NCLEX Exam Preview | Practice Questions & Answers | Comprehensive Exam Prep
The charge nurse has received a change-of-shift report on 2. first stage of labor whose contractions are occurring every 30 seconds
the following clients in labor. The charge nurse should ask Contractions should be no longer than 90 secs and no closer than 2 mins (120
a staff member to first see the client in the secs)
1. first stage of labor who has an oral temperature of 99.7° 90 secs is the duration, 2 mins is the frequency.
F (37.6° C)
2. first stage of labor whose contractions are occurring Rationale:
every 30 seconds 1. Elevated temp is normal during labor
3. second stage of labor who has respirations of 26 3. Increased resps are normal during labor "pant-pant-blow" "hee-hee-hoo"
4. second stage of labor whose contractions are lasting for breathing pattern
60 seconds 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
The nurse is observing a staff member caring for a client 2. placing a box of disposable face shields outside the client's room
who has chickenpox. disposable face masks are not suitable for airborne precautions
Which of the following actions by the staff member would
require the nurse to intervene? Rationale:
1. placing the client in a private room with monitored Varicella (chickenpox) is airborne precaution. Private, negative pressure room,
negative air pressure universal precautions (hand sanitizer in room) and placing surgical mask on client
2. placing a box of disposable face shields outside the during transport are all correct interventions for Varicilla.
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
The nurse is caring for a client who reports feeling faint 2. transcutaneous pacing
and is experiencing the cardiac rhythm shown in the - external pacing that stimulates the ventricles to pump at a set rate
electrocardiogram (ECG) strip below. 5. Assess the client for angina
- BRADYCARDIA (it is more than 5 spaces apart, sinus - Angina (Chest pain) can be caused by both tachycardia (most common) and
rhythm) bradycardia (rare but can happen). Assessment of angina is appropriate
Which of the following actions would be appropriate for the
nurse to take? Select all that apply: Rationale:
1. Administer the client's prescribed beta blocker. 1. Beta blocker would further decrease HR
2. Prepare for transcutaneous pacing. 3. Valsalva maneuver/Vagal stimulation would further decrease HR. (can be
3. Instruct the client to perform the Valsalva maneuver. indicated for sinus Tachy)
4. Begin chest compressions. 4. Chest compressions are for cardiac arrest
5. Assess the client for angina.
The nurse is planning care for a client with moderate 1. Encourage the client to reminisce about happy memories.
Alzheimer's disease (AD). Its possible for AD patients to retain long-term memories
Which of the following interventions should the nurse
include in the client's plan of care? Rationale:
1. Encourage the client to reminisce about happy 2. Acknowledge feelings --> Redirect is protocol for Dementia. Don't confront; they
memories. can't learn
2. Confront the client when inappropriate or agitated 3. AD is irreversible
behaviors occur. 4. In moderate AD, dementia has already progressed to where pt needs help with
3. Administer to the client the cholinesterase inhibitor to ADLs and planning daily activities. Asking them to plan can frustrate them and
reverse the course of AD. cause distress.
4. Provide the client with information about activity choices STRUCTURED pleasant activities that consider the persons likes and interests are
in the morning so the client can make plans for the day. the best.
The nurse is teaching a client how to ambulate using 1. "Use your hands and arms to support your body weight."
crutches. Which of the following information should the True! But watch out if it isn't 2-3 finger-widths, crutch paralysis can occur. s/s:
nurse include? paresis and paresthesias in wrists and hands
1. "Use your hands and arms to support your body weight."
2. "Wear slippers when ambulating with the crutches in Rationales:
your home." 2. Fall risk!
3. "Maintain the crutches 12 in (30 cm) in front of your feet 3. Should be 6 in. in front and 6 in. lateral
while standing." 4. Elbows should be bent at 30 degree angle
4. "Adjust the hand grips of the crutches so that your
elbows are fully extended."
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The nurse has taught a client with multiple sclerosis (MS). 4. "I should expect the blurred vision to resolve after I have received medications for
Which of the following statements by the client would several weeks."
indicate a correct understanding of the teaching? MS causes nerve damage and can result in optic neuritis (vision loss, burry vision).
1. "I will complete all of my household chores in the In most cases it resolves itself in 4-12 weeks, but medication (steroids) can speed
morning when I am well rested." up the process and resolve it quicker
2. "I have learned how to massage my bladder to help
empty my bladder completely." Rationale:
3. "I will take a hot bath in the evening to help me relax if I 1. MS patients should not exert themselves too much at one time. Space out
have had a stressful day at work." activities and allow time for rest.
4. "I should expect the blurred vision to resolve after I have 2. Urinary retention is primarily treated by medication (bethanochol), and exercises
received medications for several weeks." can aid with it but are not the primary treatment
3. Hot temperatures are bad for MS and can worsen symptoms. Your nerves are
already fcked up and extra heat can stress your body into overdrive
The nurse has attended a staff education program about 2. "Clients may develop stress ulcers and gastrointestinal bleeding."
caring for clients who are receiving positive pressure Rationale: Postive Pressure Ventilation may cause stress ulcers and GI bleeding
mechanical ventilation. Which of the following statements because
by the nurse would indicate a correct understanding of the
teaching?
1. "Clients should avoid range-of-motion (ROM) exercises
until weaned from ventilation."
2. "Clients may develop stress ulcers and gastrointestinal
bleeding."
3. "Clients will be chemically paralyzed to improve
oxygenation."
4. "Clients will experience diuresis and polyuria."
The charge nurse must transfer a female client from the 3. 56 years old, has hepatitis C (HCV) and has been afebrile for 24 hours
medical-surgical unit to the maternity unit to make a bed
available. It would be most appropriate for the nurse to
transfer the client who is
1. 28 years old, had a right mastectomy and has a closed-
wound drainage system
2. 49 years old, has diabetes mellitus (type 2) and has
begun receiving insulin
3. 56 years old, has hepatitis C (HCV) and has been
afebrile for 24 hours
4. 70 years old, has a fractured left tibia and had an
external fixation device applied 48 hours ago
The nurse has been made aware of the following client 1. heart failure who has a productive cough and is anxious
situations. The nurse should first assess the client with: Productive cough (pink frothy sputum) indicates pulmonary edema, anxiety might be
1. heart failure who has a productive cough and is anxious caused by decreased perfusion
2. regional enteritis (Crohn's disease) who is reporting
cramping abdominal pain and diarrhea
3. idiopathic thrombocytopenic purpura (ITP) who has
petechiae on the trunk and is reporting heavy menses
4. chronic obstructive pulmonary disease (COPD) who has
dyspnea with exertion and is using accessory muscles to
breathe
The nurse and unlicensed assistive personnel (UAP) are 1. assisting a client with atrial fibrillation to shower
caring for assigned clients. Which of the following tasks UAP can perform hygiene
would be appropriate for the nurse to assign to UAP?
1. assisting a client with atrial fibrillation to shower Rationale:
2. checking the ability of a client to swallow water after a Only nurses can assess. Transporting a client in respiratory arrest is not safe to
transesophageal echocardiogram (TEE) delegate to a UAP
3. observing while a client with dysphagia begins a
thickened liquid diet
4. transporting a client with respiratory distress to the
radiology department for a chest radiograph
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The nurse has taken a nutritional history from parents of 3. 9-month-old client whose typical daily diet includes 10 bottles of 2% milk, 1 cup of
clients. It would be a priority for the nurse to follow up with apple juice, and 3 servings of infant cereal
the
1. 5-month-old client whose only source of nutrition is 5 Rationale: Cows milk should be introduced at 12 months old. It doesn't provide the
formula feedings daily necessary nutrients and baby can develop iron deficiency
2. 7-month-old client who eats several crackers as finger
food
3. 9-month-old client whose typical daily diet includes 10
bottles of 2% milk, 1 cup of apple juice, and 3 servings of
infant cereal
4. 1-year-old client whose typical food intake includes 4
breast-feedings and 3 servings of cooked vegetables,
pears, or sliced cheese
The nurse is planning a staff education program about 2. sharing the client's blood alcohol level (BAL) test result with the police officer who
client privacy. Which of the following scenarios should the brought the client to the emergency department (ED)
nurse include as an example of a violation of client
privacy? Rationale: PHI is permitted to be disclosed to police when PHI is needed to
1. discussing with an unlicensed assistive personnel (UAP) apprehend the perpetrator of a violent crime, suspect, or fugitive.
that the UAP's assigned client will require a smaller
condom catheter
2. sharing the client's blood alcohol level (BAL) test result
with the police officer who brought the client to the
emergency department (ED)
3. responding to the call light of the client who is assigned
to another nurse and needs assistance in the bathroom
4. allowing a nursing student who has been assigned to
the client to review the client's medical record
The nurse has become aware of the following client 4. with heart failure who has a productive cough and is restless
situations. The nurse should first assess the client Productive cough (pink frothy sputum) is indicative of pulmonary edema which is
1. who had a right pneumonectomy 24 hours ago and is in life-threatening. T(x) would be to improve cardiac output by placing client in high
the high-Fowler's position while lying on the right side fowlers, O2, mechanical ventilation, meds
2. with chronic obstructive pulmonary disease (COPD) who
is using pursed-lip breathing and reporting hemoptysis
3. who had a wedge resection of the left lung 24 hours ago
and is sitting in the high-Fowler's position
4. with heart failure who has a productive cough and is
restless
The nurse is caring for a 3-year-old client with a cerebral 2. The client is sleeping but is easily aroused.
concussion who is being observed overnight in the Important to keep checking for decline in M/S with concussions, even when
pediatric unit. Which of the following observations would sleeping.
be most significant for the nurse to report to the oncoming
shift?
1. The client has a blood pressure of 94/58 mm Hg and an
apical pulse of 90.
2. The client is sleeping but is easily aroused.
3. The client's pupils are equal and reactive to light.
4. The client has an axillary temperature of 99.0° F (37.2°
C) and respirations of 24.
The nurse in the same-day surgical center has received a 1. closed reduction of a fractured tibia with cast application 1 hour ago and is
change-of-shift report on the following clients. The nurse reporting that the casted leg feels hot
should first see the client who had Pain, tightness, hot feeling can indicate that the cast is on too tight
1. closed reduction of a fractured tibia with cast application
1 hour ago and is reporting that the casted leg feels hot Rationale:
2. extraction of a cataract lens 2 hours ago and is reporting 2. Normal to feel nauseous after coming off of anesthesia
nausea 3. Knee pain is expected after knee surgery
3. an arthroscopy of the right knee 3 hours ago and is 4. Right shoulder pain is common in laparoscopic cholecystectomy due to gas left in
reporting knee pain rated as 4 on a scale of 0 (no pain) to abdomen after the procedure. Will resolve on its own
10 (severe pain)
4. a laparoscopic cholecystectomy 4 hours ago and is
reporting right shoulder pain
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The charge nurse has received a change-of-shift report on 2. first stage of labor whose contractions are occurring every 30 seconds
the following clients in labor. The charge nurse should ask Contractions should be no longer than 90 secs and no closer than 2 mins (120
a staff member to first see the client in the secs)
1. first stage of labor who has an oral temperature of 99.7° 90 secs is the duration, 2 mins is the frequency.
F (37.6° C)
2. first stage of labor whose contractions are occurring Rationale:
every 30 seconds 1. Elevated temp is normal during labor
3. second stage of labor who has respirations of 26 3. Increased resps are normal during labor "pant-pant-blow" "hee-hee-hoo"
4. second stage of labor whose contractions are lasting for breathing pattern
60 seconds 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
The nurse is observing a staff member caring for a client 2. placing a box of disposable face shields outside the client's room
who has chickenpox. disposable face masks are not suitable for airborne precautions
Which of the following actions by the staff member would
require the nurse to intervene? Rationale:
1. placing the client in a private room with monitored Varicella (chickenpox) is airborne precaution. Private, negative pressure room,
negative air pressure universal precautions (hand sanitizer in room) and placing surgical mask on client
2. placing a box of disposable face shields outside the during transport are all correct interventions for Varicilla.
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
The nurse is caring for a client who reports feeling faint 2. transcutaneous pacing
and is experiencing the cardiac rhythm shown in the - external pacing that stimulates the ventricles to pump at a set rate
electrocardiogram (ECG) strip below. 5. Assess the client for angina
- BRADYCARDIA (it is more than 5 spaces apart, sinus - Angina (Chest pain) can be caused by both tachycardia (most common) and
rhythm) bradycardia (rare but can happen). Assessment of angina is appropriate
Which of the following actions would be appropriate for the
nurse to take? Select all that apply: Rationale:
1. Administer the client's prescribed beta blocker. 1. Beta blocker would further decrease HR
2. Prepare for transcutaneous pacing. 3. Valsalva maneuver/Vagal stimulation would further decrease HR. (can be
3. Instruct the client to perform the Valsalva maneuver. indicated for sinus Tachy)
4. Begin chest compressions. 4. Chest compressions are for cardiac arrest
5. Assess the client for angina.
The nurse is planning care for a client with moderate 1. Encourage the client to reminisce about happy memories.
Alzheimer's disease (AD). Its possible for AD patients to retain long-term memories
Which of the following interventions should the nurse
include in the client's plan of care? Rationale:
1. Encourage the client to reminisce about happy 2. Acknowledge feelings --> Redirect is protocol for Dementia. Don't confront; they
memories. can't learn
2. Confront the client when inappropriate or agitated 3. AD is irreversible
behaviors occur. 4. In moderate AD, dementia has already progressed to where pt needs help with
3. Administer to the client the cholinesterase inhibitor to ADLs and planning daily activities. Asking them to plan can frustrate them and
reverse the course of AD. cause distress.
4. Provide the client with information about activity choices STRUCTURED pleasant activities that consider the persons likes and interests are
in the morning so the client can make plans for the day. the best.
The nurse is teaching a client how to ambulate using 1. "Use your hands and arms to support your body weight."
crutches. Which of the following information should the True! But watch out if it isn't 2-3 finger-widths, crutch paralysis can occur. s/s:
nurse include? paresis and paresthesias in wrists and hands
1. "Use your hands and arms to support your body weight."
2. "Wear slippers when ambulating with the crutches in Rationales:
your home." 2. Fall risk!
3. "Maintain the crutches 12 in (30 cm) in front of your feet 3. Should be 6 in. in front and 6 in. lateral
while standing." 4. Elbows should be bent at 30 degree angle
4. "Adjust the hand grips of the crutches so that your
elbows are fully extended."
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The nurse has taught a client with multiple sclerosis (MS). 4. "I should expect the blurred vision to resolve after I have received medications for
Which of the following statements by the client would several weeks."
indicate a correct understanding of the teaching? MS causes nerve damage and can result in optic neuritis (vision loss, burry vision).
1. "I will complete all of my household chores in the In most cases it resolves itself in 4-12 weeks, but medication (steroids) can speed
morning when I am well rested." up the process and resolve it quicker
2. "I have learned how to massage my bladder to help
empty my bladder completely." Rationale:
3. "I will take a hot bath in the evening to help me relax if I 1. MS patients should not exert themselves too much at one time. Space out
have had a stressful day at work." activities and allow time for rest.
4. "I should expect the blurred vision to resolve after I have 2. Urinary retention is primarily treated by medication (bethanochol), and exercises
received medications for several weeks." can aid with it but are not the primary treatment
3. Hot temperatures are bad for MS and can worsen symptoms. Your nerves are
already fcked up and extra heat can stress your body into overdrive
The nurse has attended a staff education program about 2. "Clients may develop stress ulcers and gastrointestinal bleeding."
caring for clients who are receiving positive pressure Rationale: Postive Pressure Ventilation may cause stress ulcers and GI bleeding
mechanical ventilation. Which of the following statements because
by the nurse would indicate a correct understanding of the
teaching?
1. "Clients should avoid range-of-motion (ROM) exercises
until weaned from ventilation."
2. "Clients may develop stress ulcers and gastrointestinal
bleeding."
3. "Clients will be chemically paralyzed to improve
oxygenation."
4. "Clients will experience diuresis and polyuria."
The charge nurse must transfer a female client from the 3. 56 years old, has hepatitis C (HCV) and has been afebrile for 24 hours
medical-surgical unit to the maternity unit to make a bed
available. It would be most appropriate for the nurse to
transfer the client who is
1. 28 years old, had a right mastectomy and has a closed-
wound drainage system
2. 49 years old, has diabetes mellitus (type 2) and has
begun receiving insulin
3. 56 years old, has hepatitis C (HCV) and has been
afebrile for 24 hours
4. 70 years old, has a fractured left tibia and had an
external fixation device applied 48 hours ago
The nurse has been made aware of the following client 1. heart failure who has a productive cough and is anxious
situations. The nurse should first assess the client with: Productive cough (pink frothy sputum) indicates pulmonary edema, anxiety might be
1. heart failure who has a productive cough and is anxious caused by decreased perfusion
2. regional enteritis (Crohn's disease) who is reporting
cramping abdominal pain and diarrhea
3. idiopathic thrombocytopenic purpura (ITP) who has
petechiae on the trunk and is reporting heavy menses
4. chronic obstructive pulmonary disease (COPD) who has
dyspnea with exertion and is using accessory muscles to
breathe
The nurse and unlicensed assistive personnel (UAP) are 1. assisting a client with atrial fibrillation to shower
caring for assigned clients. Which of the following tasks UAP can perform hygiene
would be appropriate for the nurse to assign to UAP?
1. assisting a client with atrial fibrillation to shower Rationale:
2. checking the ability of a client to swallow water after a Only nurses can assess. Transporting a client in respiratory arrest is not safe to
transesophageal echocardiogram (TEE) delegate to a UAP
3. observing while a client with dysphagia begins a
thickened liquid diet
4. transporting a client with respiratory distress to the
radiology department for a chest radiograph
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The nurse has taken a nutritional history from parents of 3. 9-month-old client whose typical daily diet includes 10 bottles of 2% milk, 1 cup of
clients. It would be a priority for the nurse to follow up with apple juice, and 3 servings of infant cereal
the
1. 5-month-old client whose only source of nutrition is 5 Rationale: Cows milk should be introduced at 12 months old. It doesn't provide the
formula feedings daily necessary nutrients and baby can develop iron deficiency
2. 7-month-old client who eats several crackers as finger
food
3. 9-month-old client whose typical daily diet includes 10
bottles of 2% milk, 1 cup of apple juice, and 3 servings of
infant cereal
4. 1-year-old client whose typical food intake includes 4
breast-feedings and 3 servings of cooked vegetables,
pears, or sliced cheese
The nurse is planning a staff education program about 2. sharing the client's blood alcohol level (BAL) test result with the police officer who
client privacy. Which of the following scenarios should the brought the client to the emergency department (ED)
nurse include as an example of a violation of client
privacy? Rationale: PHI is permitted to be disclosed to police when PHI is needed to
1. discussing with an unlicensed assistive personnel (UAP) apprehend the perpetrator of a violent crime, suspect, or fugitive.
that the UAP's assigned client will require a smaller
condom catheter
2. sharing the client's blood alcohol level (BAL) test result
with the police officer who brought the client to the
emergency department (ED)
3. responding to the call light of the client who is assigned
to another nurse and needs assistance in the bathroom
4. allowing a nursing student who has been assigned to
the client to review the client's medical record
The nurse has become aware of the following client 4. with heart failure who has a productive cough and is restless
situations. The nurse should first assess the client Productive cough (pink frothy sputum) is indicative of pulmonary edema which is
1. who had a right pneumonectomy 24 hours ago and is in life-threatening. T(x) would be to improve cardiac output by placing client in high
the high-Fowler's position while lying on the right side fowlers, O2, mechanical ventilation, meds
2. with chronic obstructive pulmonary disease (COPD) who
is using pursed-lip breathing and reporting hemoptysis
3. who had a wedge resection of the left lung 24 hours ago
and is sitting in the high-Fowler's position
4. with heart failure who has a productive cough and is
restless
The nurse is caring for a 3-year-old client with a cerebral 2. The client is sleeping but is easily aroused.
concussion who is being observed overnight in the Important to keep checking for decline in M/S with concussions, even when
pediatric unit. Which of the following observations would sleeping.
be most significant for the nurse to report to the oncoming
shift?
1. The client has a blood pressure of 94/58 mm Hg and an
apical pulse of 90.
2. The client is sleeping but is easily aroused.
3. The client's pupils are equal and reactive to light.
4. The client has an axillary temperature of 99.0° F (37.2°
C) and respirations of 24.
The nurse in the same-day surgical center has received a 1. closed reduction of a fractured tibia with cast application 1 hour ago and is
change-of-shift report on the following clients. The nurse reporting that the casted leg feels hot
should first see the client who had Pain, tightness, hot feeling can indicate that the cast is on too tight
1. closed reduction of a fractured tibia with cast application
1 hour ago and is reporting that the casted leg feels hot Rationale:
2. extraction of a cataract lens 2 hours ago and is reporting 2. Normal to feel nauseous after coming off of anesthesia
nausea 3. Knee pain is expected after knee surgery
3. an arthroscopy of the right knee 3 hours ago and is 4. Right shoulder pain is common in laparoscopic cholecystectomy due to gas left in
reporting knee pain rated as 4 on a scale of 0 (no pain) to abdomen after the procedure. Will resolve on its own
10 (severe pain)
4. a laparoscopic cholecystectomy 4 hours ago and is
reporting right shoulder pain
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