NCSBN TEST BANK 2021 |for NCLEX-RN & NCLEX-PN | Q&A with Rationales Question 1 A c. What document should be in guiding the care of this client? A) Client Self Determination Act B) Physician's treatmen t 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.
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