NCLEX NGN 2023-2024 ACTUAL EXAM ALL 150 QUESTIONS
AND CORRECT DETAILED ANSWERS WITH
RATIONALES|ALREADY GRADED A+
A child who is HIV-positive is scheduled to receive a mumps, measles, and rubella (MMR) vaccine. The
laboratory results show the CD4+ as 1000 cells/mm3. Which nursing action is appropriate?
Administering the vaccine
Contacting the primary health care provider
Asking the laboratory to repeat the CD4+ test
Informing the child's mother that the vaccine must not be administered at this time - answer-A
The normal CD4+ count is 500 to 1600 cells/mm3. Because this child's CD4+ count is 1000 cells/mm3,
the nurse would administer the vaccine.
A client in a manic state emerges from her room wearing provocative clothing and quickly enters the
dayroom. She announces to the group that she is the star of a burlesque show and will begin her
performance shortly. Which is the priority nursing action?
Ask the client to go to her room and to change her clothes
Tell the client firmly that burlesque shows are not allowed in the nursing unit
Tell the client that her bathroom privileges are being suspended because of her behavior
Quietly and firmly assist the client to her room and help her dress in appropriate clothes - answer-D
A client who has just received a diagnosis of asthma says to the nurse, "This is just another nail in my
coffin." Which response by the nurse is therapeutic?
"Do you think that having asthma will kill you?"
"You seem very distressed at learning that you have asthma."
"I'm not going to work with you if you can't view this as a challenge rather than a 'nail in your coffin.'"
"Asthma is a very treatable condition, but it's important to learn how to properly administer your
medications. Let's practice with your inhalant." - answer-B
During a preoperative assessment, a nurse notices the client is crying. In light of this observation, which
statement by the nurse is appropriate?
"You seem upset. Would you rather be alone?"
,"You're crying. Tell me more about how you are feeling."
"Your surgeon is the best and has done many of these operations."
"Crying before a serious operation is common, but everything will be okay." - answer-B
A client hospitalized on a mental health unit with schizophrenia tells the nurse, "The voices in my head
say that I'm worthless and that I don't deserve to be alive." What is the nurse's priority concern for this
client?
Ineffective coping skills
Perceptual disturbances
Chronic low self-esteem
Risk for self-directed violence - answer-D
A client who was sexually assaulted a year ago is self-contained and calm while discussing the assault.
The client says to the nurse, "It still doesn't seem real." The nurse is considering requesting a referral to
a mental health professional because which defense mechanism has been used for an extensive period
of time? Denial
Projection
Rationalization
Intellectualization - answer-A
A nurse completes an initial assessment of a client admitted to the mental health unit. Which
assessment finding is the priority concern?
Bruises on the client's neck
The client's report of not sleeping well
The client's report of suicidal thoughts
The spouse's statement "I don't approve of this treatment." - answer-C
A client who is delusional says to the nurse, "Terrorists have been sent here to kill me." How should the
nurse respond to the client?
"No one is going to kill you."
"Your medication is making you feel like this."
, "Are you worried that people are trying to hurt you?"
"What makes you think that terrorists were sent to hurt you?" - answer-C
A client with a manic disorder monopolizes group therapy. What should the nurse leading the group say
to the client?
"Leave the room."
"Go to the nurses' station until our group therapy session is finished."
"I will recommend that group therapy be eliminated from your treatment plan."
"Thank you for your comments. Now, try to stop talking and listen to the others." - answer-D
A child with osteosarcoma who required amputation of a lower limb is experiencing phantom limb pain.
The nurse attempts to comfort the child by providing which explanation?
The pain is a normal, temporary condition
The pain occurs because nerves have been cut
This pain will go away once a prosthesis is used
Pain medication may be needed for life to alleviate the discomfort - answer-A
Phantom limb pain is a temporary condition that some people who undergo amputation experience. This
sensation of burning, aching, or cramping in the missing limb is most distressing to the client. The child
should be reassured that the condition is normal.
A woman whose husband died 2 months ago says to the visiting nurse, "My daughter came over
yesterday to help me move my husband's things out of our bedroom, and I was so angry with her for
moving his belongings from where he always kept them. She doesn't know how much I'm hurting."
Which statement by the nurse would be therapeutic?
"I know just how you feel, because I lost my husband last summer."
"It's OK to grieve and be angry with your daughter and anyone else for a time."
"You need to focus on the many good years you enjoyed together and move on."
"I know it's a troubling time for you, but try to focus on your children and grandchildren." - answer-B
AND CORRECT DETAILED ANSWERS WITH
RATIONALES|ALREADY GRADED A+
A child who is HIV-positive is scheduled to receive a mumps, measles, and rubella (MMR) vaccine. The
laboratory results show the CD4+ as 1000 cells/mm3. Which nursing action is appropriate?
Administering the vaccine
Contacting the primary health care provider
Asking the laboratory to repeat the CD4+ test
Informing the child's mother that the vaccine must not be administered at this time - answer-A
The normal CD4+ count is 500 to 1600 cells/mm3. Because this child's CD4+ count is 1000 cells/mm3,
the nurse would administer the vaccine.
A client in a manic state emerges from her room wearing provocative clothing and quickly enters the
dayroom. She announces to the group that she is the star of a burlesque show and will begin her
performance shortly. Which is the priority nursing action?
Ask the client to go to her room and to change her clothes
Tell the client firmly that burlesque shows are not allowed in the nursing unit
Tell the client that her bathroom privileges are being suspended because of her behavior
Quietly and firmly assist the client to her room and help her dress in appropriate clothes - answer-D
A client who has just received a diagnosis of asthma says to the nurse, "This is just another nail in my
coffin." Which response by the nurse is therapeutic?
"Do you think that having asthma will kill you?"
"You seem very distressed at learning that you have asthma."
"I'm not going to work with you if you can't view this as a challenge rather than a 'nail in your coffin.'"
"Asthma is a very treatable condition, but it's important to learn how to properly administer your
medications. Let's practice with your inhalant." - answer-B
During a preoperative assessment, a nurse notices the client is crying. In light of this observation, which
statement by the nurse is appropriate?
"You seem upset. Would you rather be alone?"
,"You're crying. Tell me more about how you are feeling."
"Your surgeon is the best and has done many of these operations."
"Crying before a serious operation is common, but everything will be okay." - answer-B
A client hospitalized on a mental health unit with schizophrenia tells the nurse, "The voices in my head
say that I'm worthless and that I don't deserve to be alive." What is the nurse's priority concern for this
client?
Ineffective coping skills
Perceptual disturbances
Chronic low self-esteem
Risk for self-directed violence - answer-D
A client who was sexually assaulted a year ago is self-contained and calm while discussing the assault.
The client says to the nurse, "It still doesn't seem real." The nurse is considering requesting a referral to
a mental health professional because which defense mechanism has been used for an extensive period
of time? Denial
Projection
Rationalization
Intellectualization - answer-A
A nurse completes an initial assessment of a client admitted to the mental health unit. Which
assessment finding is the priority concern?
Bruises on the client's neck
The client's report of not sleeping well
The client's report of suicidal thoughts
The spouse's statement "I don't approve of this treatment." - answer-C
A client who is delusional says to the nurse, "Terrorists have been sent here to kill me." How should the
nurse respond to the client?
"No one is going to kill you."
"Your medication is making you feel like this."
, "Are you worried that people are trying to hurt you?"
"What makes you think that terrorists were sent to hurt you?" - answer-C
A client with a manic disorder monopolizes group therapy. What should the nurse leading the group say
to the client?
"Leave the room."
"Go to the nurses' station until our group therapy session is finished."
"I will recommend that group therapy be eliminated from your treatment plan."
"Thank you for your comments. Now, try to stop talking and listen to the others." - answer-D
A child with osteosarcoma who required amputation of a lower limb is experiencing phantom limb pain.
The nurse attempts to comfort the child by providing which explanation?
The pain is a normal, temporary condition
The pain occurs because nerves have been cut
This pain will go away once a prosthesis is used
Pain medication may be needed for life to alleviate the discomfort - answer-A
Phantom limb pain is a temporary condition that some people who undergo amputation experience. This
sensation of burning, aching, or cramping in the missing limb is most distressing to the client. The child
should be reassured that the condition is normal.
A woman whose husband died 2 months ago says to the visiting nurse, "My daughter came over
yesterday to help me move my husband's things out of our bedroom, and I was so angry with her for
moving his belongings from where he always kept them. She doesn't know how much I'm hurting."
Which statement by the nurse would be therapeutic?
"I know just how you feel, because I lost my husband last summer."
"It's OK to grieve and be angry with your daughter and anyone else for a time."
"You need to focus on the many good years you enjoyed together and move on."
"I know it's a troubling time for you, but try to focus on your children and grandchildren." - answer-B
