NCSBN TEST BANK - for the NCLEX-RN & NCLEX-
PN, Updated,Complete Questions & Answers with
rationale(Q1-Q40 7 different docx)V1
Question 1
A c. W h at document should b e in g uiding th e care of th is clie nt?
A) C lie n t Self D etermination Act
B) P h y sician's tre atment o rders
C) A d v ance Directives.
D) C lin ical Pathway p rotocols
Answer: C ) A d vance D irectives.
Question 2
Yo u a re the o f a h ealth care te am th at co nsists o f o ne lice nsed p ractical/vocational n urse, o ne n ursing
a ssista nt , a n ursing student a nd y ourself. To w hom is it a p propriate to a ssign complete care fo r
A) Yo u rself
B) T h e n ursing stu dent
C) T h e licensed v ocational n urse
D) T h e n ursing assis tant
Answer:A ) Yo u rself.
W h ile the n urse m ay d elegate a b ed b ath for a sta ble client, th is c are sh ould b e performed b y a n RN fo r a
n e w a dmission. O nly tasks th at d o n ot require in dependent ju dgment should b e d elegated.
3Question 3
A m o th er brings h er the clinic, com plaining th at the ch ild se ems to b e T h e n urse expects to find w hich o f
th e fo llowing o n th e initial h istory and p hysical assessment?
A) In cre ased te mperature and le thargy
B) R a sh a nd restlessness
C) In cre ased sle eping and listlessness
D) D ia rrh ea and p oor skin turgor
Answer:B ) R ash a n d re stlessness.
,Question 4
A s th e n urse ta kes a h istory o f a 3 y ear-old with n euroblastoma, w hat c omments b y the p arents re quire
fo llo w -up a nd are co nsistent w ith the d iagnosis?
A) "T h e ch ild h as b een listless a nd h as lost w eight."
B) "H e r u rine is d a rk y ellow a nd small in amounts."
C) "C lo th es are b ecoming tighter a cross h er a bdomen."
D + ) "We n otice m uscle weakness and some u nsteadiness."
Answer:C ) "C lo thes are becoming tig hter a cross h er a bdomen.".
O n e o f the m ost com mon signs of n euroblastoma is in creasing a bdominal g irth. T he parents'' re port that
c lo th ing is tig ht is sig nificant, and sh ould b e followed b y a dditional a ssessments.
Question 5
A 16 year-o ld p re sen ts to the eme rgen cy departmen t. The triage nu rse finds th at th is teenager is legally
mar ried and signed the con sen t form for tre atmen t. What would be the approp riate INIT IAL action by the
nurse?
A) Re fu se to see th e clie nt until a p arent or le gal g uardia n can b e c ontacted
B) W ith h old tre atment u ntilte lephone co nsent c an be o btained from th e spouse
C) Re fe r th e client to a community p ediatric h ospital e mergency ro om
D) A ss e ss and tre at in th e same m anner as any adult client
Answer:D ) A sse ss a n d treat in th e sa me manner as a n y a dult clie nt.
Mi n o rs may b ecome kn own as a n "e mancipated m inor" through m arriage, p regnancy, high s chool
g ra d uation, in dependent living o r se rvice in th e m ilitary. T herefore, th is clie nt, w ho is m a rried, h as th e legal
c a p acity of a n a dult.
Question 6
A n e w ly a dmitted elderly clie nt is se verely d ehydrated. W hen p lanning care fo r this client, w hich o ne o f the
fo llo w ing is a n a ppropriate task fo r a n U nlicensed Assistive Personnel (U AP)?
,A) O b tain a history of fluid lo ss
B) Re p ort o utput o f le ss th an 3 0 ml/hr
C) M o n itor response to IV fluids
D) C h e ck s kin tu rgor e very four h ours
Answer:B ) Re p ort o utput o f le ss th an 3 0 ml/hr.
W h e n d irecting a U AP, the n urse must communicate clearly a bout each d elegated task with sp ecific
in stru ctions o n w hat must b e re ported. B ecause th e RN is re sponsible fo r a ll care-related d ecisions,only
im p le mentation task s sh ould b e a ssigned because they do n ot re quire independent judgment.
Question 7
T h e n urse is a ssessing a 4 y ear-old for p ossible rh eumatic fever. Which of th e following w ould th e nurse
s u sp ect is related to this d iagnosis?
A) D ia g nosis o f chickenpox six m onths ago
B) E x p osure to strep th roat in d aycare last m onth
C) Tre atm ent for e ar in fection tw o m onths ago
D) E p iso de of fu ngal skin in fection la st w eek
Answer:B ) E x p osure to strep th roat in daycare las t m onth.
E v id ence s upports a strong re lationship b etween in fection w ith G roup A stre ptococci and su bsequent
rh e u matic fever (u sually w ithin 2 -6 weeks). T herefore, the h istory of playmates re covering from strep
th ro at would in dicate that th e ch ild diagnosed w ith rheumatic fe ver m ost like ly also h ad stre p throat.
S o m etimes, su ch a n in fection h as n o clinical sy mptoms.
Question 8
W h e n the nurse b ecomes a ware o f fe eling reluctant to interact w ith a manipulative client, th e B EST action
by the nurse is to
A) D is cu ss the feeling o f reluctance with an o bjective peer o r su pervisor
B) Lim it co n tacts w ith th e client to avoid reinforcing the m anipulative behavior
C) C o n front the clie nt re garding th e n egative e ffects o f h is/her b ehavior on o thers
D) D e v elop a b ehavior m odification plan that will p romote m ore fu nctional b ehavior
Answer:A ) D iscu ss th e feeling o f re luctance w ith a n objective p eer o r supervisor.
T h e n urse who is ex periencing stre ss in th e th erapeutic relationship can g ain o bjectivity th rough
s u p ervision. T he n urse must attempt to d iscover attitudes a nd fe elings in th e se lf that influence the n urse-
c lie n t relationship.
, Question 9
A clie n t is b eing tre ated for p aranoid schizophrenia. When th e clie nt b ecame lo ud and boisterous, the
n u rse immediately p laced h im in se clusion as a p re cautionary measure. T he clie nt w illingly complied. The
n u rse 's action
A) M a y re sult in ch arges o f unlawful se clusion a nd re straint
B) Le a v es the n urse vulnerable for c harges of assa ult a nd battery
C) Wa s a p propriate in v iew o f th e client's h istory o f violence
D) Wa s n e cessary to maintain th e th erapeutic m ilieu of the u nit
Answer:A ) M a y re sult in charges o f u nla wful seclusion a nd re straint. Seclusion sh ould only be u sed w hen
th e re is a n im mediate threat o f v iolence or th reatening b ehavior.
Question 10
A clie n t h as b een a dmitted to th e C oronary C are U nit w ith a M yocardial Infarction. Which o f the following
n u rsin g diagnosis sh ould h ave P RIORITY?
A) Pa in re lated to isc hemia
B) R is k fo r alte red e limination: con stipation
C) R is k fo r com plication: dysrhythmias
D) A n x iety
Answer:A ) Pa in re lated to isch emia.
Pain is related to ischemia, and re lief o f p ain w ill de crease myocard ial oxygen demands, redu ce b lood
p re ssu re and heart rate and re lieve anxiety. Pain also stimulates the sympa thetic nervous system and
in cre a sed p reload, fu rther in creasing myocardial d emands.
Question 11
T h e n urse manager w ho is responsible fo r hiring p rofessional n ursing staff is re q uired to com ply w ith th e
A m e ricans w ith D isabilities Act. T he provisions o f the la w re quire the n urse m anager to
A) M a in tain an e nvironment free fro m h azards
B) P ro v ide reasonable a ccommodations fo r d isabled individuals
C) M a k e all necessary a ccommodations for d isabled individuals
PN, Updated,Complete Questions & Answers with
rationale(Q1-Q40 7 different docx)V1
Question 1
A c. W h at document should b e in g uiding th e care of th is clie nt?
A) C lie n t Self D etermination Act
B) P h y sician's tre atment o rders
C) A d v ance Directives.
D) C lin ical Pathway p rotocols
Answer: C ) A d vance D irectives.
Question 2
Yo u a re the o f a h ealth care te am th at co nsists o f o ne lice nsed p ractical/vocational n urse, o ne n ursing
a ssista nt , a n ursing student a nd y ourself. To w hom is it a p propriate to a ssign complete care fo r
A) Yo u rself
B) T h e n ursing stu dent
C) T h e licensed v ocational n urse
D) T h e n ursing assis tant
Answer:A ) Yo u rself.
W h ile the n urse m ay d elegate a b ed b ath for a sta ble client, th is c are sh ould b e performed b y a n RN fo r a
n e w a dmission. O nly tasks th at d o n ot require in dependent ju dgment should b e d elegated.
3Question 3
A m o th er brings h er the clinic, com plaining th at the ch ild se ems to b e T h e n urse expects to find w hich o f
th e fo llowing o n th e initial h istory and p hysical assessment?
A) In cre ased te mperature and le thargy
B) R a sh a nd restlessness
C) In cre ased sle eping and listlessness
D) D ia rrh ea and p oor skin turgor
Answer:B ) R ash a n d re stlessness.
,Question 4
A s th e n urse ta kes a h istory o f a 3 y ear-old with n euroblastoma, w hat c omments b y the p arents re quire
fo llo w -up a nd are co nsistent w ith the d iagnosis?
A) "T h e ch ild h as b een listless a nd h as lost w eight."
B) "H e r u rine is d a rk y ellow a nd small in amounts."
C) "C lo th es are b ecoming tighter a cross h er a bdomen."
D + ) "We n otice m uscle weakness and some u nsteadiness."
Answer:C ) "C lo thes are becoming tig hter a cross h er a bdomen.".
O n e o f the m ost com mon signs of n euroblastoma is in creasing a bdominal g irth. T he parents'' re port that
c lo th ing is tig ht is sig nificant, and sh ould b e followed b y a dditional a ssessments.
Question 5
A 16 year-o ld p re sen ts to the eme rgen cy departmen t. The triage nu rse finds th at th is teenager is legally
mar ried and signed the con sen t form for tre atmen t. What would be the approp riate INIT IAL action by the
nurse?
A) Re fu se to see th e clie nt until a p arent or le gal g uardia n can b e c ontacted
B) W ith h old tre atment u ntilte lephone co nsent c an be o btained from th e spouse
C) Re fe r th e client to a community p ediatric h ospital e mergency ro om
D) A ss e ss and tre at in th e same m anner as any adult client
Answer:D ) A sse ss a n d treat in th e sa me manner as a n y a dult clie nt.
Mi n o rs may b ecome kn own as a n "e mancipated m inor" through m arriage, p regnancy, high s chool
g ra d uation, in dependent living o r se rvice in th e m ilitary. T herefore, th is clie nt, w ho is m a rried, h as th e legal
c a p acity of a n a dult.
Question 6
A n e w ly a dmitted elderly clie nt is se verely d ehydrated. W hen p lanning care fo r this client, w hich o ne o f the
fo llo w ing is a n a ppropriate task fo r a n U nlicensed Assistive Personnel (U AP)?
,A) O b tain a history of fluid lo ss
B) Re p ort o utput o f le ss th an 3 0 ml/hr
C) M o n itor response to IV fluids
D) C h e ck s kin tu rgor e very four h ours
Answer:B ) Re p ort o utput o f le ss th an 3 0 ml/hr.
W h e n d irecting a U AP, the n urse must communicate clearly a bout each d elegated task with sp ecific
in stru ctions o n w hat must b e re ported. B ecause th e RN is re sponsible fo r a ll care-related d ecisions,only
im p le mentation task s sh ould b e a ssigned because they do n ot re quire independent judgment.
Question 7
T h e n urse is a ssessing a 4 y ear-old for p ossible rh eumatic fever. Which of th e following w ould th e nurse
s u sp ect is related to this d iagnosis?
A) D ia g nosis o f chickenpox six m onths ago
B) E x p osure to strep th roat in d aycare last m onth
C) Tre atm ent for e ar in fection tw o m onths ago
D) E p iso de of fu ngal skin in fection la st w eek
Answer:B ) E x p osure to strep th roat in daycare las t m onth.
E v id ence s upports a strong re lationship b etween in fection w ith G roup A stre ptococci and su bsequent
rh e u matic fever (u sually w ithin 2 -6 weeks). T herefore, the h istory of playmates re covering from strep
th ro at would in dicate that th e ch ild diagnosed w ith rheumatic fe ver m ost like ly also h ad stre p throat.
S o m etimes, su ch a n in fection h as n o clinical sy mptoms.
Question 8
W h e n the nurse b ecomes a ware o f fe eling reluctant to interact w ith a manipulative client, th e B EST action
by the nurse is to
A) D is cu ss the feeling o f reluctance with an o bjective peer o r su pervisor
B) Lim it co n tacts w ith th e client to avoid reinforcing the m anipulative behavior
C) C o n front the clie nt re garding th e n egative e ffects o f h is/her b ehavior on o thers
D) D e v elop a b ehavior m odification plan that will p romote m ore fu nctional b ehavior
Answer:A ) D iscu ss th e feeling o f re luctance w ith a n objective p eer o r supervisor.
T h e n urse who is ex periencing stre ss in th e th erapeutic relationship can g ain o bjectivity th rough
s u p ervision. T he n urse must attempt to d iscover attitudes a nd fe elings in th e se lf that influence the n urse-
c lie n t relationship.
, Question 9
A clie n t is b eing tre ated for p aranoid schizophrenia. When th e clie nt b ecame lo ud and boisterous, the
n u rse immediately p laced h im in se clusion as a p re cautionary measure. T he clie nt w illingly complied. The
n u rse 's action
A) M a y re sult in ch arges o f unlawful se clusion a nd re straint
B) Le a v es the n urse vulnerable for c harges of assa ult a nd battery
C) Wa s a p propriate in v iew o f th e client's h istory o f violence
D) Wa s n e cessary to maintain th e th erapeutic m ilieu of the u nit
Answer:A ) M a y re sult in charges o f u nla wful seclusion a nd re straint. Seclusion sh ould only be u sed w hen
th e re is a n im mediate threat o f v iolence or th reatening b ehavior.
Question 10
A clie n t h as b een a dmitted to th e C oronary C are U nit w ith a M yocardial Infarction. Which o f the following
n u rsin g diagnosis sh ould h ave P RIORITY?
A) Pa in re lated to isc hemia
B) R is k fo r alte red e limination: con stipation
C) R is k fo r com plication: dysrhythmias
D) A n x iety
Answer:A ) Pa in re lated to isch emia.
Pain is related to ischemia, and re lief o f p ain w ill de crease myocard ial oxygen demands, redu ce b lood
p re ssu re and heart rate and re lieve anxiety. Pain also stimulates the sympa thetic nervous system and
in cre a sed p reload, fu rther in creasing myocardial d emands.
Question 11
T h e n urse manager w ho is responsible fo r hiring p rofessional n ursing staff is re q uired to com ply w ith th e
A m e ricans w ith D isabilities Act. T he provisions o f the la w re quire the n urse m anager to
A) M a in tain an e nvironment free fro m h azards
B) P ro v ide reasonable a ccommodations fo r d isabled individuals
C) M a k e all necessary a ccommodations for d isabled individuals
