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NCLEX EXAM PREVIEW QUESTIONS AND
ANSWERS WITH RATIONALE
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:
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
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- 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:
1. Beta blocker would further decrease HR
3. Valsalva maneuver/Vagal stimulation would
further decrease HR. (can be indicated for sinus
Tachy)
4. Chest compressions are for cardiac arrest
The nurse is planning care for a client with moderate
Alzheimer's disease (AD).
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Which of the following interventions should the
nurse include in the client's plan of care?
1. Encourage the client to reminisce about happy
memories.
2. Confront the client when inappropriate or
agitated behaviors occur.
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. - ANS-1. Encourage the
client to reminisce about happy memories.
Its possible for AD patients to retain long-term
memories Rationale:
2. Acknowledge feelings --> Redirect is protocol for
Dementia. Don't confront; they can't learn
3. AD is irreversible
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4. In moderate AD, dementia has already progressed
to where pt needs help with ADLs and planning
daily activities. Asking them to plan can frustrate
them and cause distress.
STRUCTURED pleasant activities that consider the
persons likes and interests are the best.
The nurse has taught a client with multiple sclerosis
(MS).
Which of the following statements by the client
would indicate a correct understanding of the
teaching?
1. "I will complete all of my household chores in
the morning when I am well rested."
2. "I have learned how to massage my bladder to
help empty my bladder completely."
3. "I will take a hot bath in the evening to help me
relax if I have had a stressful day at work."
NCLEX EXAM PREVIEW QUESTIONS AND
ANSWERS WITH RATIONALE
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:
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
,2 | Page
- 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:
1. Beta blocker would further decrease HR
3. Valsalva maneuver/Vagal stimulation would
further decrease HR. (can be indicated for sinus
Tachy)
4. Chest compressions are for cardiac arrest
The nurse is planning care for a client with moderate
Alzheimer's disease (AD).
,3 | Page
Which of the following interventions should the
nurse include in the client's plan of care?
1. Encourage the client to reminisce about happy
memories.
2. Confront the client when inappropriate or
agitated behaviors occur.
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. - ANS-1. Encourage the
client to reminisce about happy memories.
Its possible for AD patients to retain long-term
memories Rationale:
2. Acknowledge feelings --> Redirect is protocol for
Dementia. Don't confront; they can't learn
3. AD is irreversible
, 4 | Page
4. In moderate AD, dementia has already progressed
to where pt needs help with ADLs and planning
daily activities. Asking them to plan can frustrate
them and cause distress.
STRUCTURED pleasant activities that consider the
persons likes and interests are the best.
The nurse has taught a client with multiple sclerosis
(MS).
Which of the following statements by the client
would indicate a correct understanding of the
teaching?
1. "I will complete all of my household chores in
the morning when I am well rested."
2. "I have learned how to massage my bladder to
help empty my bladder completely."
3. "I will take a hot bath in the evening to help me
relax if I have had a stressful day at work."
