NCLEX NUR 101 NCSBN question bank
NCSBN question bank -2022
NCSBN question bank NCLEX NUR 101 written by solutions | 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) C...
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
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
Asthe nurse takes a history of a 3 year-old with neuroblastoma, what comments bythe parents require
follow-up and are consistent withthe 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 ofthe 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 tothe emergency department.the triage nurse finds that this teenager is legally
married and signedthe consent form for treatment. What would bethe appropriate INITIAL action bythe
nurse?
A) Refuse to seethe client until a parent or legal guardian can be contacted
B) Withhold treatment until telephone consent can be obtained fromthe spouse
C) Referthe client to a community pediatric hospital emergency room
D) Assess and treat inthe same manner as any adult client
Review Information:the correct answer is:D) Assess and treat inthe same manner as any adult client.
Minors may become known as an "emancipated minor" through marriage, pregnancy, high school
graduation, independent living or service inthe military. Therefore, this client, who is married, hasthe legal
capacity of an adult.
Question 6
A newly admitted elderly client is severely dehydrated. When planning care for this client, which one ofthe
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. Becausethe RN is responsible for all care-related decisions,only
implementation tasks should be assigned because they do not require independent judgment.
Question 7
The nurse is assessing a 4 year-old for possible rheumatic fever. Which ofthe following wouldthe nurse
suspect is related to this diagnosis?
A) Diagnosis of chickenpox six months ago
B) Exposure to strep throat in daycare last month
C) Treatment for ear infection two months ago
D) Episode of fungal skin infection last week
Review 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 subsequent
rheumatic fever (usually within 2-6 weeks). Therefore,the history of playmates recovering from strep
throat would indicate thatthe child diagnosed with rheumatic fever most likely also had strep throat.
Sometimes, such an infection has no clinical symptoms.
Question 8
Whenthe nurse becomes aware of feeling reluctant to interact with a manipulative client,the BEST action
bythe nurse is to
A) Discussthe feeling of reluctance with an objective peer or supervisor
B) Limit contacts withthe client to avoid reinforcingthe manipulative behavior
C) Confrontthe client regardingthe negative effects of his/her behavior on others
D) Develop a behavior modification plan that will promote more functional behavior
Review Information:the correct answer is:A) Discussthe feeling of reluctance with an objective peer or
supervisor.
The nurse who is experiencing stress inthe therapeutic relationship can gain objectivity through
supervision.the nurse must attempt to discover attitudes and feelings inthe self that influencethe nurse-
client relationship.
, Question 9
A client is being treated for paranoid schizophrenia. Whenthe client became loud and boisterous,the nurse
immediately placed him in seclusion as a precautionary measure.the client willingly complied.the nurse's
action
A) May result in charges of unlawful seclusion and restraint
B) Leavesthe nurse vulnerable for charges of assault and battery
C) Was appropriate in view ofthe client's history of violence
D) Was necessary to maintainthe therapeutic milieu ofthe unit
Review 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 10
A client has been admitted tothe Coronary Care Unit with a Myocardial Infarction. Which ofthe following
nursing diagnosis should have PRIORITY?
A) Pain related to ischemia
B) Risk for altered elimination: constipation
C) Risk for complication: dysrhythmias
D) Anxiety
Review 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 blood
pressure and heart rate and relieve anxiety. Pain also stimulatesthe sympathetic nervous system and
increased preload, further increasing myocardial demands.
Question 11
The nurse manager who is responsible for hiring professional nursing staff is required to comply withthe
Americans with Disabilities Act.the provisions ofthe law requirethe nurse manager to
A) Maintain an environment free from hazards
B) Provide reasonable accommodations for disabled individuals
C) Make all necessary accommodations for disabled individuals
D) Consider only physical disabilities in making employment decisions
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