Nclex-testbank - Nclex test bank practice material PDF

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NCLEX-PN® TEST QUESTIONS The following questions are similar to those that may appear on the NCLEX-RN ® exam. Some questions may have more than one correct response. During this review, you should select the one best response.

CHAPTER 1 1.1 A client is being discharged and needs instructions on wound care.When planning to teach the client, the nurse should: a. identify the client’s learning needs and learning ability. b. identify the client’s learning needs and advise him what to do. c. identify the client’s problems and make the appropriate referral. d. provide pamphlets or videotapes for ongoing learning.

Answer: a Rationale: To provide the most appropriate teaching, the nurse first needs to identify what the client needs to know and determine the client’s educational level and learning ability. Comprehension Implementation Health Promotion: Prevention and/or Early Detection of Health Problems

1.2 A client is requesting a second opinion. The nurse who supports and promotes the client’s rights is acting as the client’s: a. teacher. b. adviser. c. supporter. d. advocate.

Answer: d Rationale: The nurse’s role as client advocate involves actively promoting clients’ rights to make decisions and choices. Comprehension Assessment Safe, Effective Care Environment: Coordinated Care Health Promotion: Prevention and/or Early Detection of Health Problems

1.3 The client tells the nurse she has been smoking one pack of cigarettes a day for the past 20 years. The nurse recognizes this is what part of the nursing process? a. assessment b. planning c. implementation d. evaluation

Answer: a Rationale: Data collection occurs during the assessment phase; the information can be obtained during the initial assessment as well as during ongoing assessment. Knowledge Assessment Health Promotion: Prevention and/or Early Detection of Health Problems

1.4 During the assessment step of the nursing process, the nurse collects subjective and objective data. The nurse uses the information to identify: a. medical diagnoses. b. actual or potential problems. c. client’s response to illness. d. need for community support groups.

Answer: b Rationale: Information obtained during the assessment step is used in planning and implementing nursing care, based on the problems identified from the assessment data. Analysis Planning Health Promotion: Prevention and/or Early Detection of Health Problem

1.5 The nurse performs daily, routine equipment checks to detect possible malfunction. This is part of the nurse’s role in the: a. nursing process. b. quality assurance plan. c. care management. d. assessment plan.

Answer: b Rationale: Quality of care is evaluated through documentation reviews, interviews and surveys, observation and equipment checks. Application Implementation Health Promotion: Prevention and/or Early Detection of Health Problems

1.6 The nurse is developing a nursing diagnosis for a client who has pneumonia. The nurse recognizes the diagnosis describes an actual or potential problem that: a. the nurse can treat independently.

Answer: a Rationale: Nursing diagnoses reflect client problems that the nurse can treat independently. Application Planning Safe, Effective Care Environment: Coordinated Care

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b. the nurse can treat with a physician’s order. c. requires physician’s intervention. d. relates to the clients’ primary diagnosis. 1.7 After administering pain medication, the nurse returns to check the client’s level of comfort. This stage of the nursing process is known as: a. assessment. b. planning. c. implementation. d. evaluation.

Answer: d Rationale: In the evaluation step the nurse determines if the interventions were effective. Analysis/Diagnosis Evaluation Safe, Effective Care Environment: Coordinated Care

1.8 A client has lost 10 pounds related to nausea and vomiting. The nurse identifies an appropriate expected outcome: The client will: a. gain weight. b. gain 2 pounds within 1 week. c. not lose weight. d. gain 10 pounds in 2 days.

Answer: b Rationale: Expected outcomes should reflect a goal that is client centered, realistic, and measurable. Answers a and c are not measurable; d is not realistic. Analysis/Diagnosis Planning Physiological Integrity: Physiological Adaptation

1.9 A problem-solving process that requires empathy, knowledge, divergent thinking, discipline, and creativity is known as: a. critical thinking. b. nursing process. c. framework for nurses. d. care management.

Answer: a Rationale: Critical thinking involves self-directed thinking, combining the nurse’s cognitive skills as well as attitude, experience, empathy, and discipline. Comprehension Analysis/Diagnosis Safe, Effective Care Environment: Coordinated Care

1.10 At the end of the shift, the nurse is ready to leave but has not been relieved by the oncoming shift nurse. The nurse’s responsibility to provide care for clients is part of the nurse’s: a. Code of Ethics. b. nursing process. c. critical thinking. d. quality assurance.

Answer: a Rationale: The Code of Ethics guides the behavior of nurses. The nurse’s primary commitment is to the client, ensuring he or she receives safe, competent, and continual care. Comprehension Implementation Safe, Effective Care Environment: Coordinated Care

CHAPTER 2 2.1 According to Havighurst, the developmental tasks that describe adults as learning to live with a mate, have children, and hold a job are found in which of the following stages? a. young adult (18–35 years of age) b. middle adult (36–60 years of age) c. older adult (over 60 years of age) d. productive adult (18–60 years of age)

Answer: a Rationale: These tasks occur predominantly in the young adult age group. Knowledge Assessment Health Promotion: Growth and Development

2.2 When caring for the middle age adult the nurse recognizes a major risk factor is: a. cigarette smoking. b. multiple sex partners. c. decreased physical activity. d. obesity.

Answer: c Rationale: Due to a decrease in basal metabolic rate and often activity level as well, the middle adult is at risk for weight gain and obesity. Comprehension Integrative process: Assessment Test plan: Health Promotion: Prevention and/or Early Detection of Health Problems

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2.3 Because of the physiologic changes in the gastrointestinal system, the nurse should encourage the older adult to consume a diet high in: a. Na. b. fiber. c. carbohydrates. d. calories.

Answer: b Rationale: A decrease in peristalsis can lead to constipation; increasing fiber in the diet will help to combat this. Comprehension Planning Health Promotion: Growth and Development

2.4 Women in the middle adult age group are at risk for cancer of the breast and reproductive organs. The nurse can suggest the following in health promotion teaching: a. “You need to contact your physician about mammography.” b. “If there is not a history of cancer in the women of your family, you need not be concerned.” c. “An annual physical exam is important to detect early signs and symptoms of cancer.” d. “Self-breast exam monthly and an annual Pap smear are necessary for early detection of cancer.”

Answer: d Rationale: This option gives the most specific recommendations for tests that should be done to detect cancer. The other options provide more general information. Application Implementation Health Promotion: Prevention and/or Early Detection of Health Problems

2.5 When teaching the old-old adult (over age 85) who has been diagnosed with a new illness, the nurse recognizes this age group: a. needs client teaching at a slower pace, with visual aids and repetition. b. does not profit from patient teaching. c. learns at the same rate as young-old adults. d. is generally cognitively impaired and unable to learn new information.

Answer: a Rationale: Due to neurovascular and sensory losses, older adults need adjustment in teaching methods, although they still have the ability to learn. Application Planning Health Promotion: Growth and Development

2.6 When planning care for elderly clients in long-term care facilities, the nurse gives highest priority to: a. ensuring that they consume at least 1,200 calories a day. b. providing regular periods of exercise daily. c. maintaining a safe environment. d. providing opportunities for social interactions.

Answer: c Rationale: Although all the options are important, maintenance of a safe environment is always of highest priority. Application Implementation Safe, Effective Care Environment: Safety and Infection Control

2.7 The nurse visits an elderly client who lives alone, is not eating well, and has very little food available in the home. The nurse may also want to assess the client’s: a. ability to do her own grocery shopping. b. access to local restaurants. c. number of visits by family. d. availability of local grocery stores.

Answer: a Rationale: Assessing the client’s ability to obtain food would be essential to determine why the client isn’t eating and has little food available. Analysis Assessment Health Promotion: Prevention and/or Early Detection of Health Problems

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2.8 A client is experiencing a significant change from his normal health. In the first stage of an acute illness, the nurse can expect the client to report having: a. bleeding. b. cough. c. fever. d. pain.

Answer: d Rationale: Pain is the most frequently reported manifestation of acute illnesses. Analysis Assessment Physiological Integrity: Physiological Adaptation

2.9 When caring for a client with a chronic illness, the nurse is aware the client will have: a. impaired function. b. persistent pain. c. reversible conditions. d. severe symptoms.

Answer: a Rationale: Chronic illness is characterized by impaired functioning of one or more body systems. Persistent pain and severity of symptoms vary with the client and condition. Chronic conditions are not reversible. Comprehension Assessment Physiological Integrity: Physiological Adaptation

2.10 The nurse is planning interventions beneficial to clients with chronic illness. The nurse should focus on: a. pain management. b. education to promote independent functioning. c. securing assistance from family members. d. assisting the client to accept her illness.

Answer: b Rationale: Nursing interventions should focus on promoting independence, reducing health care costs, and improving quality of life. Application Intervention Safe, Effective Care Environment: Coordinated Care

CHAPTER 3 3.1 The nurse is planning to teach an older client how to check her blood sugar. To promote short-term memory activity, the nurse should: a. have the client repeat the steps of the procedure back to the nurse. b. ensure environment is free of distracting stimuli. c. review the procedure with client on several occasions. d. limit teaching session to 5 to 10 minutes in length.

Answer: c Rationale: Repetitive presentations promote short memory retention. All of the other options are helpful to the learning process, but c is the best option. Application Planning Health Promotion and Maintenance; Growth and Development

3.2 When doing a physical assessment of an old-old client, the nurse could expect to see which of the following? a. dilated pupils b. thin and brittle nails c. an increase in tear production d. a decrease in pubic hair

Answer: d Rationale: Age-related physical changes include decreased scalp, axillary, and pubic hair. Pupils are smaller. Nails often become thick and brittle. Tear production decreases. Comprehension Assessment Health Promotion and Maintenance; Growth and Development

3.3 A client who was previously independent with bathing is hospitalized for a possible bowel obstruction.When the client asks the nurse for help with bathing the nurse recognizes the client’s need to: a. revert to a more dependent stage of development. b. adjust for disease symptoms by restricting activity. c. use the physical ailment to solicit more attention for himself. d. have more physical contact with another human being.

Answer: b Rationale: Restriction of activity allows the elder client to adapt to an acute illness or change in routine. Restriction of activity may be misinterpreted as dependent or attention-seeking behavior. Application Evaluation Health Promotion and Maintenance; Growth and Development

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3.4 An elder client is being prepared for transfer to a long-term care facility and expresses sorrow at not being able to return to his own home. The nurse can best help the client cope with this change by: a. explaining why it is necessary to move to the new facility. b. explaining why it would be unsafe to remain in his own home. c. showing him pictures of the new facility. d. asking him to tell you about significant events in his life.

Answer: d Rationale: Life review or reminiscence can be used therapeutically to facilitate coping with change and allows the older adult to maintain/achieve ego integrity. The other options can be used as the client moves into the adjustment phase. Application Planning Health Promotion and Maintenance: Growth and Development

3.5 An elderly client is seen in the clinic. When reviewing his health care maintenance, the nurse recommends that the client should have: a. a digital rectal examination for prostate enlargement every 3 months. b. a blood test for prostate specific antigen (PSA) yearly. c. a monthly screening for fecal occult blood. d. An eye examination every 2 years.

Answer: b Rationale: A digital rectal exam and PSA blood test should be done yearly in males over 65 years of age. Screening for fecal occult blood is indicated yearly. Application Implementation Health Promotion and Maintenance: Prevention and Early Detection of Health Problems

3.6 The nurse is teaching an elder client who is recovering from a prolonged illness about a new medication regimen.The most appropriate teaching aid would be: a. assist client with making a written list of medication times. b. instruct a family member on the times of the new medications. c. encourage the client to ask frequent questions. d. have the client repeat the instructions back to you.

Answer: a Rationale: Since short-term memory loss frequently occurs in the elderly, written lists and use of calendars is helpful in assisting elderly clients with recall of information. Instructing family members doesn’t involve the client, although they should have a copy of the list as well. Options c and d are helpful techniques, but the client may still forget the instructions. Application Implementation Health Promotion and Maintenance: Prevention and Early Detection of Health Problems.

3.7 The nurse is assisting in a teaching program for clients in a senior citizen center. The nurse informs the clients that healthy behaviors in the older adult include: a. having a pneumonia immunization if over age 65. b. consuming at least 2000 mg of calcium daily. c. having a yearly tetanus immunization. d. engaging in 60 minutes of aerobic exercise daily.

Answer: a Rationale: It is recommended that people over age 65 or with chronic illness have a pneumonia vaccine. The recommended calcium intake is 1200 mg. Tetanus immunizations are recommended every 10 years. Thirty to 60 minutes of moderately strenuous, but aerobic activity is not necessarily recommended. Application Implementation Health Promotion and Maintenance: Prevention and Early Detection of Health Problems

3.8 A client is admitted with complaints of right upper quadrant pain, nausea, and vomiting. The nurse recognizes these symptoms correlate with which of the following physical changes in the elder adult? a. a greater risk to develop gallstones b. an increased gag reflex c. decreased sense of smell d. increased stomach emptying

Answer: a Rationale: Intestinal motility and liver function decrease, putting elderly at greater risk for gallstone formation. The gag reflex and stomach emptying decrease. Sense of smell is decreased, but would not contribute to the listed symptoms. Analysis Assessment Health Promotion and Maintenance: Growth and Development

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3.9 When developing a care plan for the older adult the nurse recognizes that age-related physical changes indicate: a. a need for greater analgesic since the pain threshold decreases. b. strong odors are more offensive since the sense of smell is increased. c. night lights should be available since night vision is decreased. d. bathing should be done daily since sebum production is increased.

Answer: c Rationale: Pupils are smaller, therefore reducing night vision. The pain threshold and sense of smell both increase. Sebaceous gland activity decreases, resulting in dry skin. Application Planning Health Promotion and Maintenance: Growth and Development

3.10 When caring for a client in a longterm care facility, the nurse facilitates reminiscing by: a. encouraging client to focus on her current situation. b. reminding client what her current strengths are. c. asking client to tell about her childhood. d. helping client to remember what activities she did in the past week.

Answer: c Rationale: Reminiscing involves recall of past events that are significant to the individual. Remembrance of recent activities would only involve recall of shortterm memory. Application Implementation Health Promotion and Maintenance: Growth and Development

CHAPTER 4 4.1 A nurse is planning to recommend a community clinic to a client. The nurse will need to consider the: a. socioeconomic status of the client. b. ethnicity of the client. c. gender of the client. d. availability of transportation.

Answer: d Rationale: The nurse will need to determine if the client has access to the community clinic. The other options will not affect the client’s use of the clinic. Analysis Assessment Safe, Effective Care Environment: Coordinated Care

4.2 The nurse is caring for an elderly person with a fractured hip who lives alone. The client may require which of the following types of care after discharge from the hospital? a. transitional care b. nursing home care c. intermediate care d. retirement center

Answer: a Rationale: Before returning to their home independently, clients often need a skilled nursing care facility while transitioning from the acute care setting to home. Comprehension Planning Safe, Effective Care Environment: Coordinated Care

4.3 The nurse understands that home health care is provided to clients who are: a. chronically ill, disabled, or recuperating. b. acutely ill. c. unable to afford hospitalization. d. not covered by medical insurance.

Answer: a Rationale: Home health care is provided to the chronically ill, those with disabilities, or clients recovering from an acute illness. Acutely ill clients need to be in an inpatient facility. Insurance and payment options may impact the type and/or length of care provided in the home. Knowledge Implementation Safe, Effective Care Environment: Coordinated Care

4.4 A client who is scheduled to have home health services asks the nurse who will come to see her in her home. The nurse explains home health care is provided by: a. registered nurses only. b. a multidisciplinary team of providers. c. home health aides. d. volunteers.

Answer: b Rational...