NCLEX-RN TEST BANK Updated 2022, Complete Questions & Answers with rationale

Browse through Financial institution For NCLEX-RN Question Bank Updated for 2022, All Questions & Answers with explanations

NCSBN Question Bank – for the NCLEX-RN & NCLEX-PN, Updated 2022/2023, All Questions & Answers with explanations. Query 1 A c. Which document should be 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 lead a health care team comprising a licensed practical/vocational nurse, a nursing assistant, a nursing student, and yourself. Who should Full care be assigned to? 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 can delegate basic care for a stable client, care for a new admission should be conducted by an RN. Only tasks not requiring independent judgment should be delegated. Question 3 A mother brings her child to the clinic, mentioning that the child seems off. What would the nurse expect to find on initial history and physical assessment? A) Elevated 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 gathers a history of a 3-year-old with neuroblastoma, what statements by the parents need follow-up and align with the diagnosis? A) “The child has been listless and has lost weight” B) “Her urine is dark yellow and in small amounts” C) “Clothes have become tighter around her abdomen” D+) “We notice muscle weakness and some unsteadiness” Review Information: The correct answer is: C) “Clothes have become tighter around her abdomen”. Increasing abdominal girth is a common sign of neuroblastoma and requires further assessment. Question 5 A 16-year-old arrives at the emergency department. The triage nurse discovers that this teenager is legally married and consented to treatment. What would be the appropriate INITIAL action by the nurse? A) Refuse to treat the client until a parent or legal guardian is contacted B) Withhold treatment until verbal consent is obtained from the spouse C) Refer the client to a local pediatric hospital emergency room D) Evaluate and treat as with any adult client Review Information: The correct answer is: D) Evaluate and treat as with any adult client. Minors can be considered “emancipated minors” through various means, including marriage, pregnancy, graduation, independent living, or military service, granting them legal adult status. Question 6 A newly admitted elderly client is severely dehydrated. What is an appropriate task for an Unlicensed Assistive Personnel (UAP) when planning care for this client? 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 4 hours Review Information: The correct answer is: B) Report output of less than 30 ml/hr. When assigning tasks to a UAP, the nurse must provide clear instructions on what needs to be reported as the RN is responsible for all decisions. Only implementation tasks that do not require independent judgment should be assigned. Question 7 The nurse is evaluating a 4-year-old for possible rheumatic fever. Which of the following might be 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. Rheumatic fever often follows infection with Group A streptococci within 2-6 weeks. Hence, a history of playmates recovering from strep throat would indicate a likely connection with rheumatic fever. Question 8 When the nurse feels hesitant to interact with a manipulative client, what is the BEST action for the nurse to take? A) Discuss the reluctance with an impartial colleague or supervisor B) Limit interactions with the client to avoid reinforcing manipulative behavior C) Confront the client about the negative effects of their behavior D) Develop a behavior modification plan to encourage more functional behavior Review Information: The correct answer is: A) Discuss the reluctance with an impartial colleague or supervisor. Seeking supervision can help the nurse gain objectivity in the therapeutic relationship. It’s important to address one’s own feelings and attitudes that may impact the nurse-client interaction. Question 9 A client with paranoid schizophrenia is placed in seclusion by the nurse when becoming loud and boisterous. The client complies willingly. What might be the outcome of the nurse’s action? A) May lead to charges of illegal seclusion and restraint B) Leaves the nurse open to charges of assault and battery C) Was justified due to the client’s history of violence D) Was necessary to maintain the therapeutic environment of the unit Review Information: The correct answer is: A) May lead to charges of illegal seclusion and restraint. Seclusion should only be used in imminent threat situations. Question 10 A client is admitted to the Coronary Care Unit with a Myocardial Infarction. Which nursing diagnosis should be given 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. Alleviating pain can reduce myocardial oxygen demands, blood pressure, heart rate, and anxiety. Pain can elevate sympathetic activity, preload, and myocardial demands. Question 11 The nurse supervisor responsible for hiring nursing staff must comply with the Americans with Disabilities Act. The law requires the nurse supervisor to: A) Maintain a suitable environm