NUR 101 NCSBN TEST BANK for NCLEX-RN & NCLEX-PN
Examination
Pretest
Question 1
A c. What document should be in guiding the care of this client?
A) Client Self Determination Act
B) Physician's treatment orders
C) Advance Directives.
D) Clinical Pathway protocols
Review Information: The correct answer is: C) Advance
Directives. This document specifies the client's wishes
Question 2
You are the of a health care team that consists of one licensed
practical/vocational nurse, one nursing assistant , a nursing student
and yourself. To whom is it appropriate to assign complete care for
A) Yourself
B) The nursing student
C) The licensed vocational nurse
D) The nursing assistant
,Review 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 a new admission. Only
tasks that do not require independent judgment should be
delegated.
3Question 3
A mother brings her the clinic, complaining that the child seems to
be The nurse expects to find which of the following on the initial
history and physical assessment?
A) Increased temperature and lethargy
B) Rash and restlessness
C) Increased sleeping and listlessness
D) Diarrhea and poor skin turgor
Review Information: The correct answer is:B) Rash and
restlessness.
Question 4
As the nurse takes a history of a 3 year-old with neuroblastoma,
what comments by the parents require follow-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 that clothing is tight is
significant, and should be followed by additional assessments.
Question 5
A 16 year-old presents to the emergency department. The triage
nurse finds that this teenager is legally married and signed the
consent form for treatment. What would be the appropriate
INITIAL action by the nurse?
A) Refuse to see the client until a parent or legal guardian can be
contacted
B) Withhold treatment until telephone consent can be obtained
from the spouse
C) Refer the client to a community pediatric hospital emergency
room
D) Assess and treat in the same manner as any adult client
Review 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 school graduation, independent living or
, service in the military. Therefore, this client, who is married, has
the legal capacity of an adult.
Question 6
A newly admitted elderly client is severely dehydrated. When
planning care for this client, which one of the following is an
appropriate task for an Unlicensed Assistive Personnel (UAP)?
A) Obtain a history of fluid loss
B) Report output of less than 30 ml/hr
C) Monitor response to IV fluids
D) Check skin turgor every four hours
Review 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 specific instructions on what must be
reported. Because the RN is responsible for all care-related
decisions,only implementation tasks should be assigned because
they do not require independent judgment.
Question 7
Examination
Pretest
Question 1
A c. What document should be in guiding the care of this client?
A) Client Self Determination Act
B) Physician's treatment orders
C) Advance Directives.
D) Clinical Pathway protocols
Review Information: The correct answer is: C) Advance
Directives. This document specifies the client's wishes
Question 2
You are the of a health care team that consists of one licensed
practical/vocational nurse, one nursing assistant , a nursing student
and yourself. To whom is it appropriate to assign complete care for
A) Yourself
B) The nursing student
C) The licensed vocational nurse
D) The nursing assistant
,Review 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 a new admission. Only
tasks that do not require independent judgment should be
delegated.
3Question 3
A mother brings her the clinic, complaining that the child seems to
be The nurse expects to find which of the following on the initial
history and physical assessment?
A) Increased temperature and lethargy
B) Rash and restlessness
C) Increased sleeping and listlessness
D) Diarrhea and poor skin turgor
Review Information: The correct answer is:B) Rash and
restlessness.
Question 4
As the nurse takes a history of a 3 year-old with neuroblastoma,
what comments by the parents require follow-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 that clothing is tight is
significant, and should be followed by additional assessments.
Question 5
A 16 year-old presents to the emergency department. The triage
nurse finds that this teenager is legally married and signed the
consent form for treatment. What would be the appropriate
INITIAL action by the nurse?
A) Refuse to see the client until a parent or legal guardian can be
contacted
B) Withhold treatment until telephone consent can be obtained
from the spouse
C) Refer the client to a community pediatric hospital emergency
room
D) Assess and treat in the same manner as any adult client
Review 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 school graduation, independent living or
, service in the military. Therefore, this client, who is married, has
the legal capacity of an adult.
Question 6
A newly admitted elderly client is severely dehydrated. When
planning care for this client, which one of the following is an
appropriate task for an Unlicensed Assistive Personnel (UAP)?
A) Obtain a history of fluid loss
B) Report output of less than 30 ml/hr
C) Monitor response to IV fluids
D) Check skin turgor every four hours
Review 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 specific instructions on what must be
reported. Because the RN is responsible for all care-related
decisions,only implementation tasks should be assigned because
they do not require independent judgment.
Question 7
