NCSBN Question Bank NUR 101 NCSBN TEST BANK
X X X X X X X
for NCLEX RN & NCLEX PN Examination-Pretest-
X X X X X X
Q& A X X
X
Pretest
QuestionX1
AXc.XWhatXdocumentXshouldXbeXinXguidingXtheXcareXofXthisXclient?X
A) ClientXSelfXDeterminationXActX
B) Physician'sXtreatmentXordersX
C) AdvanceXDirectives.X
D) ClinicalXPathwayXprotocolsX
X
ReviewXXInformation:XTheXcorrectXanswerXis:XC)XAdvanceXDirectives.XThisXdocumentXspecifiesXtheXclient'sX
wishesX
X
X
X
QuestionX2
YouXareXtheXofXaXhealthXcareXteamXthatXconsistsXofXoneXlicensedXpractical/vocationalXnurse,XoneXnursingXassistantX,X
aXnursingXstudentXandXyourself.XToXwhomXisXitXappropriateXtoXassignXcompleteXcareXforX
A) YourselfX
B) TheXnursingXstudentX
C) TheXlicensedXvocationalXnurseX
D) TheXnursingXassistantX
ReviewXXInformation:XTheXcorrectXanswerXis:A)XYourself.X
X
WhileXtheXnurseXmayXdelegateXaXbedXbathXforXaXstableXclient,XthisXcareXshouldXbeXperformedXbyXanXRNXforXaXnewXadm
ission.XOnlyXtasksXthat XdoXnotXrequireXindependentXjudgmentXshouldXbeXdelegated.X
X
X
X
3QuestionX3
AXmotherXbringsXherXtheXclinic,XcomplainingXthatXtheXchildXseemsXtoXbeXXTheXnurseXexpectsXtoXfindXwhichXofXtheXfollo
wingXonXtheXinitialXhistoryXandXphysicalXassessment?X
A) IncreasedXtemperatureXandXlethargyX
X
B) RashXandXrestlessnessX
X
C) IncreasedXsleepingXandXlistlessnessX
D) DiarrheaXandXpoorXskinXturgorX
ReviewXXInformation:XTheXcorrectXanswerXis:B)XRashXandXrestlessness.X
X
, NCSBN Question Bank NUR 101 NCSBN TEST BANK
X X X X X X X
for NCLEX RN & NCLEX PN Examination-Pretest-
X X X X X X
Q& A X X
X
X
QuestionX4
AsXtheXnurseXtakesXaXhistoryXofXaX3Xyear-oldXwithXneuroblastoma,XwhatXcommentsXbyXtheXparentsXrequireXfollow-
upXandXareXconsistentXwithXtheXdiagnosis?X
A) "TheXchildXhasXbeenXlistlessXandXhasXlostXweight."X
B) "HerXurineXisXdarkXyellowXandXsmallXinXamounts."X
C) "ClothesXareXbecomingXtighterXacrossXherXabdomen."XXD+)X"
WeXnoticeXmuscleXweaknessXandXsomeXunsteadiness."X
ReviewXXInformation:XTheXcorrectXanswerXis:C)X"ClothesXareXbecomingXtighterXacrossXherXabdomen.".X
X
OneXofXtheXmostXcommonXsignsXofXneuroblastomaXisXincreasingXabdominalXgirth.XTheXparents''XreportXthatX
clothingXisXtightXisXsignificant,XandXshouldXbeXfollowedXbyXadditionalXassessments.X
X
X
X
QuestionX5
AX16Xyear-
oldXpresentsXtoXtheXemergencyXdepartment.XTheXtriageXnurseXfindsXthatXthisXteenagerXisXlegallyXmarriedXandXsigne
dXtheXconsentXformXforXtreatment.XWhatXwouldXbeXtheXappropriateXINITIALXactionXbyXtheXnurse?X
A) RefuseXtoXseeXtheXclientXuntilXaXparentXorXlegalXguardianXcanXbeXcontactedX
B) WithholdXtreatmentXuntilXtelephoneXconsentXcanXbeXobtainedXfromXtheXspouseX
C) ReferXtheXclientXtoXaXcommunityXpediatricXhospitalXemergencyXroomX
D) AssessXandXtreatXinXtheXsameXmannerXasXanyXadultXclientX
ReviewXXInformation:XTheXcorrectXanswerXis:D)XAssessXandXtreatXinXtheXsameXmannerXasXanyXadultXclient.X
X
MinorsXmayXbecomeXknownXasXanX"emancipatedXminor"XthroughXmarriage,Xpregnancy,XhighXschoolX
graduation,XindependentXlivingXorXserviceXinXtheXmilitary.XTherefore,XthisXclient,XwhoXisXmarried,XhasXtheXlegalXcapacityXofX
anXadult.X
X
X
X
X
X
X
X
X
X
X
QuestionX6
AXnewlyXadmittedXelderlyXclientXisXseverelyXdehydrated.XWhenXplanningXcareXforXthisXclient,XwhichXoneXofXtheX
X
, NCSBN Question Bank NUR 101 NCSBN TEST BANK
X X X X X X X
for NCLEX RN & NCLEX PN Examination-Pretest-
X X X X X X
Q& A X X
X
followingXisXanXappropriateXtaskXforXanXUnlicensedXAssistiveXPersonnelX(UAP)?X
X
, NCSBN Question Bank NUR 101 NCSBN TEST BANK
X X X X X X X
for NCLEX RN & NCLEX PN Examination-Pretest-
X X X X X X
Q& A X X
X
A) ObtainXaXhistoryXofXfluidXlossX
B) ReportXoutputXofXlessXthanX30Xml/hrX
C) MonitorXresponseXtoXIVXfluidsX
D) CheckXskinXturgorXeveryXfourXhoursX
ReviewXXInformation:XTheXcorrectXanswerXis:B)XReportXoutputXofXlessXthanX30Xml/hr.X
X
WhenXdirectingXaXUAP,XtheXnurseXmustXcommunicateXclearlyXaboutXeachXdelegatedXtaskXwithXspecificXinstructionsX
onXwhatXmustXbeXreported.XBecauseXtheXRNXisXresponsibleXforXallXcare-
relatedXdecisions,onlyXimplementationXtasksXshouldXbeXassignedXbecauseXtheyXdoXnotXrequireXindependentXjudg
ment.X
X
X
X
QuestionX7
TheXnurseXisXassessingXaX4Xyear-
oldXforXpossibleXrheumaticXfever.XWhichXofXtheXfollowingXwouldXtheXnurseXsuspectXisXrelatedXtoXthisXdiagnosis?X
A) DiagnosisXofXchickenpoxXsixXmonthsXagoX
B) ExposureXtoXstrepXthroat XinXdaycareXlastXmonthX
C) TreatmentXforXearXinfectionXtwoXmonthsXagoX
D) EpisodeXofXfungalXskinXinfectionXlastXweekX
ReviewXXInformation:XTheXcorrectXanswerXis:B)XExposureXtoXstrepXthroatXinXdaycareXlastXmonth.X
X
EvidenceXsupportsXaXstrongXrelationshipXbetweenXinfectionXwithXGroupXAXstreptococciXandXsubsequentXrheumat
icXfeverX(usuallyXwithinX2-
6Xweeks).XTherefore,XtheXhistoryXofXplaymatesXrecoveringXfromXstrepXthroatXwouldXindicateXthatXtheXchildXdiagnos
edXwithXrheumaticXfeverXmostXlikelyXalsoXhadXstrepXthroat.XSometimes,XsuchXanXinfectionXhasXnoXclinicalXsymptom
s.X
X
X
X
QuestionX8
WhenXtheXnurseXbecomesXawareXofXfeelingXreluctantXtoXinteractXwithXaXmanipulativeXclient,XtheXBESTXactionXbyXtheXn
urseXisXtoX
A) DiscussXtheXfeelingXofXreluctanceXwithXanXobjectiveXpeerXorXsupervisorX
B) LimitXcontactsXwithXtheXclientXtoXavoidXreinforcingXtheXmanipulativeXbehaviorX
C) ConfrontXtheXclientXregardingXtheXnegativeXeffectsXofXhis/herXbehaviorXonXothersX
D) DevelopXaXbehaviorXmodificationXplanXthatXwillXpromoteXmoreXfunctionalXbehaviorX
X
ReviewXXInformation:XTheXcorrectXanswerXis:A)XDiscussXtheXfeelingXofXreluctanceXwithXanXobjectiveXpeerXorXsupervisor.
X
X
X
X X X X X X X
for NCLEX RN & NCLEX PN Examination-Pretest-
X X X X X X
Q& A X X
X
Pretest
QuestionX1
AXc.XWhatXdocumentXshouldXbeXinXguidingXtheXcareXofXthisXclient?X
A) ClientXSelfXDeterminationXActX
B) Physician'sXtreatmentXordersX
C) AdvanceXDirectives.X
D) ClinicalXPathwayXprotocolsX
X
ReviewXXInformation:XTheXcorrectXanswerXis:XC)XAdvanceXDirectives.XThisXdocumentXspecifiesXtheXclient'sX
wishesX
X
X
X
QuestionX2
YouXareXtheXofXaXhealthXcareXteamXthatXconsistsXofXoneXlicensedXpractical/vocationalXnurse,XoneXnursingXassistantX,X
aXnursingXstudentXandXyourself.XToXwhomXisXitXappropriateXtoXassignXcompleteXcareXforX
A) YourselfX
B) TheXnursingXstudentX
C) TheXlicensedXvocationalXnurseX
D) TheXnursingXassistantX
ReviewXXInformation:XTheXcorrectXanswerXis:A)XYourself.X
X
WhileXtheXnurseXmayXdelegateXaXbedXbathXforXaXstableXclient,XthisXcareXshouldXbeXperformedXbyXanXRNXforXaXnewXadm
ission.XOnlyXtasksXthat XdoXnotXrequireXindependentXjudgmentXshouldXbeXdelegated.X
X
X
X
3QuestionX3
AXmotherXbringsXherXtheXclinic,XcomplainingXthatXtheXchildXseemsXtoXbeXXTheXnurseXexpectsXtoXfindXwhichXofXtheXfollo
wingXonXtheXinitialXhistoryXandXphysicalXassessment?X
A) IncreasedXtemperatureXandXlethargyX
X
B) RashXandXrestlessnessX
X
C) IncreasedXsleepingXandXlistlessnessX
D) DiarrheaXandXpoorXskinXturgorX
ReviewXXInformation:XTheXcorrectXanswerXis:B)XRashXandXrestlessness.X
X
, NCSBN Question Bank NUR 101 NCSBN TEST BANK
X X X X X X X
for NCLEX RN & NCLEX PN Examination-Pretest-
X X X X X X
Q& A X X
X
X
QuestionX4
AsXtheXnurseXtakesXaXhistoryXofXaX3Xyear-oldXwithXneuroblastoma,XwhatXcommentsXbyXtheXparentsXrequireXfollow-
upXandXareXconsistentXwithXtheXdiagnosis?X
A) "TheXchildXhasXbeenXlistlessXandXhasXlostXweight."X
B) "HerXurineXisXdarkXyellowXandXsmallXinXamounts."X
C) "ClothesXareXbecomingXtighterXacrossXherXabdomen."XXD+)X"
WeXnoticeXmuscleXweaknessXandXsomeXunsteadiness."X
ReviewXXInformation:XTheXcorrectXanswerXis:C)X"ClothesXareXbecomingXtighterXacrossXherXabdomen.".X
X
OneXofXtheXmostXcommonXsignsXofXneuroblastomaXisXincreasingXabdominalXgirth.XTheXparents''XreportXthatX
clothingXisXtightXisXsignificant,XandXshouldXbeXfollowedXbyXadditionalXassessments.X
X
X
X
QuestionX5
AX16Xyear-
oldXpresentsXtoXtheXemergencyXdepartment.XTheXtriageXnurseXfindsXthatXthisXteenagerXisXlegallyXmarriedXandXsigne
dXtheXconsentXformXforXtreatment.XWhatXwouldXbeXtheXappropriateXINITIALXactionXbyXtheXnurse?X
A) RefuseXtoXseeXtheXclientXuntilXaXparentXorXlegalXguardianXcanXbeXcontactedX
B) WithholdXtreatmentXuntilXtelephoneXconsentXcanXbeXobtainedXfromXtheXspouseX
C) ReferXtheXclientXtoXaXcommunityXpediatricXhospitalXemergencyXroomX
D) AssessXandXtreatXinXtheXsameXmannerXasXanyXadultXclientX
ReviewXXInformation:XTheXcorrectXanswerXis:D)XAssessXandXtreatXinXtheXsameXmannerXasXanyXadultXclient.X
X
MinorsXmayXbecomeXknownXasXanX"emancipatedXminor"XthroughXmarriage,Xpregnancy,XhighXschoolX
graduation,XindependentXlivingXorXserviceXinXtheXmilitary.XTherefore,XthisXclient,XwhoXisXmarried,XhasXtheXlegalXcapacityXofX
anXadult.X
X
X
X
X
X
X
X
X
X
X
QuestionX6
AXnewlyXadmittedXelderlyXclientXisXseverelyXdehydrated.XWhenXplanningXcareXforXthisXclient,XwhichXoneXofXtheX
X
, NCSBN Question Bank NUR 101 NCSBN TEST BANK
X X X X X X X
for NCLEX RN & NCLEX PN Examination-Pretest-
X X X X X X
Q& A X X
X
followingXisXanXappropriateXtaskXforXanXUnlicensedXAssistiveXPersonnelX(UAP)?X
X
, NCSBN Question Bank NUR 101 NCSBN TEST BANK
X X X X X X X
for NCLEX RN & NCLEX PN Examination-Pretest-
X X X X X X
Q& A X X
X
A) ObtainXaXhistoryXofXfluidXlossX
B) ReportXoutputXofXlessXthanX30Xml/hrX
C) MonitorXresponseXtoXIVXfluidsX
D) CheckXskinXturgorXeveryXfourXhoursX
ReviewXXInformation:XTheXcorrectXanswerXis:B)XReportXoutputXofXlessXthanX30Xml/hr.X
X
WhenXdirectingXaXUAP,XtheXnurseXmustXcommunicateXclearlyXaboutXeachXdelegatedXtaskXwithXspecificXinstructionsX
onXwhatXmustXbeXreported.XBecauseXtheXRNXisXresponsibleXforXallXcare-
relatedXdecisions,onlyXimplementationXtasksXshouldXbeXassignedXbecauseXtheyXdoXnotXrequireXindependentXjudg
ment.X
X
X
X
QuestionX7
TheXnurseXisXassessingXaX4Xyear-
oldXforXpossibleXrheumaticXfever.XWhichXofXtheXfollowingXwouldXtheXnurseXsuspectXisXrelatedXtoXthisXdiagnosis?X
A) DiagnosisXofXchickenpoxXsixXmonthsXagoX
B) ExposureXtoXstrepXthroat XinXdaycareXlastXmonthX
C) TreatmentXforXearXinfectionXtwoXmonthsXagoX
D) EpisodeXofXfungalXskinXinfectionXlastXweekX
ReviewXXInformation:XTheXcorrectXanswerXis:B)XExposureXtoXstrepXthroatXinXdaycareXlastXmonth.X
X
EvidenceXsupportsXaXstrongXrelationshipXbetweenXinfectionXwithXGroupXAXstreptococciXandXsubsequentXrheumat
icXfeverX(usuallyXwithinX2-
6Xweeks).XTherefore,XtheXhistoryXofXplaymatesXrecoveringXfromXstrepXthroatXwouldXindicateXthatXtheXchildXdiagnos
edXwithXrheumaticXfeverXmostXlikelyXalsoXhadXstrepXthroat.XSometimes,XsuchXanXinfectionXhasXnoXclinicalXsymptom
s.X
X
X
X
QuestionX8
WhenXtheXnurseXbecomesXawareXofXfeelingXreluctantXtoXinteractXwithXaXmanipulativeXclient,XtheXBESTXactionXbyXtheXn
urseXisXtoX
A) DiscussXtheXfeelingXofXreluctanceXwithXanXobjectiveXpeerXorXsupervisorX
B) LimitXcontactsXwithXtheXclientXtoXavoidXreinforcingXtheXmanipulativeXbehaviorX
C) ConfrontXtheXclientXregardingXtheXnegativeXeffectsXofXhis/herXbehaviorXonXothersX
D) DevelopXaXbehaviorXmodificationXplanXthatXwillXpromoteXmoreXfunctionalXbehaviorX
X
ReviewXXInformation:XTheXcorrectXanswerXis:A)XDiscussXtheXfeelingXofXreluctanceXwithXanXobjectiveXpeerXorXsupervisor.
X
X
X
