NCLEX EXAM PREVIEW 2023 QUESTIONS AND ANSWERS WITH RATIONALE

NCLEX EXAM PREVIEW 2023 QUESTIONS AND ANSWERS WITH RATIONALE The nurse is teaching a client how to ambulate using crutches. Which of the following information should the nurse include? 1. "Use your hands and arms to support your body weight." 2. "Wear slippers when ambulating with the crutches in your home." 3. "Maintain the crutches 12 in (30 cm) in front of your feet while standing." 4. "Adjust the hand grips of the crutches so that your elbows are fully extended." - ANS-1. "Use your hands and arms to support your body weight." True! But watch out if it isn't 2-3 finger-widths, crutch paralysis can occur. s/s: paresis and paresthesias in wrists and hands Rationales: 2. Fall risk! 3. Should be 6 in. in front and 6 in. lateral 4. Elbows should be bent at 30 degree angle The nurse has taken a nutritional history from parents of clients. It would be a priority for the nurse to follow up with the 1. 5-month-old client whose only source of nutrition is 5 formula feedings daily 2. 7-month-old client who eats several crackers as finger food 3. 9-month-old client whose typical daily diet includes 10 bottles of 2% milk, 1 cup of apple juice, and 3 servings of infant cereal 4. 1-year-old client whose typical food intake includes 4 breast-feedings and 3 servings of cooked vegetables, pears, or sliced cheese - ANS-3. 9-month-old client whose typical daily diet includes 10 bottles of 2% milk, 1 cup of apple juice, and 3 servings of infant cereal Rationale: Cows milk should be introduced at 12 months old. It doesn't provide the necessary nutrients and baby can develop iron deficiency 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: 1. Elevated temp is normal during labor 3. Increased resps are normal during labor "pant-pantblow" "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 nurse is observing a staff member caring for a client who has chickenpox. 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: 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. 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 - 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