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NCLEX EXAM PREVIEW WITH REAL
EXAM STUDY TIPS
[RATIONALES PROVIDED]
NEWLY FORMATTED DOCUMENT
The charge nurse has 2. first stage of labor whose contractions are
received a change-of- occurring every 30 seconds
shift report on the Contractions should be no longer than 90 secs and
following clients in no closer than 2 mins (120 secs)
labor. The 90 secs is the duration, 2 mins is the frequency.
charge nurse should ask a
Rationale:
staff member to first see
1. Elevated temp is normal during labor
the client in the
3. Increased resps are normal during labor "pant-
1. first stage of labor who
pant-blow" "hee-hee-hoo" breathing pattern
has an oral temperature
4. Contractions shouldn't be longer than 90 secs, 60
of 99.7° F (37.6° C)
secs is okay and normal
2. first stage of labor whose
contractions are occurring Second stage: 2-3 mins apart, 60-90 secs long, 10 cm
every 30 seconds dilated, strong pain
3. second stage of labor
who has respirations
of 26
4. second stage of labor
whose contractions are
lasting for 60 seconds
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The nurse is observing a 2. placing a box of disposable face shields outside the
staff member caring for a client's room
client who has disposable face masks are not suitable for airborne
precautions
chickenpox.
Which of the following Rationale:
actions by the staff Varicella (chickenpox) is airborne precaution.
member would Private, negative pressure room, universal
require the nurse to precautions (hand sanitizer in room) and placing
intervene?
1. placing the client in a surgical mask on client during transport are all
correct interventions for Varicilla.
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
The nurse is caring for a 2. transcutaneous pacing
client who reports feeling - external pacing that stimulates the ventricles to
faint and is pump at a set rate
experiencing the cardiac 5. Assess the client for angina
- Angina (Chest pain) can be caused by both
rhythm shown in the
tachycardia (most common) and bradycardia (rare
electrocardiogram (ECG)
but can happen). Assessment of angina is
strip below.
appropriate
- BRADYCARDIA (it is more
than 5 spaces apart, sinus
Rationale:
rhythm)
1. Beta blocker would further decrease HR
Which of the following
3. Valsalva maneuver/Vagal stimulation would further
actions would be
decrease HR. (can be indicated for sinus Tachy)
appropriate for the 4. Chest compressions are for cardiac arrest
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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.
The nurse is planning care 1. Encourage the client to reminisce about happy
for a client with moderate memories. Its possible for AD patients to retain
Alzheimer's disease (AD). long-term memories
Which of the following
interventions should the Rationale:
nurse include in the 2. Acknowledge feelings --> Redirect is protocol for
client's plan of care? Dementia. Don't confront; they can't learn
1. Encourage the 3. AD is irreversible
client to reminisce 4. In moderate AD, dementia has already progressed
about happy to where pt needs help with ADLs and planning daily
memories. activities. Asking them to plan can frustrate them
2. Confront the client and cause distress.
when inappropriate STRUCTURED pleasant activities that consider the
or agitated persons likes and interests are the best.
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
, 4|Page
in the morning so the
client can make plans
for the day.
NCLEX EXAM PREVIEW WITH REAL
EXAM STUDY TIPS
[RATIONALES PROVIDED]
NEWLY FORMATTED DOCUMENT
The charge nurse has 2. first stage of labor whose contractions are
received a change-of- occurring every 30 seconds
shift report on the Contractions should be no longer than 90 secs and
following clients in no closer than 2 mins (120 secs)
labor. The 90 secs is the duration, 2 mins is the frequency.
charge nurse should ask a
Rationale:
staff member to first see
1. Elevated temp is normal during labor
the client in the
3. Increased resps are normal during labor "pant-
1. first stage of labor who
pant-blow" "hee-hee-hoo" breathing pattern
has an oral temperature
4. Contractions shouldn't be longer than 90 secs, 60
of 99.7° F (37.6° C)
secs is okay and normal
2. first stage of labor whose
contractions are occurring Second stage: 2-3 mins apart, 60-90 secs long, 10 cm
every 30 seconds dilated, strong pain
3. second stage of labor
who has respirations
of 26
4. second stage of labor
whose contractions are
lasting for 60 seconds
,2|Page
The nurse is observing a 2. placing a box of disposable face shields outside the
staff member caring for a client's room
client who has disposable face masks are not suitable for airborne
precautions
chickenpox.
Which of the following Rationale:
actions by the staff Varicella (chickenpox) is airborne precaution.
member would Private, negative pressure room, universal
require the nurse to precautions (hand sanitizer in room) and placing
intervene?
1. placing the client in a surgical mask on client during transport are all
correct interventions for Varicilla.
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
The nurse is caring for a 2. transcutaneous pacing
client who reports feeling - external pacing that stimulates the ventricles to
faint and is pump at a set rate
experiencing the cardiac 5. Assess the client for angina
- Angina (Chest pain) can be caused by both
rhythm shown in the
tachycardia (most common) and bradycardia (rare
electrocardiogram (ECG)
but can happen). Assessment of angina is
strip below.
appropriate
- BRADYCARDIA (it is more
than 5 spaces apart, sinus
Rationale:
rhythm)
1. Beta blocker would further decrease HR
Which of the following
3. Valsalva maneuver/Vagal stimulation would further
actions would be
decrease HR. (can be indicated for sinus Tachy)
appropriate for the 4. Chest compressions are for cardiac arrest
,3|Page
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.
The nurse is planning care 1. Encourage the client to reminisce about happy
for a client with moderate memories. Its possible for AD patients to retain
Alzheimer's disease (AD). long-term memories
Which of the following
interventions should the Rationale:
nurse include in the 2. Acknowledge feelings --> Redirect is protocol for
client's plan of care? Dementia. Don't confront; they can't learn
1. Encourage the 3. AD is irreversible
client to reminisce 4. In moderate AD, dementia has already progressed
about happy to where pt needs help with ADLs and planning daily
memories. activities. Asking them to plan can frustrate them
2. Confront the client and cause distress.
when inappropriate STRUCTURED pleasant activities that consider the
or agitated persons likes and interests are the best.
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
, 4|Page
in the morning so the
client can make plans
for the day.
