- NCLEX Examination - Chapter 11 BRAND NEW
SOLUTION FOR 2025/2026 Review Questions
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
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 -
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 home-health nurse is assigned to visit the following clients who live within 3
miles (4.8 km) of one another. The nurse should first visit the client with
1. breast cancer who had a mastectomy 2 days ago and has had 25 mL of drainage
from the closed-wound drainage system in the past 12 hours
2. lung cancer who received a dose of chemotherapy 2 weeks ago and has a
temperature of 101.1° F (38.4° C)
3. chronic obstructive pulmonary disease (COPD) who is reporting expectorating
large amounts of thick, yellow mucus
4. diabetes mellitus (type 1) who had a right below-the-knee amputation (BKA)
and is reporting having right toe pain - answer-1. breast cancer who had a
,mastectomy 2 days ago and has had 25 mL of drainage from the closed-wound
drainage system in the past 12 hours
This is really little blood in 12 hours for a surgery that was only 2 days ago. Nurse
should assess for obstruction of the drainage system which could be life-
threatening if not resolved.
The nurse has become aware of the following client situations. The nurse should
first assess the client
1. who had a total abdominal hysterectomy (TAH) 1 day ago and is unable to void
7 hours after the indwelling urethral catheter was removed
2. who had a total knee replacement 24 hours ago, is restless, and has a petechial
rash on the chest
3. with bacterial pneumonia who has bronchial breath sounds auscultated
between the scapulae and a temperature of 103.3° F (39.6° C)
4. with hepatic cirrhosis who has an elevated aspartate aminotransferase (AST)
level and respirations of 24 - answer-2. who had a total knee replacement 24
hours ago, is restless, and has a petechial rash on the chest
petechial rash — sign of DIC or fat embolus
The nurse is planning care for a pediatric client being admitted with pertussis.
Which of the following interventions should the nurse include in the client's plan
of care?
1. Keep the client NPO.
2. Place a dehumidifier in the client's room.
3. Encourage the client to ambulate frequently.
4. Implement droplet precautions. - answer-4. Implement droplet precautions.
, The nurse has attended a staff education program about infection control
precautions. It would indicate a correct understanding of the teaching if the nurse
is observed
1. wearing a particulate respirator mask (N95) when entering the room of a client
with Haemophilus influenzae pneumonia
2. placing a client with streptococcal pneumonia in a room with a client who has
respiratory syncytial virus (RSV)
3. wearing a protective gown when entering the room of a client with Escherichia
coli who is incontinent
4. placing a client with pediculosis capitis (head lice) in a room with a client who
has scabies - answer-3. wearing a protective gown when entering the room of a
client with Escherichia coli who is incontinent
E. Coli is contact precautions; wear gown whenever coming in contact with bodily
fluids which is highly likely with an incontinent patient
Rationale:
1. H. flu is droplet precautions
2. Strep is droplet and RSV is contact
4. They will infect each other, they need private rooms
The nurse is assessing an older adult client who is scheduled for discharge and is
at risk for falls. Which of the following are extrinsic risk factors for falling? Select
all that apply.
1. uneven stairs
2. throw rugs
3. hemiparesis
4. dim lighting
SOLUTION FOR 2025/2026 Review Questions
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
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 -
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 home-health nurse is assigned to visit the following clients who live within 3
miles (4.8 km) of one another. The nurse should first visit the client with
1. breast cancer who had a mastectomy 2 days ago and has had 25 mL of drainage
from the closed-wound drainage system in the past 12 hours
2. lung cancer who received a dose of chemotherapy 2 weeks ago and has a
temperature of 101.1° F (38.4° C)
3. chronic obstructive pulmonary disease (COPD) who is reporting expectorating
large amounts of thick, yellow mucus
4. diabetes mellitus (type 1) who had a right below-the-knee amputation (BKA)
and is reporting having right toe pain - answer-1. breast cancer who had a
,mastectomy 2 days ago and has had 25 mL of drainage from the closed-wound
drainage system in the past 12 hours
This is really little blood in 12 hours for a surgery that was only 2 days ago. Nurse
should assess for obstruction of the drainage system which could be life-
threatening if not resolved.
The nurse has become aware of the following client situations. The nurse should
first assess the client
1. who had a total abdominal hysterectomy (TAH) 1 day ago and is unable to void
7 hours after the indwelling urethral catheter was removed
2. who had a total knee replacement 24 hours ago, is restless, and has a petechial
rash on the chest
3. with bacterial pneumonia who has bronchial breath sounds auscultated
between the scapulae and a temperature of 103.3° F (39.6° C)
4. with hepatic cirrhosis who has an elevated aspartate aminotransferase (AST)
level and respirations of 24 - answer-2. who had a total knee replacement 24
hours ago, is restless, and has a petechial rash on the chest
petechial rash — sign of DIC or fat embolus
The nurse is planning care for a pediatric client being admitted with pertussis.
Which of the following interventions should the nurse include in the client's plan
of care?
1. Keep the client NPO.
2. Place a dehumidifier in the client's room.
3. Encourage the client to ambulate frequently.
4. Implement droplet precautions. - answer-4. Implement droplet precautions.
, The nurse has attended a staff education program about infection control
precautions. It would indicate a correct understanding of the teaching if the nurse
is observed
1. wearing a particulate respirator mask (N95) when entering the room of a client
with Haemophilus influenzae pneumonia
2. placing a client with streptococcal pneumonia in a room with a client who has
respiratory syncytial virus (RSV)
3. wearing a protective gown when entering the room of a client with Escherichia
coli who is incontinent
4. placing a client with pediculosis capitis (head lice) in a room with a client who
has scabies - answer-3. wearing a protective gown when entering the room of a
client with Escherichia coli who is incontinent
E. Coli is contact precautions; wear gown whenever coming in contact with bodily
fluids which is highly likely with an incontinent patient
Rationale:
1. H. flu is droplet precautions
2. Strep is droplet and RSV is contact
4. They will infect each other, they need private rooms
The nurse is assessing an older adult client who is scheduled for discharge and is
at risk for falls. Which of the following are extrinsic risk factors for falling? Select
all that apply.
1. uneven stairs
2. throw rugs
3. hemiparesis
4. dim lighting
