NCLEX-RN Exam Preview
Study online at https://quizlet.com/_f5agih
1. The charge nurse has received a 2. First stage of labor whose contractions are
change-of-shift report on the following occurring every 30 seconds
clients in labor.
The charge nurse should ask a staff Rationale:
member to first see the client in the 1. Elevated temperature is normal during labor.
1. First stage of labor who has an oral 3. Increased respirations are normal during la-
temperature of 99.7F (37.6 C) bor "pant-pant-blow" "hee-hee-hoo" breath-
2. First stage of labor whose contrac- ing pattern.
tions are occurring every 30 seconds 4. Contractions shouldn't be longer than 90
3. Second stage of labor who has respi- seconds, 60 seconds is okay and normal. Sec-
rations of 26. ond stage: 2-3 minutes apart, 60-90 seconds
4. Second stage of labor whose contrac- long, 10cm dilated, strong pain.
tions are lasting for 60 seconds.
2. The nurse is caring for a client who re- 2. Prepare for transcutaneous pacing.
ports feeling faint and is experiencing & 5. Assess the client for angina.
the cardiac rhythm shown in the electro-
cardiogram (ECG) strip below. Rationale:
Which of the following actions would be 1. Beta Blockers would further decrease HR.
appropriate for the nurse to take? Select 2. External pacing stimulates the ventricles to
all that apply. pump at a set rate.
1. Administer the client's prescribed 3. Valsalva maneuver would further decrease
beta blocker. HR.
2. Prepare for transcutaneous pacing. 4. Chest compressions are for cardiac arrest.
3. Instruct the client to perform the Val- 5. Angina (Chest pain) can be caused by both
salva maneuver. tachycardia (most common) and bradycardia
4. Begin chest compressions. (rare but can happen). Therefore, assessment
5. Assess the client for angina. of angina is appropriate.
, NCLEX-RN Exam Preview
Study online at https://quizlet.com/_f5agih
3. The nurse is planning care for a 1. Encourage the client to reminisce about hap-
client with moderate Alzheimer's Dis- py memories.
ease (AD).
Which of the following interventions Rationale:
should the nurse include in the client's 1. Is correct because it is possible for AD pa-
plan of care? tients to retain long-term memories.
1. Encourage the client to reminisce 2. Redirect is protocol for dementia. Don't con-
about happy memories. front, they can't learn.
2. Confront the client when inappropri- 3. AD is irreversible.
ate or agitated behaviors occur. 4. In the moderate AD, dementia has already
3. Administer to the client the progressed to where the patient needs help
cholinesterase inhibitor to reverse the with ADL's & planning daily activities. Asking
course of AD. them to plan can frustrate them & cause dis-
4. Provide the client with information tress. Structured, pleasant activities that consid-
about activity choices in the morning so er the person's likes & interests are the best.
the client can make plans for the day.
4. The nurse is teaching a client how to 1. "Use your hands and arms to support your
ambulate using crutches. body weight."
Which of the following information
should the nurse include? Rationale:
1. "Use your hands and arms to support 1. Is true, but watch out if it isn't 2-3 fin-
your body weight." ger-widths, because crutch paralysis can occur.
2. "Wear slippers when ambulating with S/S: Paresis & Paresthesias in wrist & hands.
the crutches in your home." 2. Is a fall risk.
3. "Maintain the crutches 12inch (30cm) 3. Crutches should be 6 inches in front & 6
, NCLEX-RN Exam Preview
Study online at https://quizlet.com/_f5agih
in front of your feet while standing." inches lateral.
4. "Adjust the hand grips of the crutches 4. Elbow should be bent at a 30 degree angle.
so that your elbows are fully extended."
5. The nurse has taught a client with mul- 4. "I should expect the blurred vision to resolve
tiple sclerosis (MS). after I have received medications for several
Which of the following statements by weeks."
the client would indicate a correct un-
derstanding of the teaching? Rationale:
1. "I will complete all of my household MS causes nerve damage & can result in op-
chores in the morning when I am well tic neuritis (Vision loss, blurry vision). In most
rested." cases it resolves itself in 4-12 weeks, but med-
2. "I have learned how to massage my ications (steroids can speed up the process &
bladder to help empty my bladder com- resolve it quicker.
pletely." 1. MS patients should not exert themselves too
3. "I will take a hot bath in the evening much at one time. Space out activities & allow
to help me relax if I have had a stressful time for rest.
day at work." 2. Urinary retention is primarily treated by med-
4. "I should expect the blurred vision ication (bethanochol), and exercises can aid
to resolve after I have received medica- with it but are not the primary treatment.
tions for several weeks." 3. Hot temperatures are bad for MS and can
worsen symptoms. Your nerves are already
messed up and extra heat can stress the body
into overdrive.
6. The nurse in the emergency depart- Highlight:
ment (ED) is caring for a 41-year-old "Loss of appetite"
male client. "Abdominal pain rated 7/10 on the Numerical
Highlight the findings below that would Rating Scale for 1 week."
require follow-up. "Client states, "The abdominal pain started af-
(See Picture) ter my 7-year-old child accidentally kicked me
in the stomach."
, NCLEX-RN Exam Preview
Study online at https://quizlet.com/_f5agih
"Vital signs: T 103.4 F (39.7 C), P 92, RR 22, BP
130/86, pulse oximetry reading 98% on room
air.
Rationale:
Loss of appetite may indicate an underlying
medical condition or infection.
The intensity of abdominal pain requires eval-
uation to determine the cause.
Trauma to the abdomen can cause internal in-
juries that need to be assessed to ensure no
significant damage or complications.
7. The nurse in the emergency depart- Answer:
ment is caring for a 41-year-old male Bowel obstruction: Appetite, Bowel Pattern,
client. Gastrointestinal Symptoms.
Appendicitis: Pain level.
Nurse's Notes: Ruptured Spleen: Pain level.
11:00: Client reports nausea, loss of
appetite, vomiting, fever, and constipa-
tion for the past 2 weeks and abdom-
inal pain rated 7/10 on the Numerical
Rating Scale for 1 week. Client states
"The abdominal pain started after my
7-year-old child accidentally kicked me
in the stomach." Client plays soccer with
the child once a week. Vital signs: T
103.4 F (39.7 C), P 92, RR 22, BP 130/86,
Study online at https://quizlet.com/_f5agih
1. The charge nurse has received a 2. First stage of labor whose contractions are
change-of-shift report on the following occurring every 30 seconds
clients in labor.
The charge nurse should ask a staff Rationale:
member to first see the client in the 1. Elevated temperature is normal during labor.
1. First stage of labor who has an oral 3. Increased respirations are normal during la-
temperature of 99.7F (37.6 C) bor "pant-pant-blow" "hee-hee-hoo" breath-
2. First stage of labor whose contrac- ing pattern.
tions are occurring every 30 seconds 4. Contractions shouldn't be longer than 90
3. Second stage of labor who has respi- seconds, 60 seconds is okay and normal. Sec-
rations of 26. ond stage: 2-3 minutes apart, 60-90 seconds
4. Second stage of labor whose contrac- long, 10cm dilated, strong pain.
tions are lasting for 60 seconds.
2. The nurse is caring for a client who re- 2. Prepare for transcutaneous pacing.
ports feeling faint and is experiencing & 5. Assess the client for angina.
the cardiac rhythm shown in the electro-
cardiogram (ECG) strip below. Rationale:
Which of the following actions would be 1. Beta Blockers would further decrease HR.
appropriate for the nurse to take? Select 2. External pacing stimulates the ventricles to
all that apply. pump at a set rate.
1. Administer the client's prescribed 3. Valsalva maneuver would further decrease
beta blocker. HR.
2. Prepare for transcutaneous pacing. 4. Chest compressions are for cardiac arrest.
3. Instruct the client to perform the Val- 5. Angina (Chest pain) can be caused by both
salva maneuver. tachycardia (most common) and bradycardia
4. Begin chest compressions. (rare but can happen). Therefore, assessment
5. Assess the client for angina. of angina is appropriate.
, NCLEX-RN Exam Preview
Study online at https://quizlet.com/_f5agih
3. The nurse is planning care for a 1. Encourage the client to reminisce about hap-
client with moderate Alzheimer's Dis- py memories.
ease (AD).
Which of the following interventions Rationale:
should the nurse include in the client's 1. Is correct because it is possible for AD pa-
plan of care? tients to retain long-term memories.
1. Encourage the client to reminisce 2. Redirect is protocol for dementia. Don't con-
about happy memories. front, they can't learn.
2. Confront the client when inappropri- 3. AD is irreversible.
ate or agitated behaviors occur. 4. In the moderate AD, dementia has already
3. Administer to the client the progressed to where the patient needs help
cholinesterase inhibitor to reverse the with ADL's & planning daily activities. Asking
course of AD. them to plan can frustrate them & cause dis-
4. Provide the client with information tress. Structured, pleasant activities that consid-
about activity choices in the morning so er the person's likes & interests are the best.
the client can make plans for the day.
4. The nurse is teaching a client how to 1. "Use your hands and arms to support your
ambulate using crutches. body weight."
Which of the following information
should the nurse include? Rationale:
1. "Use your hands and arms to support 1. Is true, but watch out if it isn't 2-3 fin-
your body weight." ger-widths, because crutch paralysis can occur.
2. "Wear slippers when ambulating with S/S: Paresis & Paresthesias in wrist & hands.
the crutches in your home." 2. Is a fall risk.
3. "Maintain the crutches 12inch (30cm) 3. Crutches should be 6 inches in front & 6
, NCLEX-RN Exam Preview
Study online at https://quizlet.com/_f5agih
in front of your feet while standing." inches lateral.
4. "Adjust the hand grips of the crutches 4. Elbow should be bent at a 30 degree angle.
so that your elbows are fully extended."
5. The nurse has taught a client with mul- 4. "I should expect the blurred vision to resolve
tiple sclerosis (MS). after I have received medications for several
Which of the following statements by weeks."
the client would indicate a correct un-
derstanding of the teaching? Rationale:
1. "I will complete all of my household MS causes nerve damage & can result in op-
chores in the morning when I am well tic neuritis (Vision loss, blurry vision). In most
rested." cases it resolves itself in 4-12 weeks, but med-
2. "I have learned how to massage my ications (steroids can speed up the process &
bladder to help empty my bladder com- resolve it quicker.
pletely." 1. MS patients should not exert themselves too
3. "I will take a hot bath in the evening much at one time. Space out activities & allow
to help me relax if I have had a stressful time for rest.
day at work." 2. Urinary retention is primarily treated by med-
4. "I should expect the blurred vision ication (bethanochol), and exercises can aid
to resolve after I have received medica- with it but are not the primary treatment.
tions for several weeks." 3. Hot temperatures are bad for MS and can
worsen symptoms. Your nerves are already
messed up and extra heat can stress the body
into overdrive.
6. The nurse in the emergency depart- Highlight:
ment (ED) is caring for a 41-year-old "Loss of appetite"
male client. "Abdominal pain rated 7/10 on the Numerical
Highlight the findings below that would Rating Scale for 1 week."
require follow-up. "Client states, "The abdominal pain started af-
(See Picture) ter my 7-year-old child accidentally kicked me
in the stomach."
, NCLEX-RN Exam Preview
Study online at https://quizlet.com/_f5agih
"Vital signs: T 103.4 F (39.7 C), P 92, RR 22, BP
130/86, pulse oximetry reading 98% on room
air.
Rationale:
Loss of appetite may indicate an underlying
medical condition or infection.
The intensity of abdominal pain requires eval-
uation to determine the cause.
Trauma to the abdomen can cause internal in-
juries that need to be assessed to ensure no
significant damage or complications.
7. The nurse in the emergency depart- Answer:
ment is caring for a 41-year-old male Bowel obstruction: Appetite, Bowel Pattern,
client. Gastrointestinal Symptoms.
Appendicitis: Pain level.
Nurse's Notes: Ruptured Spleen: Pain level.
11:00: Client reports nausea, loss of
appetite, vomiting, fever, and constipa-
tion for the past 2 weeks and abdom-
inal pain rated 7/10 on the Numerical
Rating Scale for 1 week. Client states
"The abdominal pain started after my
7-year-old child accidentally kicked me
in the stomach." Client plays soccer with
the child once a week. Vital signs: T
103.4 F (39.7 C), P 92, RR 22, BP 130/86,
