NCLEX EXAM PREVIEW exam with
correct answers
Thechargenursehasreceivedachange-of-
shiftreportonthefollowingclientsinlabor.Thechargenurseshouldaskastaffmembertofirstseetheclientinthe
1.firststageoflaborwhohasanoraltemperatureof99.7°F(37.6°C)
2.firststageoflaborwhosecontractionsareoccurringevery30seconds
3.secondstageoflaborwhohasrespirationsof26
4.secondstageoflaborwhosecontractionsarelastingfor60seconds-VERIFIEDANSWER✔✔-
2.firststageoflaborwhosecontractionsareoccurringevery30seconds
Contractionsshouldbenolongerthan90secsandnocloserthan2mins(120secs)
90secsistheduration,2minsisthefrequency.
Rationale:
1.Elevatedtempisnormalduringlabor
3.Increasedrespsarenormalduringlabor"pant-pant-blow""hee-hee-hoo"breathingpattern
4.Contractionsshouldn'tbelongerthan90secs,60secsisokayandnormal
Secondstage:2-3minsapart,60-90secslong,10cmdilated,strongpain
Thenurseisobservingastaffmembercaringforaclientwhohaschickenpox.
Whichofthefollowingactionsbythestaffmemberwouldrequirethenursetointervene?
1.placingtheclientinaprivateroomwithmonitorednegativeairpressure
2.placingaboxofdisposablefaceshieldsoutsidetheclient'sroom
3.placinganalcohol-basedhandrubintheclient'sroomforhandhygiene
4.placingasurgicalmaskontheclientduringtransportoutoftheclient'sroom-VERIFIEDANSWER✔✔-
2.placingaboxofdisposablefaceshieldsoutsidetheclient'sroom
disposablefacemasksarenotsuitableforairborneprecautions
Rationale:
,Varicella(chickenpox)isairborneprecaution.Private,negativepressureroom,universalprecautions(handsani
tizerinroom)andplacingsurgicalmaskonclientduringtransportareallcorrectinterventionsforVaricilla.
Thenurseiscaringforaclientwhoreportsfeelingfaintandisexperiencingthecardiacrhythmshownintheelectro
cardiogram(ECG)stripbelow.
-BRADYCARDIA(itismorethan5spacesapart,sinusrhythm)
Whichofthefollowingactionswouldbeappropriateforthenursetotake?Selectallthatapply:
1.Administertheclient'sprescribedbetablocker.
2.Preparefortranscutaneouspacing.
3.InstructtheclienttoperformtheValsalvamaneuver.
4.Beginchestcompressions.
5.Assesstheclientforangina.-VERIFIEDANSWER✔✔-2.transcutaneouspacing
-externalpacingthatstimulatestheventriclestopumpatasetrate
5.Assesstheclientforangina
-
Angina(Chestpain)canbecausedbybothtachycardia(mostcommon)andbradycardia(rarebutcanhappen).As
sessmentofanginaisappropriate
Rationale:
1.BetablockerwouldfurtherdecreaseHR
3.Valsalvamaneuver/VagalstimulationwouldfurtherdecreaseHR.(canbeindicatedforsinusTachy)
4.Chestcompressionsareforcardiacarrest
ThenurseisplanningcareforaclientwithmoderateAlzheimer'sdisease(AD).
Whichofthefollowinginterventionsshouldthenurseincludeintheclient'splanofcare?
1.Encouragetheclienttoreminisceabouthappymemories.
2.Confronttheclientwheninappropriateoragitatedbehaviorsoccur.
3.AdministertotheclientthecholinesteraseinhibitortoreversethecourseofAD.
4.Providetheclientwithinformationaboutactivitychoicesinthemorningsotheclientcanmakeplansfortheday.
-VERIFIEDANSWER✔✔-1.Encouragetheclienttoreminisceabouthappymemories.
ItspossibleforADpatientstoretainlong-termmemories
,Rationale:
2.Acknowledgefeelings-->RedirectisprotocolforDementia.Don'tconfront;theycan'tlearn
3.ADisirreversible
4.InmoderateAD,dementiahasalreadyprogressedtowhereptneedshelpwithADLsandplanningdailyactivitie
s.Askingthemtoplancanfrustratethemandcausedistress.
STRUCTUREDpleasantactivitiesthatconsiderthepersonslikesandinterestsarethebest.
Thenurseisteachingaclienthowtoambulateusingcrutches.Whichofthefollowinginformationshouldthenurs
einclude?
1."Useyourhandsandarmstosupportyourbodyweight."
2."Wearslipperswhenambulatingwiththecrutchesinyourhome."
3."Maintainthecrutches12in(30cm)infrontofyourfeetwhilestanding."
4."Adjustthehandgripsofthecrutchessothatyourelbowsarefullyextended."-VERIFIEDANSWER✔✔-
1."Useyourhandsandarmstosupportyourbodyweight."
True!Butwatchoutifitisn't2-3finger-widths,crutchparalysiscanoccur.s/
s:paresisandparesthesiasinwristsandhands
Rationales:
2.Fallrisk!
3.Shouldbe6in.infrontand6in.lateral
4.Elbowsshouldbebentat30degreeangle
Thenursehastaughtaclientwithmultiplesclerosis(MS).
Whichofthefollowingstatementsbytheclientwouldindicateacorrectunderstandingoftheteaching?
1."IwillcompleteallofmyhouseholdchoresinthemorningwhenIamwellrested."
2."Ihavelearnedhowtomassagemybladdertohelpemptymybladdercompletely."
3."IwilltakeahotbathintheeveningtohelpmerelaxifIhavehadastressfuldayatwork."
4."IshouldexpecttheblurredvisiontoresolveafterIhavereceivedmedicationsforseveralweeks."-
VERIFIEDANSWER✔✔-
4."IshouldexpecttheblurredvisiontoresolveafterIhavereceivedmedicationsforseveralweeks."
MScausesnervedamageandcanresultinopticneuritis(visionloss,burryvision).Inmostcasesitresolvesitselfin4
-12weeks,butmedication(steroids)canspeeduptheprocessandresolveitquicker
, Rationale:
1.MSpatientsshouldnotexertthemselvestoomuchatonetime.Spaceoutactivitiesandallowtimeforrest.
2.Urinaryretentionisprimarilytreatedbymedication(bethanochol),andexercisescanaidwithitbutarenotthe
primarytreatment
3.HottemperaturesarebadforMSandcanworsensymptoms.Yournervesarealreadyfckedupandextraheatca
nstressyourbodyintooverdrive
Thenursehasattendedastaffeducationprogramaboutcaringforclientswhoarereceivingpositivepressureme
chanicalventilation.Whichofthefollowingstatementsbythenursewouldindicateacorrectunderstandingofth
eteaching?
1."Clientsshouldavoidrange-of-motion(ROM)exercisesuntilweanedfromventilation."
2."Clientsmaydevelopstressulcersandgastrointestinalbleeding."
3."Clientswillbechemicallyparalyzedtoimproveoxygenation."
4."Clientswillexperiencediuresisandpolyuria."-VERIFIEDANSWER✔✔-
2."Clientsmaydevelopstressulcersandgastrointestinalbleeding."
Rationale:PostivePressureVentilationmaycausestressulcersandGIbleedingbecause
Thechargenursemusttransferafemaleclientfromthemedical-
surgicalunittothematernityunittomakeabedavailable.Itwouldbemostappropriateforthenursetotransferth
eclientwhois
1.28yearsold,hadarightmastectomyandhasaclosed-wounddrainagesystem
2.49yearsold,hasdiabetesmellitus(type2)andhasbegunreceivinginsulin
3.56yearsold,hashepatitisC(HCV)andhasbeenafebrilefor24hours
4.70yearsold,hasafracturedlefttibiaandhadanexternalfixationdeviceapplied48hoursago-
VERIFIEDANSWER✔✔-3.56yearsold,hashepatitisC(HCV)andhasbeenafebrilefor24hours
Thenursehasbeenmadeawareofthefollowingclientsituations.Thenurseshouldfirstassesstheclientwith:
1.heartfailurewhohasaproductivecoughandisanxious
2.regionalenteritis(Crohn'sdisease)whoisreportingcrampingabdominalpainanddiarrhea
3.idiopathicthrombocytopenicpurpura(ITP)whohaspetechiaeonthetrunkandisreportingheavymenses
4.chronicobstructivepulmonarydisease(COPD)whohasdyspneawithexertionandisusingaccessorymusclest
obreathe-VERIFIEDANSWER✔✔-1.heartfailurewhohasaproductivecoughandisanxious
Productivecough(pinkfrothysputum)indicatespulmonaryedema,anxietymightbecausedbydecreasedperfu
sion
Thenurseandunlicensedassistivepersonnel(UAP)arecaringforassignedclients.Whichofthefollowingtasksw
ouldbeappropriateforthenursetoassigntoUAP?
correct answers
Thechargenursehasreceivedachange-of-
shiftreportonthefollowingclientsinlabor.Thechargenurseshouldaskastaffmembertofirstseetheclientinthe
1.firststageoflaborwhohasanoraltemperatureof99.7°F(37.6°C)
2.firststageoflaborwhosecontractionsareoccurringevery30seconds
3.secondstageoflaborwhohasrespirationsof26
4.secondstageoflaborwhosecontractionsarelastingfor60seconds-VERIFIEDANSWER✔✔-
2.firststageoflaborwhosecontractionsareoccurringevery30seconds
Contractionsshouldbenolongerthan90secsandnocloserthan2mins(120secs)
90secsistheduration,2minsisthefrequency.
Rationale:
1.Elevatedtempisnormalduringlabor
3.Increasedrespsarenormalduringlabor"pant-pant-blow""hee-hee-hoo"breathingpattern
4.Contractionsshouldn'tbelongerthan90secs,60secsisokayandnormal
Secondstage:2-3minsapart,60-90secslong,10cmdilated,strongpain
Thenurseisobservingastaffmembercaringforaclientwhohaschickenpox.
Whichofthefollowingactionsbythestaffmemberwouldrequirethenursetointervene?
1.placingtheclientinaprivateroomwithmonitorednegativeairpressure
2.placingaboxofdisposablefaceshieldsoutsidetheclient'sroom
3.placinganalcohol-basedhandrubintheclient'sroomforhandhygiene
4.placingasurgicalmaskontheclientduringtransportoutoftheclient'sroom-VERIFIEDANSWER✔✔-
2.placingaboxofdisposablefaceshieldsoutsidetheclient'sroom
disposablefacemasksarenotsuitableforairborneprecautions
Rationale:
,Varicella(chickenpox)isairborneprecaution.Private,negativepressureroom,universalprecautions(handsani
tizerinroom)andplacingsurgicalmaskonclientduringtransportareallcorrectinterventionsforVaricilla.
Thenurseiscaringforaclientwhoreportsfeelingfaintandisexperiencingthecardiacrhythmshownintheelectro
cardiogram(ECG)stripbelow.
-BRADYCARDIA(itismorethan5spacesapart,sinusrhythm)
Whichofthefollowingactionswouldbeappropriateforthenursetotake?Selectallthatapply:
1.Administertheclient'sprescribedbetablocker.
2.Preparefortranscutaneouspacing.
3.InstructtheclienttoperformtheValsalvamaneuver.
4.Beginchestcompressions.
5.Assesstheclientforangina.-VERIFIEDANSWER✔✔-2.transcutaneouspacing
-externalpacingthatstimulatestheventriclestopumpatasetrate
5.Assesstheclientforangina
-
Angina(Chestpain)canbecausedbybothtachycardia(mostcommon)andbradycardia(rarebutcanhappen).As
sessmentofanginaisappropriate
Rationale:
1.BetablockerwouldfurtherdecreaseHR
3.Valsalvamaneuver/VagalstimulationwouldfurtherdecreaseHR.(canbeindicatedforsinusTachy)
4.Chestcompressionsareforcardiacarrest
ThenurseisplanningcareforaclientwithmoderateAlzheimer'sdisease(AD).
Whichofthefollowinginterventionsshouldthenurseincludeintheclient'splanofcare?
1.Encouragetheclienttoreminisceabouthappymemories.
2.Confronttheclientwheninappropriateoragitatedbehaviorsoccur.
3.AdministertotheclientthecholinesteraseinhibitortoreversethecourseofAD.
4.Providetheclientwithinformationaboutactivitychoicesinthemorningsotheclientcanmakeplansfortheday.
-VERIFIEDANSWER✔✔-1.Encouragetheclienttoreminisceabouthappymemories.
ItspossibleforADpatientstoretainlong-termmemories
,Rationale:
2.Acknowledgefeelings-->RedirectisprotocolforDementia.Don'tconfront;theycan'tlearn
3.ADisirreversible
4.InmoderateAD,dementiahasalreadyprogressedtowhereptneedshelpwithADLsandplanningdailyactivitie
s.Askingthemtoplancanfrustratethemandcausedistress.
STRUCTUREDpleasantactivitiesthatconsiderthepersonslikesandinterestsarethebest.
Thenurseisteachingaclienthowtoambulateusingcrutches.Whichofthefollowinginformationshouldthenurs
einclude?
1."Useyourhandsandarmstosupportyourbodyweight."
2."Wearslipperswhenambulatingwiththecrutchesinyourhome."
3."Maintainthecrutches12in(30cm)infrontofyourfeetwhilestanding."
4."Adjustthehandgripsofthecrutchessothatyourelbowsarefullyextended."-VERIFIEDANSWER✔✔-
1."Useyourhandsandarmstosupportyourbodyweight."
True!Butwatchoutifitisn't2-3finger-widths,crutchparalysiscanoccur.s/
s:paresisandparesthesiasinwristsandhands
Rationales:
2.Fallrisk!
3.Shouldbe6in.infrontand6in.lateral
4.Elbowsshouldbebentat30degreeangle
Thenursehastaughtaclientwithmultiplesclerosis(MS).
Whichofthefollowingstatementsbytheclientwouldindicateacorrectunderstandingoftheteaching?
1."IwillcompleteallofmyhouseholdchoresinthemorningwhenIamwellrested."
2."Ihavelearnedhowtomassagemybladdertohelpemptymybladdercompletely."
3."IwilltakeahotbathintheeveningtohelpmerelaxifIhavehadastressfuldayatwork."
4."IshouldexpecttheblurredvisiontoresolveafterIhavereceivedmedicationsforseveralweeks."-
VERIFIEDANSWER✔✔-
4."IshouldexpecttheblurredvisiontoresolveafterIhavereceivedmedicationsforseveralweeks."
MScausesnervedamageandcanresultinopticneuritis(visionloss,burryvision).Inmostcasesitresolvesitselfin4
-12weeks,butmedication(steroids)canspeeduptheprocessandresolveitquicker
, Rationale:
1.MSpatientsshouldnotexertthemselvestoomuchatonetime.Spaceoutactivitiesandallowtimeforrest.
2.Urinaryretentionisprimarilytreatedbymedication(bethanochol),andexercisescanaidwithitbutarenotthe
primarytreatment
3.HottemperaturesarebadforMSandcanworsensymptoms.Yournervesarealreadyfckedupandextraheatca
nstressyourbodyintooverdrive
Thenursehasattendedastaffeducationprogramaboutcaringforclientswhoarereceivingpositivepressureme
chanicalventilation.Whichofthefollowingstatementsbythenursewouldindicateacorrectunderstandingofth
eteaching?
1."Clientsshouldavoidrange-of-motion(ROM)exercisesuntilweanedfromventilation."
2."Clientsmaydevelopstressulcersandgastrointestinalbleeding."
3."Clientswillbechemicallyparalyzedtoimproveoxygenation."
4."Clientswillexperiencediuresisandpolyuria."-VERIFIEDANSWER✔✔-
2."Clientsmaydevelopstressulcersandgastrointestinalbleeding."
Rationale:PostivePressureVentilationmaycausestressulcersandGIbleedingbecause
Thechargenursemusttransferafemaleclientfromthemedical-
surgicalunittothematernityunittomakeabedavailable.Itwouldbemostappropriateforthenursetotransferth
eclientwhois
1.28yearsold,hadarightmastectomyandhasaclosed-wounddrainagesystem
2.49yearsold,hasdiabetesmellitus(type2)andhasbegunreceivinginsulin
3.56yearsold,hashepatitisC(HCV)andhasbeenafebrilefor24hours
4.70yearsold,hasafracturedlefttibiaandhadanexternalfixationdeviceapplied48hoursago-
VERIFIEDANSWER✔✔-3.56yearsold,hashepatitisC(HCV)andhasbeenafebrilefor24hours
Thenursehasbeenmadeawareofthefollowingclientsituations.Thenurseshouldfirstassesstheclientwith:
1.heartfailurewhohasaproductivecoughandisanxious
2.regionalenteritis(Crohn'sdisease)whoisreportingcrampingabdominalpainanddiarrhea
3.idiopathicthrombocytopenicpurpura(ITP)whohaspetechiaeonthetrunkandisreportingheavymenses
4.chronicobstructivepulmonarydisease(COPD)whohasdyspneawithexertionandisusingaccessorymusclest
obreathe-VERIFIEDANSWER✔✔-1.heartfailurewhohasaproductivecoughandisanxious
Productivecough(pinkfrothysputum)indicatespulmonaryedema,anxietymightbecausedbydecreasedperfu
sion
Thenurseandunlicensedassistivepersonnel(UAP)arecaringforassignedclients.Whichofthefollowingtasksw
ouldbeappropriateforthenursetoassigntoUAP?
