2026 NCSBN NCLEX RN EXAM 4 TEST
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The nurse educator is delivering a lecture on nursing as a profession to a group of nursing
students who have recently joined the baccalaureate nursing degree course. The nurse is
explaining the nursing processes by giving examples. Which examples should the nurse give
while explaining nursing assessment? Select all that apply.
A+ TEST BANK 1
, NCSBN NCLEX RN EXAM
1
Recording body temperature two hours after administering antipyretic medication.
2
Teaching the patient about the lifestyle changes required to reduce the risks of having
coronary artery disease.
3
Asking the patient about hygiene and sanitation in the patient's community.
4
Asking the patient to demonstrate the technique of breast self-examination after teaching
the technique.
5
Identifying the signs of respiratory distress in a hospitalized patient. –
Correct Answer :1, 3, 5
The nurse is responsible for collecting comprehensive data about the patient's health. The
nurse records the body temperature after 2 hours to assess the effectiveness of the
antipyretic medication. The nurse also asks the patient about the hygiene of the surrounding
environment to assess the risk of acquiring infections caused by unhygienic surroundings.
Nursing assessment also includes identifying the signs of a particular condition. Teaching a
patient about the lifestyle changes required to reduce risks of ischemic heart disease is an
example of the nursing process of implementation, not assessment. Asking the patient to
demonstrate a technique after teaching it forms a part of the evaluation process, not the
assessment process.
An 18-year-old patient is in the emergency department with fever and cough. The nurse
obtains vital signs, auscultates lung sounds, listens to heart sounds, determines patient's level
of comfort, and collects blood and sputum samples for analysis. Which standard of practice is
performed?
A+ TEST BANK 2
, NCSBN NCLEX RN EXAM
1
Diagnosis
2
Evaluation
3
Assessment
4
Implementation –
Correct Answer :3
Assessment is the collection of comprehensive data pertinent to the patient's health and/or
the situation.
Which roles and responsibilities should every nurse be expected to fill? Select all that apply.
1
Caregiver
2
Autonomy and accountability
3
Patient advocate
4
Health promotion
5
Lobbyist –
A+ TEST BANK 3
, NCSBN NCLEX RN EXAM
Correct Answer :1, 2, 3, 4
Each of these roles includes activities for the professional nurse. Each is used in direct care or
is part of the professionalism that guides nursing practice. Some nurses are lobbyists, but
being a lobbyist is not expected of all professional nurses.
A nurse prepares to administer eye drops to a six year-old child. Which of these descriptions
describe the correct method for the instillation of eye drops?
1. Under the upper lid as it is pulled upward
2. In the conjunctival sac as the lower lid is pulled down
3. In the corner where the lids meet
4. Directly on the anterior surface of the eyeball –
Correct Answer :2. In the conjunctival sac as the lower lid is pulled down
A nurse is caring for a client with sickle cell disease who is scheduled to receive a unit of
packed red blood cells. Which is an appropriate action for the nurse during the administration
of the infusion?
1. Assess vital signs every 15 minutes throughout the entire infusion
2. Store the packed red cells in the medicine refrigerator while starting IV line
3. Limit the infusion time of the unit to a maximum of four hours
4. Slow the rate of infusion if the client develops a fever or chills –
Correct Answer :3. Limit the infusion time of the unit to a maximum of four hours
A nurse is caring for a trauma victim with a significant blood loss. Immediately after multiple
transfusions, what is the most accurate indicator of oxygenation?
A+ TEST BANK 4