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NCLEX NCLEX-RN Exam
National Council Licensure Examination - NCLEX-RN (Page 35 )

Updated On: 12-Jan-2026
Page 35 of 345
PDF with 862 Questions

A 32-year-old mother of two was brought to the hospital by her husband. He reported that his wife could no longer manage the house and children. She does not sleep and talks day and night. She has purchased some very expensive clothes. The nurse noted that the client speaks rapidly and changes the subject irrationally. This is an example of:

  1. Flight of ideas
  2. Delusions
  3. Hallucinations
  4. Echolalia

Answer(s): A

Explanation:

(A) Rapidly moving from one topic to another without following any logical sequence is called flight of ideas. (B) False beliefs are delusions. (C) False sensory perceptions are hallucinations ("hearing voices"). (D) Repeating words is called echolalia.



A client returned to the unit following a pneumonectomy. As the nurse is assessing her incision, she notices fresh blood on the dressing. The nurse should first:

  1. Reinforce the dressing.
  2. Continue to monitor the dressing.
  3. Notify the physician.
  4. Note the time and amount of blood.

Answer(s): C

Explanation:

(A) The dressing should not be reinforced without first notifying the physician. The decision may be made by the physician to reinforce the dressing after assessing the amount of bleeding. (B) Blood on the dressing is unusual and should make the nurse aware that something more than continuing to monitor the dressing should be done. (C) The physician should be notified immediately, because if the bleeding persists, the client may have to be taken back to surgery. (D) The time and amount of blood do need to be recorded after the physician is notified.



A client's renal calculi are identified as consisting of calcium phosphate. Which of the following diets would be appropriate?

  1. High calcium, low phosphorus
  2. Low calcium, high phosphorus
  3. Two-gram sodium diet
  4. Low calcium and phosphorus, acid ash

Answer(s): D

Explanation:

(A) The stones consist of calcium and phosphorus; therefore, these minerals should be avoided. A high-calcium diet is contraindicated. (B) A high-phosphorus diet is contraindicated. (C) A 2-g sodium diet is a cardiac diet. (D) A low-calcium and phosphorus diet will reduce further calculi formation.



A 52-year-old client is scheduled for a small-bowel resection in the morning. In conjunction with other preoperative preparation, the nurse is teaching her diaphragmatic breathing exercises. She will teach the client to:

  1. Inhale slowly and deeply through the nose until the lungs are fully expanded, hold the breath a couple of seconds, and then exhale slowly through the mouth. Repeat 2­3 more times to complete the series every 1­2 hours while awake
  2. Purse the lips and take quick, short breaths approximately 18­20 times/min
  3. Take a large gulp of air into the mouth, hold it for 10­15 seconds, and then expel it through the nose. Repeat 4­5 times to complete the series
  4. Inhale as deeply as possible and then immediately exhale as deeply as possible at a rate of approximately 20­24 times/min

Answer(s): A

Explanation:

(A) This is the correct method of teaching diaphragmatic breathing, which allows full lung expansion to increase oxygenation, prevent atelectasis, and move secretions up and out of the lungs to decrease risk of pneumonia. (B) Quick, short breaths do not allow for full lung expansion and movement of secretions up and out of the lungs. Quick, short breaths may lead to O2 depletion, hyperventilation, and hypoxia. (C) Expelling breaths through the nose does not allow for full lung expansion and the use of diaphragmatic muscles to assist in moving secretions up and out of the lungs. (D) Inhaling and exhaling at a rate of 20­24 times/min does not allow time for full lung expansion to increase oxygenation. This would most likely lead to O2 depletion and hypoxia.



A 75-year-old client is hospitalized with pneumonia caused by gram-positive bacteria. Which one of the following best describes a gram-positive bacterial pneumonia?

  1. Klebsiellapneumonia
  2. Pneumococcal pneumonia
  3. Legionella pneumophilapneumonia
  4. Escherichia colipneumonia

Answer(s): B

Explanation:

(A)Klebsiellapneumonia is caused by gram-negative bacteria. (B) Pneumococcal pneumonia is caused by gram-positive bacteria. (C)Legionella pneumophilapneumonia is a nonbacterial pneumonia. (D)E.colipneumonia is caused by gram-negative bacteria.



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