# NCLEX-RN Health Care Questions with
Rationale and Correct ANSWERs, Latest
2023/2024 Edition
---
**01.** A nurse is caring for a client who refuses a blood transfusion due to religious beliefs. The client’s
hemoglobin is 6.5 g/dL. Which action should the nurse take?
A) Administer the transfusion because it is medically necessary.
B) Notify the provider and respect the client’s decision.
C) Ask the family to convince the client to accept the transfusion.
D) Document the refusal and proceed with the transfusion.
🔍 RATIONALE💡-- Clients have the right to refuse treatment based on religious or personal beliefs. The
nurse must respect autonomy, notify the provider, and explore alternative treatments. Transfusing
against the client’s will is battery.
ANSWER💫✔️-- B) Notify the provider and respect the client’s decision.
---
**02.** A nurse is delegating tasks to an unlicensed assistive personnel (UAP). Which task is appropriate
to delegate?
A) Performing a sterile dressing change
B) Inserting a urinary catheter
C) Measuring the client’s intake and output
D) Administering oral medications
,🔍 RATIONALE💡-- UAPs can measure intake and output, obtain vital signs, and assist with activities of
daily living. Sterile procedures, catheter insertion, and medication administration require licensed
nursing judgment.
ANSWER💫✔️-- C) Measuring the client’s intake and output
---
**03.** A nurse is caring for a client who has a do-not-resuscitate (DNR) order. The client’s family
member requests that resuscitation be attempted if the client’s heart stops. What is the nurse’s best
response?
A) “I will call the provider to discuss changing the DNR order.”
B) “We will follow the family’s wishes regardless of the DNR order.”
C) “The DNR order is legally binding; resuscitation will not be performed.”
D) “I will resuscitate the client and then notify the provider.”
🔍 RATIONALE💡-- A valid DNR order must be honored by the healthcare team. If the family disagrees,
the provider should be consulted to review the order. The nurse should not unilaterally change the plan.
ANSWER💫✔️-- A) “I will call the provider to discuss changing the DNR order.”
---
**04.** A nurse is preparing to discharge a client who speaks a different language. Which action is most
appropriate to ensure informed consent for follow-up care?
A) Use a family member to interpret the discharge instructions.
B) Provide written instructions in the client’s native language without verbal explanation.
C) Obtain a certified medical interpreter to explain the instructions.
D) Use hand gestures and basic words in the client’s language.
, 🔍 RATIONALE💡-- Certified medical interpreters ensure accurate communication and protect client
confidentiality. Family members may not be qualified and can introduce errors or bias.
ANSWER💫✔️-- C) Obtain a certified medical interpreter to explain the instructions.
---
**05.** A nurse is caring for a client who is considering leaving the hospital against medical advice
(AMA). Which action should the nurse take first?
A) Notify the security department.
B) Inform the client of the risks of leaving AMA.
C) Have the client sign the AMA form immediately.
D) Restrain the client to prevent leaving.
🔍 RATIONALE💡-- The nurse should first discuss the risks and consequences of leaving AMA with the
client. If the client still chooses to leave, the nurse should notify the provider and have the client sign the
AMA form. Restraint is not appropriate.
ANSWER💫✔️-- B) Inform the client of the risks of leaving AMA.
---
**06.** A nurse is performing a root cause analysis after a medication error. What is the primary
purpose of this analysis?
A) To assign blame to the nurse who made the error
B) To identify system failures that contributed to the error
C) To report the error to the state board of nursing
D) To determine the financial cost of the error
🔍 RATIONALE💡-- Root cause analysis focuses on identifying underlying system vulnerabilities (e.g.,
look-alike medications, distractions, workflow issues) to prevent future errors, not to punish individuals.
Rationale and Correct ANSWERs, Latest
2023/2024 Edition
---
**01.** A nurse is caring for a client who refuses a blood transfusion due to religious beliefs. The client’s
hemoglobin is 6.5 g/dL. Which action should the nurse take?
A) Administer the transfusion because it is medically necessary.
B) Notify the provider and respect the client’s decision.
C) Ask the family to convince the client to accept the transfusion.
D) Document the refusal and proceed with the transfusion.
🔍 RATIONALE💡-- Clients have the right to refuse treatment based on religious or personal beliefs. The
nurse must respect autonomy, notify the provider, and explore alternative treatments. Transfusing
against the client’s will is battery.
ANSWER💫✔️-- B) Notify the provider and respect the client’s decision.
---
**02.** A nurse is delegating tasks to an unlicensed assistive personnel (UAP). Which task is appropriate
to delegate?
A) Performing a sterile dressing change
B) Inserting a urinary catheter
C) Measuring the client’s intake and output
D) Administering oral medications
,🔍 RATIONALE💡-- UAPs can measure intake and output, obtain vital signs, and assist with activities of
daily living. Sterile procedures, catheter insertion, and medication administration require licensed
nursing judgment.
ANSWER💫✔️-- C) Measuring the client’s intake and output
---
**03.** A nurse is caring for a client who has a do-not-resuscitate (DNR) order. The client’s family
member requests that resuscitation be attempted if the client’s heart stops. What is the nurse’s best
response?
A) “I will call the provider to discuss changing the DNR order.”
B) “We will follow the family’s wishes regardless of the DNR order.”
C) “The DNR order is legally binding; resuscitation will not be performed.”
D) “I will resuscitate the client and then notify the provider.”
🔍 RATIONALE💡-- A valid DNR order must be honored by the healthcare team. If the family disagrees,
the provider should be consulted to review the order. The nurse should not unilaterally change the plan.
ANSWER💫✔️-- A) “I will call the provider to discuss changing the DNR order.”
---
**04.** A nurse is preparing to discharge a client who speaks a different language. Which action is most
appropriate to ensure informed consent for follow-up care?
A) Use a family member to interpret the discharge instructions.
B) Provide written instructions in the client’s native language without verbal explanation.
C) Obtain a certified medical interpreter to explain the instructions.
D) Use hand gestures and basic words in the client’s language.
, 🔍 RATIONALE💡-- Certified medical interpreters ensure accurate communication and protect client
confidentiality. Family members may not be qualified and can introduce errors or bias.
ANSWER💫✔️-- C) Obtain a certified medical interpreter to explain the instructions.
---
**05.** A nurse is caring for a client who is considering leaving the hospital against medical advice
(AMA). Which action should the nurse take first?
A) Notify the security department.
B) Inform the client of the risks of leaving AMA.
C) Have the client sign the AMA form immediately.
D) Restrain the client to prevent leaving.
🔍 RATIONALE💡-- The nurse should first discuss the risks and consequences of leaving AMA with the
client. If the client still chooses to leave, the nurse should notify the provider and have the client sign the
AMA form. Restraint is not appropriate.
ANSWER💫✔️-- B) Inform the client of the risks of leaving AMA.
---
**06.** A nurse is performing a root cause analysis after a medication error. What is the primary
purpose of this analysis?
A) To assign blame to the nurse who made the error
B) To identify system failures that contributed to the error
C) To report the error to the state board of nursing
D) To determine the financial cost of the error
🔍 RATIONALE💡-- Root cause analysis focuses on identifying underlying system vulnerabilities (e.g.,
look-alike medications, distractions, workflow issues) to prevent future errors, not to punish individuals.
