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NCLEX EXAM PREVIEW | UPDATED 2025–
2026 IN-DEPTH GUIDE TO EXAM
STRUCTURE, ADAPTIVE TESTING, NGN
CASE STUDIES & CLINICAL JUDGMENT
MEASUREMENT
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
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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
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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
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.
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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.
- ANSWER-2. transcutaneous pacing
- external pacing that stimulates the ventricles to
pump at a set rate
5. Assess the client for angina
NCLEX EXAM PREVIEW | UPDATED 2025–
2026 IN-DEPTH GUIDE TO EXAM
STRUCTURE, ADAPTIVE TESTING, NGN
CASE STUDIES & CLINICAL JUDGMENT
MEASUREMENT
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
,2|Page
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
,3|Page
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
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.
, 4|Page
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.
- ANSWER-2. transcutaneous pacing
- external pacing that stimulates the ventricles to
pump at a set rate
5. Assess the client for angina
