NCSBN TEST BANK - g g g
for the NCLEX-
g g
RN & NCLEX-
g g
PN,Updated 2021, C
g g g
omplete Questions g g
& Answers With Rati
g g g
onale
,Questiong1
Agc.gWhatgdocumentgshouldgbegingguidinggthegcaregofgthisgclient?
A) ClientgSelfgDeterminationgAct
B) Physician'sgtreatmentgorders
C) Advance g Directives.
D) ClinicalgPathwaygprotocols
Reviewg Information:gThegcorrectganswergis:gC)gAdvancegDirectives.gThisgdocumentgspecifiesgthegclient'sgwishes
Questiong2
Yougaregthegofgaghealthgcaregteamgthatgconsistsgofgoneglicensedgpractical/vocationalgnurse,gonegnursinggassistantg,ga
gnursinggstudentgandgyourself. gTogwhomgisgitgappropriategtogassigngcompletegcaregfor
A) Yourself
B) Theg nursinggstudent
C) Theglicensedgvocationalgnurse
D) Thegnursinggassistant
ReviewgInformation:gThegcorrectganswergis:A)gYourself.
Whilegthegnursegmaygdelegategagbedgbathgforgagstablegclient,gthisgcaregshouldgbegperformedgbygangRNgforgagnewgadmiss
ion.gOnlygtasksgthatgdognotgrequiregindependentgjudgmentgshouldgbegdelegated.
3Questiong3
Agmothergbringsghergthegclinic,gcomplaininggthatgthegchildgseemsgtogbeg Thegnursegexpectsgtogfindgwhichgofgthegfollo
winggongtheginitialghistorygandgphysicalgassessment?
A) Increasedgtemperaturegandglethargy
B) Rashgandgrestlessness
C) Increasedgsleepinggandglistlessness
D) Diarrheagandgpoorgskingturgor
Reviewg Information:gThegcorrectganswergis:B)gRashgandgrestlessness.
,Questiong4
Asgthegnursegtakesgaghistorygofgag3gyear-oldgwithgneuroblastoma,gwhatgcommentsgbygthegparentsgrequiregfollow-
upgandgaregconsistentgwithgthegdiagnosis?
A) "Thegchildghasgbeenglistlessgandghasglostgweight."
B) "Hergurinegisgdarkgyellowgandgsmallgingamounts."
C) "Clothesgaregbecominggtightergacrossghergabdomen."gD+)g
"Wegnoticegmusclegweaknessgandgsomegunsteadiness."
Reviewg Information:g Theg correctg answerg is:C)g "Clothesg areg becomingg tighterg acrossg hergabdomen.".
Onegofgthegmostgcommongsignsgofgneuroblastomagisgincreasinggabdominalggirth.gThegparents''greportgthatgclothi
nggisgtightgisgsignificant,gandgshouldgbegfollowedgbygadditionalgassessments.
Questiong5
Ag16gyear-
oldgpresentsgtogthegemergencygdepartment.gThegtriagegnursegfindsgthatgthisgteenagergisglegallygmarriedgandgsign
edgthegconsentgformgforgtreatment.gWhatgwouldgbegthegappropriategINITIALgactiongbygthegnurse?
A) Refusegtogseegthegclientguntilgagparentgorglegalgguardiangcangbegcontacted
B) Withholdgtreatmentg untilg telephoneg consentgcang beg obtainedgfromg theg spouse
C) Refergthegclientgtogagcommunitygpediatricghospitalgemergencygroom
D) Assessgandgtreatgingthegsamegmannergasganygadultgclient
Reviewg Information:gThegcorrectganswergis:D)gAssessgandgtreatgingthegsamegmannergasganygadultgclient.
Minorsgmaygbecomegknowngasgang"emancipatedgminor"gthroughgmarriage,gpregnancy,ghighgschoolggraduation,gind
ependentglivinggorgservicegingthegmilitary.gTherefore,gthisgclient,gwhogisgmarried,ghasgtheglegalgcapacitygofgangadult
.
Questiong6
Agnewlygadmittedgelderlygclientgisgseverelygdehydrated.gWhengplanninggcaregforgthisgclient,gwhichgonegofgthegfollowinggisg
angappropriategtaskgforgangUnlicensedgAssistivegPersonnelg(UAP)?
, A) Obtaingaghistorygofgfluidgloss
B) Reportgoutputgofglessgthang30gml/hr
C) MonitorgresponsegtogIVgfluids
D) Checkgskingturgorgeverygfourghours
Reviewg Information:gTheg correctganswerg is:B)gReportg outputg ofg lessgthang30g ml/hr.
WhengdirectinggagUAP,gthegnursegmustgcommunicategclearlygaboutgeachgdelegatedgtaskgwithgspecificginstruction
sgongwhatgmustgbegreported.gBecausegthegRNgisgresponsiblegforgallgcare-
relatedgdecisions,onlygimplementationgtasksgshouldgbegassignedgbecausegtheygdognotgrequiregindependentgjudg
ment.
Questiong7
Thegnursegisgassessinggag4gyear-
oldgforgpossiblegrheumaticgfever.gWhichgofgthegfollowinggwouldgthegnursegsuspectgisgrelatedgtogthisgdiagnosis?
A) Diagnosisgofg chickenpoxg sixg monthsg ago
B) Exposuregtogstrepgthroatgingdaycareglastgmonth
C) Treatmentgforgearginfectiongtwogmonthsgago
D) Episodegofgfungalgskinginfectionglastgweek
Reviewg Information:gThegcorrectganswergis:B)gExposuregtogstrepgthroatgingdaycareglastgmonth.
EvidencegsupportsgagstronggrelationshipgbetweenginfectiongwithgGroupgAgstreptococcigandgsubsequentgrheu
maticgfeverg(usuallygwithing2-
6gweeks).gTherefore,gtheghistorygofgplaymatesgrecoveringgfromgstrepgthroatgwouldgindicategthatgthegchildgdia
gnosedgwithgrheumaticgfevergmostglikelygalsoghadgstrepgthroat.gSometimes,gsuchganginfectionghasgnogclinica
lgsymptoms.
Questiong8
Whengthegnursegbecomesgawaregofgfeelinggreluctantgtoginteractgwithgagmanipulativegclient,gthegBESTgactiongbygth
egnursegisgto
A) Discussgthegfeelinggofgreluctancegwithgangobjectivegpeergorgsupervisor
B) Limitgcontactsgwithgthegclientgtogavoidgreinforcinggthegmanipulativegbehavior
C) Confrontgthegclientgregardinggthegnegativegeffectsgofghis/hergbehaviorgongothers
D) Developgagbehaviorgmodificationgplangthatgwillgpromotegmoregfunctionalgbehavior
Reviewg Information:gThegcorrectganswergis:A)gDiscussgthegfeelinggofgreluctancegwithgangobjectivegpeergorgsupervisor.
Thegnursegwhogisgexperiencinggstressgingthegtherapeuticgrelationshipgcanggaingobjectivitygthroughgsupervision.gT
hegnursegmustgattemptgtogdiscovergattitudesgandgfeelingsgingthegselfgthatginfluencegthegnurse-gclientgrelationship.
for the NCLEX-
g g
RN & NCLEX-
g g
PN,Updated 2021, C
g g g
omplete Questions g g
& Answers With Rati
g g g
onale
,Questiong1
Agc.gWhatgdocumentgshouldgbegingguidinggthegcaregofgthisgclient?
A) ClientgSelfgDeterminationgAct
B) Physician'sgtreatmentgorders
C) Advance g Directives.
D) ClinicalgPathwaygprotocols
Reviewg Information:gThegcorrectganswergis:gC)gAdvancegDirectives.gThisgdocumentgspecifiesgthegclient'sgwishes
Questiong2
Yougaregthegofgaghealthgcaregteamgthatgconsistsgofgoneglicensedgpractical/vocationalgnurse,gonegnursinggassistantg,ga
gnursinggstudentgandgyourself. gTogwhomgisgitgappropriategtogassigngcompletegcaregfor
A) Yourself
B) Theg nursinggstudent
C) Theglicensedgvocationalgnurse
D) Thegnursinggassistant
ReviewgInformation:gThegcorrectganswergis:A)gYourself.
Whilegthegnursegmaygdelegategagbedgbathgforgagstablegclient,gthisgcaregshouldgbegperformedgbygangRNgforgagnewgadmiss
ion.gOnlygtasksgthatgdognotgrequiregindependentgjudgmentgshouldgbegdelegated.
3Questiong3
Agmothergbringsghergthegclinic,gcomplaininggthatgthegchildgseemsgtogbeg Thegnursegexpectsgtogfindgwhichgofgthegfollo
winggongtheginitialghistorygandgphysicalgassessment?
A) Increasedgtemperaturegandglethargy
B) Rashgandgrestlessness
C) Increasedgsleepinggandglistlessness
D) Diarrheagandgpoorgskingturgor
Reviewg Information:gThegcorrectganswergis:B)gRashgandgrestlessness.
,Questiong4
Asgthegnursegtakesgaghistorygofgag3gyear-oldgwithgneuroblastoma,gwhatgcommentsgbygthegparentsgrequiregfollow-
upgandgaregconsistentgwithgthegdiagnosis?
A) "Thegchildghasgbeenglistlessgandghasglostgweight."
B) "Hergurinegisgdarkgyellowgandgsmallgingamounts."
C) "Clothesgaregbecominggtightergacrossghergabdomen."gD+)g
"Wegnoticegmusclegweaknessgandgsomegunsteadiness."
Reviewg Information:g Theg correctg answerg is:C)g "Clothesg areg becomingg tighterg acrossg hergabdomen.".
Onegofgthegmostgcommongsignsgofgneuroblastomagisgincreasinggabdominalggirth.gThegparents''greportgthatgclothi
nggisgtightgisgsignificant,gandgshouldgbegfollowedgbygadditionalgassessments.
Questiong5
Ag16gyear-
oldgpresentsgtogthegemergencygdepartment.gThegtriagegnursegfindsgthatgthisgteenagergisglegallygmarriedgandgsign
edgthegconsentgformgforgtreatment.gWhatgwouldgbegthegappropriategINITIALgactiongbygthegnurse?
A) Refusegtogseegthegclientguntilgagparentgorglegalgguardiangcangbegcontacted
B) Withholdgtreatmentg untilg telephoneg consentgcang beg obtainedgfromg theg spouse
C) Refergthegclientgtogagcommunitygpediatricghospitalgemergencygroom
D) Assessgandgtreatgingthegsamegmannergasganygadultgclient
Reviewg Information:gThegcorrectganswergis:D)gAssessgandgtreatgingthegsamegmannergasganygadultgclient.
Minorsgmaygbecomegknowngasgang"emancipatedgminor"gthroughgmarriage,gpregnancy,ghighgschoolggraduation,gind
ependentglivinggorgservicegingthegmilitary.gTherefore,gthisgclient,gwhogisgmarried,ghasgtheglegalgcapacitygofgangadult
.
Questiong6
Agnewlygadmittedgelderlygclientgisgseverelygdehydrated.gWhengplanninggcaregforgthisgclient,gwhichgonegofgthegfollowinggisg
angappropriategtaskgforgangUnlicensedgAssistivegPersonnelg(UAP)?
, A) Obtaingaghistorygofgfluidgloss
B) Reportgoutputgofglessgthang30gml/hr
C) MonitorgresponsegtogIVgfluids
D) Checkgskingturgorgeverygfourghours
Reviewg Information:gTheg correctganswerg is:B)gReportg outputg ofg lessgthang30g ml/hr.
WhengdirectinggagUAP,gthegnursegmustgcommunicategclearlygaboutgeachgdelegatedgtaskgwithgspecificginstruction
sgongwhatgmustgbegreported.gBecausegthegRNgisgresponsiblegforgallgcare-
relatedgdecisions,onlygimplementationgtasksgshouldgbegassignedgbecausegtheygdognotgrequiregindependentgjudg
ment.
Questiong7
Thegnursegisgassessinggag4gyear-
oldgforgpossiblegrheumaticgfever.gWhichgofgthegfollowinggwouldgthegnursegsuspectgisgrelatedgtogthisgdiagnosis?
A) Diagnosisgofg chickenpoxg sixg monthsg ago
B) Exposuregtogstrepgthroatgingdaycareglastgmonth
C) Treatmentgforgearginfectiongtwogmonthsgago
D) Episodegofgfungalgskinginfectionglastgweek
Reviewg Information:gThegcorrectganswergis:B)gExposuregtogstrepgthroatgingdaycareglastgmonth.
EvidencegsupportsgagstronggrelationshipgbetweenginfectiongwithgGroupgAgstreptococcigandgsubsequentgrheu
maticgfeverg(usuallygwithing2-
6gweeks).gTherefore,gtheghistorygofgplaymatesgrecoveringgfromgstrepgthroatgwouldgindicategthatgthegchildgdia
gnosedgwithgrheumaticgfevergmostglikelygalsoghadgstrepgthroat.gSometimes,gsuchganginfectionghasgnogclinica
lgsymptoms.
Questiong8
Whengthegnursegbecomesgawaregofgfeelinggreluctantgtoginteractgwithgagmanipulativegclient,gthegBESTgactiongbygth
egnursegisgto
A) Discussgthegfeelinggofgreluctancegwithgangobjectivegpeergorgsupervisor
B) Limitgcontactsgwithgthegclientgtogavoidgreinforcinggthegmanipulativegbehavior
C) Confrontgthegclientgregardinggthegnegativegeffectsgofghis/hergbehaviorgongothers
D) Developgagbehaviorgmodificationgplangthatgwillgpromotegmoregfunctionalgbehavior
Reviewg Information:gThegcorrectganswergis:A)gDiscussgthegfeelinggofgreluctancegwithgangobjectivegpeergorgsupervisor.
Thegnursegwhogisgexperiencinggstressgingthegtherapeuticgrelationshipgcanggaingobjectivitygthroughgsupervision.gT
hegnursegmustgattemptgtogdiscovergattitudesgandgfeelingsgingthegselfgthatginfluencegthegnurse-gclientgrelationship.
