NCLEX EXAM PREVIEW WITH QUESTIONS AND CORRECT ANSWERS
WITH SOLUTIONS
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 evaluating a staff member's care of a client with active pulmonary tuberculosis
(TB). Which of the following actions by the staff member would indicate to the nurse an
understanding of the principles of infection control for tuberculosis isolation?
1. instructing visitors to wash their hands before entering the client's room
2. putting on a mask, gown, and gloves before entering the client's room
3. placing tissues and a trash receptacle within the client's reach
4. asking the client to put on a clean mask each time someone enters the room - CORRECT
ANSWER-3. placing tissues and a trash receptacle within the client's reach
Important to not leave tissues laying around and to put them in a leak proof bag in the trash.
The nurse in the pediatric unit is preparing to admit a client with rubeola (measles). The nurse
should assign the client to a
1. private room at the end of the hallway
2. private room with monitored negative air pressure
3. room with a client who has chickenpox
4. room with a client who has atopic dermatitis (eczema) - CORRECT ANSWER-2. private room
with monitored negative air pressure
Measles is airborne (MTV) and requires a private room with negative air pressure
The charge nurse is observing the following client situations. It would require intervention if a
1. client with hepatitis B (HBV) is eating food brought into the facility by a visitor
,2. visitor is sitting on the side of the bed of a client with acute pancreatitis
3. staff member is entering the room of a client with Haemophilus influenzae meningitis
wearing a protective gown and gloves
4. family member of a client with mycoplasma pneumonia leaves the door to the client's room
open - CORRECT ANSWER-1. client with hepatitis B (HBV) is eating food brought into the facility
by a visitor
HBV is spread through contact with body fluids including saliva, so it is important to intervene if
the patient is eating and possibly sharing food with another person.
The nurse is reviewing the orders of a client who has acute kidney injury. Which of the following
orders should the nurse clarify?
1. computed tomography (CT) scan of the abdomen with intravenous contrast media
2. urine specimen for urinalysis
3. blood specimen for arterial blood gas (ABG)
4. referral to registered dietitian for parenteral nutrition evaluation - CORRECT ANSWER-1.
computed tomography (CT) scan of the abdomen with intravenous contrast media
CTs use iodinated contrast which is harmful to the kidneys and therefore contraindicated in a
client with AKI
The nurse is planning a staff education program about caring for clients with restraints. Which of
the following information should the nurse include?
1. "Restraints should be removed once during a shift to perform passive range-of-motion (ROM)
exercises for the client."
2. "Restraints should be secured to the side rails of the client's bed for quick release."
3. "Restraints require an order from the primary health care provider."
4. "Restraints may be used p.r.n. for clients who are confused." - CORRECT ANSWER-3.
"Restraints require an order from the primary health care provider."
Rationale:
, 1. Restraints are removed every 2 HOURS for ROM exercises, toileting, and fluids. Assess every
15 mins for the first hour and then every 30 minutes
2. Restraints should be secured to the bed, not side rails
4. Restraints are never PRN
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?
WITH SOLUTIONS
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 evaluating a staff member's care of a client with active pulmonary tuberculosis
(TB). Which of the following actions by the staff member would indicate to the nurse an
understanding of the principles of infection control for tuberculosis isolation?
1. instructing visitors to wash their hands before entering the client's room
2. putting on a mask, gown, and gloves before entering the client's room
3. placing tissues and a trash receptacle within the client's reach
4. asking the client to put on a clean mask each time someone enters the room - CORRECT
ANSWER-3. placing tissues and a trash receptacle within the client's reach
Important to not leave tissues laying around and to put them in a leak proof bag in the trash.
The nurse in the pediatric unit is preparing to admit a client with rubeola (measles). The nurse
should assign the client to a
1. private room at the end of the hallway
2. private room with monitored negative air pressure
3. room with a client who has chickenpox
4. room with a client who has atopic dermatitis (eczema) - CORRECT ANSWER-2. private room
with monitored negative air pressure
Measles is airborne (MTV) and requires a private room with negative air pressure
The charge nurse is observing the following client situations. It would require intervention if a
1. client with hepatitis B (HBV) is eating food brought into the facility by a visitor
,2. visitor is sitting on the side of the bed of a client with acute pancreatitis
3. staff member is entering the room of a client with Haemophilus influenzae meningitis
wearing a protective gown and gloves
4. family member of a client with mycoplasma pneumonia leaves the door to the client's room
open - CORRECT ANSWER-1. client with hepatitis B (HBV) is eating food brought into the facility
by a visitor
HBV is spread through contact with body fluids including saliva, so it is important to intervene if
the patient is eating and possibly sharing food with another person.
The nurse is reviewing the orders of a client who has acute kidney injury. Which of the following
orders should the nurse clarify?
1. computed tomography (CT) scan of the abdomen with intravenous contrast media
2. urine specimen for urinalysis
3. blood specimen for arterial blood gas (ABG)
4. referral to registered dietitian for parenteral nutrition evaluation - CORRECT ANSWER-1.
computed tomography (CT) scan of the abdomen with intravenous contrast media
CTs use iodinated contrast which is harmful to the kidneys and therefore contraindicated in a
client with AKI
The nurse is planning a staff education program about caring for clients with restraints. Which of
the following information should the nurse include?
1. "Restraints should be removed once during a shift to perform passive range-of-motion (ROM)
exercises for the client."
2. "Restraints should be secured to the side rails of the client's bed for quick release."
3. "Restraints require an order from the primary health care provider."
4. "Restraints may be used p.r.n. for clients who are confused." - CORRECT ANSWER-3.
"Restraints require an order from the primary health care provider."
Rationale:
, 1. Restraints are removed every 2 HOURS for ROM exercises, toileting, and fluids. Assess every
15 mins for the first hour and then every 30 minutes
2. Restraints should be secured to the bed, not side rails
4. Restraints are never PRN
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?
