Details of NCLEX-PN TEST QUESTIONS WITH CORRECT ANSWERS GRADED A+ 2021
NCLEX-PN TEST
QUESTIONS WITH
CORRECT ANSWERS
GRADED A+ 2021
398 NCLEX-PN®
... [Show More] Test Bank Questions © 2007 Pearson Education, Inc.
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
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
1.5 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.
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
© 2007 Pearson Education, Inc. NCLEX-PN® Test Bank Questions 399
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
400 NCLEX-PN® Test Bank Questions © 2007 Pearson Education, Inc.
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
© 2007 Pearson Education, Inc. NCLEX-PN® Test Bank Questions 401
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.
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
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
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
3.3 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
Answer: d
Rationale: Pain is the most frequently reported manifestation of acute illnesses.
Analysis
Assessment
Physiological Integrity: Physiological Adaptation
402 NCLEX-PN® Test Bank Questions © 2007 Pearson Education, Inc.
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
© 2007 Pearson Education, Inc. NCLEX-PN® Test Bank Questions 403
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
Rationale: Home health care may involve a variety of services, including nursing,
social services, therapists, and volunteers.
Assessment
Comprehension
Safe, Effective Care Environment: Coordinated Care
404 NCLEX-PN® Test Bank Questions © 2007 Pearson Education, Inc.
4.5 A 75-year-old client expresses
concern over not being eligible for
home health visits. The nurse explains
to the client that the elderly are entitled
to home care under which of the
following legislation?
a. diagnosis-related groups (DRGs)
b. Omnibus Reconciliation Act
c. Medicaid Act
d. Medicare Act
Answer: d
Rationale: Medicare legislation entitles the elderly to home care services.DRGs
and Medicaid have affected home health services, but came into effect after
Medicare.
Assessment
Comprehension
Safe, Effective Environment: Coordinated Care
4.6 The nurse is caring for a client in
the acute care setting who will need
home care. The client will initially need
to have:
a. physician’s order and treatment plan.
b. nursing orders and care plan.
c. a referral source and recommendation.
d. approval by Medicare for payment.
Answer: a
Rationale: Home care cannot begin without physician orders and a physicianapproved
treatment plan. Options b and c become a part of the treatment plan.
Home care reimbursement may include Medicare, Medicaid, private insurance,
and self-pay.
Comprehension
Assessment
Safe, Effective Care Environment: Coordinated Care
4.7 When providing care to a client in
the home setting, the nurse understands
reimbursement sources such as Medicare
will approve payment only on:
a. medications ordered by the
physician.
b. interventions provided by licensed
nurses.
c. interventions documented on the
progress notes.
d. interventions identified on the
treatment plan.
Answer: d
Rationale: The nurse must confirm that all interventions are included in the
physician’s treatment plan. Payment will not be made if the intervention is not
part of the treatment plan.
Assessment
Comprehension
Safe, Effective Care Environment: Coordinated Care
4.8 The nurse providing home care is a
guest in the client’s home and must:
a. make home visits only when it is
convenient for the client.
b. respect boundaries and maintain
confidentiality.
c. obtain written consent from family
members to make visits.
d. take direction from the client for
interventions.
Answer: b
Rationale: Patient confidentiality and respect for property are part of a home
health agency’s bill of rights.Visit times are arranged between the nurse and the
family. The client gives written consent and interventions are based on the
physician’s treatment plan.
Application
Implementation
Safe, Effective Care Environment: Coordinated Care
4.9 Infection control can present a
challenge to the home care nurse,
especially with clients who have open
wounds. Important client teaching by
the nurse must include:
a. avoiding contact with the open
wound.
b. prohibiting family members to
change dressings.
c. hand washing and proper disposal of
waste.
d. documentation of wound care
procedures.
Answer: c
Rationale: Effective hand washing and waste disposal are of paramount
importance to infection control. Clients may have contact with their own
wounds and family members are taught to do the dressing changes.
Documentation is important, but a not a part of infection control
Application
Implementation
Physiological Integrity: Reduction of Risk Potential
© 2007 Pearson Education, Inc. NCLEX-PN® Test Bank Questions 405
4.10 The rehabilitation nurse performs
a primary assessment in order to
determine the client’s:
a. medical condition.
b. insurance provider.
c. level of function.
d. nutritional status.
Answer: c
Rationale: To develop an individualized plan of care, the nurse must first
determine the client’s level of physical function. The medical condition and
insurance provider will already be documented. Nutritional assessment will be
determined after the primary assessment.
Analysis
Assessment
Physiological Integrity: Physiological Adaptation
5.2 When collecting assessment data on
a client, the nurse can obtain data from a
secondary source if:
a. the client is under 21 years of age.
b. the client is over 65 years of age.
c. the client refuses care.
d. the client is unable to speak English.
Answer: d
Rationale: When the client does not speak the same language as the nurse,
information may need to be obtained from another source; a translator may also
assist.
Comprehension
Assessment
Health Promotion: Prevention and/or Early Detection of Health Problems
5.3 During an assessment the client
complains of back pain. It is important
for the nurse to determine:
a. the exact cause of the pain.
b. the length of time the client has
experienced the pain.
c. the location on the back and severity
of the pain.
d. the client’s exercise schedule.
Answer: c
Rationale: The client’s complaint of pain is general in nature and warrants further
clarification. The other options can be explored when more specific information
about the pain has been determined.
Analysis
Assessment
Physiological Integrity: Physiological Adaptation
CHAPTER 5
5.1 During the assessment the client
tells the nurse he has pain in the left
knee. This information is considered:
a. objective data.
b. subjective data.
c. nonrelevant data.
d. historical data.
Answer: b
Rationale: Subjective data is information only the client can describe. Objective
data is observable and measurable. A complaint of pain is also relevant and
current data.
Comprehension
Assessment
Physiological Integrity: Physiological Adaptation
5.4 When assessing the client, the nurse
uses percussion to determine:
a. equal symmetry of chest expansion.
b. heart sounds.
c. presence of gas in the intestines.
d. presence of fluid in the lungs.
Answer: c
Rationale: Percussion is most often used to assess abdominal structures and
check for tympany or dullness.Options b and d would be assessed through
auscultation. Option a involves inspection.
Comprehension
Assessment
Health Promotion: Prevention and/or Early Detection of Health Problems
5.5 In the general survey, the nurse can
obtain an indication of the client’s
general health by inspecting the:
a. general environment.
b. respiration rate.
c. skin, hair, and nails.
d. range of motion of the extremities.
Answer: c
Rationale: The integumentary system often provides a general indication of
overall health. The general environment does not reflect the client’s health.
Respiration and range of motion are more specific to one body system.
Comprehension
Assessment
Health Promotion: Prevention and/or Early Detection of Health Problems
5.6 The nurse observes the client has
cyanosis, a blue or gray discoloration of
the skin, and recognizes this is seen in
clients with decreased:
a. oxygen levels.
b. activity.
c. heart sounds.
d. lung sounds.
Answer: a
Rationale: Cyanosis is a result of decreased levels of oxygen in the blood.
Comprehension
Assessment
Health Promotion: Prevention and/or Early Detection of Health Problems
406 NCLEX-PN® Test Bank Questions © 2007 Pearson Education, Inc.
5.7 On assessment the nurse observes
small red spots caused by capillary
bleeding and documents the client has:
a. erythema.
b. petechiae.
c. lesions.
d. rash.
Answer: b
Rationale: The spots describe petechiae. Erythema is a redness of the skin.
Lesions involve disruption of the skin surface and rashes occur secondary to
irritation or allergic reactions.
Comprehension
Assessment
Health Promotion: Prevention and/or Early Detection of Health Problems
5.8 The nurse determines a client’s skin
turgor is nonelastic and the skin folds
remain elevated. The nurse recognizes a
cause of this is:
a. edema.
b. cold temperature.
c. dehydration.
d. lesions.
Answer: c
Rationale: A lack of water as seen with dehydration decreases the fullness and
elasticity of the skin. Excess fluid would cause edema. Temperature and lesions
usually do not affect skin turgor.
Analysis
Assessment
Physiological [Show Less]