NCLEX-RN Exam Preview
2. First stage of labor whose contractions
The charge nurse has received a
are occurring every 30 seconds
change-of-shift report on the following
clients in labor.
Rationale:
The charge nurse should ask a staff
1. Elevated temperature is normal during
member to first see the client in the
labor.
1. First stage of labor who has an oral
3. Increased respirations are nor-
temperature of 99.7F (37.6 C)
mal during labor "pant-pant-blow"
2. First stage of labor whose contractions
"hee-hee-hoo" breathing pattern.
are occurring every 30 seconds
4. Contractions shouldn't be longer than
3. Second stage of labor who has respi-
90 seconds, 60 seconds is okay and
rations of 26.
normal. Second stage: 2-3 minutes
4. Second stage of labor whose contrac-
apart, 60-90 seconds long, 10cm dilated,
tions are lasting for 60 seconds.
strong pain.
The nurse is observing a staff member
caring for a client who has chickenpox.
2. Placing a box of disposable face
Which of the following actions by the staff
shields outside the client's room.
member would require the nurse to inter-
vene?
Rationale:
1. Placing the client in a private room with
Varicella AKA chicken pox is an air-
monitored negative air pressure.
borne precaution. Private, negative pres-
2. Placing a box of disposable face
sure room, universal precautions (hand
shields outside the client's room.
sanitizer in room) and placing a surgical
3. Placing an alcohol-based hand rub in
mask on client during transport are all
the client's room for hand hygiene.
correct interventions for varicella.
4. Placing a surgical mask on the client
during transport out of the client's room.
The nurse is caring for a client who re-
2. Prepare for transcutaneous pacing. ports feeling faint and is experiencing the
& 5. Assess the client for angina. cardiac rhythm shown in the electrocar-
diogram (ECG) strip below.
Rationale: Which of the following actions would be
1. Beta Blockers would further decrease appropriate for the nurse to take? Select
HR. all that apply.
2. External pacing stimulates the ventri- 1. Administer the client's prescribed beta
cles to pump at a set rate. blocker.
3. Valsalva maneuver would further de- 2. Prepare for transcutaneous pacing.
3. Instruct the client to perform the Val-
, NCLEX-RN Exam Preview
salva maneuver.
crease HR. 4. Begin chest compressions.
4. Chest compressions are for cardiac 5. Assess the client for angina.
arrest.
5. Angina (Chest pain) can be caused
by both tachycardia (most common)
and bradycardia (rare but can happen).
Therefore, assessment of angina is ap-
propriate.
1. Encourage the client to reminisce The nurse is planning care for a
about happy memories. client with moderate Alzheimer's Dis-
ease (AD).
Rationale: Which of the following interventions
1. Is correct because it is possible for AD should the nurse include in the client's
patients to retain long-term memories. plan of care?
2. Redirect is protocol for dementia. Don't 1. Encourage the client to reminisce
confront, they can't learn. about happy memories.
3. AD is irreversible. 2. Confront the client when inappropriate
4. In the moderate AD, dementia has or agitated behaviors occur.
already progressed to where the patient 3. Administer to the client the
needs help with ADL's & planning daily cholinesterase inhibitor to reverse the
activities. Asking them to plan can frus- course of AD.
trate them & cause distress. Structured, 4. Provide the client with information
pleasant activities that consider the per- about activity choices in the morning so
son's likes & interests are the best. the client can make plans for the day.
1. "Use your hands and arms to support
The nurse is teaching a client how to
your body weight."
ambulate using crutches.
Which of the following information should
Rationale:
the nurse include?
1. Is true, but watch out if it isn't 2-3
1. "Use your hands and arms to support
finger-widths, because crutch paralysis
your body weight."
can occur. S/S: Paresis & Paresthesias
2. "Wear slippers when ambulating with
in wrist & hands.
the crutches in your home."
2. Is a fall risk.
3. "Maintain the crutches 12inch (30cm)
3. Crutches should be 6 inches in front &
in front of your feet while standing."
6 inches lateral.
4. "Adjust the hand grips of the crutches
4. Elbow should be bent at a 30 degree
so that your elbows are fully extended."
angle.
, NCLEX-RN Exam Preview
4. "I should expect the blurred vision to
resolve after I have received medications
for several weeks."
The nurse has taught a client with multi-
ple sclerosis (MS).
Rationale:
Which of the following statements by the
MS causes nerve damage & can result
client would indicate a correct under-
in optic neuritis (Vision loss, blurry vi-
standing of the teaching?
sion). In most cases it resolves itself in
1. "I will complete all of my household
4-12 weeks, but medications (steroids
chores in the morning when I am well
can speed up the process & resolve it
rested."
quicker.
2. "I have learned how to massage my
1. MS patients should not exert them-
bladder to help empty my bladder com-
selves too much at one time. Space out
pletely."
activities & allow time for rest.
3. "I will take a hot bath in the evening to
2. Urinary retention is primarily treated
help me relax if I have had a stressful day
by medication (bethanochol), and exer-
at work."
cises can aid with it but are not the pri-
4. "I should expect the blurred vision to
mary treatment.
resolve after I have received medications
3. Hot temperatures are bad for MS and
for several weeks."
can worsen symptoms. Your nerves are
already messed up and extra heat can
stress the body into overdrive.
Highlight:
"Loss of appetite"
"Abdominal pain rated 7/10 on the Nu- The nurse in the emergency department
merical Rating Scale for 1 week." (ED) is caring for a 41-year-old male
"Client states, "The abdominal pain start- client.
ed after my 7-year-old child accidentally Highlight the findings below that would
kicked me in the stomach." require follow-up.
"Vital signs: T 103.4 F (39.7 C), P 92, RR (See Picture)
22, BP 130/86, pulse oximetry reading
98% on room air.
Rationale:
Loss of appetite may indicate an under-
lying medical condition or infection.
The intensity of abdominal pain requires
evaluation to determine the cause.
, NCLEX-RN Exam Preview
Trauma to the abdomen can cause inter-
nal injuries that need to be assessed to
ensure no significant damage or compli-
cations.
The nurse in the emergency department
is caring for a 41-year-old male client.
Nurse's Notes:
11:00: Client reports nausea, loss of ap-
petite, vomiting, fever, and constipation
for the past 2 weeks and abdominal pain
rated 7/10 on the Numerical Rating Scale
for 1 week. Client states "The abdomi-
nal pain started after my 7-year-old child
accidentally kicked me in the stomach."
Client plays soccer with the child once
Answer: a week. Vital signs: T 103.4 F (39.7 C),
Bowel obstruction: Appetite, Bowel Pat- P 92, RR 22, BP 130/86, pulse oximetry
tern, Gastrointestinal Symptoms. reading 98% on room air. No significant
Appendicitis: Pain level. past medical or surgical history. Body
Ruptured Spleen: Pain level. mass index (BMI) 32. Drinks alcohol only
during social occasions, usually 3 bev-
erages. Smokes cigarettes during social
occasions.
For each assessment finding below, click
to specify if the finding is consistent with
the disease process of bowel obstruc-
tion, appendicitis, or ruptured spleen.
Each finding may support more than 1
disease process.
Answer:
•Anemia
•Peritonitis
•Septic Shock
2. First stage of labor whose contractions
The charge nurse has received a
are occurring every 30 seconds
change-of-shift report on the following
clients in labor.
Rationale:
The charge nurse should ask a staff
1. Elevated temperature is normal during
member to first see the client in the
labor.
1. First stage of labor who has an oral
3. Increased respirations are nor-
temperature of 99.7F (37.6 C)
mal during labor "pant-pant-blow"
2. First stage of labor whose contractions
"hee-hee-hoo" breathing pattern.
are occurring every 30 seconds
4. Contractions shouldn't be longer than
3. Second stage of labor who has respi-
90 seconds, 60 seconds is okay and
rations of 26.
normal. Second stage: 2-3 minutes
4. Second stage of labor whose contrac-
apart, 60-90 seconds long, 10cm dilated,
tions are lasting for 60 seconds.
strong pain.
The nurse is observing a staff member
caring for a client who has chickenpox.
2. Placing a box of disposable face
Which of the following actions by the staff
shields outside the client's room.
member would require the nurse to inter-
vene?
Rationale:
1. Placing the client in a private room with
Varicella AKA chicken pox is an air-
monitored negative air pressure.
borne precaution. Private, negative pres-
2. Placing a box of disposable face
sure room, universal precautions (hand
shields outside the client's room.
sanitizer in room) and placing a surgical
3. Placing an alcohol-based hand rub in
mask on client during transport are all
the client's room for hand hygiene.
correct interventions for varicella.
4. Placing a surgical mask on the client
during transport out of the client's room.
The nurse is caring for a client who re-
2. Prepare for transcutaneous pacing. ports feeling faint and is experiencing the
& 5. Assess the client for angina. cardiac rhythm shown in the electrocar-
diogram (ECG) strip below.
Rationale: Which of the following actions would be
1. Beta Blockers would further decrease appropriate for the nurse to take? Select
HR. all that apply.
2. External pacing stimulates the ventri- 1. Administer the client's prescribed beta
cles to pump at a set rate. blocker.
3. Valsalva maneuver would further de- 2. Prepare for transcutaneous pacing.
3. Instruct the client to perform the Val-
, NCLEX-RN Exam Preview
salva maneuver.
crease HR. 4. Begin chest compressions.
4. Chest compressions are for cardiac 5. Assess the client for angina.
arrest.
5. Angina (Chest pain) can be caused
by both tachycardia (most common)
and bradycardia (rare but can happen).
Therefore, assessment of angina is ap-
propriate.
1. Encourage the client to reminisce The nurse is planning care for a
about happy memories. client with moderate Alzheimer's Dis-
ease (AD).
Rationale: Which of the following interventions
1. Is correct because it is possible for AD should the nurse include in the client's
patients to retain long-term memories. plan of care?
2. Redirect is protocol for dementia. Don't 1. Encourage the client to reminisce
confront, they can't learn. about happy memories.
3. AD is irreversible. 2. Confront the client when inappropriate
4. In the moderate AD, dementia has or agitated behaviors occur.
already progressed to where the patient 3. Administer to the client the
needs help with ADL's & planning daily cholinesterase inhibitor to reverse the
activities. Asking them to plan can frus- course of AD.
trate them & cause distress. Structured, 4. Provide the client with information
pleasant activities that consider the per- about activity choices in the morning so
son's likes & interests are the best. the client can make plans for the day.
1. "Use your hands and arms to support
The nurse is teaching a client how to
your body weight."
ambulate using crutches.
Which of the following information should
Rationale:
the nurse include?
1. Is true, but watch out if it isn't 2-3
1. "Use your hands and arms to support
finger-widths, because crutch paralysis
your body weight."
can occur. S/S: Paresis & Paresthesias
2. "Wear slippers when ambulating with
in wrist & hands.
the crutches in your home."
2. Is a fall risk.
3. "Maintain the crutches 12inch (30cm)
3. Crutches should be 6 inches in front &
in front of your feet while standing."
6 inches lateral.
4. "Adjust the hand grips of the crutches
4. Elbow should be bent at a 30 degree
so that your elbows are fully extended."
angle.
, NCLEX-RN Exam Preview
4. "I should expect the blurred vision to
resolve after I have received medications
for several weeks."
The nurse has taught a client with multi-
ple sclerosis (MS).
Rationale:
Which of the following statements by the
MS causes nerve damage & can result
client would indicate a correct under-
in optic neuritis (Vision loss, blurry vi-
standing of the teaching?
sion). In most cases it resolves itself in
1. "I will complete all of my household
4-12 weeks, but medications (steroids
chores in the morning when I am well
can speed up the process & resolve it
rested."
quicker.
2. "I have learned how to massage my
1. MS patients should not exert them-
bladder to help empty my bladder com-
selves too much at one time. Space out
pletely."
activities & allow time for rest.
3. "I will take a hot bath in the evening to
2. Urinary retention is primarily treated
help me relax if I have had a stressful day
by medication (bethanochol), and exer-
at work."
cises can aid with it but are not the pri-
4. "I should expect the blurred vision to
mary treatment.
resolve after I have received medications
3. Hot temperatures are bad for MS and
for several weeks."
can worsen symptoms. Your nerves are
already messed up and extra heat can
stress the body into overdrive.
Highlight:
"Loss of appetite"
"Abdominal pain rated 7/10 on the Nu- The nurse in the emergency department
merical Rating Scale for 1 week." (ED) is caring for a 41-year-old male
"Client states, "The abdominal pain start- client.
ed after my 7-year-old child accidentally Highlight the findings below that would
kicked me in the stomach." require follow-up.
"Vital signs: T 103.4 F (39.7 C), P 92, RR (See Picture)
22, BP 130/86, pulse oximetry reading
98% on room air.
Rationale:
Loss of appetite may indicate an under-
lying medical condition or infection.
The intensity of abdominal pain requires
evaluation to determine the cause.
, NCLEX-RN Exam Preview
Trauma to the abdomen can cause inter-
nal injuries that need to be assessed to
ensure no significant damage or compli-
cations.
The nurse in the emergency department
is caring for a 41-year-old male client.
Nurse's Notes:
11:00: Client reports nausea, loss of ap-
petite, vomiting, fever, and constipation
for the past 2 weeks and abdominal pain
rated 7/10 on the Numerical Rating Scale
for 1 week. Client states "The abdomi-
nal pain started after my 7-year-old child
accidentally kicked me in the stomach."
Client plays soccer with the child once
Answer: a week. Vital signs: T 103.4 F (39.7 C),
Bowel obstruction: Appetite, Bowel Pat- P 92, RR 22, BP 130/86, pulse oximetry
tern, Gastrointestinal Symptoms. reading 98% on room air. No significant
Appendicitis: Pain level. past medical or surgical history. Body
Ruptured Spleen: Pain level. mass index (BMI) 32. Drinks alcohol only
during social occasions, usually 3 bev-
erages. Smokes cigarettes during social
occasions.
For each assessment finding below, click
to specify if the finding is consistent with
the disease process of bowel obstruc-
tion, appendicitis, or ruptured spleen.
Each finding may support more than 1
disease process.
Answer:
•Anemia
•Peritonitis
•Septic Shock
