NCLEX EXAM PREVIEW: Study Guide 2025
A parent is discussing with the nurse about the behaviors of a 4-year-old child
following the death of a grandparent.
The nurse should understand that the child may be experiencing dysfunctional
grieving if the parent reports that the child
1. conducts mock funerals with stuffed animals
2. refuses to go to sleep at night
3. continues to talk about the grandparent coming to visit
4. asks to play with the grandparent while at the cemetery - ans2. refuses to go to
sleep at night
Day 2 - 0830: Withdrawn. Remains in assigned client room. Exhibiting blunted affect
and jumbled, illogical speech. Experiencing auditory hallucinations and paranoid
delusions.
Psych Findings: Third admission this year for acute signs and symptoms of
schizophrenia; fam history of mental illness.
Orders: Attend group sessions when stabilized, Risperidone 4mg PO
Which of the following interventions should the nurse take next?
1. Encourage the client to attend 1 group session today.
2. Teach the client's family members about how to prevent a relapse.
3. Administer the prescribed dose of risperidone.
4. Prepare to discharge the client to a community treatment program. - ans3.
Administer the prescribed dose of risperidone.
I think this is the right answer because you would have to stabilize them first (with
,meds) and then once they are stable they can be encouraged to attend a group
session
The charge nurse has received a change-of-shift report on the following clients in
labor. The charge nurse should ask a staff member to first see the client in the
1. first stage of labor who has an oral temperature of 99.7° F (37.6° C)
2. first stage of labor whose 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 - ans2. first
stage of labor whose contractions are occurring every 30 seconds
Contractions should be no longer than 90 secs and no closer than 2 mins (120 secs)
90 secs is the duration, 2 mins is the frequency.
Rationale:
1. Elevated temp is normal during labor
3. Increased resps are normal during labor "pant-pant-blow" "hee-hee-hoo"
breathing pattern
4. Contractions shouldn't be longer than 90 secs, 60 secs is okay and normal
Second stage: 2-3 mins apart, 60-90 secs long, 10 cm dilated, strong pain
The charge nurse is observing the following client situations. It would require
intervention if a
1. client with hepatitis B (HBV) is eating food brought into the facility by a visitor
2. visitor is sitting on the side of the bed of a client with acute pancreatitis
,3. staff member is entering the room of a client with Haemophilus influenzae
meningitis wearing a protective gown and gloves
4. family member of a client with mycoplasma pneumonia leaves the door to the
client's room open - ans1. client with hepatitis B (HBV) is eating food brought into the
facility by a visitor
HBV is spread through contact with body fluids including saliva, so it is important to
intervene if the patient is eating and possibly sharing food with another person.
The charge nurse must transfer a client from a locked psychiatric unit to an unlocked
unit in order to make a bed available. The charge nurse should recommend for
transfer the client with
1. depression who has suddenly become more animated and involved in unit
activities
2. bipolar I disorder who is experiencing a manic episode, is disrobing, and is laughing
with other clients
3. schizophrenia who is withdrawn and requires assistance with activities of daily
living (ADL)
4. dementia who is delusional about being poisoned by staff members - ans3.
schizophrenia who is withdrawn and requires assistance with activities of daily living
(ADL)
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 - ans3. 56 years old, has hepatitis C (HCV) and has been afebrile for 24
hours
The home-health nurse is assigned to visit the following clients who live within 3
miles (4.8 km) of one another. The nurse should first visit the client with
1. breast cancer who had a mastectomy 2 days ago and has had 25 mL of drainage
from the closed-wound drainage system in the past 12 hours
2. lung cancer who received a dose of chemotherapy 2 weeks ago and has a
temperature of 101.1° F (38.4° C)
3. chronic obstructive pulmonary disease (COPD) who is reporting expectorating large
amounts of thick, yellow mucus
4. diabetes mellitus (type 1) who had a right below-the-knee amputation (BKA) and is
reporting having right toe pain - ans1. breast cancer who had a mastectomy 2 days
ago and has had 25 mL of drainage from the closed-wound drainage system in the
past 12 hours
This is really little blood in 12 hours for a surgery that was only 2 days ago. Nurse
should assess for obstruction of the drainage system which could be life-threatening
if not resolved.
The home-health nurse is teaching the parents of a 4-year-old client with impetigo.
Which of the following information should the nurse include?
1. "Put a surgical mask on your child when around siblings."
2. "Cleanse the lesions with a povidone-iodine solution daily."
3. "Apply petroleum jelly to the lesions daily."
4. "Instruct your child not to use the same towels as siblings." - ans4. "Instruct your
child not to use the same towels as siblings."
A parent is discussing with the nurse about the behaviors of a 4-year-old child
following the death of a grandparent.
The nurse should understand that the child may be experiencing dysfunctional
grieving if the parent reports that the child
1. conducts mock funerals with stuffed animals
2. refuses to go to sleep at night
3. continues to talk about the grandparent coming to visit
4. asks to play with the grandparent while at the cemetery - ans2. refuses to go to
sleep at night
Day 2 - 0830: Withdrawn. Remains in assigned client room. Exhibiting blunted affect
and jumbled, illogical speech. Experiencing auditory hallucinations and paranoid
delusions.
Psych Findings: Third admission this year for acute signs and symptoms of
schizophrenia; fam history of mental illness.
Orders: Attend group sessions when stabilized, Risperidone 4mg PO
Which of the following interventions should the nurse take next?
1. Encourage the client to attend 1 group session today.
2. Teach the client's family members about how to prevent a relapse.
3. Administer the prescribed dose of risperidone.
4. Prepare to discharge the client to a community treatment program. - ans3.
Administer the prescribed dose of risperidone.
I think this is the right answer because you would have to stabilize them first (with
,meds) and then once they are stable they can be encouraged to attend a group
session
The charge nurse has received a change-of-shift report on the following clients in
labor. The charge nurse should ask a staff member to first see the client in the
1. first stage of labor who has an oral temperature of 99.7° F (37.6° C)
2. first stage of labor whose 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 - ans2. first
stage of labor whose contractions are occurring every 30 seconds
Contractions should be no longer than 90 secs and no closer than 2 mins (120 secs)
90 secs is the duration, 2 mins is the frequency.
Rationale:
1. Elevated temp is normal during labor
3. Increased resps are normal during labor "pant-pant-blow" "hee-hee-hoo"
breathing pattern
4. Contractions shouldn't be longer than 90 secs, 60 secs is okay and normal
Second stage: 2-3 mins apart, 60-90 secs long, 10 cm dilated, strong pain
The charge nurse is observing the following client situations. It would require
intervention if a
1. client with hepatitis B (HBV) is eating food brought into the facility by a visitor
2. visitor is sitting on the side of the bed of a client with acute pancreatitis
,3. staff member is entering the room of a client with Haemophilus influenzae
meningitis wearing a protective gown and gloves
4. family member of a client with mycoplasma pneumonia leaves the door to the
client's room open - ans1. client with hepatitis B (HBV) is eating food brought into the
facility by a visitor
HBV is spread through contact with body fluids including saliva, so it is important to
intervene if the patient is eating and possibly sharing food with another person.
The charge nurse must transfer a client from a locked psychiatric unit to an unlocked
unit in order to make a bed available. The charge nurse should recommend for
transfer the client with
1. depression who has suddenly become more animated and involved in unit
activities
2. bipolar I disorder who is experiencing a manic episode, is disrobing, and is laughing
with other clients
3. schizophrenia who is withdrawn and requires assistance with activities of daily
living (ADL)
4. dementia who is delusional about being poisoned by staff members - ans3.
schizophrenia who is withdrawn and requires assistance with activities of daily living
(ADL)
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 - ans3. 56 years old, has hepatitis C (HCV) and has been afebrile for 24
hours
The home-health nurse is assigned to visit the following clients who live within 3
miles (4.8 km) of one another. The nurse should first visit the client with
1. breast cancer who had a mastectomy 2 days ago and has had 25 mL of drainage
from the closed-wound drainage system in the past 12 hours
2. lung cancer who received a dose of chemotherapy 2 weeks ago and has a
temperature of 101.1° F (38.4° C)
3. chronic obstructive pulmonary disease (COPD) who is reporting expectorating large
amounts of thick, yellow mucus
4. diabetes mellitus (type 1) who had a right below-the-knee amputation (BKA) and is
reporting having right toe pain - ans1. breast cancer who had a mastectomy 2 days
ago and has had 25 mL of drainage from the closed-wound drainage system in the
past 12 hours
This is really little blood in 12 hours for a surgery that was only 2 days ago. Nurse
should assess for obstruction of the drainage system which could be life-threatening
if not resolved.
The home-health nurse is teaching the parents of a 4-year-old client with impetigo.
Which of the following information should the nurse include?
1. "Put a surgical mask on your child when around siblings."
2. "Cleanse the lesions with a povidone-iodine solution daily."
3. "Apply petroleum jelly to the lesions daily."
4. "Instruct your child not to use the same towels as siblings." - ans4. "Instruct your
child not to use the same towels as siblings."
