National Council Licensure
Examination (NCLEX) Preview with
Rationale
The nurse has taught a client with multiple sclerosis (MS).
Which of the following statements by the client would indicate a correct understanding
of the teaching?
1. "I will complete all of my household chores in the morning when I am well rested."
2. "I have learned how to massage my bladder to help empty my bladder completely."
3. "I will take a hot bath in the evening to help me relax if I have had a stressful day at
work."
4. "I should expect the blurred vision to resolve after I have received medications for
several weeks."
4. "I should expect the blurred vision to resolve after I have received medications for
several weeks."
MS causes nerve damage and can result in optic neuritis (vision loss, burry vision). In
most cases it resolves itself in 4-12 weeks, but medication (steroids) can speed up the
process and resolve it quicker
Rationale:
1. MS patients should not exert themselves too much at one time. Space out activities
and allow time for rest.
2. Urinary retention is primarily treated by medication (bethanechol), and exercises 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 faked up and extra heat can stress your body into overdrive
,The nurse has attended a staff education program about caring for clients who are
receiving positive pressure mechanical ventilation. Which of the following statements 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."
2. "Clients may develop stress ulcers and gastrointestinal bleeding."
Rationale: Positive Pressure Ventilation may cause stress ulcers and GI bleeding
because
The charge nurse must transfer a female client from the 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
3. 56 years old, has hepatitis C (HCV) and has been afebrile for 24 hours
The nurse has been made aware of the following client situations. The nurse should first
assess the client with:
1. heart failure who has a productive cough and is anxious
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
1. heart failure who has a productive cough and is anxious
Productive cough (pink frothy sputum) indicates pulmonary edema, anxiety might be
caused by decreased perfusion
The nurse and unlicensed assistive personnel (UAP) are caring for assigned clients.
Which of the following tasks would be appropriate for the nurse to assign to UAP?
1. assisting a client with atrial fibrillation to shower
2. checking the ability of a client to swallow water after a transesophageal
echocardiogram (TEE)
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
1. assisting a client with atrial fibrillation to shower
UAP can perform hygiene
Rationale:
Only nurses can assess. Transporting a client in respiratory arrest is not safe to
delegate to a UAP
The nurse has taken a nutritional history from parents of clients. It would be a priority for
the nurse to follow up with the
1. 5-month-old client whose only source of nutrition is 5 formula feedings daily
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
, 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
Rationale: Cow’s milk should be introduced at 12 months old. It doesn't provide the
necessary nutrients and baby can develop iron deficiency
The nurse is planning a staff education program about client privacy. Which of the
following scenarios should the nurse include as an example of a violation of client
privacy?
1. discussing with an unlicensed assistive personnel (UAP) 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
2. sharing the client's blood alcohol level (BAL) test result with the police officer who
brought the client to the emergency department (ED)
Rationale: PHI is permitted to be disclosed to police when PHI is needed to apprehend
the perpetrator of a violent crime, suspect, or fugitive.
AD
The nurse has become aware of the following client situations. The nurse should first
assess the client
1. who had a right pneumonectomy 24 hours ago and is in the high-Fowler's position
while lying on the right side
Examination (NCLEX) Preview with
Rationale
The nurse has taught a client with multiple sclerosis (MS).
Which of the following statements by the client would indicate a correct understanding
of the teaching?
1. "I will complete all of my household chores in the morning when I am well rested."
2. "I have learned how to massage my bladder to help empty my bladder completely."
3. "I will take a hot bath in the evening to help me relax if I have had a stressful day at
work."
4. "I should expect the blurred vision to resolve after I have received medications for
several weeks."
4. "I should expect the blurred vision to resolve after I have received medications for
several weeks."
MS causes nerve damage and can result in optic neuritis (vision loss, burry vision). In
most cases it resolves itself in 4-12 weeks, but medication (steroids) can speed up the
process and resolve it quicker
Rationale:
1. MS patients should not exert themselves too much at one time. Space out activities
and allow time for rest.
2. Urinary retention is primarily treated by medication (bethanechol), and exercises 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 faked up and extra heat can stress your body into overdrive
,The nurse has attended a staff education program about caring for clients who are
receiving positive pressure mechanical ventilation. Which of the following statements 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."
2. "Clients may develop stress ulcers and gastrointestinal bleeding."
Rationale: Positive Pressure Ventilation may cause stress ulcers and GI bleeding
because
The charge nurse must transfer a female client from the 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
3. 56 years old, has hepatitis C (HCV) and has been afebrile for 24 hours
The nurse has been made aware of the following client situations. The nurse should first
assess the client with:
1. heart failure who has a productive cough and is anxious
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
1. heart failure who has a productive cough and is anxious
Productive cough (pink frothy sputum) indicates pulmonary edema, anxiety might be
caused by decreased perfusion
The nurse and unlicensed assistive personnel (UAP) are caring for assigned clients.
Which of the following tasks would be appropriate for the nurse to assign to UAP?
1. assisting a client with atrial fibrillation to shower
2. checking the ability of a client to swallow water after a transesophageal
echocardiogram (TEE)
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
1. assisting a client with atrial fibrillation to shower
UAP can perform hygiene
Rationale:
Only nurses can assess. Transporting a client in respiratory arrest is not safe to
delegate to a UAP
The nurse has taken a nutritional history from parents of clients. It would be a priority for
the nurse to follow up with the
1. 5-month-old client whose only source of nutrition is 5 formula feedings daily
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
, 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
Rationale: Cow’s milk should be introduced at 12 months old. It doesn't provide the
necessary nutrients and baby can develop iron deficiency
The nurse is planning a staff education program about client privacy. Which of the
following scenarios should the nurse include as an example of a violation of client
privacy?
1. discussing with an unlicensed assistive personnel (UAP) 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
2. sharing the client's blood alcohol level (BAL) test result with the police officer who
brought the client to the emergency department (ED)
Rationale: PHI is permitted to be disclosed to police when PHI is needed to apprehend
the perpetrator of a violent crime, suspect, or fugitive.
AD
The nurse has become aware of the following client situations. The nurse should first
assess the client
1. who had a right pneumonectomy 24 hours ago and is in the high-Fowler's position
while lying on the right side
