398 NCLEX-PN Test Bank Questions 2007 Pearson Education, Inc.

398 NCLEX-PN® Test Bank Questions © 2007 Pearson Education, Inc.

NCLEX-PN

®

TESTQUESTIONS

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.

CHAPTER1

1.1A client is being discharged and needs instructions on wound care.When planning to teach the client, the nurse

should:

• identify the client’s learning needs

and learning ability.

• identify the client’s learning needs

and advise him what to do.

• identify the client’s problems and

make the appropriate referral.

• 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

1.2A client is requesting a second opinion. The nurse who supports and promotes the client’s rights is acting as

the client’s:

• teacher.
• adviser.
• supporter.
• 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

1.3The 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?

• assessment
• planning
• implementation
• 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

1.4During the assessment step of the nursing process, the nurse collects subjective and objective data. The nurse

uses the information to identify:

• medical diagnoses.
• actual or potential problems.
• client’s response to illness.
• 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

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

1.5The nurse performs daily, routine equipment checks to detect possible malfunction. This is part of the nurse’s

role in the:

• nursing process.
• quality assurance plan.
• care management.
• assessment plan.

1.6The nurse is developing a nursing diagnosis for a client who has pneumonia. The nurse recognizes the diagnosis describes an actual or

potential problem that:

• 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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© 2007 Pearson Education, Inc. NCLEX-PN® Test Bank Questions399

• the nurse can treat with a physician’s

order.

• requires physician’s intervention.
• relates to the clients’ primary

diagnosis.

1.7After administering pain medication, the nurse returns to check the client’s level of comfort. This stage

of the nursing process is known as:

• assessment.
• planning.
• implementation.
• 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

1.8A client has lost 10 pounds related to nausea and vomiting. The nurse identifies an appropriate expected outcome: The client will:

• gain weight.
• gain 2 pounds within 1 week.
• not lose weight.
• 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

1.9A problem-solving process that requires empathy, knowledge, divergent thinking, discipline, and creativity is

known as:

• critical thinking.
• nursing process.
• framework for nurses.
• 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

1.10At 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:

• Code of Ethics.
• nursing process.
• critical thinking.
• 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

CHAPTER2

2.1According 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?

• young adult (18–35 years of age)
• middle adult (36–60 years of age)
• older adult (over 60 years of age)
• 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

2.2When caring for the middle age adult the nurse recognizes a major risk

factor is:

• cigarette smoking.
• multiple sex partners.
• decreased physical activity.
• 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 BURKMX01_0132371103.QXD 4/22/06 5:12 PM Page 399 2 / 4

400 NCLEX-PN® Test Bank Questions © 2007 Pearson Education, Inc.

2.3Because of the physiologic changes in the gastrointestinal system, the nurse should encourage the older adult to

consume a diet high in:

• Na.
• fiber.
• carbohydrates.
• 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

2.4Women 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:

• “You need to contact your physician

about mammography.”

• “If there is not a history of cancer in

the women of your family, you need not be concerned.”

• “An annual physical exam is

important to detect early signs and symptoms of cancer.”

• “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

2.5When teaching the old-old adult (over age 85) who has been diagnosed with a new illness, the nurse recognizes

this age group:

• needs client teaching at a slower

pace, with visual aids and repetition.

• does not profit from patient

teaching.

• learns at the same rate as young-old

adults.

• 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

2.6When planning care for elderly clients in long-term care facilities, the

nurse gives highest priority to:

• ensuring that they consume at least

1,200 calories a day.

• providing regular periods of exercise

daily.

• maintaining a safe environment.
• 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

2.7The 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:

• ability to do her own grocery

shopping.

• access to local restaurants.
• number of visits by family.
• 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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© 2007 Pearson Education, Inc. NCLEX-PN® Test Bank Questions401 2.8A 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:

• bleeding.
• cough.
• fever.
• pain.

2.9When caring for a client with a chronic illness, the nurse is aware the

client will have:

• impaired function.
• persistent pain.
• reversible conditions.
• 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

2.10The nurse is planning interventions beneficial to clients with chronic illness.

The nurse should focus on:

• pain management.
• education to promote independent

functioning.

• securing assistance from family

members.

• 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

3.2When doing a physical assessment of an old-old client, the nurse could expect to see which of the following?

• dilated pupils
• thin and brittle nails
• an increase in tear production
• 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

CHAPTER3

3.1The nurse is planning to teach an older client how to check her blood sugar. To promote short-term memory

activity, the nurse should:

• have the client repeat the steps of

the procedure back to the nurse.

• ensure environment is free of

distracting stimuli.

• review the procedure with client on

several occasions.

• 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 3.3A 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:

• revert to a more dependent stage of

development.

• adjust for disease symptoms by

restricting activity.

• use the physical ailment to solicit

more attention for himself.

• 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

Answer: d

Rationale: Pain is the most frequently reported manifestation of acute illnesses.Analysis Assessment

Physiological Integrity: Physiological Adaptation

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