NCLEXvnEXAMvnPREVIEW
Thevnchargevnnursevnhasvnreceivedvnavnchange-of-
shiftvnreportvnonvnthevnfollowingvnclientsvninvnlabor.vnThevnchargevnnursevnshou
ldvnaskvnavnstaffvnmembervntovnfirstvnseevnthevnclientvninvnthe
1.vnfirstvnstagevnofvnlaborvnwhovnhasvnanvnoralvntemperaturevnofvn99.7°vnFvn(37.6
°vnC)vn
2.vnfirstvnstagevnofvnlaborvnwhosevncontractionsvnarevnoccurringvneveryvn30vnsec
ondsvn
3.vnsecondvnstagevnofvnlaborvnwhovnhasvnrespirationsvnofvn26vn
4.vnsecondvnstagevnofvnlaborvnwhosevncontractionsvnarevnlastingvnforvn60vnsecon
dsvn-vncorrectvnanswer✔ ✔
2.vnfirstvnstagevnofvnlaborvnwhosevncontractionsvnarevnoccurringvneveryvn30vns
econdsvn
Contractionsvnshouldvnbevnnovnlongervnthanvn90vnsecsvnandvnnovncloservnthanvn2v
nminsvn(120vnsecs)
90vnsecsvnisvnthevnduration,vn2vnminsvnisvnthevnfrequency.
Rationale:
1.vnElevatedvntempvnisvnnormalvnduringvnlabor
3.vnIncreasedvnrespsvnarevnnormalvnduringvnlaborvn"pant-pant-blow"vn"hee-
hee-hoo"vnbreathingvnpattern
4.vnContractionsvnshouldn'tvnbevnlongervnthanvn90vnsecs,vn60vnsecsvnisvnokayvnan
dvnnormal
,Secondvnstage:vn2-3vnminsvnapart,vn60-
90vnsecsvnlong,vn10vncmvndilated,vnstrongvnpain
Thevnnursevnisvnobservingvnavnstaffvnmembervncaringvnforvnavnclientvnwhovnhasvn
chickenpox.
vnWhichvnofvnthevnfollowingvnactionsvnbyvnthevnstaffvnmembervnwouldvnrequirev
nthevnnursevntovnintervene?
1.vnplacingvnthevnclientvninvnavnprivatevnroomvnwithvnmonitoredvnnegativevnairvn
pressure
2.vnplacingvnavnboxvnofvndisposablevnfacevnshieldsvnoutsidevnthevnclient'svnroom
3.vnplacingvnanvnalcohol-
basedvnhandvnrubvninvnthevnclient'svnroomvnforvnhandvnhygiene
4.vnplacingvnavnsurgicalvnmaskvnonvnthevnclientvnduringvntransportvnoutvnofvnthevn
client'svnroomvn-vncorrectvnanswer✔ ✔
2.vnplacingvnavnboxvnofvndisposablevnfacevnshieldsvnoutsidevnthevnclient'svnroo
m
disposablevnfacevnmasksvnarevnnotvnsuitablevnforvnairbornevnprecautions
Rationale:
Varicellavn(chickenpox)vnisvnairbornevnprecaution.vnPrivate,vnnegativevnpress
urevnroom,vnuniversalvnprecautionsvn(handvnsanitizervninvnroom)vnandvnplacing
vnsurgicalvnmaskvnon vnclientvnduringvntransportvnarevnallvncorrectvnintervention
svnforvnVaricilla.
,Thevnnursevnisvncaringvnforvnavnclientvnwhovnreportsvnfeelingvnfaintvnandvnisvnexp
eriencingvnthevncardiacvnrhythmvnshownvninvnthevnelectrocardiogramvn(ECG)vn
stripvnbelow.
-vnBRADYCARDIAvn(itvnisvnmorevnthanvn5vnspacesvnapart,vnsinusvnrhythm)
Whichvnofvnthevnfollowingvnactionsvnwouldvnbevnappropriatevnforvnthevnnursevnt
ovntake?vnSelectvnallvnthatvnapply:
1.vnAdministervnthevnclient'svnprescribedvnbetavnblocker.
2.vnPreparevnforvntranscutaneousvnpacing.
3.vnInstructvnthevnclientvntovnperformvnthevnValsalvavnmaneuver.
4.vnBeginvnchestvncompressions.
5.vnAssessvnthevnclientvnforvnangina.vn-vncorrectvnanswer✔ ✔
2.vntranscutaneousvnpacingvn
-vnexternalvnpacingvnthatvnstimulatesvnthevnventriclesvntovnpumpvnatvnavnsetvnrate
5.vnAssessvnthevnclientvnforvnanginavn
-
Anginavn(Chestvnpain)vncanvnbevncausedvnbyvnbothvntachycardiavn(mostvncom
vn
mon)vnandvnbradycardiavn(rarevnbutvncanvnhappen).vnAssessmentvnofvnanginavni
svnappropriate
Rationale:
1.vnBetavnblockervnwouldvnfurthervndecreasevnHR
3.vnValsalvavnmaneuver/VagalvnstimulationvnwouldvnfurthervndecreasevnHR.vn
(canvnbevnindicatedvnforvnsinusvnTachy)
, 4.vnChestvncompressionsvnarevnforvncardiacvnarrest
ThevnnursevnisvnplanningvncarevnforvnavnclientvnwithvnmoderatevnAlzheimer'svnd
iseasevn(AD).
Whichvnofvnthevnfollowingvninterventionsvnshouldvnthevnnursevnincludevninvnth
vn
evnclient'svnplanvnofvncare?
1.vnEncouragevnthevnclientvntovnreminiscevnaboutvnhappyvnmemories.
2.vnConfrontvnthevnclientvnwhenvninappropriatevnorvnagitatedvnbehaviorsvnoccu
r.
3.vnAdministervntovnthevnclientvnthevncholinesterasevninhibitorvntovnreversevnthe
vncoursevnofvnAD.
4.vnProvidevnthevnclientvnwithvninformationvnaboutvnactivityvnchoicesvninvnthevn
morningvnsovnthevnclientvncanvnmakevnplansvnforvnthevnday.vn-vncorrectvnanswer
✔ ✔ 1.vnEncouragevnthevnclientvntovnreminiscevnaboutvnhappyvnmemories.
ItsvnpossiblevnforvnADvnpatientsvntovnretainvnlong-termvnmemories
Rationale:
2.vnAcknowledgevnfeelingsvn--
>vnRedirectvnisvnprotocolvnforvnDementia.vnDon'tvnconfront;vntheyvncan'tvnlearn
3.vnADvnisvnirreversible
4.vnInvnmoderatevnAD,vndementiavnhasvnalreadyvnprogressedvntovnwherevnptvnne
edsvnhelpvnwithvnADLsvnandvnplanningvndailyvnactivities.vnAskingvnthemvntovnp
lanvncanvnfrustratevnthemvnandvncausevndistress.vn
Thevnchargevnnursevnhasvnreceivedvnavnchange-of-
shiftvnreportvnonvnthevnfollowingvnclientsvninvnlabor.vnThevnchargevnnursevnshou
ldvnaskvnavnstaffvnmembervntovnfirstvnseevnthevnclientvninvnthe
1.vnfirstvnstagevnofvnlaborvnwhovnhasvnanvnoralvntemperaturevnofvn99.7°vnFvn(37.6
°vnC)vn
2.vnfirstvnstagevnofvnlaborvnwhosevncontractionsvnarevnoccurringvneveryvn30vnsec
ondsvn
3.vnsecondvnstagevnofvnlaborvnwhovnhasvnrespirationsvnofvn26vn
4.vnsecondvnstagevnofvnlaborvnwhosevncontractionsvnarevnlastingvnforvn60vnsecon
dsvn-vncorrectvnanswer✔ ✔
2.vnfirstvnstagevnofvnlaborvnwhosevncontractionsvnarevnoccurringvneveryvn30vns
econdsvn
Contractionsvnshouldvnbevnnovnlongervnthanvn90vnsecsvnandvnnovncloservnthanvn2v
nminsvn(120vnsecs)
90vnsecsvnisvnthevnduration,vn2vnminsvnisvnthevnfrequency.
Rationale:
1.vnElevatedvntempvnisvnnormalvnduringvnlabor
3.vnIncreasedvnrespsvnarevnnormalvnduringvnlaborvn"pant-pant-blow"vn"hee-
hee-hoo"vnbreathingvnpattern
4.vnContractionsvnshouldn'tvnbevnlongervnthanvn90vnsecs,vn60vnsecsvnisvnokayvnan
dvnnormal
,Secondvnstage:vn2-3vnminsvnapart,vn60-
90vnsecsvnlong,vn10vncmvndilated,vnstrongvnpain
Thevnnursevnisvnobservingvnavnstaffvnmembervncaringvnforvnavnclientvnwhovnhasvn
chickenpox.
vnWhichvnofvnthevnfollowingvnactionsvnbyvnthevnstaffvnmembervnwouldvnrequirev
nthevnnursevntovnintervene?
1.vnplacingvnthevnclientvninvnavnprivatevnroomvnwithvnmonitoredvnnegativevnairvn
pressure
2.vnplacingvnavnboxvnofvndisposablevnfacevnshieldsvnoutsidevnthevnclient'svnroom
3.vnplacingvnanvnalcohol-
basedvnhandvnrubvninvnthevnclient'svnroomvnforvnhandvnhygiene
4.vnplacingvnavnsurgicalvnmaskvnonvnthevnclientvnduringvntransportvnoutvnofvnthevn
client'svnroomvn-vncorrectvnanswer✔ ✔
2.vnplacingvnavnboxvnofvndisposablevnfacevnshieldsvnoutsidevnthevnclient'svnroo
m
disposablevnfacevnmasksvnarevnnotvnsuitablevnforvnairbornevnprecautions
Rationale:
Varicellavn(chickenpox)vnisvnairbornevnprecaution.vnPrivate,vnnegativevnpress
urevnroom,vnuniversalvnprecautionsvn(handvnsanitizervninvnroom)vnandvnplacing
vnsurgicalvnmaskvnon vnclientvnduringvntransportvnarevnallvncorrectvnintervention
svnforvnVaricilla.
,Thevnnursevnisvncaringvnforvnavnclientvnwhovnreportsvnfeelingvnfaintvnandvnisvnexp
eriencingvnthevncardiacvnrhythmvnshownvninvnthevnelectrocardiogramvn(ECG)vn
stripvnbelow.
-vnBRADYCARDIAvn(itvnisvnmorevnthanvn5vnspacesvnapart,vnsinusvnrhythm)
Whichvnofvnthevnfollowingvnactionsvnwouldvnbevnappropriatevnforvnthevnnursevnt
ovntake?vnSelectvnallvnthatvnapply:
1.vnAdministervnthevnclient'svnprescribedvnbetavnblocker.
2.vnPreparevnforvntranscutaneousvnpacing.
3.vnInstructvnthevnclientvntovnperformvnthevnValsalvavnmaneuver.
4.vnBeginvnchestvncompressions.
5.vnAssessvnthevnclientvnforvnangina.vn-vncorrectvnanswer✔ ✔
2.vntranscutaneousvnpacingvn
-vnexternalvnpacingvnthatvnstimulatesvnthevnventriclesvntovnpumpvnatvnavnsetvnrate
5.vnAssessvnthevnclientvnforvnanginavn
-
Anginavn(Chestvnpain)vncanvnbevncausedvnbyvnbothvntachycardiavn(mostvncom
vn
mon)vnandvnbradycardiavn(rarevnbutvncanvnhappen).vnAssessmentvnofvnanginavni
svnappropriate
Rationale:
1.vnBetavnblockervnwouldvnfurthervndecreasevnHR
3.vnValsalvavnmaneuver/VagalvnstimulationvnwouldvnfurthervndecreasevnHR.vn
(canvnbevnindicatedvnforvnsinusvnTachy)
, 4.vnChestvncompressionsvnarevnforvncardiacvnarrest
ThevnnursevnisvnplanningvncarevnforvnavnclientvnwithvnmoderatevnAlzheimer'svnd
iseasevn(AD).
Whichvnofvnthevnfollowingvninterventionsvnshouldvnthevnnursevnincludevninvnth
vn
evnclient'svnplanvnofvncare?
1.vnEncouragevnthevnclientvntovnreminiscevnaboutvnhappyvnmemories.
2.vnConfrontvnthevnclientvnwhenvninappropriatevnorvnagitatedvnbehaviorsvnoccu
r.
3.vnAdministervntovnthevnclientvnthevncholinesterasevninhibitorvntovnreversevnthe
vncoursevnofvnAD.
4.vnProvidevnthevnclientvnwithvninformationvnaboutvnactivityvnchoicesvninvnthevn
morningvnsovnthevnclientvncanvnmakevnplansvnforvnthevnday.vn-vncorrectvnanswer
✔ ✔ 1.vnEncouragevnthevnclientvntovnreminiscevnaboutvnhappyvnmemories.
ItsvnpossiblevnforvnADvnpatientsvntovnretainvnlong-termvnmemories
Rationale:
2.vnAcknowledgevnfeelingsvn--
>vnRedirectvnisvnprotocolvnforvnDementia.vnDon'tvnconfront;vntheyvncan'tvnlearn
3.vnADvnisvnirreversible
4.vnInvnmoderatevnAD,vndementiavnhasvnalreadyvnprogressedvntovnwherevnptvnne
edsvnhelpvnwithvnADLsvnandvnplanningvndailyvnactivities.vnAskingvnthemvntovnp
lanvncanvnfrustratevnthemvnandvncausevndistress.vn
