nclex exam question

NCSBN exam

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

 

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

 

 

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

 

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."

 

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

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

 

 

Question 7 

The nurse is assessing a 4 year-old for possible rheumatic fever. Which of the following would the 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

 

Question 8 

When the nurse becomes aware of feeling reluctant to interact with a manipulative client, the BEST action by the nurse is to

A) Discuss the feeling of reluctance with an objective peer or supervisor

B) Limit contacts with the client to avoid reinforcing the manipulative behavior

C) Confront the client regarding the negative effects of his/her behavior on others

D) Develop a behavior modification plan that will promote more functional behavior

Question 9 

A client is being treated for paranoid schizophrenia. When the 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) Leaves the nurse vulnerable for charges of assault and battery

C) Was appropriate in view of the client's history of violence

D) Was necessary to maintain the therapeutic milieu of the unit

Question 10 

A client has been admitted to the Coronary Care Unit with a Myocardial Infarction. Which of the following nursing diagnosis should have PRIORITY?

A) Pain related to ischemia

B) Risk for altered elimination: constipation

C) Risk for complication: dysrhythmias

D) Anxiety