NCLEX EXAM PREVIEW EXAM PREP
QUESTIONS AND ANSWERS COMPLETE
CERTIFICATION STUDY SHEET
The charge nurse has received a change-of-shift report on the
following clients in labor. The charge nurse should ask a staff
member to first see the client in the
1. first stage of labor who has an oral temperature of 99.7° F
(37.6° C)
2. first stage of labor whose contractions are occurring every
30 seconds
3. second stage of labor who has respirations of 26
4. second stage of labor whose contractions are lasting for 60
seconds - Correct Answers ✅2. first stage of labor whose
contractions are occurring every 30 seconds
Contractions should be no longer than 90 secs and no closer
than 2 mins (120 secs)
90 secs is the duration, 2 mins is the frequency.
Rationale:
1. Elevated temp is normal during labor
3. Increased resps are normal during labor "pant-pant-blow"
"hee-hee-hoo" breathing pattern
4. Contractions shouldn't be longer than 90 secs, 60 secs is
okay and normal
Second stage: 2-3 mins apart, 60-90 secs long, 10 cm dilated,
strong pain
,NCLEX EXAM PREVIEW EXAM PREP
QUESTIONS AND ANSWERS COMPLETE
CERTIFICATION STUDY SHEET
The nurse is observing a staff member caring for a client who
has chickenpox.
Which of the following actions by the staff member would
require the nurse to intervene?
1. placing the client in a private room with monitored
negative air pressure
2. placing a box of disposable face shields outside the client's
room
3. placing an alcohol-based hand rub in the client's room for
hand hygiene
4. placing a surgical mask on the client during transport out
of the client's room - Correct Answers ✅2. placing a box of
disposable face shields outside the client's room
disposable face masks are not suitable for airborne
precautions
Rationale:
Varicella (chickenpox) is airborne precaution. Private,
negative pressure room, universal precautions (hand sanitizer
in room) and placing surgical mask on client during transport
are all correct interventions for Varicilla.
The nurse is caring for a client who reports feeling faint and is
experiencing the cardiac rhythm shown in the
electrocardiogram (ECG) strip below.
,NCLEX EXAM PREVIEW EXAM PREP
QUESTIONS AND ANSWERS COMPLETE
CERTIFICATION STUDY SHEET
- BRADYCARDIA (it is more than 5 spaces apart, sinus rhythm)
Which of the following actions would be appropriate for the
nurse to take? Select all that apply:
1. Administer the client's prescribed beta blocker.
2. Prepare for transcutaneous pacing.
3. Instruct the client to perform the Valsalva maneuver.
4. Begin chest compressions.
5. Assess the client for angina. - Correct Answers ✅2.
transcutaneous pacing
- external pacing that stimulates the ventricles to pump at a
set rate
5. Assess the client for angina
- Angina (Chest pain) can be caused by both tachycardia
(most common) and bradycardia (rare but can happen).
Assessment of angina is appropriate
Rationale:
1. Beta blocker would further decrease HR
3. Valsalva maneuver/Vagal stimulation would further
decrease HR. (can be indicated for sinus Tachy)
4. Chest compressions are for cardiac arrest
The nurse is planning care for a client with moderate
Alzheimer's disease (AD).
, NCLEX EXAM PREVIEW EXAM PREP
QUESTIONS AND ANSWERS COMPLETE
CERTIFICATION STUDY SHEET
Which of the following interventions should the nurse include
in the client's plan of care?
1. Encourage the client to reminisce about happy memories.
2. Confront the client when inappropriate or agitated
behaviors occur.
3. Administer to the client the cholinesterase inhibitor to
reverse the course of AD.
4. Provide the client with information about activity choices in
the morning so the client can make plans for the day. -
Correct Answers ✅1. Encourage the client to reminisce
about happy memories.
Its possible for AD patients to retain long-term memories
Rationale:
2. Acknowledge feelings --> Redirect is protocol for
Dementia. Don't confront; they can't learn
3. AD is irreversible
4. In moderate AD, dementia has already progressed to
where pt needs help with ADLs and planning daily activities.
Asking them to plan can frustrate them and cause distress.
STRUCTURED pleasant activities that consider the persons
likes and interests are the best.
QUESTIONS AND ANSWERS COMPLETE
CERTIFICATION STUDY SHEET
The charge nurse has received a change-of-shift report on the
following clients in labor. The charge nurse should ask a staff
member to first see the client in the
1. first stage of labor who has an oral temperature of 99.7° F
(37.6° C)
2. first stage of labor whose contractions are occurring every
30 seconds
3. second stage of labor who has respirations of 26
4. second stage of labor whose contractions are lasting for 60
seconds - Correct Answers ✅2. first stage of labor whose
contractions are occurring every 30 seconds
Contractions should be no longer than 90 secs and no closer
than 2 mins (120 secs)
90 secs is the duration, 2 mins is the frequency.
Rationale:
1. Elevated temp is normal during labor
3. Increased resps are normal during labor "pant-pant-blow"
"hee-hee-hoo" breathing pattern
4. Contractions shouldn't be longer than 90 secs, 60 secs is
okay and normal
Second stage: 2-3 mins apart, 60-90 secs long, 10 cm dilated,
strong pain
,NCLEX EXAM PREVIEW EXAM PREP
QUESTIONS AND ANSWERS COMPLETE
CERTIFICATION STUDY SHEET
The nurse is observing a staff member caring for a client who
has chickenpox.
Which of the following actions by the staff member would
require the nurse to intervene?
1. placing the client in a private room with monitored
negative air pressure
2. placing a box of disposable face shields outside the client's
room
3. placing an alcohol-based hand rub in the client's room for
hand hygiene
4. placing a surgical mask on the client during transport out
of the client's room - Correct Answers ✅2. placing a box of
disposable face shields outside the client's room
disposable face masks are not suitable for airborne
precautions
Rationale:
Varicella (chickenpox) is airborne precaution. Private,
negative pressure room, universal precautions (hand sanitizer
in room) and placing surgical mask on client during transport
are all correct interventions for Varicilla.
The nurse is caring for a client who reports feeling faint and is
experiencing the cardiac rhythm shown in the
electrocardiogram (ECG) strip below.
,NCLEX EXAM PREVIEW EXAM PREP
QUESTIONS AND ANSWERS COMPLETE
CERTIFICATION STUDY SHEET
- BRADYCARDIA (it is more than 5 spaces apart, sinus rhythm)
Which of the following actions would be appropriate for the
nurse to take? Select all that apply:
1. Administer the client's prescribed beta blocker.
2. Prepare for transcutaneous pacing.
3. Instruct the client to perform the Valsalva maneuver.
4. Begin chest compressions.
5. Assess the client for angina. - Correct Answers ✅2.
transcutaneous pacing
- external pacing that stimulates the ventricles to pump at a
set rate
5. Assess the client for angina
- Angina (Chest pain) can be caused by both tachycardia
(most common) and bradycardia (rare but can happen).
Assessment of angina is appropriate
Rationale:
1. Beta blocker would further decrease HR
3. Valsalva maneuver/Vagal stimulation would further
decrease HR. (can be indicated for sinus Tachy)
4. Chest compressions are for cardiac arrest
The nurse is planning care for a client with moderate
Alzheimer's disease (AD).
, NCLEX EXAM PREVIEW EXAM PREP
QUESTIONS AND ANSWERS COMPLETE
CERTIFICATION STUDY SHEET
Which of the following interventions should the nurse include
in the client's plan of care?
1. Encourage the client to reminisce about happy memories.
2. Confront the client when inappropriate or agitated
behaviors occur.
3. Administer to the client the cholinesterase inhibitor to
reverse the course of AD.
4. Provide the client with information about activity choices in
the morning so the client can make plans for the day. -
Correct Answers ✅1. Encourage the client to reminisce
about happy memories.
Its possible for AD patients to retain long-term memories
Rationale:
2. Acknowledge feelings --> Redirect is protocol for
Dementia. Don't confront; they can't learn
3. AD is irreversible
4. In moderate AD, dementia has already progressed to
where pt needs help with ADLs and planning daily activities.
Asking them to plan can frustrate them and cause distress.
STRUCTURED pleasant activities that consider the persons
likes and interests are the best.
