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NCLEX NCLEX-RN Exam
National Council Licensure Examination - NCLEX-RN (Page 59 )

Updated On: 26-Jan-2026
Page 59 of 345
PDF with 862 Questions

The nurse assists a client with advanced emphysema to the bathroom. The client becomes extremely short of breath while returning to bed. The nurse should:

  1. Increase his nasal O2 to 6 L/min
  2. Place him in a lateral Sims' position
  3. Encourage pursed-lip breathing
  4. Have him breathe into a paper bag

Answer(s): C

Explanation:

(A) Giving too high a concentration of O2 to a client with em-physema may remove his stimulus to breathe. (B) The client should sit forward with his hands on his knees or an overbed table and with shoulders elevated. (C) Pursed-lip breathing helps the client to blow off CO2 and to keep air passages open. (D) Covering the face of a client extremely short of breath may cause anxiety and further increase dyspnea.



Three weeks following discharge, a male client is readmitted to the psychiatric unit for depression. His wife stated that he had threatened to kill himself with a handgun. As the nurse admits him to the unit, he says, "I wish I were dead because I am worthless to everyone; I guess I am just no good." Which response by the nurse is most appropriate at this time?

  1. "I don't think you are worthless. I'm glad to see you, and we will help you."
  2. "Don't you think this is a sign of your illness?"
  3. "I know with your wife and new baby that you do have a lot to live for."
  4. "You've been feeling sad and alone for some time now?"

Answer(s): D

Explanation:

(A) This response does not acknowledge the client's feelings.
(B) This is a closed question and does not encourage communication.
(C) This response negates the client's feelings and does not require a response from the client. (D) This acknowledges the client's implied thoughts and feelings and encourages a response.



The most commonly known vectors of Lyme disease are:

  1. Mites
  2. Fleas
  3. Ticks
  4. Mosquitoes

Answer(s): C

Explanation:

(A) Mites are not the common vector of Lyme disease. (B) Fleas are not the common vector of Lyme disease. (C) Ticks are the common vector of Lyme disease. (D) Mosquitoes are not the common vector of Lyme disease.



Proper positioning for the child who is in Bryant's traction is:

  1. Both hips flexed at a 90-degree angle with the knees extended and the buttocks elevated off the bed
  2. Both legs extended, and the hips are not flexed
  3. The affected leg extended with slight hip flexion
  4. Both hips and knees maintained at a 90-degree flexion angle, and the back flat on the bed

Answer(s): A

Explanation:

(A) The child's weight supplies the countertraction for Bryant's traction; the buttocks are slightly elevated off the bed, and the hips are flexed at a 90-degree angle. Both legs are suspended by skin traction. (B) The child in Buck's extension traction maintains the legs extended and parallel to the bed. (C) The child in Russell traction maintains hip flexion of the affected leg at the prescribed angle with the leg extended. (D) The child in "90­90" traction maintains both hips and knees at a 90-degree flexion angle and the back is flat on the bed.



A child sustains a supracondylar fracture of the femur. When assessing for vascular injury, the nurse should be
alert for the signs of ischemia, which include:

  1. Bleeding, bruising, and hemorrhage
  2. Increase in serum levels of creatinine, alkaline phosphatase, and aspartate transaminase
  3. Pain, pallor, pulselessness, paresthesia, and paralysis
  4. Generalized swelling, pain, and diminished functional use with muscle rigidity and crepitus

Answer(s): C

Explanation:

(A) Bleeding, bruising, and hemorrhage may occur due to injury but are not classic signs of ischemia. (B) An increase in serum levels of creatinine, alkaline phosphatase, and aspartate transaminase is related to the disruption of muscle integrity. (C) Classic signs of ischemia related to vascular injury secondary to long bone fractures include the five "P's": pain, pallor, pulselessness, paresthesia, and paralysis. (D) Generalized swelling, pain, and diminished functional use with muscle rigidity and crepitus are common clinical manifestations of a fracture but not ischemia.



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