NCSBN TEST BANK - for the NCLEX-RN &
NCLEX-PN UPDATED andAnswers
1
A c. What document should be in guiding the care of this patient?
A) Patient Self Determination Act
B) Physician's treatment orders
C) Advance Directives.
D) Clinical Pathway protocols
Feedback: The correct answer is: C) Advance Directives. This documentspecifies the
patient's wishes
2
You are the of a health care team that consists of one licensed practical/vocational
registered nurse, one nursing assistant, a nursing student and yourself. To whom is it
appropriate to assigncomplete care for
A) Yourself
B) The nursing student
C) The licensed vocational registered nurse
D) The nursing assistant
Feedback: The correct answer is:A) Yourself.
While the registered nurse may delegate a bed bath for a stable patient, this care should
be performedby an RN for a new admission. Only tasks that do not require independent
judgment should be delegated.
3
,A mother brings her the clinic, complaining that the child seems to be .The registered
nurse expectsto 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
Feedback: The correct answer is: B) Rash and restlessness.
4
As the registered nurse takes a history of a 3 year-old with neuroblastoma, what comments
by theparents 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."
Feedback: The correct answer is:C) "Clothes are becoming tighter across herabdomen.".
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.
5
A 16 year-old presents to the emergency department. The triage registered nurse finds that
this teenager is legally married and signed the consent form for treatment. What would be
theappropriate INITIAL action by the registered nurse?
A) Refuse to see the patient until a parent or legal guardian can be contacted
,B) Withhold treatment until telephone consent can be obtained from the spouse
C) Refer the patient to a community pediatric hospital emergency room
D) Assess and treat in the same manner as any adult patient
Feedback: The correct answer is:D) Assess and treat in the same manner asany adult
patient.
Minors may become known as an "emancipated minor" through marriage, pregnancy,
high school graduation, independent living or service in the military. Therefore, this
patient, who is married, has the legal capacity of an adult.
6
A newly admitted elderly patient is severely dehydrated. When planning care for
this patient, which one of the following is an appropriate task for an Unlicensed
AssistivePersonnel (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
Feedback: The correct answer is:B) Report output of less than 30 ml/hr.
When directing a UAP, the registered nurse must communicate clearly about each
delegated task with specific instructions on what must be reported. Because the RN is
responsible for allcare-related decisions,only implementation tasks should be assigned
because they do not require independent judgment.
7
The registered nurse is assessing a 4 year-old for possible rheumatic fever. Which of the
followingwould the registered 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
Feedback: The correct answer is:B) Exposure to strep throat in daycare lastmonth.
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.
8
When the registered nurse becomes aware of feeling reluctant to interact with a
manipulative patient,the BEST action by the registered nurse is to
A) Discuss the feeling of reluctance with an objective peer or supervisor
B) Limit contacts with the patient to avoid reinforcing the manipulative behavior
C) Confront the patient regarding the negative effects of his/her behavior on others
D) Develop a behavior modification plan that will promote more functional behavior
Feedback: The correct answer is:A) Discuss the feeling of reluctance with anobjective
peer or supervisor.
The registered nurse who is experiencing stress in the therapeutic relationship can gain
objectivity through supervision. The registered nurse must attempt to discover attitudes
and feelings in the selfthat influence the registered nurse-patient relationship.
9
A patient is being treated for paranoid schizophrenia. When the patient became loud
and boisterous, the registered nurse immediately placed him in seclusion as a
precautionary measure.The patient willingly complied. The registered nurse's action
A) May result in charges of unlawful seclusion and restraint
B) Leaves the registered nurse vulnerable for charges of assault and battery
NCLEX-PN UPDATED andAnswers
1
A c. What document should be in guiding the care of this patient?
A) Patient Self Determination Act
B) Physician's treatment orders
C) Advance Directives.
D) Clinical Pathway protocols
Feedback: The correct answer is: C) Advance Directives. This documentspecifies the
patient's wishes
2
You are the of a health care team that consists of one licensed practical/vocational
registered nurse, one nursing assistant, a nursing student and yourself. To whom is it
appropriate to assigncomplete care for
A) Yourself
B) The nursing student
C) The licensed vocational registered nurse
D) The nursing assistant
Feedback: The correct answer is:A) Yourself.
While the registered nurse may delegate a bed bath for a stable patient, this care should
be performedby an RN for a new admission. Only tasks that do not require independent
judgment should be delegated.
3
,A mother brings her the clinic, complaining that the child seems to be .The registered
nurse expectsto 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
Feedback: The correct answer is: B) Rash and restlessness.
4
As the registered nurse takes a history of a 3 year-old with neuroblastoma, what comments
by theparents 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."
Feedback: The correct answer is:C) "Clothes are becoming tighter across herabdomen.".
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.
5
A 16 year-old presents to the emergency department. The triage registered nurse finds that
this teenager is legally married and signed the consent form for treatment. What would be
theappropriate INITIAL action by the registered nurse?
A) Refuse to see the patient until a parent or legal guardian can be contacted
,B) Withhold treatment until telephone consent can be obtained from the spouse
C) Refer the patient to a community pediatric hospital emergency room
D) Assess and treat in the same manner as any adult patient
Feedback: The correct answer is:D) Assess and treat in the same manner asany adult
patient.
Minors may become known as an "emancipated minor" through marriage, pregnancy,
high school graduation, independent living or service in the military. Therefore, this
patient, who is married, has the legal capacity of an adult.
6
A newly admitted elderly patient is severely dehydrated. When planning care for
this patient, which one of the following is an appropriate task for an Unlicensed
AssistivePersonnel (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
Feedback: The correct answer is:B) Report output of less than 30 ml/hr.
When directing a UAP, the registered nurse must communicate clearly about each
delegated task with specific instructions on what must be reported. Because the RN is
responsible for allcare-related decisions,only implementation tasks should be assigned
because they do not require independent judgment.
7
The registered nurse is assessing a 4 year-old for possible rheumatic fever. Which of the
followingwould the registered 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
Feedback: The correct answer is:B) Exposure to strep throat in daycare lastmonth.
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.
8
When the registered nurse becomes aware of feeling reluctant to interact with a
manipulative patient,the BEST action by the registered nurse is to
A) Discuss the feeling of reluctance with an objective peer or supervisor
B) Limit contacts with the patient to avoid reinforcing the manipulative behavior
C) Confront the patient regarding the negative effects of his/her behavior on others
D) Develop a behavior modification plan that will promote more functional behavior
Feedback: The correct answer is:A) Discuss the feeling of reluctance with anobjective
peer or supervisor.
The registered nurse who is experiencing stress in the therapeutic relationship can gain
objectivity through supervision. The registered nurse must attempt to discover attitudes
and feelings in the selfthat influence the registered nurse-patient relationship.
9
A patient is being treated for paranoid schizophrenia. When the patient became loud
and boisterous, the registered nurse immediately placed him in seclusion as a
precautionary measure.The patient willingly complied. The registered nurse's action
A) May result in charges of unlawful seclusion and restraint
B) Leaves the registered nurse vulnerable for charges of assault and battery
