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BSN 366 NCLEX2026 EXAM guide
questions and expert verified answers
with rationales already graded A+,
exams of nursing.
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 --//ANS//--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
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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 --//ANS//--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.
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5. Assess the client for angina. --//ANS//--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. --//ANS//--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
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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 has become aware of the following client situations. The nurse should first assess the
client
1. who had a right pneumonectomy 24 hours ago and is in the high-Fowler's position while lying
on the right side
2. with chronic obstructive pulmonary disease (COPD) who is using pursed-lip breathing and
reporting hemoptysis
3. who had a wedge resection of the left lung 24 hours ago and is sitting in the high-Fowler's
position
4. with heart failure who has a productive cough and is restless --//ANS//--4. with heart failure
who has a productive cough and is restless
Productive cough (pink frothy sputum) is indicative of pulmonary edema which is life-
threatening. T(x) would be to improve cardiac output by placing client in high fowlers, O2,
mechanical ventilation, meds
The nurse is caring for a 3-year-old client with a cerebral concussion who is being observed
overnight in the pediatric unit. Which of the following observations would be most significant
for the nurse to report to the oncoming shift?
1. The client has a blood pressure of 94/58 mm Hg and an apical pulse of 90.
BSN 366 NCLEX2026 EXAM guide
questions and expert verified answers
with rationales already graded A+,
exams of nursing.
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 --//ANS//--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
,2|Page
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 --//ANS//--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.
,3|Page
5. Assess the client for angina. --//ANS//--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. --//ANS//--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
, 4|Page
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 has become aware of the following client situations. The nurse should first assess the
client
1. who had a right pneumonectomy 24 hours ago and is in the high-Fowler's position while lying
on the right side
2. with chronic obstructive pulmonary disease (COPD) who is using pursed-lip breathing and
reporting hemoptysis
3. who had a wedge resection of the left lung 24 hours ago and is sitting in the high-Fowler's
position
4. with heart failure who has a productive cough and is restless --//ANS//--4. with heart failure
who has a productive cough and is restless
Productive cough (pink frothy sputum) is indicative of pulmonary edema which is life-
threatening. T(x) would be to improve cardiac output by placing client in high fowlers, O2,
mechanical ventilation, meds
The nurse is caring for a 3-year-old client with a cerebral concussion who is being observed
overnight in the pediatric unit. Which of the following observations would be most significant
for the nurse to report to the oncoming shift?
1. The client has a blood pressure of 94/58 mm Hg and an apical pulse of 90.
