NCSBNeTESTeBANK
Pretest
Questione1
Aec.eWhatedocumenteshouldebeeineguidingetheecareeofethiseclient?
A) ClienteSelfeDeterminationeAct
B) Physician'setreatmenteorders
C) Advance e Directives.
D) ClinicalePathwayeprotocols
Reviewe Information:eTheecorrecteanswereis:eC)eAdvanceeDirectives.eThisedocumentespecifiesetheeclient'sewishes
Questione2
Youeareetheeofeaehealthecareeteamethateconsistseofeoneelicensedepractical/vocationalenurse,eoneenursingeassistante,eaen
ursingestudenteandeyourself.eToewhomeiseiteappropriateetoeassignecompleteecareefor
A) Yourself
B) Thee nursingestudent
C) Theelicensedevocationalenurse
D) Theenursingeassistant
RevieweInformation:eTheecorrecteanswereis:A)eYourself.
Whileetheenurseemayedelegateeaebedebatheforeaestableeclient,ethisecareeshouldebeeperformedebyeaneRNeforeaeneweadmiss
ion.eOnlyetasksethatedoenoterequireeindependentejudgmenteshouldebeedelegated.
3Questione3
Aemotherebringseheretheeclinic,ecomplainingethatetheechildeseemsetoebee Theenurseeexpectsetoefindewhicheofetheefollo
wingeonetheeinitialehistoryeandephysicaleassessment?
A) Increasedetemperatureeandelethargy
B) Rasheanderestlessness
C) Increasedesleepingeandelistlessness
D) Diarrheaeandepooreskineturgor
Reviewe Information:eTheecorrecteanswereis:B)eRasheanderestlessness.
,NCSBNeTESTeBANK
Questione4
Asetheenurseetakeseaehistoryeofeae3eyear-oldewitheneuroblastoma,ewhatecommentsebyetheeparentserequireefollow-
upeandeareeconsistentewithetheediagnosis?
A) "Theechildehasebeenelistlesseandehaselosteweight."
B) "Hereurineeisedarkeyelloweandesmalleineamounts."
C) "Clotheseareebecomingetightereacrossehereabdomen."eD+)e
"Weenoticeemuscleeweaknesseandesomeeunsteadiness."
Reviewe Information:e Thee correcte answere is:C)e "Clothese aree becominge tightere acrosse hereabdomen.".
Oneeofetheemostecommonesignseofeneuroblastomaeiseincreasingeabdominalegirth.eTheeparents''ereportethateclothi
ngeisetighteisesignificant,eandeshouldebeefollowedebyeadditionaleassessments.
Questione5
Ae16eyear-
oldepresentsetoetheeemergencyedepartment.eTheetriageenurseefindsethatethiseteenagereiselegallyemarriedeandesign
edetheeconsenteformeforetreatment.eWhatewouldebeetheeappropriateeINITIALeactionebyetheenurse?
A) Refuseetoeseeetheeclienteuntileaeparenteorelegaleguardianecanebeecontacted
B) Withholdetreatmente untile telephonee consentecane bee obtainedefrome thee spouse
C) Referetheeclientetoeaecommunityepediatricehospitaleemergencyeroom
D) Assesseandetreateinetheesameemannereaseanyeadulteclient
Reviewe Information:eTheecorrecteanswereis:D)eAssesseandetreateinetheesameemannereaseanyeadulteclient.
Minorsemayebecomeeknowneaseane"emancipatedeminor"ethroughemarriage,epregnancy,ehigheschoolegraduation,eind
ependentelivingeoreserviceeinetheemilitary.eTherefore,ethiseclient,ewhoeisemarried,ehasetheelegalecapacityeofeaneadult
.
Questione6
Aenewlyeadmittedeelderlyeclienteiseseverelyedehydrated.eWheneplanningecareeforethiseclient,ewhicheoneeofetheefollowin
geiseaneappropriateetaskeforeaneUnlicensedeAssistiveePersonnele(UAP)?
,NCSBNeTESTeBANK
A) Obtaineaehistoryeofefluideloss
B) Reporteoutputeofelessethane30eml/hr
C) MonitoreresponseetoeIVefluids
D) Checkeskineturgoreeveryefourehours
Reviewe Information:eThee correcteanswere is:B)eReporte outpute ofe lessethane30e ml/hr.
WhenedirectingeaeUAP,etheenurseemustecommunicateeclearlyeabouteeachedelegatedetaskewithespecificeinstructionse
onewhatemustebeereported.eBecauseetheeRNeiseresponsibleeforeallecare-
relatededecisions,onlyeimplementationetaskseshouldebeeassignedebecauseetheyedoenoterequireeindependentejudgm
ent.
Questione7
Theenurseeiseassessingeae4eyear-
oldeforepossibleerheumaticefever.eWhicheofetheefollowingewouldetheenurseesuspecteiserelatedetoethisediagnosis?
A) Diagnosiseofe chickenpoxe sixe monthse ago
B) Exposureetoestrepethroateinedaycareelastemonth
C) Treatmenteforeeareinfectionetwoemonthseago
D) Episodeeofefungaleskineinfectionelasteweek
Reviewe Information:eTheecorrecteanswereis:B)eExposureetoestrepethroateinedaycareelastemonth.
EvidenceesupportseaestrongerelationshipebetweeneinfectionewitheGroupeAestreptococcieandesubsequenterheu
maticefevere(usuallyewithine2-
6eweeks).eTherefore,etheehistoryeofeplaymateserecoveringefromestrepethroatewouldeindicateethatetheechildedia
gnosedewitherheumaticefeveremostelikelyealsoehadestrepethroat.eSometimes,esucheaneinfectionehasenoeclinica
lesymptoms.
Questione8
Whenetheenurseebecomeseawareeofefeelingereluctantetoeinteractewitheaemanipulativeeclient,etheeBESTeactionebyeth
eenurseeiseto
A) Discussetheefeelingeofereluctanceewitheaneobjectiveepeereoresupervisor
B) Limitecontactsewithetheeclientetoeavoidereinforcingetheemanipulativeebehavior
C) Confrontetheeclienteregardingetheenegativeeeffectseofehis/herebehavioreoneothers
D) Developeaebehavioremodificationeplanethatewillepromoteemoreefunctionalebehavior
Reviewe Information:eTheecorrecteanswereis:A)eDiscussetheefeelingeofereluctanceewitheaneobjectiveepeereoresupervi
sor.
Theenurseewhoeiseexperiencingestresseinetheetherapeuticerelationshipecanegaineobjectivityethroughesupervision.eTh
eenurseemusteattemptetoediscovereattitudeseandefeelingseinetheeselfethateinfluenceetheenurse-eclienterelationship.
, NCSBNeTESTeBANK
Questione9
Aeclienteisebeingetreatedeforeparanoideschizophrenia.eWhenetheeclientebecameeloudeandeboisterous,etheenurseeimme
diatelyeplacedehimeineseclusioneaseaeprecautionaryemeasure.eTheeclientewillinglyecomplied.eTheenurse'seaction
A) Mayeresulteinechargeseofeunlawfuleseclusioneanderestraint
B) Leavesetheenurseevulnerableeforechargeseofeassaulteandebattery
C) Waseappropriateeinevieweofetheeclient'sehistoryeofeviolence
D) Wasenecessaryetoemaintainetheetherapeuticemilieueofetheeunit
Reviewe Information:eTheecorrecteanswereis:A)eMayeresulteinechargeseofeunlawfuleseclusioneanderestraint.eSeclusi
oneshouldeonlyebeeusedewhenethereeiseaneimmediateethreateofeviolenceeorethreateningebehavior.
Questione10
AeclientehasebeeneadmittedetoetheeCoronaryeCareeUnitewitheaeMyocardialeInfarction.eWhicheofetheefollowingenursingedi
agnosiseshouldehaveePRIORITY?
A) Painerelatedetoeischemia
B) Riskeforealteredeelimination:econstipation
C) Riskeforecomplication:edysrhythmias
D) Anxiety
Reviewe Information:eTheecorrecteanswere is:A)ePaine relatedetoe ischemia.
Paineiserelatedetoeischemia,eandereliefeofepainewilledecreaseemyocardialeoxygenedemands,ereduceebloodepressu
reeandehearterateeanderelieveeanxiety.ePainealsoestimulatesetheesympatheticenervousesystemeandeincreasedepr
eload,efurthereincreasingemyocardialedemands.
Questione11
TheenurseemanagerewhoeiseresponsibleeforehiringeprofessionalenursingestaffeiserequiredetoecomplyewithetheeAmericanse
witheDisabilitieseAct.eTheeprovisionseofetheelawerequireetheenurseemanagereto
A) Maintaine ane environmente freee frome hazards
B) Provideereasonableeaccommodationseforedisabledeindividuals
C) Makeeallenecessaryeaccommodationseforedisabledeindividuals
Pretest
Questione1
Aec.eWhatedocumenteshouldebeeineguidingetheecareeofethiseclient?
A) ClienteSelfeDeterminationeAct
B) Physician'setreatmenteorders
C) Advance e Directives.
D) ClinicalePathwayeprotocols
Reviewe Information:eTheecorrecteanswereis:eC)eAdvanceeDirectives.eThisedocumentespecifiesetheeclient'sewishes
Questione2
Youeareetheeofeaehealthecareeteamethateconsistseofeoneelicensedepractical/vocationalenurse,eoneenursingeassistante,eaen
ursingestudenteandeyourself.eToewhomeiseiteappropriateetoeassignecompleteecareefor
A) Yourself
B) Thee nursingestudent
C) Theelicensedevocationalenurse
D) Theenursingeassistant
RevieweInformation:eTheecorrecteanswereis:A)eYourself.
Whileetheenurseemayedelegateeaebedebatheforeaestableeclient,ethisecareeshouldebeeperformedebyeaneRNeforeaeneweadmiss
ion.eOnlyetasksethatedoenoterequireeindependentejudgmenteshouldebeedelegated.
3Questione3
Aemotherebringseheretheeclinic,ecomplainingethatetheechildeseemsetoebee Theenurseeexpectsetoefindewhicheofetheefollo
wingeonetheeinitialehistoryeandephysicaleassessment?
A) Increasedetemperatureeandelethargy
B) Rasheanderestlessness
C) Increasedesleepingeandelistlessness
D) Diarrheaeandepooreskineturgor
Reviewe Information:eTheecorrecteanswereis:B)eRasheanderestlessness.
,NCSBNeTESTeBANK
Questione4
Asetheenurseetakeseaehistoryeofeae3eyear-oldewitheneuroblastoma,ewhatecommentsebyetheeparentserequireefollow-
upeandeareeconsistentewithetheediagnosis?
A) "Theechildehasebeenelistlesseandehaselosteweight."
B) "Hereurineeisedarkeyelloweandesmalleineamounts."
C) "Clotheseareebecomingetightereacrossehereabdomen."eD+)e
"Weenoticeemuscleeweaknesseandesomeeunsteadiness."
Reviewe Information:e Thee correcte answere is:C)e "Clothese aree becominge tightere acrosse hereabdomen.".
Oneeofetheemostecommonesignseofeneuroblastomaeiseincreasingeabdominalegirth.eTheeparents''ereportethateclothi
ngeisetighteisesignificant,eandeshouldebeefollowedebyeadditionaleassessments.
Questione5
Ae16eyear-
oldepresentsetoetheeemergencyedepartment.eTheetriageenurseefindsethatethiseteenagereiselegallyemarriedeandesign
edetheeconsenteformeforetreatment.eWhatewouldebeetheeappropriateeINITIALeactionebyetheenurse?
A) Refuseetoeseeetheeclienteuntileaeparenteorelegaleguardianecanebeecontacted
B) Withholdetreatmente untile telephonee consentecane bee obtainedefrome thee spouse
C) Referetheeclientetoeaecommunityepediatricehospitaleemergencyeroom
D) Assesseandetreateinetheesameemannereaseanyeadulteclient
Reviewe Information:eTheecorrecteanswereis:D)eAssesseandetreateinetheesameemannereaseanyeadulteclient.
Minorsemayebecomeeknowneaseane"emancipatedeminor"ethroughemarriage,epregnancy,ehigheschoolegraduation,eind
ependentelivingeoreserviceeinetheemilitary.eTherefore,ethiseclient,ewhoeisemarried,ehasetheelegalecapacityeofeaneadult
.
Questione6
Aenewlyeadmittedeelderlyeclienteiseseverelyedehydrated.eWheneplanningecareeforethiseclient,ewhicheoneeofetheefollowin
geiseaneappropriateetaskeforeaneUnlicensedeAssistiveePersonnele(UAP)?
,NCSBNeTESTeBANK
A) Obtaineaehistoryeofefluideloss
B) Reporteoutputeofelessethane30eml/hr
C) MonitoreresponseetoeIVefluids
D) Checkeskineturgoreeveryefourehours
Reviewe Information:eThee correcteanswere is:B)eReporte outpute ofe lessethane30e ml/hr.
WhenedirectingeaeUAP,etheenurseemustecommunicateeclearlyeabouteeachedelegatedetaskewithespecificeinstructionse
onewhatemustebeereported.eBecauseetheeRNeiseresponsibleeforeallecare-
relatededecisions,onlyeimplementationetaskseshouldebeeassignedebecauseetheyedoenoterequireeindependentejudgm
ent.
Questione7
Theenurseeiseassessingeae4eyear-
oldeforepossibleerheumaticefever.eWhicheofetheefollowingewouldetheenurseesuspecteiserelatedetoethisediagnosis?
A) Diagnosiseofe chickenpoxe sixe monthse ago
B) Exposureetoestrepethroateinedaycareelastemonth
C) Treatmenteforeeareinfectionetwoemonthseago
D) Episodeeofefungaleskineinfectionelasteweek
Reviewe Information:eTheecorrecteanswereis:B)eExposureetoestrepethroateinedaycareelastemonth.
EvidenceesupportseaestrongerelationshipebetweeneinfectionewitheGroupeAestreptococcieandesubsequenterheu
maticefevere(usuallyewithine2-
6eweeks).eTherefore,etheehistoryeofeplaymateserecoveringefromestrepethroatewouldeindicateethatetheechildedia
gnosedewitherheumaticefeveremostelikelyealsoehadestrepethroat.eSometimes,esucheaneinfectionehasenoeclinica
lesymptoms.
Questione8
Whenetheenurseebecomeseawareeofefeelingereluctantetoeinteractewitheaemanipulativeeclient,etheeBESTeactionebyeth
eenurseeiseto
A) Discussetheefeelingeofereluctanceewitheaneobjectiveepeereoresupervisor
B) Limitecontactsewithetheeclientetoeavoidereinforcingetheemanipulativeebehavior
C) Confrontetheeclienteregardingetheenegativeeeffectseofehis/herebehavioreoneothers
D) Developeaebehavioremodificationeplanethatewillepromoteemoreefunctionalebehavior
Reviewe Information:eTheecorrecteanswereis:A)eDiscussetheefeelingeofereluctanceewitheaneobjectiveepeereoresupervi
sor.
Theenurseewhoeiseexperiencingestresseinetheetherapeuticerelationshipecanegaineobjectivityethroughesupervision.eTh
eenurseemusteattemptetoediscovereattitudeseandefeelingseinetheeselfethateinfluenceetheenurse-eclienterelationship.
, NCSBNeTESTeBANK
Questione9
Aeclienteisebeingetreatedeforeparanoideschizophrenia.eWhenetheeclientebecameeloudeandeboisterous,etheenurseeimme
diatelyeplacedehimeineseclusioneaseaeprecautionaryemeasure.eTheeclientewillinglyecomplied.eTheenurse'seaction
A) Mayeresulteinechargeseofeunlawfuleseclusioneanderestraint
B) Leavesetheenurseevulnerableeforechargeseofeassaulteandebattery
C) Waseappropriateeinevieweofetheeclient'sehistoryeofeviolence
D) Wasenecessaryetoemaintainetheetherapeuticemilieueofetheeunit
Reviewe Information:eTheecorrecteanswereis:A)eMayeresulteinechargeseofeunlawfuleseclusioneanderestraint.eSeclusi
oneshouldeonlyebeeusedewhenethereeiseaneimmediateethreateofeviolenceeorethreateningebehavior.
Questione10
AeclientehasebeeneadmittedetoetheeCoronaryeCareeUnitewitheaeMyocardialeInfarction.eWhicheofetheefollowingenursingedi
agnosiseshouldehaveePRIORITY?
A) Painerelatedetoeischemia
B) Riskeforealteredeelimination:econstipation
C) Riskeforecomplication:edysrhythmias
D) Anxiety
Reviewe Information:eTheecorrecteanswere is:A)ePaine relatedetoe ischemia.
Paineiserelatedetoeischemia,eandereliefeofepainewilledecreaseemyocardialeoxygenedemands,ereduceebloodepressu
reeandehearterateeanderelieveeanxiety.ePainealsoestimulatesetheesympatheticenervousesystemeandeincreasedepr
eload,efurthereincreasingemyocardialedemands.
Questione11
TheenurseemanagerewhoeiseresponsibleeforehiringeprofessionalenursingestaffeiserequiredetoecomplyewithetheeAmericanse
witheDisabilitieseAct.eTheeprovisionseofetheelawerequireetheenurseemanagereto
A) Maintaine ane environmente freee frome hazards
B) Provideereasonableeaccommodationseforedisabledeindividuals
C) Makeeallenecessaryeaccommodationseforedisabledeindividuals
