NCLEX EXAM PREVIEW Questions with
Complete Solutions (Latest 2025)
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 -
Correct Answers✅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-pant-blow" "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 - Correct Answers✅2. placing a box of disposable face shields outside
the client's room
,NCLEX EXAM PREVIEW Questions with
Complete Solutions (Latest 2025)
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. - Correct Answers✅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
,NCLEX EXAM PREVIEW Questions with
Complete Solutions (Latest 2025)
The nurse is planning care for a client with moderate Alzheimer's disease
(AD).
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. - Correct Answers✅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. 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 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."
, NCLEX EXAM PREVIEW Questions with
Complete Solutions (Latest 2025)
4. "Adjust the hand grips of the crutches so that your elbows are fully
extended." - Correct Answers✅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 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."
4. "I should expect the blurred vision to resolve after I have received
medications for several weeks." - Correct Answers✅4. "I should expect the
blurred vision to resolve after I have received medications for several
weeks."
MS causes nerve damage and can result in optic neuritis (vision loss, burry
vision). In most cases it resolves itself in 4-12 weeks, but medication
(steroids) can speed up the process and resolve it quicker
Rationale:
1. MS patients should not exert themselves too much at one time. Space out
activities and allow time for rest.
Complete Solutions (Latest 2025)
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 -
Correct Answers✅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-pant-blow" "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 - Correct Answers✅2. placing a box of disposable face shields outside
the client's room
,NCLEX EXAM PREVIEW Questions with
Complete Solutions (Latest 2025)
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. - Correct Answers✅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
,NCLEX EXAM PREVIEW Questions with
Complete Solutions (Latest 2025)
The nurse is planning care for a client with moderate Alzheimer's disease
(AD).
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. - Correct Answers✅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. 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 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."
, NCLEX EXAM PREVIEW Questions with
Complete Solutions (Latest 2025)
4. "Adjust the hand grips of the crutches so that your elbows are fully
extended." - Correct Answers✅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 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."
4. "I should expect the blurred vision to resolve after I have received
medications for several weeks." - Correct Answers✅4. "I should expect the
blurred vision to resolve after I have received medications for several
weeks."
MS causes nerve damage and can result in optic neuritis (vision loss, burry
vision). In most cases it resolves itself in 4-12 weeks, but medication
(steroids) can speed up the process and resolve it quicker
Rationale:
1. MS patients should not exert themselves too much at one time. Space out
activities and allow time for rest.
