NCLEX EXAM PREVIEW EXAM |
QUESTIONS & ANSWERS (VERIFIED) |
LATEST UPDATE | GRADED A+
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 Answer: 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 Answer: 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.
Correct Answer: 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
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 Answer: 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."
4. "Adjust the hand grips of the crutches so that your elbows are fully extended."
Correct Answer: 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:
QUESTIONS & ANSWERS (VERIFIED) |
LATEST UPDATE | GRADED A+
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 Answer: 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 Answer: 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.
Correct Answer: 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
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 Answer: 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."
4. "Adjust the hand grips of the crutches so that your elbows are fully extended."
Correct Answer: 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:
