NCLEX EXAM PREVIEW
Nursing Practice & Patient Care
1. Prioritization in Labor
Question: 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
Answer: 2. first stage of labor whose contractions are occurring every 30 seconds
Rationale:
During the first stage of labor, contractions should ideally be no longer than 90 seconds and have
a frequency of no closer than 2 minutes (120 seconds).
Contractions occurring every 30 seconds are too frequent and could compromise fetal
oxygenation.
Incorrect Rationale:
1. An elevated temperature up to 100.4° F (38° C) can be normal during labor.
2. Increased respirations can be a normal finding during the second stage of labor, often associated
with the "pant-pant-blow" or "hee-hee-hoo" breathing patterns.
3. Contractions lasting 60 seconds are within the expected range for the second stage of labor
(typically 60-90 seconds with a frequency of 2-3 minutes).
2. Chickenpox Precautions
Question: 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
,Answer: 2. placing a box of disposable face shields outside the client's room
Rationale:
Varicella (chickenpox) requires airborne precautions.
Appropriate measures include a private, negative pressure room, universal precautions
(including hand hygiene with alcohol-based rub), and placing a surgical mask on the client
during transport.
Disposable face shields are not a substitute for the respiratory protection required for airborne
precautions.
3. Bradycardia Management
Question: The nurse is caring for a client who reports feeling faint and is experiencing the cardiac
rhythm shown in the electrocardiogram (ECG) strip below (indicating bradycardia - more than 5 large
boxes between R waves, 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.
Answer: 2. Prepare for transcutaneous pacing. and 5. Assess the client for angina.
Rationale:
The client is symptomatic (fainting) with bradycardia, indicating potential hemodynamic
instability. Transcutaneous pacing is an appropriate intervention to increase the heart rate.
Angina (chest pain) can be associated with both tachycardia (more common) and bradycardia
(less common) due to decreased cardiac output and potential myocardial ischemia. Assessing for
angina is therefore appropriate.
Incorrect Rationale:
1. Beta blockers decrease heart rate and would exacerbate the client's bradycardia.
2. The Valsalva maneuver stimulates the vagal nerve and can further decrease heart rate; it is
contraindicated in symptomatic bradycardia. It can be used for sinus tachycardia.
3. Chest compressions are indicated for cardiac arrest (absence of pulse), not symptomatic
bradycardia with a present pulse.
4. Alzheimer's Disease Care (Moderate Stage)
,Question: 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.
Answer: 1. Encourage the client to reminisce about happy memories.
Rationale:
Clients with moderate AD may retain long-term memories. Reminiscing can provide comfort
and a sense of connection.
Incorrect Rationale:
2. The recommended approach for managing inappropriate or agitated behaviors in dementia is to
acknowledge feelings and then redirect the client. Confrontation can increase agitation.
3. Alzheimer's disease is progressive and irreversible. Cholinesterase inhibitors may help
manage symptoms but do not reverse the disease process.
4. In moderate AD, cognitive decline has progressed to the point where the client needs assistance
with Activities of Daily Living (ADLs) and planning. Offering too many choices can be
overwhelming and cause distress. Providing structured, pleasant activities based on the client's
interests is more effective.
5. Crutch Walking Instructions
Question: 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."
Answer: 1. "Use your hands and arms to support your body weight."
Rationale:
Weight should be borne by the hands and arms to prevent pressure on the axillae, which can
lead to nerve damage (crutch paralysis). Monitor for signs and symptoms like paresis and
paresthesias in the wrists and hands.
, Incorrect Rationale:
2. Slippers increase the risk of falls. Clients should wear supportive, non-skid footwear.
3. Crutches should be positioned approximately 6 inches in front and 6 inches lateral to the feet
for a stable base of support.
4. The elbows should be bent at a 30-degree angle when the client is holding the hand grips.
6. Multiple Sclerosis (MS) Teaching
Question: 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."
Answer: 4. "I should expect the blurred vision to resolve after I have received medications for
several weeks."
Rationale:
MS can cause optic neuritis, leading to vision loss or blurred vision. In many cases, this resolves
spontaneously within 4-12 weeks. Corticosteroids may be used to expedite recovery.
Incorrect Rationale:
1. Clients with MS should pace activities and avoid overexertion. They should space out chores
and allow for rest periods.
2. While exercises can aid in bladder management, urinary retention in MS is primarily treated
with medications like bethanecol.
3. Heat exacerbates MS symptoms. Hot baths should be avoided.
7. Positive Pressure Mechanical Ventilation
Question: The nurse has attended a staff education program about caring for clients who are receiving
positive pressure mechanical ventilation. Which of the following statements by the nurse would
indicate a correct understanding of the teaching?
1. "Clients should avoid range-of-motion (ROM) exercises until weaned from ventilation."
2. "Clients may develop stress ulcers and gastrointestinal bleeding."
3. "Clients will be chemically paralyzed to improve oxygenation."
4. "Clients will experience diuresis and polyuria."
Nursing Practice & Patient Care
1. Prioritization in Labor
Question: 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
Answer: 2. first stage of labor whose contractions are occurring every 30 seconds
Rationale:
During the first stage of labor, contractions should ideally be no longer than 90 seconds and have
a frequency of no closer than 2 minutes (120 seconds).
Contractions occurring every 30 seconds are too frequent and could compromise fetal
oxygenation.
Incorrect Rationale:
1. An elevated temperature up to 100.4° F (38° C) can be normal during labor.
2. Increased respirations can be a normal finding during the second stage of labor, often associated
with the "pant-pant-blow" or "hee-hee-hoo" breathing patterns.
3. Contractions lasting 60 seconds are within the expected range for the second stage of labor
(typically 60-90 seconds with a frequency of 2-3 minutes).
2. Chickenpox Precautions
Question: 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
,Answer: 2. placing a box of disposable face shields outside the client's room
Rationale:
Varicella (chickenpox) requires airborne precautions.
Appropriate measures include a private, negative pressure room, universal precautions
(including hand hygiene with alcohol-based rub), and placing a surgical mask on the client
during transport.
Disposable face shields are not a substitute for the respiratory protection required for airborne
precautions.
3. Bradycardia Management
Question: The nurse is caring for a client who reports feeling faint and is experiencing the cardiac
rhythm shown in the electrocardiogram (ECG) strip below (indicating bradycardia - more than 5 large
boxes between R waves, 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.
Answer: 2. Prepare for transcutaneous pacing. and 5. Assess the client for angina.
Rationale:
The client is symptomatic (fainting) with bradycardia, indicating potential hemodynamic
instability. Transcutaneous pacing is an appropriate intervention to increase the heart rate.
Angina (chest pain) can be associated with both tachycardia (more common) and bradycardia
(less common) due to decreased cardiac output and potential myocardial ischemia. Assessing for
angina is therefore appropriate.
Incorrect Rationale:
1. Beta blockers decrease heart rate and would exacerbate the client's bradycardia.
2. The Valsalva maneuver stimulates the vagal nerve and can further decrease heart rate; it is
contraindicated in symptomatic bradycardia. It can be used for sinus tachycardia.
3. Chest compressions are indicated for cardiac arrest (absence of pulse), not symptomatic
bradycardia with a present pulse.
4. Alzheimer's Disease Care (Moderate Stage)
,Question: 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.
Answer: 1. Encourage the client to reminisce about happy memories.
Rationale:
Clients with moderate AD may retain long-term memories. Reminiscing can provide comfort
and a sense of connection.
Incorrect Rationale:
2. The recommended approach for managing inappropriate or agitated behaviors in dementia is to
acknowledge feelings and then redirect the client. Confrontation can increase agitation.
3. Alzheimer's disease is progressive and irreversible. Cholinesterase inhibitors may help
manage symptoms but do not reverse the disease process.
4. In moderate AD, cognitive decline has progressed to the point where the client needs assistance
with Activities of Daily Living (ADLs) and planning. Offering too many choices can be
overwhelming and cause distress. Providing structured, pleasant activities based on the client's
interests is more effective.
5. Crutch Walking Instructions
Question: 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."
Answer: 1. "Use your hands and arms to support your body weight."
Rationale:
Weight should be borne by the hands and arms to prevent pressure on the axillae, which can
lead to nerve damage (crutch paralysis). Monitor for signs and symptoms like paresis and
paresthesias in the wrists and hands.
, Incorrect Rationale:
2. Slippers increase the risk of falls. Clients should wear supportive, non-skid footwear.
3. Crutches should be positioned approximately 6 inches in front and 6 inches lateral to the feet
for a stable base of support.
4. The elbows should be bent at a 30-degree angle when the client is holding the hand grips.
6. Multiple Sclerosis (MS) Teaching
Question: 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."
Answer: 4. "I should expect the blurred vision to resolve after I have received medications for
several weeks."
Rationale:
MS can cause optic neuritis, leading to vision loss or blurred vision. In many cases, this resolves
spontaneously within 4-12 weeks. Corticosteroids may be used to expedite recovery.
Incorrect Rationale:
1. Clients with MS should pace activities and avoid overexertion. They should space out chores
and allow for rest periods.
2. While exercises can aid in bladder management, urinary retention in MS is primarily treated
with medications like bethanecol.
3. Heat exacerbates MS symptoms. Hot baths should be avoided.
7. Positive Pressure Mechanical Ventilation
Question: The nurse has attended a staff education program about caring for clients who are receiving
positive pressure mechanical ventilation. Which of the following statements by the nurse would
indicate a correct understanding of the teaching?
1. "Clients should avoid range-of-motion (ROM) exercises until weaned from ventilation."
2. "Clients may develop stress ulcers and gastrointestinal bleeding."
3. "Clients will be chemically paralyzed to improve oxygenation."
4. "Clients will experience diuresis and polyuria."
