NCLEX-RN Exam Preview
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1. The charge nurse has received 2. First stage of labor whose contractions are occurring every
a change-of-shift report on the 30 seconds
following clients in labor.
The charge nurse should ask a Rationale:
staff member to first see the 1. Elevated temperature is normal during labor.
client in the 3. Increased respirations are normal during labor
1. First stage of labor who has "pant-pant-blow" "hee-hee-hoo" breathing pattern.
an oral temperature of 99.7F 4. Contractions shouldn't be longer than 90 seconds, 60 sec-
(37.6 C) onds is okay and normal. Second stage: 2-3 minutes apart,
2. First stage of labor whose 60-90 seconds long, 10cm dilated, strong pain.
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. The nurse is observing a staff 2. Placing a box of disposable face shields outside the client's
member caring for a client room.
who has chickenpox.
Which of the following actions Rationale:
by the staff member would re- Varicella AKA chicken pox is an airborne precaution. Private,
quire the nurse to intervene? negative pressure room, universal precautions (hand sanitizer
1. Placing the client in a private in room) and placing a surgical mask on client during trans-
room with monitored negative port are all correct interventions for varicella.
air pressure.
2. Placing a box of dispos-
able face shields outside the
client's room.
3. Placing an alcohol-based
hand rub in the client's room
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for hand hygiene.
4. Placing a surgical mask on
the client during transport out
of the client's room.
3. 2. Prepare for transcutaneous The nurse is caring for a client who reports feeling faint and is
pacing. experiencing the cardiac rhythm shown in the electrocardio-
& 5. Assess the client for angi-gram (ECG) strip below.
na. 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 Blockers would further 2. Prepare for transcutaneous pacing.
decrease HR. 3. Instruct the client to perform the Valsalva maneuver.
2. External pacing stimulates 4. Begin chest compressions.
the ventricles to pump at a set 5. Assess the client for angina.
rate.
3. Valsalva maneuver would
further decrease HR.
4. Chest compressions are for
cardiac arrest.
5. Angina (Chest pain) can
be caused by both tachy-
cardia (most common) and
bradycardia (rare but can hap-
pen). Therefore, assessment
of angina is appropriate.
4. 1. Encourage the client to rem- The nurse is planning care for a client with moderate
inisce about happy memories. Alzheimer's Disease (AD).
Which of the following interventions should the nurse include
Rationale: in the client's plan of care?
1. Is correct because it is pos- 1. Encourage the client to reminisce about happy memories.
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sible for AD patients to retain 2. Confront the client when inappropriate or agitated behav-
long-term memories. iors occur.
2. Redirect is protocol for de- 3. Administer to the client the cholinesterase inhibitor to re-
mentia. Don't confront, they verse the course of AD.
can't learn. 4. Provide the client with information about activity choices in
3. AD is irreversible. the morning so the client can make plans for the day.
4. In the moderate AD, demen-
tia has already progressed to
where the patient needs help
with ADL's & planning daily ac-
tivities. Asking them to plan
can frustrate them & cause
distress. Structured, pleasant
activities that consider the per-
son's likes & interests are the
best.
5. 1. "Use your hands and arms The nurse is teaching a client how to ambulate using crutches.
to support your body weight." Which of the following information should the nurse include?
1. "Use your hands and arms to support your body weight."
Rationale: 2. "Wear slippers when ambulating with the crutches in your
1. Is true, but watch out if home."
it isn't 2-3 finger-widths, be- 3. "Maintain the crutches 12inch (30cm) in front of your feet
cause crutch paralysis can oc- while standing."
cur. S/S: Paresis & Paresthesias 4. "Adjust the hand grips of the crutches so that your elbows
in wrist & hands. are fully extended."
2. Is a fall risk.
3. Crutches should be 6 inches
in front & 6 inches lateral.
4. Elbow should be bent at a 30
degree angle.
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6. 4. "I should expect the blurred The nurse has taught a client with multiple sclerosis (MS).
vision to resolve after I have Which of the following statements by the client would indicate
received medications for sev- a correct understanding of the teaching?
eral weeks." 1. "I will complete all of my household chores in the morning
when I am well rested."
Rationale: 2. "I have learned how to massage my bladder to help empty
MS causes nerve damage & my bladder completely."
can result in optic neuritis (Vi- 3. "I will take a hot bath in the evening to help me relax if I
sion loss, blurry vision). In have had a stressful day at work."
most cases it resolves itself in 4. "I should expect the blurred vision to resolve after I have
4-12 weeks, but medications received medications for several weeks."
(steroids can speed up the
process & resolve it quicker.
1. MS patients should not exert
themselves too much at one
time. Space out activities & al-
low time for rest.
2. Urinary retention is pri-
marily treated by medication
(bethanochol), and exercises
can aid with it but are not the
primary treatment.
3. Hot temperatures are bad
for MS and can worsen symp-
toms. Your nerves are already
messed up and extra heat can
stress the body into overdrive.
7. Highlight: The nurse in the emergency department (ED) is caring for a
"Loss of appetite" 41-year-old male client.
"Abdominal pain rated 7/10 on Highlight the findings below that would require follow-up.
the Numerical Rating Scale for (See Picture)
Study online at https://quizlet.com/_ec21b6
1. The charge nurse has received 2. First stage of labor whose contractions are occurring every
a change-of-shift report on the 30 seconds
following clients in labor.
The charge nurse should ask a Rationale:
staff member to first see the 1. Elevated temperature is normal during labor.
client in the 3. Increased respirations are normal during labor
1. First stage of labor who has "pant-pant-blow" "hee-hee-hoo" breathing pattern.
an oral temperature of 99.7F 4. Contractions shouldn't be longer than 90 seconds, 60 sec-
(37.6 C) onds is okay and normal. Second stage: 2-3 minutes apart,
2. First stage of labor whose 60-90 seconds long, 10cm dilated, strong pain.
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. The nurse is observing a staff 2. Placing a box of disposable face shields outside the client's
member caring for a client room.
who has chickenpox.
Which of the following actions Rationale:
by the staff member would re- Varicella AKA chicken pox is an airborne precaution. Private,
quire the nurse to intervene? negative pressure room, universal precautions (hand sanitizer
1. Placing the client in a private in room) and placing a surgical mask on client during trans-
room with monitored negative port are all correct interventions for varicella.
air pressure.
2. Placing a box of dispos-
able face shields outside the
client's room.
3. Placing an alcohol-based
hand rub in the client's room
, NCLEX-RN Exam Preview
Study online at https://quizlet.com/_ec21b6
for hand hygiene.
4. Placing a surgical mask on
the client during transport out
of the client's room.
3. 2. Prepare for transcutaneous The nurse is caring for a client who reports feeling faint and is
pacing. experiencing the cardiac rhythm shown in the electrocardio-
& 5. Assess the client for angi-gram (ECG) strip below.
na. 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 Blockers would further 2. Prepare for transcutaneous pacing.
decrease HR. 3. Instruct the client to perform the Valsalva maneuver.
2. External pacing stimulates 4. Begin chest compressions.
the ventricles to pump at a set 5. Assess the client for angina.
rate.
3. Valsalva maneuver would
further decrease HR.
4. Chest compressions are for
cardiac arrest.
5. Angina (Chest pain) can
be caused by both tachy-
cardia (most common) and
bradycardia (rare but can hap-
pen). Therefore, assessment
of angina is appropriate.
4. 1. Encourage the client to rem- The nurse is planning care for a client with moderate
inisce about happy memories. Alzheimer's Disease (AD).
Which of the following interventions should the nurse include
Rationale: in the client's plan of care?
1. Is correct because it is pos- 1. Encourage the client to reminisce about happy memories.
, NCLEX-RN Exam Preview
Study online at https://quizlet.com/_ec21b6
sible for AD patients to retain 2. Confront the client when inappropriate or agitated behav-
long-term memories. iors occur.
2. Redirect is protocol for de- 3. Administer to the client the cholinesterase inhibitor to re-
mentia. Don't confront, they verse the course of AD.
can't learn. 4. Provide the client with information about activity choices in
3. AD is irreversible. the morning so the client can make plans for the day.
4. In the moderate AD, demen-
tia has already progressed to
where the patient needs help
with ADL's & planning daily ac-
tivities. Asking them to plan
can frustrate them & cause
distress. Structured, pleasant
activities that consider the per-
son's likes & interests are the
best.
5. 1. "Use your hands and arms The nurse is teaching a client how to ambulate using crutches.
to support your body weight." Which of the following information should the nurse include?
1. "Use your hands and arms to support your body weight."
Rationale: 2. "Wear slippers when ambulating with the crutches in your
1. Is true, but watch out if home."
it isn't 2-3 finger-widths, be- 3. "Maintain the crutches 12inch (30cm) in front of your feet
cause crutch paralysis can oc- while standing."
cur. S/S: Paresis & Paresthesias 4. "Adjust the hand grips of the crutches so that your elbows
in wrist & hands. are fully extended."
2. Is a fall risk.
3. Crutches should be 6 inches
in front & 6 inches lateral.
4. Elbow should be bent at a 30
degree angle.
, NCLEX-RN Exam Preview
Study online at https://quizlet.com/_ec21b6
6. 4. "I should expect the blurred The nurse has taught a client with multiple sclerosis (MS).
vision to resolve after I have Which of the following statements by the client would indicate
received medications for sev- a correct understanding of the teaching?
eral weeks." 1. "I will complete all of my household chores in the morning
when I am well rested."
Rationale: 2. "I have learned how to massage my bladder to help empty
MS causes nerve damage & my bladder completely."
can result in optic neuritis (Vi- 3. "I will take a hot bath in the evening to help me relax if I
sion loss, blurry vision). In have had a stressful day at work."
most cases it resolves itself in 4. "I should expect the blurred vision to resolve after I have
4-12 weeks, but medications received medications for several weeks."
(steroids can speed up the
process & resolve it quicker.
1. MS patients should not exert
themselves too much at one
time. Space out activities & al-
low time for rest.
2. Urinary retention is pri-
marily treated by medication
(bethanochol), and exercises
can aid with it but are not the
primary treatment.
3. Hot temperatures are bad
for MS and can worsen symp-
toms. Your nerves are already
messed up and extra heat can
stress the body into overdrive.
7. Highlight: The nurse in the emergency department (ED) is caring for a
"Loss of appetite" 41-year-old male client.
"Abdominal pain rated 7/10 on Highlight the findings below that would require follow-up.
the Numerical Rating Scale for (See Picture)
