NCSBN TEST BANK - for the NCLEX-RN & NCLEX-PN, Updated 2020, Complete Questions & Answers, A+ Guide.

NCSBN TEST BANK - for the NCLEX-RN &

NCLEX-PN, Updated 2020, Complete

Questions & 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: 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

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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.

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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 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 modification plan that will promote more functional behavior

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Review Information: The correct answer 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 influence the nurseclient relationship.

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

A) May result in charges of unlawful seclusion and restraint

B) Leaves the nurse vulnerable for charges of assault and battery

C) Was appropriate in view of the client's history of violence

D) Was necessary to maintain the therapeutic milieu of the unit

Review Information: The correct answer is:A) May result in charges of unlawful seclusion and restraint.

Seclusion should only be used when there is an immediate threat of violence or threatening behavior.

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?

A) Pain related to ischemia

B) Risk for altered elimination: constipation

C) Risk for complication: dysrhythmias

D) Anxiety

Review Information: The correct answer is:A) Pain related to ischemia.

Pain is related to ischemia, and relief of pain will decrease myocardial oxygen demands, reduce blood

pressure and heart rate and relieve anxiety. Pain also stimulates the sympathetic nervous system and

increased preload, further increasing myocardial demands.

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

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A) Maintain an environment free from hazards

B) Provide reasonable accommodations for disabled individuals

C) Make all necessary accommodations for disabled individuals

D) Consider only physical disabilities in making employment decisions

Review Information: The correct answer is:B) Provide reasonable accommodations for disabled

individuals.

The law is designed to permit persons with disabilities access to job opportunities. Employers must

evaluate an applicant's ability to perform the job and not discriminate on the basis of a disability.

Employers also must make "reasonable accommodations.

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?

A) Scratching the outside of the cast vigorously, applying pressure over the area

B) Blowing a hair dryer or heat lamp on the cast over the area that is itching

C) Using a long, smooth piece of wood to gently scratch the affected area

D) Applying an ice pack over the area of the cast that is affected

Review Information: The correct answer is:D) Applying an ice pack over the area of the cast that is

affected.

Applying ice is a safe method of relieving the itching.

Question 13

Which of the following BEST describes the application of time management strategies in the role of the

nurse manager?

A) Scheduling staff efficiently to cover client needs

B) Assuming a fair share of the client care as a role model

C) Setting daily goals to prioritize work

D) Delegating tasks to reduce work load

Review Information: The correct answer is:C) Setting daily goals to prioritize work.

Time management strategies must include setting priorities and meeting goals.

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Question 14

The clinic nurse assesses a toddler with a tentative diagnosis of neuroblastoma. Symptoms the nurse

observes that suggest this problem include

A) Lymphedema and nerve palsy

B) Hearing loss and ataxia

C) Headaches and vomiting

D) Abdominal mass and weakness

Review Information: The correct answer is:D) Abdominal mass and weakness.

Clinical manifestations of neuroblastoma include an irregular abdominal mass that crosses the midline,

weakness, pallor, anorexia, weight loss and irritability.

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?

A) "I will only have to wear this for six months."

B) "I should inspect my skin daily."

C) "The brace will be worn day and night."

D) "I can take it off when I shower."

Review Information: The correct answer is:A) "I will only have to wear this for six months.".

The brace must be worn long-term, usually for 1-2 years.

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 selfscheduling knowing that

A) Quality of care will improve

B) Staff turnover should decrease

C) Flexible scheduling will occur

D) Team morale will improve

Review Information: The correct answer is:D) Team morale will improve.

Nurses are more satisfied with autonomy and control. The nurse manager becomes the facilitator of

scheduling rather than the decision-maker of the schedule.

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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?

A) Diffuse expiratory wheezing

B) Loose, productive cough

C) No relief from inhalant

D) Fever and chills

Review Information: The correct answer is:A) Diffuse expiratory wheezing.

In asthma, the airways are narrowed - creating difficulty getting air in and a wheezing sound.

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

A) Walk up to the physician and quietly ask that this unacceptable behavior stop

B) Allow the staff nurse to handle this situation without interference

C) Notify the Nursing Director and Medical Staff Chief of a breech of professional conduct

D) Request an immediate private meeting with the physician and staff nurse

Review Information: The correct answer is:D) Request an immediate private meeting with the physician

and staff nurse.

Assertive communication respects the needs of all parties to express themselves, but not at the expense

of others. The nurse manager needs first to protect clients and other staff from this display and come to

the assistance of the nurse employee.

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

A) Tell the client that she cannot be released because she is still suicidal

B) Inform the client that she can be released only if she signs a no suicide contract

C) Discuss with the client the decision to leave and prepare for her discharge

D) Instruct her regarding her right to sign out upon receipt of the physician's discharge order

Review Information: The correct answer is:C) Discuss with the client the decision to leave and prepare

for her discharge.

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Clients voluntarily admitted to the hospital have a right to demand and obtain release. Discussing the

decision allows opportunity for other interventions.

Question 20

A client is admitted with infective endocarditis (IE). Which symptom would alert the nurse to a

complication of this condition?

A) Dyspnea

B) Heart murmur

C) Macular rash

D) Hemorrhage

Review Information: The correct answer is:B) Heart murmur.

Large, soft, rapidly developing vegetations attach to the heart valves. They have a tendency to break off,

causing emboli and leaving ulcerations on the valve leaflets. These emboli produce symptoms of cardiac

murmur, fever, anorexia, malaise and neurologic sequelae of emboli. Furthermore, the vegetations may

travel to various organs such as spleen, kidney, coronary artery, brain and lungs and obstruct blood flow.

Question 21

A nurseadmits 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

A) Stabilize thermoregulation

B) Maintain alveolar surface tension

C) Begin normal pulmonary blood flow

D) Regulate intracardiac pressure

Review Information: The correct answer is:B) Maintain alveolar surface tension.

Respiratory distress syndrome is primarily a disease related to developmental delay in lung maturation.

Although many factors lead to the development of the problem, the central factor relates to the lack of a

normally functioning surfactant system due to immaturity in lung development.

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

A) Response to stimuli

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B) Bladder control

C) Respiratory function

D) Muscle weakness

Review Information: The correct answer is:

C) Respiratory function.

Spinal injury at the C-2 level results in quadriplegia. While the client will experience all of the problems

identified, respiratory assessment is a priority.

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?

A) Hourly urine output

B) White blood count

C) Blood glucose every four hours

D) Temperature every two hours

Review Information: The correct answer is:A) Hourly urine output.

Clients who have had an episode of decreased glomerular perfusion are at risk for pre-renal failure. This is

caused by any abnormal decline in kidney perfusion that reduces glomerular perfusion. Pre-renal failure

occurs when the effective arterial blood volume falls. Examples of this phenomena include a drop in

circulating blood volume as in a cardiac arrest state or in low cardiac perfusion states such as congestive

heart failure associated with a cardiomyopathy. Close observation of hourly urinary output is necessary for

early detection of this condition.

Question 24

The nurse admitting a 5 month-old who vomited nine times in the past six hours should observe for signs

of

A) Metabolic acidosis

B) Metabolic alkalosis

C) Respiratory acidosis

D) Respiratory alkalosis

Review Information: The correct answer is:B) Metabolic alkalosis.

Vomiting causes loss of acid from the stomach. Prolonged vomiting can result in excess loss and lead to

metabolic alkalosis.

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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

A) Call for emergency transport to the hospital

B) Immobilize the limb and joints above and below the injury

C) Assess the child and the extent of the injury

D) Apply cold compresses to the injured area

Review Information: The correct answer is:C) Assess the child and the extent of the injury.

When applying the nursing process, assessment is the first step in providing care. The 5 "Ps" of vascular

impairment can be used as a guide (pain, pulse, pallor, paresthesia, paralysis).

Question 26

As the nurse interviews the parents of a child with asthma, it is a PRIORITY to ask about

A) Household pets

B) New furniture

C) Lead based paint

D) Plants such as cactus

Review Information: The correct answer is:A) Household pets.

Animal dander is a very common allergen affecting persons with asthma. Other triggers may include

pollens, carpeting and household dust.

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?

A) Slurred speech

B) Incontinence

C) Muscle weakness

D) Rapid pulse

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