NCLEX-RN Exam Preview
The charge nurse has received a 2. First stage of labor whose contractions are occurring every 30
change-of-shift report on the 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 "pant-pant-
1. First stage of labor who has an blow" "hee-hee-hoo" breathing pattern.
oral temperature of 99.7F (37.6 4. Contractions shouldn't be longer than 90 seconds, 60 seconds
C) is okay and normal. Second stage: 2-3 minutes apart, 60-90
2. First stage of labor whose 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.
The nurse is caring for a client 2. Prepare for transcutaneous pacing.
who reports feeling faint and is & 5. Assess the client for angina.
experiencing the cardiac rhythm
shown in the electrocardiogram Rationale:
(ECG) strip below. 1. Beta Blockers would further
Which of the following actions decrease HR.
would be appropriate for the 2. External pacing stimulates the
nurse to take? Select all that ventricles to pump at a set rate.
apply. 3. Valsalva maneuver would further
1. Administer the client's decrease HR.
prescribed beta blocker. 4. Chest compressions are for cardiac
2. Prepare for transcutaneous arrest.
pacing. 5. Angina (Chest pain) can be caused
3. Instruct the client to perform by both tachycardia (most common)
the Valsalva maneuver. and bradycardia (rare but can happen).
4. Begin chest compressions. Therefore, assessment of angina is
5. Assess the client for angina. appropriate.
1 …..NCLEX-RN EXAM PREVIEW_________________
,The nurse is planning care for a 1. Encourage the client to reminisce about happy memories.
client with moderate Alzheimer's
Disease (AD). Rationale:
Which of the following 1. Is correct because it is possible for AD patients to retain long-
interventions should the nurse term memories.
include in the client's plan of 2. Redirect is protocol for dementia. Don't confront, they can't
care? learn.
1. Encourage the client to 3. AD is irreversible.
reminisce about happy 4. In the moderate AD, dementia has already progressed to
memories. where the patient needs help with ADL's & planning daily
2. Confront the client when activities. Asking them to plan can frustrate them & cause
inappropriate or agitated distress. Structured, pleasant activities that consider the person's
behaviors occur. likes & interests are the best.
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.
The nurse is teaching a client 1. "Use your hands and arms to support your body weight."
how to ambulate using crutches.
Which of the following Rationale:
information should the nurse 1. Is true, but watch out if it isn't 2-3 finger-widths, because crutch
include? paralysis can occur. S/S: Paresis & Paresthesias in wrist & hands.
1. "Use your hands and arms to 2. Is a fall risk.
support your body weight." 3. Crutches should be 6 inches in front & 6 inches lateral.
2. "Wear slippers when 4. Elbow should be bent at a 30 degree angle.
ambulating with the crutches in
your home."
3. "Maintain the crutches 12inch
(30cm) in front of your feet while
standing."
4. "Adjust the hand grips of the
crutches so that your elbows are
fully extended."
2 …..NCLEX-RN EXAM PREVIEW_________________
,The nurse has taught a client 4. "I should expect the blurred vision to resolve after I have
with multiple sclerosis (MS). received medications for several weeks."
Which of the following
statements by the client would Rationale:
indicate a correct understanding MS causes nerve damage & can result in optic neuritis (Vision
of the teaching? loss, blurry vision). In most cases it resolves itself in 4-12 weeks,
1. "I will complete all of my but medications (steroids can speed up the process & resolve it
household chores in the quicker.
morning when I am well rested." 1. MS patients should not exert themselves too much at one time.
2. "I have learned how to Space out activities & allow time for rest.
massage my bladder to help 2. Urinary retention is primarily treated by medication
empty my bladder completely." (bethanochol), and exercises can aid with it but are not the
3. "I will take a hot bath in the primary treatment.
evening to help me relax if I 3. Hot temperatures are bad for MS and can worsen symptoms.
have had a stressful day at Your nerves are already messed up and extra heat can stress the
work." body into overdrive.
4. "I should expect the blurred
vision to resolve after I have
received medications for several
weeks."
Highlight:
"Loss of appetite"
"Abdominal pain rated 7/10 on the
Numerical Rating Scale for 1 week."
"Client states, "The abdominal pain
started after my 7-year-old child
accidentally kicked me in the
stomach."
"Vital signs: T 103.4 F (39.7 C), P 92, RR
The nurse in the emergency
22, BP 130/86, pulse oximetry reading
department (ED) is caring for a
98% on room air.
41-year-old male client.
Highlight the findings below that
Rationale:
would require follow-up.
Loss of appetite may indicate an
(See Picture)
underlying medical condition or
infection.
The intensity of abdominal pain
requires evaluation to determine the
cause.
Trauma to the abdomen can cause
internal injuries that need to be
assessed to ensure no significant
damage or complications.
3 …..NCLEX-RN EXAM PREVIEW_________________
, The nurse in the emergency Answer:
department is caring for a 41- Bowel obstruction: Appetite, Bowel
year-old male client. Pattern, Gastrointestinal Symptoms.
Appendicitis: Pain level.
Nurse's Notes: Ruptured Spleen: Pain level.
11:00: Client reports nausea, loss
of appetite, 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 abdominal pain started
after my 7-year-old child
accidentally kicked me in the
stomach." Client plays soccer
with the child once a week. Vital
signs: T 103.4 F (39.7 C), P 92, RR
22, BP 130/86, pulse oximetry
reading 98% on room air. No
significant past medical or
surgical history. Body mass index
(BMI) 32. Drinks alcohol only
during social occasions, usually
3 beverages. Smokes cigarettes
during social occasions.
For each assessment finding
below, click to specify if the
finding is consistent with the
disease process of bowel
obstruction, appendicitis, or
ruptured spleen. Each finding
may support more than 1 disease
process.
4 …..NCLEX-RN EXAM PREVIEW_________________
The charge nurse has received a 2. First stage of labor whose contractions are occurring every 30
change-of-shift report on the 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 "pant-pant-
1. First stage of labor who has an blow" "hee-hee-hoo" breathing pattern.
oral temperature of 99.7F (37.6 4. Contractions shouldn't be longer than 90 seconds, 60 seconds
C) is okay and normal. Second stage: 2-3 minutes apart, 60-90
2. First stage of labor whose 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.
The nurse is caring for a client 2. Prepare for transcutaneous pacing.
who reports feeling faint and is & 5. Assess the client for angina.
experiencing the cardiac rhythm
shown in the electrocardiogram Rationale:
(ECG) strip below. 1. Beta Blockers would further
Which of the following actions decrease HR.
would be appropriate for the 2. External pacing stimulates the
nurse to take? Select all that ventricles to pump at a set rate.
apply. 3. Valsalva maneuver would further
1. Administer the client's decrease HR.
prescribed beta blocker. 4. Chest compressions are for cardiac
2. Prepare for transcutaneous arrest.
pacing. 5. Angina (Chest pain) can be caused
3. Instruct the client to perform by both tachycardia (most common)
the Valsalva maneuver. and bradycardia (rare but can happen).
4. Begin chest compressions. Therefore, assessment of angina is
5. Assess the client for angina. appropriate.
1 …..NCLEX-RN EXAM PREVIEW_________________
,The nurse is planning care for a 1. Encourage the client to reminisce about happy memories.
client with moderate Alzheimer's
Disease (AD). Rationale:
Which of the following 1. Is correct because it is possible for AD patients to retain long-
interventions should the nurse term memories.
include in the client's plan of 2. Redirect is protocol for dementia. Don't confront, they can't
care? learn.
1. Encourage the client to 3. AD is irreversible.
reminisce about happy 4. In the moderate AD, dementia has already progressed to
memories. where the patient needs help with ADL's & planning daily
2. Confront the client when activities. Asking them to plan can frustrate them & cause
inappropriate or agitated distress. Structured, pleasant activities that consider the person's
behaviors occur. likes & interests are the best.
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.
The nurse is teaching a client 1. "Use your hands and arms to support your body weight."
how to ambulate using crutches.
Which of the following Rationale:
information should the nurse 1. Is true, but watch out if it isn't 2-3 finger-widths, because crutch
include? paralysis can occur. S/S: Paresis & Paresthesias in wrist & hands.
1. "Use your hands and arms to 2. Is a fall risk.
support your body weight." 3. Crutches should be 6 inches in front & 6 inches lateral.
2. "Wear slippers when 4. Elbow should be bent at a 30 degree angle.
ambulating with the crutches in
your home."
3. "Maintain the crutches 12inch
(30cm) in front of your feet while
standing."
4. "Adjust the hand grips of the
crutches so that your elbows are
fully extended."
2 …..NCLEX-RN EXAM PREVIEW_________________
,The nurse has taught a client 4. "I should expect the blurred vision to resolve after I have
with multiple sclerosis (MS). received medications for several weeks."
Which of the following
statements by the client would Rationale:
indicate a correct understanding MS causes nerve damage & can result in optic neuritis (Vision
of the teaching? loss, blurry vision). In most cases it resolves itself in 4-12 weeks,
1. "I will complete all of my but medications (steroids can speed up the process & resolve it
household chores in the quicker.
morning when I am well rested." 1. MS patients should not exert themselves too much at one time.
2. "I have learned how to Space out activities & allow time for rest.
massage my bladder to help 2. Urinary retention is primarily treated by medication
empty my bladder completely." (bethanochol), and exercises can aid with it but are not the
3. "I will take a hot bath in the primary treatment.
evening to help me relax if I 3. Hot temperatures are bad for MS and can worsen symptoms.
have had a stressful day at Your nerves are already messed up and extra heat can stress the
work." body into overdrive.
4. "I should expect the blurred
vision to resolve after I have
received medications for several
weeks."
Highlight:
"Loss of appetite"
"Abdominal pain rated 7/10 on the
Numerical Rating Scale for 1 week."
"Client states, "The abdominal pain
started after my 7-year-old child
accidentally kicked me in the
stomach."
"Vital signs: T 103.4 F (39.7 C), P 92, RR
The nurse in the emergency
22, BP 130/86, pulse oximetry reading
department (ED) is caring for a
98% on room air.
41-year-old male client.
Highlight the findings below that
Rationale:
would require follow-up.
Loss of appetite may indicate an
(See Picture)
underlying medical condition or
infection.
The intensity of abdominal pain
requires evaluation to determine the
cause.
Trauma to the abdomen can cause
internal injuries that need to be
assessed to ensure no significant
damage or complications.
3 …..NCLEX-RN EXAM PREVIEW_________________
, The nurse in the emergency Answer:
department is caring for a 41- Bowel obstruction: Appetite, Bowel
year-old male client. Pattern, Gastrointestinal Symptoms.
Appendicitis: Pain level.
Nurse's Notes: Ruptured Spleen: Pain level.
11:00: Client reports nausea, loss
of appetite, 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 abdominal pain started
after my 7-year-old child
accidentally kicked me in the
stomach." Client plays soccer
with the child once a week. Vital
signs: T 103.4 F (39.7 C), P 92, RR
22, BP 130/86, pulse oximetry
reading 98% on room air. No
significant past medical or
surgical history. Body mass index
(BMI) 32. Drinks alcohol only
during social occasions, usually
3 beverages. Smokes cigarettes
during social occasions.
For each assessment finding
below, click to specify if the
finding is consistent with the
disease process of bowel
obstruction, appendicitis, or
ruptured spleen. Each finding
may support more than 1 disease
process.
4 …..NCLEX-RN EXAM PREVIEW_________________
