NCLEX RN & NCLEX PN Examination
Question and Answers with Review Information
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.
,Question 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
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.
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
Review Information: The correct answer is:A) Discuss the feeling of reluctance with an
objective peer or supervisor.
Question and Answers with Review Information
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.
,Question 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
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.
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
Review Information: The correct answer is:A) Discuss the feeling of reluctance with an
objective peer or supervisor.
