NCSBN TEST-BANK - FOR THE NCLEX-RN & NCLEX-
PN, UPDATED 2023, ALL QUESTIONS & ANSWERS
WITH RATIONALE
Multiple Questions with 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: CORRECT ANS >> is: C) Advance Directives. This document speci$es 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: CORRECT ANS >> 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 $nd which of
the following on the initial history and physical assessment?
A) Increased temperature and lethargy
B) Rash and restlessness
C) Increased sleeping and listlessness
D) Diarrhea and poor skin turgor
Review Information: CORRECT ANS >> is:B) Rash and restlessness.
,Question 4
As the nurse takes a history of a 3 year-old with neuroblastoma, what comments by the parents require
follow-up and are consistent with the diagnosis?
A) "The child has been listless and has lost weight."
B) "Her urine is dark yellow and small in amounts."
C) "Clothes are becoming tighter across her abdomen."
D+) "We notice muscle weakness and some unsteadiness."
Review Information: CORRECT ANS >> is:C) "Clothes are becoming tighter across her abdomen.".
One of the most common signs of neuroblastoma is increasing abdominal girth. The parents'' report that
clothing is tight is signi$cant, and should be followed by additional assessments.
Question 5
A 16 year-old presents to the emergency department. The triage nurse $nds that this teenager is legally
married and signed the consent form for treatment. What would be the appropriate INITIAL action by the
nurse?
A) Refuse to see the client until a parent or legal guardian can be contacted
B) Withhold treatment until telephone consent can be obtained from the spouse
C) Refer the client to a community pediatric hospital emergency room
D) Assess and treat in the same manner as any adult client
Review Information: CORRECT ANS >> is:D) Assess and treat in the same manner as any adult
client.
Minors may become known as an "emancipated minor" through marriage, pregnancy, high school
graduation, independent living or service in the military. Therefore, this client, who is married, has the legal
capacity of an adult.
Question 6
A newly admitted elderly client is severely dehydrated. When planning care for this client, which one of the
following is an appropriate task for an Unlicensed Assistive Personnel (UAP)?
, A) Obtain a history of ;uid loss
B) Report output of less than 30 ml/hr
C) Monitor response to IV ;uids
D) Check skin turgor every four hours
Review Information: CORRECT ANS >> is:B) Report output of less than 30 ml/hr.
When directing a UAP, the nurse must communicate clearly about each delegated task with speci$c
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: CORRECT ANS >> 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 modi$cation plan that will promote more functional behavior
Review Information: CORRECT ANS >> is:A) Discuss the feeling of reluctance with an objective
peer or supervisor.
The nurse who is experiencing stress in the therapeutic relationship can gain objectivity through
supervision. The nurse must attempt to discover attitudes and feelings in the self that in;uence the nurse-
client relationship.
PN, UPDATED 2023, ALL QUESTIONS & ANSWERS
WITH RATIONALE
Multiple Questions with Answers
Question 1
A c. What document should be in guiding the care of this client?
A) Client Self Determination Act
B) Physician's treatment orders
C) Advance Directives.
D) Clinical Pathway protocols
Review Information: CORRECT ANS >> is: C) Advance Directives. This document speci$es 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: CORRECT ANS >> 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 $nd which of
the following on the initial history and physical assessment?
A) Increased temperature and lethargy
B) Rash and restlessness
C) Increased sleeping and listlessness
D) Diarrhea and poor skin turgor
Review Information: CORRECT ANS >> is:B) Rash and restlessness.
,Question 4
As the nurse takes a history of a 3 year-old with neuroblastoma, what comments by the parents require
follow-up and are consistent with the diagnosis?
A) "The child has been listless and has lost weight."
B) "Her urine is dark yellow and small in amounts."
C) "Clothes are becoming tighter across her abdomen."
D+) "We notice muscle weakness and some unsteadiness."
Review Information: CORRECT ANS >> is:C) "Clothes are becoming tighter across her abdomen.".
One of the most common signs of neuroblastoma is increasing abdominal girth. The parents'' report that
clothing is tight is signi$cant, and should be followed by additional assessments.
Question 5
A 16 year-old presents to the emergency department. The triage nurse $nds that this teenager is legally
married and signed the consent form for treatment. What would be the appropriate INITIAL action by the
nurse?
A) Refuse to see the client until a parent or legal guardian can be contacted
B) Withhold treatment until telephone consent can be obtained from the spouse
C) Refer the client to a community pediatric hospital emergency room
D) Assess and treat in the same manner as any adult client
Review Information: CORRECT ANS >> is:D) Assess and treat in the same manner as any adult
client.
Minors may become known as an "emancipated minor" through marriage, pregnancy, high school
graduation, independent living or service in the military. Therefore, this client, who is married, has the legal
capacity of an adult.
Question 6
A newly admitted elderly client is severely dehydrated. When planning care for this client, which one of the
following is an appropriate task for an Unlicensed Assistive Personnel (UAP)?
, A) Obtain a history of ;uid loss
B) Report output of less than 30 ml/hr
C) Monitor response to IV ;uids
D) Check skin turgor every four hours
Review Information: CORRECT ANS >> is:B) Report output of less than 30 ml/hr.
When directing a UAP, the nurse must communicate clearly about each delegated task with speci$c
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: CORRECT ANS >> 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 modi$cation plan that will promote more functional behavior
Review Information: CORRECT ANS >> 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 in;uence the nurse-
client relationship.
