NCSBNgTESTgBANKg-gforgthegNCLEX-RNg&gNCLEX-
PN,gUpdatedg2022,gCompletegQuestionsg&gAnswersgwit
hgrationale
BESTgEXAMgSOLUTIONgGRADEDgA+
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,gagn
ursinggstudentgandgyourself.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.
,NCSBNgTESTgBANKg-gforgthegNCLEX-RNg&gNCLEX-
PN,gUpdatedg2022,gCompletegQuestionsg&gAnswersgwit
hgrationale
BESTgEXAMgSOLUTIONgGRADEDgA+
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,gwhichgonegofgthegfollowin
ggisgangappropriategtaskgforgangUnlicensedgAssistivegPersonnelg(UAP)?
,NCSBNgTESTgBANKg-gforgthegNCLEX-RNg&gNCLEX-
PN,gUpdatedg2022,gCompletegQuestionsg&gAnswersgwit
hgrationale
BESTgEXAMgSOLUTIONgGRADEDgA+
A) Obtaingaghistorygofgfluidgloss
B) Reportgoutputgofglessgthang30gml/hr
C) MonitorgresponsegtogIVgfluids
D) Checkgskingturgorgeverygfourghours
Reviewg Information:gTheg correctganswerg is:B)gReportg outputg ofg lessgthang30g ml/hr.
WhengdirectinggagUAP,gthegnursegmustgcommunicategclearlygaboutgeachgdelegatedgtaskgwithgspecificginstructionsg
ongwhatgmustgbegreported.gBecausegthegRNgisgresponsiblegforgallgcare-
relatedgdecisions,onlygimplementationgtasksgshouldgbegassignedgbecausegtheygdognotgrequiregindependentgjudgm
ent.
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)gDiscussgthegfeelinggofgreluctancegwithgangobjectivegpeergorgsupervis
or.
Thegnursegwhogisgexperiencinggstressgingthegtherapeuticgrelationshipgcanggaingobjectivitygthroughgsupervision.gTh
egnursegmustgattemptgtogdiscovergattitudesgandgfeelingsgingthegselfgthatginfluencegthegnurse-
, NCSBNgTESTgBANKg-gforgthegNCLEX-RNg&gNCLEX-
PN,gUpdatedg2022,gCompletegQuestionsg&gAnswersgwit
hgrationale
BESTgEXAMgSOLUTIONgGRADEDgA+
clientgrelationship.
PN,gUpdatedg2022,gCompletegQuestionsg&gAnswersgwit
hgrationale
BESTgEXAMgSOLUTIONgGRADEDgA+
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,gagn
ursinggstudentgandgyourself.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.
,NCSBNgTESTgBANKg-gforgthegNCLEX-RNg&gNCLEX-
PN,gUpdatedg2022,gCompletegQuestionsg&gAnswersgwit
hgrationale
BESTgEXAMgSOLUTIONgGRADEDgA+
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,gwhichgonegofgthegfollowin
ggisgangappropriategtaskgforgangUnlicensedgAssistivegPersonnelg(UAP)?
,NCSBNgTESTgBANKg-gforgthegNCLEX-RNg&gNCLEX-
PN,gUpdatedg2022,gCompletegQuestionsg&gAnswersgwit
hgrationale
BESTgEXAMgSOLUTIONgGRADEDgA+
A) Obtaingaghistorygofgfluidgloss
B) Reportgoutputgofglessgthang30gml/hr
C) MonitorgresponsegtogIVgfluids
D) Checkgskingturgorgeverygfourghours
Reviewg Information:gTheg correctganswerg is:B)gReportg outputg ofg lessgthang30g ml/hr.
WhengdirectinggagUAP,gthegnursegmustgcommunicategclearlygaboutgeachgdelegatedgtaskgwithgspecificginstructionsg
ongwhatgmustgbegreported.gBecausegthegRNgisgresponsiblegforgallgcare-
relatedgdecisions,onlygimplementationgtasksgshouldgbegassignedgbecausegtheygdognotgrequiregindependentgjudgm
ent.
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)gDiscussgthegfeelinggofgreluctancegwithgangobjectivegpeergorgsupervis
or.
Thegnursegwhogisgexperiencinggstressgingthegtherapeuticgrelationshipgcanggaingobjectivitygthroughgsupervision.gTh
egnursegmustgattemptgtogdiscovergattitudesgandgfeelingsgingthegselfgthatginfluencegthegnurse-
, NCSBNgTESTgBANKg-gforgthegNCLEX-RNg&gNCLEX-
PN,gUpdatedg2022,gCompletegQuestionsg&gAnswersgwit
hgrationale
BESTgEXAMgSOLUTIONgGRADEDgA+
clientgrelationship.
