NCSBN TEST BANK _NCLEX-RN & NCLEX-PN, Updated for 2023. Contains Over 1500 MCQ

NCSBN TEST BANK _NCLEX-RN & NCLEX-PN, Updated for 2023. Contains Over 1500 MCQ

Question 1A c. What document should be in guiding the care of this client?A) Client Self Determination ActB) Physician's treatment ordersC) Advance Directives.D) Clinical Pathway protocolsReview Information: The correct answer is: C) Advance Directives. This document specifies the client'swishesQuestion 2You are the of a health care team that consists of one licensed practical/vocational nurse, one nursingassistant , a nursing student and yourself. To whom is it appropriate to assign complete care forA) YourselfB) The nursing studentC) The licensed vocational nurseD) The nursing assistantReview Information: The correct answer is:A) Yourself.While the nurse may delegate a bed bath for a stable client, this care should be performed by an RN for anew admission. Only tasks that do not require independent judgment should be delegated.3Question 3A mother brings her the clinic, complaining that the child seems to be The nurse expects to find which ofthe following on the initial history and physical assessment?A) Increased temperature and lethargyB) Rash and restlessnessC) Increased sleeping and listlessnessD) Diarrhea and poor skin turgorReview Information: The correct answer is:B) Rash and restlessness.Question 4As the nurse takes a history of a 3 year-old with neuroblastoma, what comments by the parents requirefollow-up and are consistent with the diagnosis?A) "The child has been listless and has lost weight."B) "Her urine is dark yellow and small in amounts."C) "Clothes are becoming tighter across her abdomen."D+) "We notice muscle weakness and some unsteadiness."Review Information: The correct answer is:C) "Clothes are becoming tighter across her abdomen.".One of the most common signs of neuroblastoma is increasing abdominal girth. The parents'' report thatclothing is tight is significant, and should be followed by additional assessments.Question 5A 16 year-old presents to the emergency department. The triage nurse finds that this teenager is legallymarried and signed the consent form for treatment. What would be the appropriate INITIAL action by thenurse?A) Refuse to see the client until a parent or legal guardian can be contactedB) Withhold treatment until telephone consent can be obtained from the spouseC) Refer the client to a community pediatric hospital emergency roomD) Assess and treat in the same manner as any adult clientReview Information: The correct answer is:D) Assess and treat in the same manner as any adult client.Minors may become known as an "emancipated minor" through marriage, pregnancy, high schoolgraduation, independent living or service in the military. Therefore, this client, who is married, has the legalcapacity of an adult.Question 6A newly admitted elderly client is severely dehydrated. When planning care for this client, which one of thefollowing is an appropriate task for an Unlicensed Assistive Personnel (UAP)?A) Obtain a history of fluid lossB) Report output of less than 30 ml/hrC) Monitor response to IV fluidsD) Check skin turgor every four hoursReview Information: The correct answer is:B) Report output of less than 30 ml/hr.When directing a UAP, the nurse must communicate clearly about each delegated task with specificinstructions on what must be reported. Because the RN is responsible for all care-related decisions,onlyimplementation tasks should be assigned because they do not require independent judgment.Question 7The nurse is assessing a 4 year-old for possible rheumatic fever. Which of the following would the nursesuspect is related to this diagnosis?A) Diagnosis of chickenpox six months agoB) Exposure to strep throat in daycare last monthC) Treatment for ear infection two months agoD) Episode of fungal skin infection last weekReview Information: The correct answer is:B) Exposure to strep throat in daycare last month.Evidence supports a strong relationship between infection with Group A streptococci and subsequentrheumatic fever (usually within 2-6 weeks). Therefore, the history of playmates recovering from strepthroat would indicate that the child diagnosed with rheumatic fever most likely also had strep throat.Sometimes, such an infection has no clinical symptoms.Question 8When the nurse becomes aware of feeling reluctant to interact with a manipulative client, the BEST actionby the nurse is toA) Discuss the feeling of reluctance with an objective peer or supervisorB) Limit contacts with the client to avoid reinforcing the manipulative behaviorC) Confront the client regarding the negative effects of his/her behavior on othersD) Develop a behavior modification plan that will promote more functional behaviorReview Information: The correct answer is:A) Discuss the feeling of reluctance with an objective peer orsupervisor.The nurse who is experiencing stress in the therapeutic relationship can gain objectivity throughsupervision. The nurse must attempt to discover attitudes and feelings in the self that influence the nurseclient relationship.Question 9A client is being treated for paranoid schizophrenia. When the client became loud and boisterous, thenurse immediately placed him in seclusion as a precautionary measure. The client willingly complied. Thenurse's actionA) May result in charges of unlawful seclusion and restraintB) Leaves the nurse vulnerable for charges of assault and batteryC) Was appropriate in view of the client's history of violenceD) Was necessary to maintain the therapeutic milieu of the unitReview Information: The correct answer is:A) May result in charges of unlawful seclusion and restraint.Seclusion should only be used when there is an immediate threat of violence or threatening behavior.Question 10A client has been admitted to the Coronary Care Unit with a Myocardial Infarction. Which of the followingnursing diagnosis should have PRIORITY?A) Pain related to ischemiaB) Risk for altered elimination: constipationC) Risk for complication: dysrhythmiasD) AnxietyReview Information: The correct answer is:A) Pain related to ischemia.Pain is related to ischemia, and relief of pain will decrease myocardial oxygen demands, reduce bloodpressure and heart rate and relieve anxiety. Pain also stimulates the sympathetic nervous system andincreased preload, further increasing myocardial demands.Question 11The nurse manager who is responsible for hiring professional nursing staff is required to comply with theAmericans with Disabilities Act. The provisions of the law require the nurse manager toA) Maintain an environment free from hazardsB) Provide reasonable accommodations for disabled individualsC) Make all necessary accommodations for disabled individualsD) Consider only physical disabilities in making employment decisionsReview Information: The correct answer is:B) Provide reasonable accommodations for disabledindividuals.The law is designed to permit persons with disabilities access to job opportunities. Employers mustevaluate an applicant's ability to perform the job and not discriminate on the basis of a disability.Employers also must make "reasonable accommodations.Question 12The mother of a school-aged child in a long leg cast asks the nurse how to relieve itching inside the cast.Which of the following is appropriate for the nurse to suggest as a remedy?A) Scratching the outside of the cast vigorously, applying pressure over the areaB) Blowing a hair dryer or heat lamp on the cast over the area that is itchingC) Using a long, smooth piece of wood to gently scratch the affected areaD) Applying an ice pack over the area of the cast that is affectedReview Information: The correct answer is:D) Applying an ice pack over the area of the cast that isaffected.Applying ice is a safe method of relieving the itching.Question 13Which of the following BEST describes the application of time management strategies in the role of thenurse manager?A) Scheduling staff efficiently to cover client needsB) Assuming a fair share of the client care as a role modelC) Setting daily goals to prioritize workD) Delegating tasks to reduce work loadReview Information: The correct answer is:C) Setting daily goals to prioritize work.Time management strategies must include setting priorities and meeting goals.Question 14The clinic nurse assesses a toddler with a tentative diagnosis of neuroblastoma. Symptoms the nurseobserves that suggest this problem includeA) Lymphedema and nerve palsyB) Hearing loss and ataxiaC) Headaches and vomitingD) Abdominal mass and weaknessReview Information: The correct answer is:D) Abdominal mass and weakness.Clinical manifestations of neuroblastoma include an irregular abdominal mass that crosses the midline,weakness, pallor, anorexia, weight loss and irritability.Question 15A fifteen year-old client has been placed in a Milwaukee Brace. Which one of the following statements from the clientindicates the need for additional teaching?A) "I will only have to wear this for six months."B) "I should inspect my skin daily."C) "The brace will be worn day and night."D) "I can take it off when I shower."Review Information: The correct answer is:A) "I will only have to wear this for six months.".The brace must be worn long-term, usually for 1-2 years.Question 16The nurse manager has been using a decentralized block scheduling plan to staff the nursing unit. However, staff haveasked for many changes and exceptions to the schedule over the past few months. The manager considers self-schedulingknowing thatA) Quality of care will improveB) Staff turnover should decreaseC) Flexible scheduling will occurD) Team morale will improveReview Information: The correct answer is:D) Team morale will improve.Nurses are more satisfied with autonomy and control. The nurse manager becomes the facilitator ofscheduling rather than the decision-maker of the schedule.Question 17A client is admitted to the emergency room following an acute asthma attack. Which of the followingassessments would be expected by the nurse?A) Diffuse expiratory wheezingB) Loose, productive coughC) No relief from inhalantD) Fever and chillsReview Information: The correct answer is:A) Diffuse expiratory wheezing.In asthma, the airways are narrowed - creating difficulty getting air in and a wheezing sound.Question 18The nurse manager hears a physician loudly criticizing one of the staff nurses in the hearing of others. Theemployee does not respond to the physician's complaints. The nurse manager's FIRST action should beA) Walk up to the physician and quietly ask that this unacceptable behavior stopB) Allow the staff nurse to handle this situation without interferenceC) Notify the Nursing Director and Medical Staff Chief of a breech of professional conductD) Request an immediate private meeting with the physician and staff nurseReview Information: The correct answer is:D) Request an immediate private meeting with the physicianand staff nurse.Assertive communication respects the needs of all parties to express themselves, but not at the expenseof others. The nurse manager needs first to protect clients and other staff from this display and come tothe assistance of the nurse employee.Question 19A client voluntarily admits herself to the hospital due to suicidal ideation. The client has been on the unitfor two days and is now demanding to be released. The MOST appropriate action is for the nurse toA) Tell the client that she cannot be released because she is still suicidalB) Inform the client that she can be released only if she signs a no suicide contractC) Discuss with the client the decision to leave and prepare for her dischargeD) Instruct her regarding her right to sign out upon receipt of the physician's discharge orderReview Information: The correct answer is:C) Discuss with the client the decision to leave and preparefor her discharge.Clients voluntarily admitted to the hospital have a right to demand and obtain release. Discussing thedecision allows opportunity for other interventions.Question 20A client is admitted with infective endocarditis (IE). Which symptom would alert the nurse to acomplication of this condition?A) DyspneaB) Heart murmurC) Macular rashD) HemorrhageReview Information: The correct answer is:B) Heart murmur.Large, soft, rapidly developing vegetations attach to the heart valves. They have a tendency to break off,causing emboli and leaving ulcerations on the valve leaflets. These emboli produce symptoms of cardiacmurmur, fever, anorexia, malaise and neurologic sequelae of emboli. Furthermore, the vegetations maytravel to various organs such as spleen, kidney, coronary artery, brain and lungs and obstruct blood flow.Question 21A nurseadmits a premature infant who has respiratory distress syndrome. In planning care, nursing actionsare based on the fact that the MOST likely cause of this problem stems from the infant's inability toA) Stabilize thermoregulationB) Maintain alveolar surface tensionC) Begin normal pulmonary blood flowD) Regulate intracardiac pressureReview Information: The correct answer is:B) Maintain alveolar surface tension.Respiratory distress syndrome is primarily a disease related to developmental delay in lung maturation.Although many factors lead to the development of the problem, the central factor relates to the lack of anormally functioning surfactant system due to immaturity in lung development.Question 22An 18 year-old client is admitted to intensive care from the emergency room following a diving accident.The injury is suspected to be at the level of the 2nd cervical vertebrae. The nurse's PRIORITY assessmentshould beA) Response to stimuliB) Bladder controlC) Respiratory functionD) Muscle weaknessReview Information: The correct answer is:C) Respiratory function.Spinal injury at the C-2 level results in quadriplegia. While the client will experience all of the problemsidentified, respiratory assessment is a priority.Question 23The nurse is caring for a client who was successfully resuscitated from a pulseless dysrhythmia. Which ofthe following assessments is CRITICAL for the nurse to include in the plan of care?A) Hourly urine outputB) White blood countC) Blood glucose every four hoursD) Temperature every two hoursReview Information: The correct answer is:A) Hourly urine output.Clients who have had an episode of decreased glomerular perfusion are at risk for pre-renal failure. This iscaused by any abnormal decline in kidney perfusion that reduces glomerular perfusion. Pre-renal failureoccurs when the effective arterial blood volume falls. Examples of this phenomena include a drop incirculating blood volume as in a cardiac arrest state or in low cardiac perfusion states such as congestiveheart failure associated with a cardiomyopathy. Close observation of hourly urinary output is necessary forearly detection of this condition.Question 24The nurse admitting a 5 month-old who vomited nine times in the past six hours should observe for signsofA) Metabolic acidosisB) Metabolic alkalosisC) Respiratory acidosisD) Respiratory alkalosisReview Information: The correct answer is:B) Metabolic alkalosis.Vomiting causes loss of acid from the stomach. Prolonged vomiting can result in excess loss and lead tometabolic alkalosis.Question 25A child is injured on the school playground and appears to have a fractured leg. The FIRST action theschool nurse should take isA) Call for emergency transport to the hospitalB) Immobilize the limb and joints above and below the injuryC) Assess the child and the extent of the injuryD) Apply cold compresses to the injured areaReview Information: The correct answer is:C) Assess the child and the extent of the injury.When applying the nursing process, assessment is the first step in providing care. The 5 "Ps" of vascularimpairment can be used as a guide (pain, pulse, pallor, paresthesia, paralysis).Question 26As the nurse interviews the parents of a child with asthma, it is a PRIORITY to ask aboutA) Household petsB) New furnitureC) Lead based paintD) Plants such as cactusReview Information: The correct answer is:A) Household pets.Animal dander is a very common allergen affecting persons with asthma. Other triggers may includepollens, carpeting and household dust.Question 27An 80 year-old client was admitted with a diagnosis of possible cerebral vascular accident. Blood pressurehas ranged from 180/110 to 160/100. Over the past several hours, the nurse noted increasing lethargy.Which of the following assessments should the nurse report IMMEDIATELY to the physician?A) Slurred speechB) IncontinenceC) Muscle weaknessD) Rapid pulseReview Information: The correct answer is:A) Slurred speech.Changes in speech patterns and level of conscious can be indicators of continued intercranial bleeding.Treatment options may change based on further diagnostic tests.Question 28A 3 year-old child is brought to the clinic by his grandmother to be seen for "scratching his bottom andwetting the bed at night." Based on these complaints, the nurse would INITIALLY assess forA) AllergiesB) HyperactivityC) RegressionD) PinwormsReview Information: The correct answer is:D) Pinworms.Signs of pinworm infection include intense perianal itching, poor sleep patterns, general irritability,restlessness, bed-wetting, distractibility and short attention span.