NCLEX EXAM PREVIEW
The charge nurse has received a change-of-shift report on the following
The
clientscharge nurse should ask a staff member to first see the
in labor.
client
1. firstinstage
the of labor who has an oral temperature of 99.7° F
(37.6°
2. first C)
stage of labor whose contractions are occurring every
30second
3. secondsstage of labor who has
respirations
4. second stage of 26of labor whose contractions are lasting for 60 seconds
Correct
2. answers
first stage of labor whose contractions are occurring every
30 seconds should be no longer than 90 secs and no closer than 2 mins
Contractions
(120
90 secs)
secs is the duration, 2 mins is the
frequency.
Rational
e:
1. Elevated temp is normal during
labor
3. Increased resps are normal during labor "pant-pant-blow" "hee-hee-hoo"
breathing
patter
n
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
airplacing
2. pressure 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
4. hygiene
placing a surgical mask on the client during transport out of the client's
room Correct
answers 2. placing a box of disposable face shields outside the
client's room
disposable face masks are not suitable for airborne
precautions
Rational
e:
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. Correct answers 2.
-transcutaneous
external pacingpacing
that stimulates the ventricles to pump at
a set
5. rate the client for
Assess
angina
- Angina (Chest pain) can be caused by both tachycardia (most
common) and
bradycardia (rare but can happen). Assessment of angina is
appropriate
Rational
e:
1. Beta blocker would further
decrease
3. ValsalvaHRmaneuver/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
Which of (AD).
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
3. occur.
Administer to the client the cholinesterase inhibitor to reverse the
course
4. of AD.
Provide the client with information about activity choices in the morning
so the
can client
make plans for the day. Correct answers 1. Encourage the client to
reminisce about
happy
memories.
Its possible for AD patients to retain long-term
memories
Rational
e:
2. Acknowledge feelings --> Redirect is protocol for Dementia. Don't
confront; they can't
lear
n
3. AD is
irreversible
4. In moderate AD, dementia has already progressed to where pt needs help
with planning
and ADLs daily activities. Asking them to plan can frustrate them and
cause distress.pleasant activities that consider the persons likes and
STRUCTURED
interests are the
best
.
The nurse is teaching a client how to ambulate using crutches. Which of
the followingshould the nurse
information
include?
1. "Use your hands and arms to support your body
weight."
2. "Wear slippers when ambulating with the crutches in
your
3. "Maintain
home." 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."
answers Correct
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
Rationale
s:
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 taught a client with multiple
sclerosis
Which of (MS).
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
2. "I rested."
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.
"4. "I should expect the blurred vision to resolve after I have received
medications
several weeks."for Correct answers 4. "I should expect the blurred vision to I
resolve
have after medications for several
received
weeks."
MS causes nerve damage and can result in optic neuritis (vision loss, burry
vision).
most In it resolves itself in 4-12 weeks, but medication (steroids) can
cases
speed upand
process theresolve it
quicker
Rational
e:
1. MS patients should not exert themselves too much at one time. Space
out activities
and allow time for
rest.
2. Urinary retention is primarily treated by medication (bethanochol), and
exercises
aid with itcanbut are not the primary
treatment
3. Hot temperatures are bad for MS and can worsen symptoms. Your
nerves are
already fcked up and extra heat can stress your body into
overdrive
The nurse has attended a staff education program about caring for
clients who
receiving are
positive pressure mechanical ventilation. Which of the following
statements
the nurse wouldby indicate a correct understanding of the
teaching?
1. "Clients should avoid range-of-motion (ROM) exercises until
weaned
ventilatiofrom
n."
2. "Clients may develop stress ulcers and gastrointestinal
bleeding."
3. "Clients will be chemically paralyzed to improve
4. "Clients will experience diuresis and polyuria." Correct answers 2.
oxygenation."
"Clients may
develop stress ulcers and gastrointestinal
bleeding."
Rationale: Postive Pressure Ventilation may cause stress ulcers and GI
bleeding
becaus
e
The charge nurse must transfer a female client from the medical-surgical
unit to theunit to make a bed available. It would be most appropriate for
maternity
the nurse
transfer theto client
who
1. 28isyears old, had a right mastectomy and has a closed-wound
drainage
2. 49 years system
old, has diabetes mellitus (type 2) and has begun
receiving
3. 56 years insulin
old, has hepatitis C (HCV) and has been afebrile for
2470
4. hours
years old, has a fractured left tibia and had an external fixation
deviceago
hours applied 48 answers 3. 56 years old, has hepatitis C (HCV) and has
Correct
been
for 24afebrile
hours
, The nurse has been made aware of the following client situations. The nurse
should the
assess first client
with:
1. heart failure who has a productive cough and is
anxious
2. regional enteritis (Crohn's disease) who is reporting cramping
abdominal pain and
diarrhe
a
3. idiopathic thrombocytopenic purpura (ITP) who has petechiae on the
trunk and heavy
reporting is
menses
4. chronic obstructive pulmonary disease (COPD) who has dyspnea with
exertion
using and is muscles to breathe Correct answers 1. heart failure
accessory
who has a cough and is
productive
anxious
Productive cough (pink frothy sputum) indicates pulmonary edema,
anxiety by
caused might be
decreased
perfusion
The nurse and unlicensed assistive personnel (UAP) are caring for
assigned
Which clients.
of the following tasks would be appropriate for the nurse to
assign
1. to UAP?
assisting a client with atrial fibrillation to
shower
2. checking the ability of a client to swallow water after a
transesophageal
echocardiogram
(TEE)
3. observing while a client with dysphagia begins a thickened
liquid
4. diet
transporting a client with respiratory distress to the radiology
departmentCorrect
radiograph for a chest
answers 1. assisting a client with atrial fibrillation
to shower
UAP can perform
hygiene
Rational
e:
Only nurses can assess. Transporting a client in respiratory arrest is
not safe to
delegate to a
UAP
The nurse has taken a nutritional history from parents of clients. It would be
a priority
the nurse for
to follow up
with
1. the
5-month-old client whose only source of nutrition is 5 formula
feedings
2. 7-month-old
daily client who eats several crackers as
finger
3. food
9-month-old client whose typical daily diet includes 10 bottles of 2%
milk, 1juice,
apple cup ofand 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 Correct answers 3. 9-
month-old
whose client
typical daily diet includes 10 bottles of 2% milk, 1 cup of apple
juice, andof3infant
servings
cereal
Rationale: Cows milk should be introduced at 12 months old. It doesn't
provide thenutrients and baby can develop iron
necessary
deficiency
The nurse is planning a staff education program about client privacy.
Which of the
following scenarios should the nurse include as an example of a
violation of client
privacy
?
1. discussing with an unlicensed assistive personnel (UAP) that the UAP's
assigned
client will require a smaller condom
catheter
The charge nurse has received a change-of-shift report on the following
The
clientscharge nurse should ask a staff member to first see the
in labor.
client
1. firstinstage
the of labor who has an oral temperature of 99.7° F
(37.6°
2. first C)
stage of labor whose contractions are occurring every
30second
3. secondsstage of labor who has
respirations
4. second stage of 26of labor whose contractions are lasting for 60 seconds
Correct
2. answers
first stage of labor whose contractions are occurring every
30 seconds should be no longer than 90 secs and no closer than 2 mins
Contractions
(120
90 secs)
secs is the duration, 2 mins is the
frequency.
Rational
e:
1. Elevated temp is normal during
labor
3. Increased resps are normal during labor "pant-pant-blow" "hee-hee-hoo"
breathing
patter
n
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
airplacing
2. pressure 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
4. hygiene
placing a surgical mask on the client during transport out of the client's
room Correct
answers 2. placing a box of disposable face shields outside the
client's room
disposable face masks are not suitable for airborne
precautions
Rational
e:
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. Correct answers 2.
-transcutaneous
external pacingpacing
that stimulates the ventricles to pump at
a set
5. rate the client for
Assess
angina
- Angina (Chest pain) can be caused by both tachycardia (most
common) and
bradycardia (rare but can happen). Assessment of angina is
appropriate
Rational
e:
1. Beta blocker would further
decrease
3. ValsalvaHRmaneuver/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
Which of (AD).
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
3. occur.
Administer to the client the cholinesterase inhibitor to reverse the
course
4. of AD.
Provide the client with information about activity choices in the morning
so the
can client
make plans for the day. Correct answers 1. Encourage the client to
reminisce about
happy
memories.
Its possible for AD patients to retain long-term
memories
Rational
e:
2. Acknowledge feelings --> Redirect is protocol for Dementia. Don't
confront; they can't
lear
n
3. AD is
irreversible
4. In moderate AD, dementia has already progressed to where pt needs help
with planning
and ADLs daily activities. Asking them to plan can frustrate them and
cause distress.pleasant activities that consider the persons likes and
STRUCTURED
interests are the
best
.
The nurse is teaching a client how to ambulate using crutches. Which of
the followingshould the nurse
information
include?
1. "Use your hands and arms to support your body
weight."
2. "Wear slippers when ambulating with the crutches in
your
3. "Maintain
home." 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."
answers Correct
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
Rationale
s:
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 taught a client with multiple
sclerosis
Which of (MS).
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
2. "I rested."
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.
"4. "I should expect the blurred vision to resolve after I have received
medications
several weeks."for Correct answers 4. "I should expect the blurred vision to I
resolve
have after medications for several
received
weeks."
MS causes nerve damage and can result in optic neuritis (vision loss, burry
vision).
most In it resolves itself in 4-12 weeks, but medication (steroids) can
cases
speed upand
process theresolve it
quicker
Rational
e:
1. MS patients should not exert themselves too much at one time. Space
out activities
and allow time for
rest.
2. Urinary retention is primarily treated by medication (bethanochol), and
exercises
aid with itcanbut are not the primary
treatment
3. Hot temperatures are bad for MS and can worsen symptoms. Your
nerves are
already fcked up and extra heat can stress your body into
overdrive
The nurse has attended a staff education program about caring for
clients who
receiving are
positive pressure mechanical ventilation. Which of the following
statements
the nurse wouldby indicate a correct understanding of the
teaching?
1. "Clients should avoid range-of-motion (ROM) exercises until
weaned
ventilatiofrom
n."
2. "Clients may develop stress ulcers and gastrointestinal
bleeding."
3. "Clients will be chemically paralyzed to improve
4. "Clients will experience diuresis and polyuria." Correct answers 2.
oxygenation."
"Clients may
develop stress ulcers and gastrointestinal
bleeding."
Rationale: Postive Pressure Ventilation may cause stress ulcers and GI
bleeding
becaus
e
The charge nurse must transfer a female client from the medical-surgical
unit to theunit to make a bed available. It would be most appropriate for
maternity
the nurse
transfer theto client
who
1. 28isyears old, had a right mastectomy and has a closed-wound
drainage
2. 49 years system
old, has diabetes mellitus (type 2) and has begun
receiving
3. 56 years insulin
old, has hepatitis C (HCV) and has been afebrile for
2470
4. hours
years old, has a fractured left tibia and had an external fixation
deviceago
hours applied 48 answers 3. 56 years old, has hepatitis C (HCV) and has
Correct
been
for 24afebrile
hours
, The nurse has been made aware of the following client situations. The nurse
should the
assess first client
with:
1. heart failure who has a productive cough and is
anxious
2. regional enteritis (Crohn's disease) who is reporting cramping
abdominal pain and
diarrhe
a
3. idiopathic thrombocytopenic purpura (ITP) who has petechiae on the
trunk and heavy
reporting is
menses
4. chronic obstructive pulmonary disease (COPD) who has dyspnea with
exertion
using and is muscles to breathe Correct answers 1. heart failure
accessory
who has a cough and is
productive
anxious
Productive cough (pink frothy sputum) indicates pulmonary edema,
anxiety by
caused might be
decreased
perfusion
The nurse and unlicensed assistive personnel (UAP) are caring for
assigned
Which clients.
of the following tasks would be appropriate for the nurse to
assign
1. to UAP?
assisting a client with atrial fibrillation to
shower
2. checking the ability of a client to swallow water after a
transesophageal
echocardiogram
(TEE)
3. observing while a client with dysphagia begins a thickened
liquid
4. diet
transporting a client with respiratory distress to the radiology
departmentCorrect
radiograph for a chest
answers 1. assisting a client with atrial fibrillation
to shower
UAP can perform
hygiene
Rational
e:
Only nurses can assess. Transporting a client in respiratory arrest is
not safe to
delegate to a
UAP
The nurse has taken a nutritional history from parents of clients. It would be
a priority
the nurse for
to follow up
with
1. the
5-month-old client whose only source of nutrition is 5 formula
feedings
2. 7-month-old
daily client who eats several crackers as
finger
3. food
9-month-old client whose typical daily diet includes 10 bottles of 2%
milk, 1juice,
apple cup ofand 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 Correct answers 3. 9-
month-old
whose client
typical daily diet includes 10 bottles of 2% milk, 1 cup of apple
juice, andof3infant
servings
cereal
Rationale: Cows milk should be introduced at 12 months old. It doesn't
provide thenutrients and baby can develop iron
necessary
deficiency
The nurse is planning a staff education program about client privacy.
Which of the
following scenarios should the nurse include as an example of a
violation of client
privacy
?
1. discussing with an unlicensed assistive personnel (UAP) that the UAP's
assigned
client will require a smaller condom
catheter
