NCLEX EXAM PREVIEW GRADED A+ 2025-2026.
,1. 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 ANS>> 2.
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 ANS>>
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 ANS>> 2-3 mins apart, 60-90 secs long, 10 cm dilated, strong
pain
2. The nurse is observing a staff member caring for a client who has chicken-
,pox.
Which of the following actions by the staff member would require the nurse
to intervene?
1. placing the client in a private room with monitored negative air pressure
2. placing a box of disposable face shields outside the client's room
3. placing an alcohol-based hand rub in the client's room for hand hygiene
4. placing a surgical mask on the client during transport out of the client's
room ANS>> 2. placing a box of disposable face shields outside the client's room
disposable face masks are not suitable for airborne precautions
Rationale ANS>>
Varicella (chickenpox) is airborne precaution. Private, negative pressure room, universal precautions (hand sanitizer in
room) and placing surgical mask on client during transport are all correct interventions for Varicilla.
3. The nurse is caring for a client who reports feeling faint and is experiencing
the cardiac rhythm shown in the electrocardiogram (ECG) strip below.
, - BRADYCARDIA (it is more than 5 spaces apart, sinus rhythm)
Which of the following actions would be appropriate for the nurse to take?
Select all that apply ANS>>
1. Administer the client's prescribed beta blocker.
2. Prepare for transcutaneous pacing.
3. Instruct the client to perform the Valsalva maneuver.
4. Begin chest compressions.
5. Assess the client for angina. ANS>> 2. transcutaneous pacing
- external pacing that stimulates the ventricles to pump at a set rate
5. Assess the client for angina
- Angina (Chest pain) can be caused by both tachycardia (most common) and bradycardia (rare but can happen).
Assessment of angina is appropriate
Rationale ANS>>
1. Beta blocker would further decrease HR
3. Valsalva maneuver/Vagal stimulation would further decrease HR. (can be indicated for sinus Tachy)
,1. 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 ANS>> 2.
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 ANS>>
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 ANS>> 2-3 mins apart, 60-90 secs long, 10 cm dilated, strong
pain
2. The nurse is observing a staff member caring for a client who has chicken-
,pox.
Which of the following actions by the staff member would require the nurse
to intervene?
1. placing the client in a private room with monitored negative air pressure
2. placing a box of disposable face shields outside the client's room
3. placing an alcohol-based hand rub in the client's room for hand hygiene
4. placing a surgical mask on the client during transport out of the client's
room ANS>> 2. placing a box of disposable face shields outside the client's room
disposable face masks are not suitable for airborne precautions
Rationale ANS>>
Varicella (chickenpox) is airborne precaution. Private, negative pressure room, universal precautions (hand sanitizer in
room) and placing surgical mask on client during transport are all correct interventions for Varicilla.
3. The nurse is caring for a client who reports feeling faint and is experiencing
the cardiac rhythm shown in the electrocardiogram (ECG) strip below.
, - BRADYCARDIA (it is more than 5 spaces apart, sinus rhythm)
Which of the following actions would be appropriate for the nurse to take?
Select all that apply ANS>>
1. Administer the client's prescribed beta blocker.
2. Prepare for transcutaneous pacing.
3. Instruct the client to perform the Valsalva maneuver.
4. Begin chest compressions.
5. Assess the client for angina. ANS>> 2. transcutaneous pacing
- external pacing that stimulates the ventricles to pump at a set rate
5. Assess the client for angina
- Angina (Chest pain) can be caused by both tachycardia (most common) and bradycardia (rare but can happen).
Assessment of angina is appropriate
Rationale ANS>>
1. Beta blocker would further decrease HR
3. Valsalva maneuver/Vagal stimulation would further decrease HR. (can be indicated for sinus Tachy)
