1
NCSBN TEST BANK - for the NCLEX-RN &
NCLEX-PN, Updated 2025, CompleteQuestions &
Answers with rationale ©NURSING
Question 1
The nurse is caring for a 4 year-old who will have surgery
for Tetralogy of Fallot tomorrow. Which laboratory report
must receive PRIORITY attention by the nurse?
A) Erythrocyte sedimentation rate
B) White blood cell count
C) Hemoglobin and hematocrit
D) Arterial blood gases
Review Information: The correct answer is:
C) Hemoglobin and hematocrit.
Tetralogy of Fallot is a cyanotic heart defect, which can
manifest in polycythemia due to release of erythropoietin.
Hemoglobin valuesof up to 20 and hematocrit''s of 60 or
higher may be seen. These must be noted and reported to
pg. 1
, 2
the physician.
Question 2
The nurse is assessing a client with portal hypertension.
Which of the following findings would the nurse expect?
A) Expiratory wheezes
B) Blurred vision
C) Acites
D) Dilated pupils
Review Information: The correct answer is:
C) Acites.
Portal hypertension can occur in a client with right-sided
heart failure or cirrhosis of the liver. Portal hypertension
can lead to acites due to the increased protal pressure as
well as a lowered osmotic pressure.
pg. 2
, 3
Question 3
A 67 year-old client with non-insulin dependent diabetes
should be instructed to contact the out-patient clinic
IMMEDIATELY if the following symptoms are present
A) Temperature of 37.5 degrees C with painful urination
B) An open wound on their heel
C) Insomnia and daytime fatigue
D) Nausea with two episodes of vomiting
Review Information: The correct answer is:
B) An open wound on their heel.
When signs of infection occur in their feet, elderly clients
who have diabetes and/or vascular disease should seek
health care quickly and continue treatment until the
infection is resolved. Without treatment, serious infection,
gangrene, limb loss, and death may result.
pg. 3
, 4
Question 4
The nurse is assessing a newborn the day after birth. The
following are noted: high pitched cry, irritability and lack of
interest in feeding. The mother signed her own discharge
against medical advice. Which of the following is
APPROPRIATE nursing care?
A) Reduce the environmental stimuli
B) Offer formula every 2 hours
C) Talk to the newborn while feeding
D) Rock the baby frequently
Review Information: The correct answer is:
A) Reduce the environmental stimuli.
This newborn appears to be withdrawing from substances
taken by the mother before its birth. Reducing noise and
light will reduce the central nervous system responses to
pg. 4
NCSBN TEST BANK - for the NCLEX-RN &
NCLEX-PN, Updated 2025, CompleteQuestions &
Answers with rationale ©NURSING
Question 1
The nurse is caring for a 4 year-old who will have surgery
for Tetralogy of Fallot tomorrow. Which laboratory report
must receive PRIORITY attention by the nurse?
A) Erythrocyte sedimentation rate
B) White blood cell count
C) Hemoglobin and hematocrit
D) Arterial blood gases
Review Information: The correct answer is:
C) Hemoglobin and hematocrit.
Tetralogy of Fallot is a cyanotic heart defect, which can
manifest in polycythemia due to release of erythropoietin.
Hemoglobin valuesof up to 20 and hematocrit''s of 60 or
higher may be seen. These must be noted and reported to
pg. 1
, 2
the physician.
Question 2
The nurse is assessing a client with portal hypertension.
Which of the following findings would the nurse expect?
A) Expiratory wheezes
B) Blurred vision
C) Acites
D) Dilated pupils
Review Information: The correct answer is:
C) Acites.
Portal hypertension can occur in a client with right-sided
heart failure or cirrhosis of the liver. Portal hypertension
can lead to acites due to the increased protal pressure as
well as a lowered osmotic pressure.
pg. 2
, 3
Question 3
A 67 year-old client with non-insulin dependent diabetes
should be instructed to contact the out-patient clinic
IMMEDIATELY if the following symptoms are present
A) Temperature of 37.5 degrees C with painful urination
B) An open wound on their heel
C) Insomnia and daytime fatigue
D) Nausea with two episodes of vomiting
Review Information: The correct answer is:
B) An open wound on their heel.
When signs of infection occur in their feet, elderly clients
who have diabetes and/or vascular disease should seek
health care quickly and continue treatment until the
infection is resolved. Without treatment, serious infection,
gangrene, limb loss, and death may result.
pg. 3
, 4
Question 4
The nurse is assessing a newborn the day after birth. The
following are noted: high pitched cry, irritability and lack of
interest in feeding. The mother signed her own discharge
against medical advice. Which of the following is
APPROPRIATE nursing care?
A) Reduce the environmental stimuli
B) Offer formula every 2 hours
C) Talk to the newborn while feeding
D) Rock the baby frequently
Review Information: The correct answer is:
A) Reduce the environmental stimuli.
This newborn appears to be withdrawing from substances
taken by the mother before its birth. Reducing noise and
light will reduce the central nervous system responses to
pg. 4
