NCLEX EXAM PREVIEW N N
The charge nurse has received a change-of-shift report on the following clients in labor. The
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charge nurse should ask a staff member to first see the client in the
N N N N N N N N N N N N N N
1. first stage of labor who has an oral temperature of 99.7° F (37.6° C)
N N N N N N N N N N N N N N N
2. first stage of labor whose contractions are occurring every 30 seconds
N N N N N N N N N N N N
3. second stage of labor who has respirations of 26
N N N N N N N N N N
4. second stage of labor whose contractions are lasting for 60 seconds - CORRECT ANSWER-2.
N N N N N N N N N N N N N NN
first stage of labor whose contractions are occurring every 30 seconds
N N N N N N N N N N N N
Contractions should be no longer than 90 secs and no closer than 2 mins (120 secs)
N N N N N N N N N N N N N N N
90 secs is the duration, 2 mins is the frequency.
N N N N N N N N N
Rationale:
1. Elevated temp is normal during labor
N N N N N N
3. Increased resps are normal during labor "pant-pant-blow" "hee-hee-hoo" breathing pattern
N N N N N N N N N N
4. Contractions shouldn't be longer than 90 secs, 60 secs is okay and normal
N N N N N N N N N N N N N
Second stage: 2-3 mins apart, 60-90 secs long, 10 cm dilated, strong pain
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The nurse is observing a staff member caring for a client who has chickenpox.
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N Which of the following actions by the staff member would require the nurse to intervene?
N N N N N N N N N N N N N N
1. placing the client in a private room with monitored negative air pressure
N N N N N N N N N N N N
2. placing a box of disposable face shields outside the client's room
N N N N N N N N N N N
3. placing an alcohol-based hand rub in the client's room for hand hygiene
N N N N N N N N N N N N
,4. placing a surgical mask on the client during transport out of the client's room - CORRECT
N N N N N N N N N N N N N N N N N
ANSWER-2. placing a box of disposable face shields outside the client's room
N N N N N N N N N N N N
disposable face masks are not suitable for airborne precautions
N N N N N N N N
Rationale:
Varicella (chickenpox) is airborne precaution. Private, negative pressure room, universal
N N N N N N N N N
precautions (hand sanitizer in room) and placing surgical mask on client during transport are all
N N N N N N N N N N N N N N N
correct interventions for Varicilla.
N N N N
The nurse is caring for a client who reports feeling faint and is experiencing the cardiac rhythm
N N N N N N N N N N N N N N N N
shown in the electrocardiogram (ECG) strip below.
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- BRADYCARDIA (it is more than 5 spaces apart, sinus rhythm)
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Which of the following actions would be appropriate for the nurse to take? Select all that apply:
N N N N N N N N N N N N N N N N
1. Administer the client's prescribed beta blocker.
N N N N N N
2. Prepare for transcutaneous pacing.
N N N N
3. Instruct the client to perform the Valsalva maneuver.
N N N N N N N N
4. Begin chest compressions.
N N N
5. Assess the client for angina. - CORRECT ANSWER-2. transcutaneous pacing
N N N N N N N NN N N N
- external pacing that stimulates the ventricles to pump at a set rate
N N N N N N N N N N N N
5. Assess the client for angina
N N N N N N
- Angina (Chest pain) can be caused by both tachycardia (most common) and bradycardia (rare
N N N N N N N N N N N N N N
Nbut can happen). Assessment of angina is appropriate
N N N N N N N
Rationale:
1. Beta blocker would further decrease HR
N N N N N N
3. Valsalva maneuver/Vagal stimulation would further decrease HR. (can be indicated for sinus
N N N N N N N N N N N N
Tachy)
N
4. Chest compressions are for cardiac arrest
N N N N N N
,The nurse is planning care for a client with moderate Alzheimer's disease (AD).
N N N N N N N N N N N N
N Which of the following interventions should the nurse include in the client's plan of care?
N N N N N N N N N N N N N N
1. Encourage the client to reminisce about happy memories.
N N N N N N N N
2. Confront the client when inappropriate or agitated behaviors occur.
N N N N N N N N N
3. Administer to the client the cholinesterase inhibitor to reverse the course of AD.
N N N N N N N N N N N N N
4. Provide the client with information about activity choices in the morning so the client can
N N N N N N N N N N N N N N N
make plans for the day. - CORRECT ANSWER-1. Encourage the client to reminisce about happy
N N N N N N N NN N N N N N N N
memories.
N
Its possible for AD patients to retain long-term memories
N N N N N N N N
Rationale:
2. Acknowledge feelings --> Redirect is protocol for Dementia. Don't confront; they can't learn
N N N N N N N N N N N N N
3. AD is irreversible
N N N
4. In moderate AD, dementia has already progressed to where pt needs help with ADLs and
N N N N N N N N N N N N N N N
planning daily activities. Asking them to plan can frustrate them and cause distress.
N N N N N N N N N N N N N N
STRUCTURED pleasant activities that consider the persons likes and interests are the best.
N N N N N N N N N N N N
The nurse is teaching a client how to ambulate using crutches. Which of the following
N N N N N N N N N N N N N N
information should the nurse include?
N N N N N
1. "Use your hands and arms to support your body weight."
N N N N N N N N N N
2. "Wear slippers when ambulating with the crutches in your home."
N N N N N N N N N N
3. "Maintain the crutches 12 in (30 cm) in front of your feet while standing."
N N N N N N N N N N N N N N
4. "Adjust the hand grips of the crutches so that your elbows are fully extended." - CORRECT
N N N N N N N N N N N N N N N N N
ANSWER-1. "Use your hands and arms to support your body weight."
N N N N N N N N N N N
True! But watch out if it isn't 2-3 finger-widths, crutch paralysis can occur. s/s: paresis and
N N N N N N N N N N N N N N N
paresthesias in wrists and hands
N N N N N
, Rationales:
2. Fall risk!
N N
3. Should be 6 in. in front and 6 in. lateral
N N N N N N N N N N
4. Elbows should be bent at 30 degree angle
N N N N N N N N
The nurse has taught a client with multiple sclerosis (MS).
N N N N N N N N N
Which of the following statements by the client would indicate a correct understanding of the
N N N N N N N N N N N N N N
teaching?
N
1. "I will complete all of my household chores in the morning when I am well rested."
N N N N N N N N N N N N N N N N
2. "I have learned how to massage my bladder to help empty my bladder completely."
N N N N N N N N N N N N N N
3. "I will take a hot bath in the evening to help me relax if I have had a stressful day at work."
N N N N N N N N N N N N N N N N N N N N N N
4. "I should expect the blurred vision to resolve after I have received medications for several
N N N N N N N N N N N N N N N
weeks." - CORRECT ANSWER-4. "I should expect the blurred vision to resolve after I have
N N N NN N N N N N N N N N N N
received medications for several weeks."
N N N N N
MS causes nerve damage and can result in optic neuritis (vision loss, burry vision). In most cases
N N N N N N N N N N N N N N N N
it resolves itself in 4-12 weeks, but medication (steroids) can speed up the process and resolve it
N N N N N N N N N N N N N N N N N
quicker
N
Rationale:
1. MS patients should not exert themselves too much at one time. Space out activities and allow
N N N N N N N N N N N N N N N N
time for rest.
N N N
2. Urinary retention is primarily treated by medication (bethanochol), and exercises can aid with
N N N N N N N N N N N N N
it but are not the primary treatment
N N N N N N N
3. Hot temperatures are bad for MS and can worsen symptoms. Your nerves are already fcked up
N N N N N N N N N N N N N N N N
and extra heat can stress your body into overdrive
N N N N N N N N N
The nurse has attended a staff education program about caring for clients who are receiving
N N N N N N N N N N N N N N
positive pressure mechanical ventilation. Which of the following statements by the nurse would
N N N N N N N N N N N N N
indicate a correct understanding of the teaching?
N N N N N N N
The charge nurse has received a change-of-shift report on the following clients in labor. The
N N N N N N N N N N N N N N
charge nurse should ask a staff member to first see the client in the
N N N N N N N N N N N N N N
1. first stage of labor who has an oral temperature of 99.7° F (37.6° C)
N N N N N N N N N N N N N N N
2. first stage of labor whose contractions are occurring every 30 seconds
N N N N N N N N N N N N
3. second stage of labor who has respirations of 26
N N N N N N N N N N
4. second stage of labor whose contractions are lasting for 60 seconds - CORRECT ANSWER-2.
N N N N N N N N N N N N N NN
first stage of labor whose contractions are occurring every 30 seconds
N N N N N N N N N N N N
Contractions should be no longer than 90 secs and no closer than 2 mins (120 secs)
N N N N N N N N N N N N N N N
90 secs is the duration, 2 mins is the frequency.
N N N N N N N N N
Rationale:
1. Elevated temp is normal during labor
N N N N N N
3. Increased resps are normal during labor "pant-pant-blow" "hee-hee-hoo" breathing pattern
N N N N N N N N N N
4. Contractions shouldn't be longer than 90 secs, 60 secs is okay and normal
N N N N N N N N N N N N N
Second stage: 2-3 mins apart, 60-90 secs long, 10 cm dilated, strong pain
N N N N N N N N N N N N
The nurse is observing a staff member caring for a client who has chickenpox.
N N N N N N N N N N N N N
N Which of the following actions by the staff member would require the nurse to intervene?
N N N N N N N N N N N N N N
1. placing the client in a private room with monitored negative air pressure
N N N N N N N N N N N N
2. placing a box of disposable face shields outside the client's room
N N N N N N N N N N N
3. placing an alcohol-based hand rub in the client's room for hand hygiene
N N N N N N N N N N N N
,4. placing a surgical mask on the client during transport out of the client's room - CORRECT
N N N N N N N N N N N N N N N N N
ANSWER-2. placing a box of disposable face shields outside the client's room
N N N N N N N N N N N N
disposable face masks are not suitable for airborne precautions
N N N N N N N N
Rationale:
Varicella (chickenpox) is airborne precaution. Private, negative pressure room, universal
N N N N N N N N N
precautions (hand sanitizer in room) and placing surgical mask on client during transport are all
N N N N N N N N N N N N N N N
correct interventions for Varicilla.
N N N N
The nurse is caring for a client who reports feeling faint and is experiencing the cardiac rhythm
N N N N N N N N N N N N N N N N
shown in the electrocardiogram (ECG) strip below.
N N N N N N N
- BRADYCARDIA (it is more than 5 spaces apart, sinus rhythm)
N N N N N N N N N N
Which of the following actions would be appropriate for the nurse to take? Select all that apply:
N N N N N N N N N N N N N N N N
1. Administer the client's prescribed beta blocker.
N N N N N N
2. Prepare for transcutaneous pacing.
N N N N
3. Instruct the client to perform the Valsalva maneuver.
N N N N N N N N
4. Begin chest compressions.
N N N
5. Assess the client for angina. - CORRECT ANSWER-2. transcutaneous pacing
N N N N N N N NN N N N
- external pacing that stimulates the ventricles to pump at a set rate
N N N N N N N N N N N N
5. Assess the client for angina
N N N N N N
- Angina (Chest pain) can be caused by both tachycardia (most common) and bradycardia (rare
N N N N N N N N N N N N N N
Nbut can happen). Assessment of angina is appropriate
N N N N N N N
Rationale:
1. Beta blocker would further decrease HR
N N N N N N
3. Valsalva maneuver/Vagal stimulation would further decrease HR. (can be indicated for sinus
N N N N N N N N N N N N
Tachy)
N
4. Chest compressions are for cardiac arrest
N N N N N N
,The nurse is planning care for a client with moderate Alzheimer's disease (AD).
N N N N N N N N N N N N
N Which of the following interventions should the nurse include in the client's plan of care?
N N N N N N N N N N N N N N
1. Encourage the client to reminisce about happy memories.
N N N N N N N N
2. Confront the client when inappropriate or agitated behaviors occur.
N N N N N N N N N
3. Administer to the client the cholinesterase inhibitor to reverse the course of AD.
N N N N N N N N N N N N N
4. Provide the client with information about activity choices in the morning so the client can
N N N N N N N N N N N N N N N
make plans for the day. - CORRECT ANSWER-1. Encourage the client to reminisce about happy
N N N N N N N NN N N N N N N N
memories.
N
Its possible for AD patients to retain long-term memories
N N N N N N N N
Rationale:
2. Acknowledge feelings --> Redirect is protocol for Dementia. Don't confront; they can't learn
N N N N N N N N N N N N N
3. AD is irreversible
N N N
4. In moderate AD, dementia has already progressed to where pt needs help with ADLs and
N N N N N N N N N N N N N N N
planning daily activities. Asking them to plan can frustrate them and cause distress.
N N N N N N N N N N N N N N
STRUCTURED pleasant activities that consider the persons likes and interests are the best.
N N N N N N N N N N N N
The nurse is teaching a client how to ambulate using crutches. Which of the following
N N N N N N N N N N N N N N
information should the nurse include?
N N N N N
1. "Use your hands and arms to support your body weight."
N N N N N N N N N N
2. "Wear slippers when ambulating with the crutches in your home."
N N N N N N N N N N
3. "Maintain the crutches 12 in (30 cm) in front of your feet while standing."
N N N N N N N N N N N N N N
4. "Adjust the hand grips of the crutches so that your elbows are fully extended." - CORRECT
N N N N N N N N N N N N N N N N N
ANSWER-1. "Use your hands and arms to support your body weight."
N N N N N N N N N N N
True! But watch out if it isn't 2-3 finger-widths, crutch paralysis can occur. s/s: paresis and
N N N N N N N N N N N N N N N
paresthesias in wrists and hands
N N N N N
, Rationales:
2. Fall risk!
N N
3. Should be 6 in. in front and 6 in. lateral
N N N N N N N N N N
4. Elbows should be bent at 30 degree angle
N N N N N N N N
The nurse has taught a client with multiple sclerosis (MS).
N N N N N N N N N
Which of the following statements by the client would indicate a correct understanding of the
N N N N N N N N N N N N N N
teaching?
N
1. "I will complete all of my household chores in the morning when I am well rested."
N N N N N N N N N N N N N N N N
2. "I have learned how to massage my bladder to help empty my bladder completely."
N N N N N N N N N N N N N N
3. "I will take a hot bath in the evening to help me relax if I have had a stressful day at work."
N N N N N N N N N N N N N N N N N N N N N N
4. "I should expect the blurred vision to resolve after I have received medications for several
N N N N N N N N N N N N N N N
weeks." - CORRECT ANSWER-4. "I should expect the blurred vision to resolve after I have
N N N NN N N N N N N N N N N N
received medications for several weeks."
N N N N N
MS causes nerve damage and can result in optic neuritis (vision loss, burry vision). In most cases
N N N N N N N N N N N N N N N N
it resolves itself in 4-12 weeks, but medication (steroids) can speed up the process and resolve it
N N N N N N N N N N N N N N N N N
quicker
N
Rationale:
1. MS patients should not exert themselves too much at one time. Space out activities and allow
N N N N N N N N N N N N N N N N
time for rest.
N N N
2. Urinary retention is primarily treated by medication (bethanochol), and exercises can aid with
N N N N N N N N N N N N N
it but are not the primary treatment
N N N N N N N
3. Hot temperatures are bad for MS and can worsen symptoms. Your nerves are already fcked up
N N N N N N N N N N N N N N N N
and extra heat can stress your body into overdrive
N N N N N N N N N
The nurse has attended a staff education program about caring for clients who are receiving
N N N N N N N N N N N N N N
positive pressure mechanical ventilation. Which of the following statements by the nurse would
N N N N N N N N N N N N N
indicate a correct understanding of the teaching?
N N N N N N N
