
clinical manifestations would be most indicative of the anemia?
❍ A. BP 146/88
❍ B. Respirations 28 shallow
❍ C. Weight gain of 10 pounds in six months
❍ D. Pink complexion
11. The nurse is teaching the client with polycythemia vera about prevention of complications of the
disease. Which of the following statements by the client indicates a need for further teaching?
❍ A. “I will drink 500mL of fluid or less each day.”
❍ B. “I will wear support hose.”
❍ C. “I will check my blood pressure regularly.”
❍ D. “I will report ankle edema.”
12. A 33-year-old male is being evaluated for possible acute leukemia. Which of the following findings
is most likely related to the diagnosis of leukemia?
❍ A. The client collects stamps as a hobby.
❍ B. The client recently lost his job as a postal worker.
❍ C. The client had radiation for treatment of Hodgkin’s disease as a teenager.
❍ D. The client’s brother had leukemia as a child.
13. Where is the best site for examining for the presence of petechiae in an African American client?
❍ A. The abdomen
❍ B. The thorax
❍ C. The earlobes
❍ D. The soles of the feet
14. The client is being evaluated for possible acute leukemia. Which inquiry by the nurse is most
important?
❍ A. “Have you noticed a change in sleeping habits recently?”
❍ B. “Have you had a respiratory infection in the last six months?”
❍ C. “Have you lost weight recently?”
❍ D. “Have you noticed changes in your alertness?”
2
, NCSBN TEST BANK
15. Which of the following would be the priority nursing diagnosis for the adult client with acute
leukemia?
❍ A. Oral mucous membrane, altered related to chemotherapy
❍ B. Risk for injury related to thrombocytopenia
❍ C. Fatigue related to the disease process
❍ D. Interrupted family processes related to life-threatening illness of a family member
16. A 21-year-old male with Hodgkin’s lymphoma is a senior at the local university. He is engaged to be
married and is to begin a new job upon graduation. Which of the following diagnoses would be a
priority for this client?
❍ A. Sexual dysfunction related to radiation therapy
❍ B. Anticipatory grieving related to terminal illness
❍ C. Tissue integrity related to prolonged bed rest
❍ D. Fatigue related to chemotherapy
17. A client has autoimmune thrombocytopenic purpura. To determine the client’s response to
treatment, the nurse would monitor:
❍ A. Platelet count
❍ B. White blood cell count
❍ C. Potassium levels
❍ D. Partial prothrombin time (PTT)
18. The home health nurse is visiting a client with autoimmune thrombocytopenic purpura (ATP). The
client’s platelet count currently is 80,000. It will be most important to teach the client and family about:
❍ A. Bleeding precautions
❍ B. Prevention of falls
❍ C. Oxygen therapy
❍ D. Conservation of energy
19. The client has surgery for removal of a Prolactinoma. Which of the following interventions would be
appropriate for this client?
❍ A. Place the client in Trendelenburg position for postural drainage.
❍ B. Encourage coughing and deep breathing every two hours.
❍ C. Elevate the head of the bed 30°.
❍ D. Encourage the Valsalva maneuver for bowel movements.
20. The client with a history of diabetes insipidus is admitted with polyuria, polydipsia, and mental
confusion. The priority intervention for this client is:
❍ A. Measure the urinary output.
❍ B. Check the vital signs.
❍ C. Encourage increased fluid intake.
❍ D. Weigh the client.
21. A client with hemophilia has a nosebleed. Which nursing action is appropriate to control the
bleeding?
❍ A. Place the client in a sitting position.
❍ B. Administer acetaminophen (Tylenol).
❍ C. Pinch the soft lower part of the nose.
❍ D. Apply ice packs to the forehead.
3
, NCSBN TEST BANK
22. A client has had a unilateral adrenalectomy to remove a tumor. The most important measurement in
the immediate post-operative period for the nurse to take is:
❍ A. The blood pressure
❍ B. The temperature
❍ C. The urinary output
❍ D. The specific gravity of the urine
23. A client with Addison’s disease has been admitted with a history of nausea and vomiting for the
past three days. The client is receiving IV glucocorticoids (Solu-Medrol). Which of the following
interventions would the nurse implement?
❍ A. Glucometer readings as ordered
❍ B. Intake/output measurements
❍ C. Evaluating the sodium and potassium levels
❍ D. Daily weights
24. A client had a total thyroidectomy yesterday. The client is complaining of tingling around the mouth
and in the fingers and toes. What would the nurses’ next action be?
❍ A. Obtain a crash cart.
❍ B. Check the calcium level.
❍ C. Assess the dressing for drainage.
❍ D. Assess the blood pressure for hypertension.
25. A 32-year-old mother of three is brought to the clinic. Her pulse is 52, there is a weight gain of 30
pounds in four months, and the client is wearing two sweaters. The client is diagnosed with
hypothyroidism. Which of the following nursing diagnoses is of highest priority?
❍ A. Impaired physical mobility related to decreased endurance
❍ B. Hypothermia r/t decreased metabolic rate
❍ C. Disturbed thought processes r/t interstitial edema
❍ D. Decreased cardiac output r/t bradycardia
26. The client presents to the clinic with a serum cholesterol of 275mg/dL and is placed on
rosuvastatin (Crestor). Which instruction should be given to the client taking rosuvastatin (Crestor)?
❍ A. Report muscle weakness to the physician.
❍ B. Allow six months for the drug to take effect.
❍ C. Take the medication with fruit juice.
❍ D. Report difficulty sleeping.
27. The client is admitted to the hospital with hypertensive crises. Diazoxide (Hyperstat) is ordered.
During administration, the nurse should:
❍ A. Utilize an infusion pump.
❍ B. Check the blood glucose level.
❍ C. Place the client in Trendelenburg position.
❍ D. Cover the solution with foil.
28. The six-month-old client with a ventral septal defect is receiving
❍ A. Blood pressure of 126/80
❍ B. Blood glucose of 110mg/dL
❍ C. Heart rate of 60bpm
❍ D. Respiratory rate of 30 per minute
4
1. A 43-year-old African American male is admitted with sickle cell anemia. The nurse plans to assess
circulation in the lower extremities every two hours. Which of the following outcome criteria?
❍ A. Body temperature of 99°F or less
❍ B. Toes moved in active range of motion
❍ C. Sensation reported when soles of feet are touched
❍ D. Capillary refill of < 3 seconds
2. A 30-year-old male from Haiti is brought to the emergency department in sickle cell crisis. What is
the best position for this client?
❍ A. Side-lying with knees flexed
❍ B. Knee-chest
❍ C. High Fowler’s with knees flexed
❍ D. Semi-Fowler’s with legs extended on the bed
3. A 25-year-old male is admitted in sickle cell crisis. Which of the following interventions would be of
highest priority for this client?
❍ A. Taking hourly blood pressures with mechanical cuff
❍ B. Encouraging fluid intake of at least 200mL per hour
❍ C. Position in high Fowler’s with knee gatch raised
❍ D. Administering Tylenol as ordered
4. Which of the following foods would the nurse encourage the client in sickle cell crisis to eat?
❍ A. Steak
❍ B. Cottage cheese
❍ C. Popsicle
❍ D. Lima beans
5. A newly admitted client has sickle cell crisis. He is complaining of pain in his feet and hands. The
nurse’s assessment finding include a pulse oximetry of 92. Assuming that all the following
interventions are ordered, which should be done first?
❍ A. Adjust the room temperature
❍ B. Give a bolus of IV fluids
❍ C. Start O 2
❍ D. Administer meperidine (Demerol) 75mg IV push
6. The nurse is instructing a client with iron-deficiency anemia. Which of the following meal plans
would the nurse expect the client to select?
❍ A. Roast beef, gelatin salad, green beans, and peach pie
❍ B. Chicken salad sandwich, coleslaw, French fries, ice cream
❍ C. Egg salad on wheat bread, carrot sticks, lettuce salad, raisin pie
❍ D. Pork chop, creamed potatoes, corn, and coconut cake
7. Clients with sickle cell anemia are taught to avoid activities that cause hypoxia and hypoxemia.
Which of the following activities would the nurse recommend?
❍ A. A family vacation in the Rocky Mountains
❍ B. Chaperoning the local boys club on a snow-skiing trip
❍ C. Traveling by airplane for business trips
❍ D. A bus trip to the Museum of Natural History
1
, NCSBN TEST BANK
8. The nurse is conducting an admission assessment of a client with Vitamin B12 deficiency. Which
finding reinforces the diagnosis of B12 deficiency?
❍ A. Enlarged spleen
❍ B. Elevated blood pressure
❍ C. Bradycardia
❍ D. Beefy tongue
9. The body part that would most likely display jaundice in the dark skinned individual is the:
❍ A. Conjunctiva of the eye
❍ B. Soles of the feet
❍ C. Roof of the mouth
❍ D. Shins
10. The nurse is conducting a physical assessment on a client with anemia. Which of the following
clinical manifestations would be most indicative of the anemia?
❍ A. BP 146/88
❍ B. Respirations 28 shallow
❍ C. Weight gain of 10 pounds in six months
❍ D. Pink complexion
11. The nurse is teaching the client with polycythemia vera about prevention of complications of the
disease. Which of the following statements by the client indicates a need for further teaching?
❍ A. “I will drink 500mL of fluid or less each day.”
❍ B. “I will wear support hose.”
❍ C. “I will check my blood pressure regularly.”
❍ D. “I will report ankle edema.”
12. A 33-year-old male is being evaluated for possible acute leukemia. Which of the following findings
is most likely related to the diagnosis of leukemia?
❍ A. The client collects stamps as a hobby.
❍ B. The client recently lost his job as a postal worker.
❍ C. The client had radiation for treatment of Hodgkin’s disease as a teenager.
❍ D. The client’s brother had leukemia as a child.
13. Where is the best site for examining for the presence of petechiae in an African American client?
❍ A. The abdomen
❍ B. The thorax
❍ C. The earlobes
❍ D. The soles of the feet
14. The client is being evaluated for possible acute leukemia. Which inquiry by the nurse is most
important?
❍ A. “Have you noticed a change in sleeping habits recently?”
❍ B. “Have you had a respiratory infection in the last six months?”
❍ C. “Have you lost weight recently?”
❍ D. “Have you noticed changes in your alertness?”
2
, NCSBN TEST BANK
15. Which of the following would be the priority nursing diagnosis for the adult client with acute
leukemia?
❍ A. Oral mucous membrane, altered related to chemotherapy
❍ B. Risk for injury related to thrombocytopenia
❍ C. Fatigue related to the disease process
❍ D. Interrupted family processes related to life-threatening illness of a family member
16. A 21-year-old male with Hodgkin’s lymphoma is a senior at the local university. He is engaged to be
married and is to begin a new job upon graduation. Which of the following diagnoses would be a
priority for this client?
❍ A. Sexual dysfunction related to radiation therapy
❍ B. Anticipatory grieving related to terminal illness
❍ C. Tissue integrity related to prolonged bed rest
❍ D. Fatigue related to chemotherapy
17. A client has autoimmune thrombocytopenic purpura. To determine the client’s response to
treatment, the nurse would monitor:
❍ A. Platelet count
❍ B. White blood cell count
❍ C. Potassium levels
❍ D. Partial prothrombin time (PTT)
18. The home health nurse is visiting a client with autoimmune thrombocytopenic purpura (ATP). The
client’s platelet count currently is 80,000. It will be most important to teach the client and family about:
❍ A. Bleeding precautions
❍ B. Prevention of falls
❍ C. Oxygen therapy
❍ D. Conservation of energy
19. The client has surgery for removal of a Prolactinoma. Which of the following interventions would be
appropriate for this client?
❍ A. Place the client in Trendelenburg position for postural drainage.
❍ B. Encourage coughing and deep breathing every two hours.
❍ C. Elevate the head of the bed 30°.
❍ D. Encourage the Valsalva maneuver for bowel movements.
20. The client with a history of diabetes insipidus is admitted with polyuria, polydipsia, and mental
confusion. The priority intervention for this client is:
❍ A. Measure the urinary output.
❍ B. Check the vital signs.
❍ C. Encourage increased fluid intake.
❍ D. Weigh the client.
21. A client with hemophilia has a nosebleed. Which nursing action is appropriate to control the
bleeding?
❍ A. Place the client in a sitting position.
❍ B. Administer acetaminophen (Tylenol).
❍ C. Pinch the soft lower part of the nose.
❍ D. Apply ice packs to the forehead.
3
, NCSBN TEST BANK
22. A client has had a unilateral adrenalectomy to remove a tumor. The most important measurement in
the immediate post-operative period for the nurse to take is:
❍ A. The blood pressure
❍ B. The temperature
❍ C. The urinary output
❍ D. The specific gravity of the urine
23. A client with Addison’s disease has been admitted with a history of nausea and vomiting for the
past three days. The client is receiving IV glucocorticoids (Solu-Medrol). Which of the following
interventions would the nurse implement?
❍ A. Glucometer readings as ordered
❍ B. Intake/output measurements
❍ C. Evaluating the sodium and potassium levels
❍ D. Daily weights
24. A client had a total thyroidectomy yesterday. The client is complaining of tingling around the mouth
and in the fingers and toes. What would the nurses’ next action be?
❍ A. Obtain a crash cart.
❍ B. Check the calcium level.
❍ C. Assess the dressing for drainage.
❍ D. Assess the blood pressure for hypertension.
25. A 32-year-old mother of three is brought to the clinic. Her pulse is 52, there is a weight gain of 30
pounds in four months, and the client is wearing two sweaters. The client is diagnosed with
hypothyroidism. Which of the following nursing diagnoses is of highest priority?
❍ A. Impaired physical mobility related to decreased endurance
❍ B. Hypothermia r/t decreased metabolic rate
❍ C. Disturbed thought processes r/t interstitial edema
❍ D. Decreased cardiac output r/t bradycardia
26. The client presents to the clinic with a serum cholesterol of 275mg/dL and is placed on
rosuvastatin (Crestor). Which instruction should be given to the client taking rosuvastatin (Crestor)?
❍ A. Report muscle weakness to the physician.
❍ B. Allow six months for the drug to take effect.
❍ C. Take the medication with fruit juice.
❍ D. Report difficulty sleeping.
27. The client is admitted to the hospital with hypertensive crises. Diazoxide (Hyperstat) is ordered.
During administration, the nurse should:
❍ A. Utilize an infusion pump.
❍ B. Check the blood glucose level.
❍ C. Place the client in Trendelenburg position.
❍ D. Cover the solution with foil.
28. The six-month-old client with a ventral septal defect is receiving
❍ A. Blood pressure of 126/80
❍ B. Blood glucose of 110mg/dL
❍ C. Heart rate of 60bpm
❍ D. Respiratory rate of 30 per minute
4
