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NCLEX NCLEX-RN Exam
National Council Licensure Examination - NCLEX-RN (Page 36 )

Updated On: 12-Jan-2026
Page 36 of 345
PDF with 862 Questions

A 30-year-old client is exhibiting auditory hallucinations. In working with this client, the nurse would be most effective if the nurse:

  1. Encourages the client to discuss the voices
  2. Attempts to direct the client's attention to the here and now
  3. Exhibits sincere interest in the delusional voices
  4. Gives the medication as necessary for the acting-out behavior

Answer(s): B

Explanation:

(A) This answer is incorrect. Encouraging discussion of the voices will reinforce the delusion. (B) This answer is correct. The nurse should appropriately present reality. (C) This answer is incorrect. Showing interest would reinforce the delusional system. (D) This answer is incorrect. The statement only indicates that the client is hearing voices. It does not state that the client is acting out.



A client's behavior is annoying other clients on the unit. He is meddling with their belongings and dominating the group. The best approach by the nurse is to:

  1. Seclude him in his room.
  2. Set limits on his behavior.
  3. Have his medication increased.
  4. Ignore him and tell the other clients that these behaviors are due to his illness and that they should understand.

Answer(s): B

Explanation:

(A) This action by the nurse would be punitive. (B) Consistent limit setting will help the client to know what is acceptable behavior. (C) This action is not within the nurse's scope of practice. (D) This could be dangerous to the client and to others and violates other clients' rights.



A 55-year-old woman entered the emergency room by ambulance. Her primary complaint is chest pain. She is receiving O2 via nasal cannula at 2 L/min for dyspnea. Which of the following findings in the client's nursing assessment demand immediate nursing action?

  1. Associated symptoms of indigestion and nausea
  2. Restlessness and apprehensiveness
  3. Inability to tolerate assessment session with the admitting nurse
  4. History of hypertension treated with pharmacological therapy

Answer(s): B

Explanation:

(A) Indigestion or nausea may accompany angina or myocardial infarction, but they do not indicate imminent danger for the client. (B) Restlessness and apprehensiveness require immediate nursing action because they are indicative of very low oxygenation of body tissues and are frequently the first indication of impending cardiac or respiratory arrest. (C) It is common for the cardiac client to experience fatigue and inability to physically tolerate long assessment sessions. (D) A history of hypertension requires no immediate nursing intervention. In the situation described, the blood pressure is not given and therefore cannot be assumed to be elevated.



A client's transfusion of packed red blood cells has been infusing for 2 hours. She is complaining of a raised, itchy rash and shortness of breath. She is wheezing, anxious, and very restless. The nurse knows these assessment findings are congruent with:

  1. Hemolytic transfusion reaction
  2. Febrile transfusion reaction
  3. Circulatory overload
  4. Allergic transfusion reaction

Answer(s): D

Explanation:

(A) A hemolytic transfusion reaction would be characterized by fever, chills, chest pain, hypotension, and tachypnea. (B) Fever, chills, and headaches are indicative of a febrile transfusion reaction. (C) Circulatory overload is manifest by dyspnea, cough, and pulmonary crackles. (D) Urticaria, pruritus, wheezing, and anxiety are indicative of an allergic transfusion reaction.



A 2-year-old child will undergo a cardiac catheterization tomorrow to evaluate his ventricular septal defect.
Based on his developmental stage, the nurse:

  1. Uses pictures to explain the procedure to the child and his parents that evening
  2. Explains the procedure using simple words and sentences just before the preoperative sedation
  3. Asks the parents to explain the procedure to the child after she explains it to them
  4. Asks the parents to leave the room while the preoperative medication and instructions are given

Answer(s): B

Explanation:

(A) A toddler is not capable of conceptualizing about the inside of his body and is concerned about body intactness; therefore, diagrams would not be useful. Also, the previous evening is too far from the procedure for the toddler to remember the instructions. (B) A simple explanation the morning of the procedure is the best developmental strategy to use, because it focuses on the toddler's need for parental support, body intactness, and short attention span. (C) A relationship between the nurse and the child needs to develop. Also, misinformation may be given to the child if the parents explain the procedure to the child. (D) The parents are the child's support system and need to be there to strengthen the child.



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