NCLEX EXAM PREVIEW VERIFIED TEST QUESTIONS WITH ACCURATE SOLUTIONS -
GRADED A+
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
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 caring for a client with active pulmonary tuberculosis (TB). Which of the
following should the nurse include in the client's plan of care?
1. placing the client in a private room with the door open
2. putting a surgical mask on the client during transport to the radiology department
3. instructing the primary caregivers to wear surgical masks when caring for the client
4. instituting the standards for droplet precautions while caring for the client
2. putting a surgical mask on the client during transport to the radiology department
,X-Ray to confirm active TB d(x)
Rationale:
1. Door should be closed
3.
4. Airborne precautions
The home-health nurse is teaching the parents of a 4-year-old client with impetigo. Which
of the following information should the nurse include?
1. "Put a surgical mask on your child when around siblings."
2. "Cleanse the lesions with a povidone-iodine solution daily."
3. "Apply petroleum jelly to the lesions daily."
4. "Instruct your child not to use the same towels as siblings."
4. "Instruct your child not to use the same towels as siblings."
Impetigo is highly contagious through contact. Towels can easily spread the infection
Rationale:
1. It is contact precautions; surgical mask would be for airborne
The nurse has attended a staff education program about bioterrorism. Which of the
following statements by the nurse would require follow-up?
1. "Botulism is transmitted by ingestion of contaminated canned foods."
2. "Hemorrhagic fever is spread by direct contact with blood or body fluids."
3. "Anthrax is spread through direct contact with the bacteria and its spores."
4. "Bubonic plague is transmitted from person to person via airborne droplets."
,4. "Bubonic plague is transmitted from person to person via airborne droplets."
It is spread through flea bites and contact with infected skin
Rationale:
1. Botulism is transmitted by foods. ex: babies getting Botulism from honey
2. Infectious diseases that affect clotting and is spread by blood or body fluids
3. Anthrax: Contact
The nurse observes a coworker who is assessing a client's thoracic expansion.
Which of the following would indicate that the coworker is using the correct assessment
technique?
1. percussion from the apex of the scapula downward on each side
2. placement of the hands flat on the back with the thumbs at the level of the tenth ribs
pointing to the spine, then asking the client to inhale
3. measurement of the anteroposterior diameter of the chest
4. placement of the palms at the level of the tenth ribs with thumbs pointing to the xiphoid
process, then asking the client to inhale
4. placement of the palms at the level of the tenth ribs with thumbs pointing to the xiphoid
process, then asking the client to inhale
This is how to measure anterior thoracic expansion.
2. Posterior thoracic expansion
The nurse at a health fair is talking with a client who is in perimenopause and is
experiencing hot flashes. Which of the following lifestyle modifications would be
appropriate for the nurse to recommend?
, 1. increasing fluid intake
2. exercising daily
3. decreasing sodium intake
4. wearing clothing in layers
4. wearing clothing in layers
Wear light layers so you can remove layers when you get a hot flash
The nurse in a community-based setting is teaching clients over 65 years of age about
health promotion activities. Which of the following information should the nurse include?
1. "Purchase all of your prescribed medications at the same pharmacy."
2. "Schedule an appointment for a vision screening every 3 years."
3. "Participate in daily aerobic exercises for 60 minutes."
4. "Increase your intake of fat-soluble vitamins."
3. "Participate in daily aerobic exercises for 60 minutes."
The nurse is screening clients for those at increased risk for developing cancer. At highest
risk for developing leukemia is the client who
1. received more than 3 blood transfusions
2. has a magnetic resonance imaging (MRI) scan annually
3. has polycythemia vera and requires phlebotomy treatments
4. had colon cancer and received chemotherapy treatments
4. had colon cancer and received chemotherapy treatments
Chemotherapy is known to cause Leukemia, and Chemo has a greater risk than radiation to
cause Leukemia.
GRADED A+
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
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 caring for a client with active pulmonary tuberculosis (TB). Which of the
following should the nurse include in the client's plan of care?
1. placing the client in a private room with the door open
2. putting a surgical mask on the client during transport to the radiology department
3. instructing the primary caregivers to wear surgical masks when caring for the client
4. instituting the standards for droplet precautions while caring for the client
2. putting a surgical mask on the client during transport to the radiology department
,X-Ray to confirm active TB d(x)
Rationale:
1. Door should be closed
3.
4. Airborne precautions
The home-health nurse is teaching the parents of a 4-year-old client with impetigo. Which
of the following information should the nurse include?
1. "Put a surgical mask on your child when around siblings."
2. "Cleanse the lesions with a povidone-iodine solution daily."
3. "Apply petroleum jelly to the lesions daily."
4. "Instruct your child not to use the same towels as siblings."
4. "Instruct your child not to use the same towels as siblings."
Impetigo is highly contagious through contact. Towels can easily spread the infection
Rationale:
1. It is contact precautions; surgical mask would be for airborne
The nurse has attended a staff education program about bioterrorism. Which of the
following statements by the nurse would require follow-up?
1. "Botulism is transmitted by ingestion of contaminated canned foods."
2. "Hemorrhagic fever is spread by direct contact with blood or body fluids."
3. "Anthrax is spread through direct contact with the bacteria and its spores."
4. "Bubonic plague is transmitted from person to person via airborne droplets."
,4. "Bubonic plague is transmitted from person to person via airborne droplets."
It is spread through flea bites and contact with infected skin
Rationale:
1. Botulism is transmitted by foods. ex: babies getting Botulism from honey
2. Infectious diseases that affect clotting and is spread by blood or body fluids
3. Anthrax: Contact
The nurse observes a coworker who is assessing a client's thoracic expansion.
Which of the following would indicate that the coworker is using the correct assessment
technique?
1. percussion from the apex of the scapula downward on each side
2. placement of the hands flat on the back with the thumbs at the level of the tenth ribs
pointing to the spine, then asking the client to inhale
3. measurement of the anteroposterior diameter of the chest
4. placement of the palms at the level of the tenth ribs with thumbs pointing to the xiphoid
process, then asking the client to inhale
4. placement of the palms at the level of the tenth ribs with thumbs pointing to the xiphoid
process, then asking the client to inhale
This is how to measure anterior thoracic expansion.
2. Posterior thoracic expansion
The nurse at a health fair is talking with a client who is in perimenopause and is
experiencing hot flashes. Which of the following lifestyle modifications would be
appropriate for the nurse to recommend?
, 1. increasing fluid intake
2. exercising daily
3. decreasing sodium intake
4. wearing clothing in layers
4. wearing clothing in layers
Wear light layers so you can remove layers when you get a hot flash
The nurse in a community-based setting is teaching clients over 65 years of age about
health promotion activities. Which of the following information should the nurse include?
1. "Purchase all of your prescribed medications at the same pharmacy."
2. "Schedule an appointment for a vision screening every 3 years."
3. "Participate in daily aerobic exercises for 60 minutes."
4. "Increase your intake of fat-soluble vitamins."
3. "Participate in daily aerobic exercises for 60 minutes."
The nurse is screening clients for those at increased risk for developing cancer. At highest
risk for developing leukemia is the client who
1. received more than 3 blood transfusions
2. has a magnetic resonance imaging (MRI) scan annually
3. has polycythemia vera and requires phlebotomy treatments
4. had colon cancer and received chemotherapy treatments
4. had colon cancer and received chemotherapy treatments
Chemotherapy is known to cause Leukemia, and Chemo has a greater risk than radiation to
cause Leukemia.
