NCSBN NCLEX QUESTIONS AND ANSWERS ALL CORRECT…TEST BANK

NCSBN NCLEX QUESTIONS AND ANSWERS ALL CORRECT…TEST BANK A LPN complains to the charge nurse that an unlicensed assistive person (UAP) consistently leaves the work area untidy and does not restock supplies. What is the best initial response by the charge nurse? 1Write down potential solutions to the problems today by shift's end 2Add this concern to the agenda of the next unit meeting 3Assure the staff nurse that the complaint will be investigated 4Explore for further identification about the nature of the problem Correct Answer: 4 Explore for further identification about the nature of the problem The nurse assists with the reinforcement of information about breast self-examination to a group of college students. A female student asks when to perform the monthly exam. The appropriate reply by the nurse should include which statement? 1"Ovulation, or midcycle is the best time to detect changes." 2"Do the exam at the same time every month." 3"Right after the period, when your breasts are less tender." 4"The first of every month, because it will be easiest to remember." Correct Answer: 3 The nurse is caring for a 75 year-old client with type 2 diabetes mellitus. The client should be instructed to contact the outpatient clinic immediately if which findings are present? 1An open wound on the heel with minimal discomfort 2Occasional hiccups and sneezing 3Sustained insomnia and daytime fatigue 4Persistent dryness and itching of the perineal area Correct Answer: 1An open wound on the heel with minimal discomfort- A pregnant woman has been advised to alter her diet during pregnancy by increasing the intake of protein and vitamin C to meet the needs of the growing fetus. Which diet choice would best meet the woman's needs? 1. 1 cup of macaroni, three-fourths cup of peas, glass whole milk, medium pear 2. Scrambled egg, hash browned potatoes, one-half glass of buttermilk, large nectarine 3. 3 oz. chicken, one-half cup of corn, lettuce salad, small banana 4. Beef, one-half cup of lima beans, glass of skim milk, three-fourths cup of strawberries Correct Answer: 4. Beef, one-half cup of lima beans, glass of skim milk, three-fourths cup of strawberries - A nurse is taking a health history from parents of a child admitted with possible Reye's syndrome. Which recent illness should the nurse recognize as being associated with an increased the risk for the development of Reye's syndrome? 1. Varicella 2. Meningitis 3. Hepatitis 4. Rubeola Correct Answer: 1. Varicella - A Native American chief visits his newborn son and performs a traditional ceremony that involves feathers and chanting. The nurse comments to a colleague: "I wonder if he has any idea how ridiculous he looks - he's a grown man!" The nurse's comment is an example of what type of attitude? 1. Prejudice 2. Ethnocentrism 3. Discrimination 4. Stereotyping Correct Answer: 1. Prejudice- A nursing student asks the licensed practical nurse (LPN) to explain the forces that drive health care reform. When responding to the student's question, what information should the nurse emphasize? 1. Increased competition between health care insurers 2. Increase in health care spending that's growing faster than the economy 3. Increase in the population who have health insurance 4. Increase in spending for end-of-life treatment Correct Answer: 2 A child is admitted to the unit with the suspected diagnosis of pertussis (whooping cough). What is the priority nursing intervention for this child? 1. Maintain hydration and encourage fluids 2. Implement droplet precautions 3. Monitor respiratory rate and oxygen saturation 4. Anti- infective therapy Correct Answer: 2 A client has an indwelling catheter with continuous bladder irrigation after undergoing a transurethral resection of the prostate (TURP) 12 hours ago. Which finding at this time should be reported to the registered nurse (RN) charge nurse? 1Complaints for the feeling of pulling on the urinary catheter 2Light, pink to clear urine 3Occasional suprapubic cramping 4Minimal drainage into the urinary collection bag Correct Answer: 4Minimal drainage into the urinary collection bag A nurse is caring for a woman two hours after a vaginal delivery. Documentation indicates that the membranes ruptured 36 hours prior to delivery. Which of these nursing diagnoses should the nurse expect the charge nurse to list as a priority at this time? 1Risk for fluid volume deficit 2Risk for excessive bleeding 3Risk for infection - 4Altered tissue perfusion Correct Answer: 3 A 14 month-old child ingests a half a bottle of baby aspirin (81 mg) tablets. Which finding should a nurse expect to see in the child? 1Hypothermia 2Nausea and vomiting 3Hypoventilation 4Bradycardia Correct Answer: 2 A school nurse monitors a child with a history of tonic-clonic seizures. The school nurse should inform teachers that if the child falls to the floor and experiences a seizure while in the classroom, which of the following would be the most important action to take during the seizure? 1Place the hands or a folded blanket under the head of the child 2Provide privacy as much as possible to minimize frightening the other children 3Move any chairs or desks at least three feet away from the child 4Note the sequence of movements with the time lapse of the event Correct Answer: 1Place the hands or a folded blanket under the head of the child - A client is admitted with diagnosis of a right upper lobe infiltrate and to rule out active tuberculosis (TB). Which type of precautions will be needed for this client? 1Droplet 2Contact 3Standard 4Airborne Correct Answer: 4 A client has had a positive reaction to purified protein derivative (PPD). Which statement made by the client suggests the client understands the teaching by the registered nurse (RN)? 1"I have active tuberculosis." 2"I have been exposed to mycobacterium tuberculosis." 3"I have never been infected with mycobacterium tuberculosis." 4"I have never had tuberculosis." Correct Answer: 2 A nurse is caring for a client with pneumococcal pneumonia. Which breath sounds would the nurse expect to disappear as the client responds to the antibiotic treatment? 1Wheezes 2Friction rubs 3Rhonchi 4Diminished sounds Correct Answer: 3 A young adult seeks treatment in an outpatient mental health center. The client tells a nurse, "I am a government official and spies are following me." Upon further questioning, the client reveals that warnings must be heeded to prevent nuclear war. What is the initial therapeutic approach that the nurse should use? 1Listen quietly without comment 2Ask for further information on the spies 3Confront the client about the delusions 4Contact security for potential safety concerns Correct Answer: 1Listen quietly without comment - Lactulose has been prescribed for a client with advanced liver disease. Which finding should the nurse use to evaluate the effectiveness of this treatment? 1Less jaundice 2Increased appetite 3Decreased lethargy 4Less edema Correct Answer: 3 The LPN is unsure about an assignment by the charge nurse to hang an intravenous (IV) infusion that contains potassium. What resource should the LPN check first to determine if LPNs can administer IV medications? 1Employer policy and procedures manuals 2Nursing faculty from a local nursing program 3The nurse practice act of the state in which the practice takes place 4American Nurses Association (ANA) professional standards Correct Answer: 3 The nurse is assisting with the delivery of a newborn infant. What is the priority nursing intervention for a normal newborn immediately after delivery? 1Dry off infant with a warm blanket or towel 2Apply identification bracelets 3Assign the one-minute APGAR score 4Obtain vital signs Correct Answer: 1Dry off infant with a warm blanket or towel - The registered nurse is teaching a childbirth education class about postpartum depression. Which statement, made by a class member, indicates that more teaching is needed? 1"I will make an effort to talk with someone about my feelings if I start to feel overwhelmed." 2"It's common for women with postpartum depression to have delusions about the infant." 3"Women with postpartum depression have feelings of guilt and worthlessness." 4"I may experience postpartum depression up to a year after delivery." Correct Answer: 2 The nurse is reinforcing information about the side effects of fluoxetine to a client. Which group of findings should be included? 1Diarrhea, dry mouth, weight loss, reduced libido 2Tachycardia, blurred vision, hypotension, anorexia 3Orthostatic hypotension, vertigo, reactions to tyramine, nausea 4Photosensitivity, seizures, edema, hyperglycemia Correct Answer: 1Diarrhea, dry mouth, weight loss, reduced libido A client has a diagnosis of heart failure. Which intervention is most important for the nurse to implement prior to the administration of digoxin? 1Use the pulse reading from the electronic blood pressure device 2Take a radial pulse, counting for a full 60 seconds 3Check for a pulse deficit at least twice with another nurse 4Assess the apical pulse, counting for a full 60 seconds Correct Answer: 4Assess the apical pulse, counting for a full 60 seconds - A client diagnosed with bipolar disorder refuses to take the prescribed medication. Which is the most therapeutic response by a nurse to the client's refusal of the medication? 1"You need to take your medicine. This is how you get better." 2"What is it about the medicine that you don't like?" 3"I can see that you are uncomfortable right now; let's talk about it tomorrow." 4"If you refuse your medicine, tell me how do you think you will get better?" Correct Answer: 2 A parent expresses frustration and anger about the toddler constantly saying "no" and refusing to follow directions. The nurse should help the parent understand that this behavior meets which developmental need? 1Self-esteem 2Initiative 3Independence 4Trust Correct Answer: 3 The LPN is assisting the RN to provide care for a client diagnosed with a traumatic brain injury. Using the Glasgow Coma Scale, when the client does not obey verbal commands to move, which technique will the RN use to evaluate motor function? 1Squeeze the trapezius muscle firmly 2Lift the client's arm and observe for pronation and drift 3Apply finger tip pressure for 10 seconds 4Rub the sternum with the knuckles Correct Answer: 1Squeeze the trapezius muscle firmly - A newborn has hyperbilirubinemia and is being treated with a biliblanket. Which intervention is indicated during this therapy? 1Discontinue breastfeeding during treatment 2Rotate the neonate to treat all of his/her skin 3Restrict holding the newborn during treatment 4Provide more frequent feedings Correct Answer: 4Provide more frequent feedings- A client with paranoid delusions stares at the nurse over a period of several days. The client suddenly walks up to the nurse and shouts, "You think you're so perfect, pure and good." How should the nurse respond? 1"You seem to be in a bad mood." 2"Perfect? I don't quite understand." 3"You sound angry right now." 4"That explains why you've been staring at me." Correct Answer: 3 The client with coronary artery disease has a prescription for nitroglycerin transdermal patches. What is the best reason the client should not wear a patch for more than 12 to 14 hours each day? 1It can cause severe headaches 2It may no longer work as well 3It will cause profound hypotensive effects 4it will irritate the skin Correct Answer: 2 A hospitalized infant is receiving gentamicin. Which nursing intervention should receive priority in the plan of care? 1Compare daily infant weights 2Monitor the infant's urine output 3Ensure appropriate fluid intake 4Maintain accurate intake and output Correct Answer: 2 A newborn is diagnosed with hypothyroidism. In discussing the condition and treatment with the family, the nurse should emphasize which point? 1They can expect the child will be mentally retarded 2Administration of a thyroid hormone will prevent problems 3This rare condition is hereditary 4Physical growth and development will be delayed Correct Answer: 2 A child is admitted to the hospital for emergency surgery. The child's parent re