NCLEX EXAM PREVIEW QUESTIONS AND ANSWERS 100% PASS

NCLEX EXAM PREVIEW QUESTIONS AND ANSWERS 100% PASS 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 - 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: Copyright ©EMILLECT 2024. ALL RIGHTS RESERVED. Page 2/87 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 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 - 2. placing a box of disposable face shields outside the client's room disposable face masks are not suitable for airborne precautions Copyright ©EMILLECT 2024. ALL RIGHTS RESERVED. Page 3/87 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. - 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. - 2. transcutaneous pacing - external pacing that stimulates the ventricles to pump at a set rate Copyright ©EMILLECT 2024. ALL RIGHTS RESERVED. Page 4/87 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). 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. Copyright ©EMILLECT 2024. ALL RIGHTS RESERVED. Page 5/87 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. - 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 t