NCSBN TEST BANK - for the NCLEX-RN & NCLEX-PN,
Latest 2022, Complete Questions & Answers with
rationale
Which individual is at greatest risk for the development of hypertension?
A. 40 year-old Caucasian nurse
B. 60 year-old Asian-American shop owner
C. 45 year-old African-American attorney
D. 55 year-old Hispanic teacher
C
The incidence of hypertension is greater among African-Americans than other groups in the United
States. The incidence among the Hispanic population is rising.
A woman, who delivered five days ago and who had been diagnosed with pregnancy induced
hypertension (PIH), calls a hospital triage nurse hotline to ask for advice. She states, "I have had the
worst headache for the past two days. It pounds and by the middle of the afternoon everything I look at
looks wavy. Nothing I have taken helps." What should the nurse do next?
A. Advise the client to have someone bring her to the emergency room as soon as possible
B. Ask the client to explain what she has taken and how often, and then evaluate other specific
complaints
C. Advise the client that the swings in her hormones may be the problem; suggest that she call her
health care provider
D. Ask the client to stay on the line, get the address, and send an ambulance to the home
D
,The woman is at risk for seizure activity. The ambulance needs to bring the woman to the hospital for
evaluation and treatment. For at-risk clients, PIH may progress to preeclampsia and eclampsia prior to,
during, or after delivery; this may occur up to 10 days after delivery.
There's a new medication order that reads: "administer 1 gtt ciprofloxacin solution OD Q 4 h" What
action should the nurse take?
A. Squeeze one drop of the medication in the left eye every 4 hours
B. Apply one drop in the right ear every 4 hours
C. Call the prescriber to clarify and rewrite the order
D. Ask other nurses for their interpretation of the order
C
Abbreviations, symbols and dose designations can be misinterpreted and lead to medication errors.
"OD" can mean "right eye" (oculus dexter) or "once daily"; it should never be used when communicating
medical information. The abbreviation "Q" should be written out as "every." Although "gtt" is not on the
official "Do Not Use List", it's best to use "drop" instead. Asking other nurses to interpret an order is a
potentially dangerous "workaround." The nurse should call the health care provider who prescribed the
medication and clarify the order.
A client expresses anger when a call light is not answered within five minutes. The client demanded a
blanket. How should the nurse respond?
A. "I see this is frustrating for you. I have a few minutes so let's talk."
B. "I am surprised that you are upset. The request could have waited a few more minutes."
C. "Let's talk. Why are you upset about this?"
D. "I apologize for the delay. I was involved in an emergency."
A
,This is the best response because it gives credence to the client's feelings and then concerns. To say
"let's talk" and ask a why question is not a therapeutic approach because it does not acknowledge or
validate the client's feelings. To apologize and not notice the client's feelings is inappropriate. To say it
could have waited a few minutes is rude and non-accepting of the client's verbalized needs.
The clinic nurse is assisting with medical billing. The nurse uses the DRG (Diagnosis Related Group)
manual for which purpose?
A. Determine reimbursement for a medical diagnosis
B. Identify findings related to a medical diagnosis
C. Classify nursing diagnoses from the client's health history
D. Implement nursing care based on case management protocol
DRGs are the basis of prospective payment plans for reimbursement for Medicare clients. Other
insurance companies often use it as a standard for determining payment.
A nurse is planning care for a 2 year-old hospitalized child. Which issue will produce the most stress at
this age?
A. Fear of pain
B. Separation anxiety
C. Loss of control
D. Bodily injury
B
While a toddler will experience all of the stresses, separation from parents is the major stressor.
Separation anxiety peaks in the toddler years.
, The nurse receives a client from the post anesthesia care unit following a left femoral-popliteal bypass
graft procedure. Which of the following assessments requires immediate notification of the health care
provider?
A. Left foot is cool to the touch
B. Absent left pedal pulse using Doppler analysis
C. Inability to palpate the left pedal pulse
D. Acute pain in the left lower leg
B
Although the inability to palpate the left pedal pulse, a cool extremity, and increased pain in the left
lower leg are important findings, they all require additional nursing assessment prior to contacting the
health care provider. In clients without palpable pedal pulses, the next step in the assessment is to
perform a Doppler analysis. The inability to locate the left pedal pulse using the Doppler analysis
requires immediately notifying the health care provider.
The nurse is reviewing the laboratory results for several clients. Which of the laboratory result indicates
a client with partly compensated metabolic acidosis?
A. PaCO2 30 mm Hg
B. Hemoglobin 15 g/dL (150 g//L)
C. Sodium 130 mEq/L (130 mmol/L)
D. Chloride 100 mEq/L (100 mmol/L)
A
Metabolic acidosis can be caused by many conditions, including renal failure, shock, severe diarrhea,
dehydration, diabetic acidosis, and salicylate poisoning. With metabolic acidosis, you should expect a
low pH (less than 7.35) and a low HCO3 (less than 22 mEq/L.) Compensation means the body is trying to
get the pH back in balance; therefore, a pure metabolic acidosis should elicit a compensatory decrease
Latest 2022, Complete Questions & Answers with
rationale
Which individual is at greatest risk for the development of hypertension?
A. 40 year-old Caucasian nurse
B. 60 year-old Asian-American shop owner
C. 45 year-old African-American attorney
D. 55 year-old Hispanic teacher
C
The incidence of hypertension is greater among African-Americans than other groups in the United
States. The incidence among the Hispanic population is rising.
A woman, who delivered five days ago and who had been diagnosed with pregnancy induced
hypertension (PIH), calls a hospital triage nurse hotline to ask for advice. She states, "I have had the
worst headache for the past two days. It pounds and by the middle of the afternoon everything I look at
looks wavy. Nothing I have taken helps." What should the nurse do next?
A. Advise the client to have someone bring her to the emergency room as soon as possible
B. Ask the client to explain what she has taken and how often, and then evaluate other specific
complaints
C. Advise the client that the swings in her hormones may be the problem; suggest that she call her
health care provider
D. Ask the client to stay on the line, get the address, and send an ambulance to the home
D
,The woman is at risk for seizure activity. The ambulance needs to bring the woman to the hospital for
evaluation and treatment. For at-risk clients, PIH may progress to preeclampsia and eclampsia prior to,
during, or after delivery; this may occur up to 10 days after delivery.
There's a new medication order that reads: "administer 1 gtt ciprofloxacin solution OD Q 4 h" What
action should the nurse take?
A. Squeeze one drop of the medication in the left eye every 4 hours
B. Apply one drop in the right ear every 4 hours
C. Call the prescriber to clarify and rewrite the order
D. Ask other nurses for their interpretation of the order
C
Abbreviations, symbols and dose designations can be misinterpreted and lead to medication errors.
"OD" can mean "right eye" (oculus dexter) or "once daily"; it should never be used when communicating
medical information. The abbreviation "Q" should be written out as "every." Although "gtt" is not on the
official "Do Not Use List", it's best to use "drop" instead. Asking other nurses to interpret an order is a
potentially dangerous "workaround." The nurse should call the health care provider who prescribed the
medication and clarify the order.
A client expresses anger when a call light is not answered within five minutes. The client demanded a
blanket. How should the nurse respond?
A. "I see this is frustrating for you. I have a few minutes so let's talk."
B. "I am surprised that you are upset. The request could have waited a few more minutes."
C. "Let's talk. Why are you upset about this?"
D. "I apologize for the delay. I was involved in an emergency."
A
,This is the best response because it gives credence to the client's feelings and then concerns. To say
"let's talk" and ask a why question is not a therapeutic approach because it does not acknowledge or
validate the client's feelings. To apologize and not notice the client's feelings is inappropriate. To say it
could have waited a few minutes is rude and non-accepting of the client's verbalized needs.
The clinic nurse is assisting with medical billing. The nurse uses the DRG (Diagnosis Related Group)
manual for which purpose?
A. Determine reimbursement for a medical diagnosis
B. Identify findings related to a medical diagnosis
C. Classify nursing diagnoses from the client's health history
D. Implement nursing care based on case management protocol
DRGs are the basis of prospective payment plans for reimbursement for Medicare clients. Other
insurance companies often use it as a standard for determining payment.
A nurse is planning care for a 2 year-old hospitalized child. Which issue will produce the most stress at
this age?
A. Fear of pain
B. Separation anxiety
C. Loss of control
D. Bodily injury
B
While a toddler will experience all of the stresses, separation from parents is the major stressor.
Separation anxiety peaks in the toddler years.
, The nurse receives a client from the post anesthesia care unit following a left femoral-popliteal bypass
graft procedure. Which of the following assessments requires immediate notification of the health care
provider?
A. Left foot is cool to the touch
B. Absent left pedal pulse using Doppler analysis
C. Inability to palpate the left pedal pulse
D. Acute pain in the left lower leg
B
Although the inability to palpate the left pedal pulse, a cool extremity, and increased pain in the left
lower leg are important findings, they all require additional nursing assessment prior to contacting the
health care provider. In clients without palpable pedal pulses, the next step in the assessment is to
perform a Doppler analysis. The inability to locate the left pedal pulse using the Doppler analysis
requires immediately notifying the health care provider.
The nurse is reviewing the laboratory results for several clients. Which of the laboratory result indicates
a client with partly compensated metabolic acidosis?
A. PaCO2 30 mm Hg
B. Hemoglobin 15 g/dL (150 g//L)
C. Sodium 130 mEq/L (130 mmol/L)
D. Chloride 100 mEq/L (100 mmol/L)
A
Metabolic acidosis can be caused by many conditions, including renal failure, shock, severe diarrhea,
dehydration, diabetic acidosis, and salicylate poisoning. With metabolic acidosis, you should expect a
low pH (less than 7.35) and a low HCO3 (less than 22 mEq/L.) Compensation means the body is trying to
get the pH back in balance; therefore, a pure metabolic acidosis should elicit a compensatory decrease
