NCLEX EXAM 2026 PREVIEW 150 QUESTIONS AND
CORRECT ANSWERS WITH RATIONALES
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 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?
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. - CORRECT ANSWER-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
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 is teaching a client how to ambulate using crutches. Which of the following information
should the nurse include?
1. "Use your hands and arms to support your body weight."
2. "Wear slippers when ambulating with the crutches in your home."
3. "Maintain the crutches 12 in (30 cm) in front of your feet while standing."
4. "Adjust the hand grips of the crutches so that your elbows are fully extended." - CORRECT
ANSWER-1. "Use your hands and arms to support your body weight."
True! But watch out if it isn't 2-3 finger-widths, crutch paralysis can occur. s/s: paresis and
paresthesias in wrists and hands
Rationales:
2. Fall risk!
3. Should be 6 in. in front and 6 in. lateral
4. Elbows should be bent at 30 degree angle
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? Select all
that apply.
1. Establish a daily routine for the client.
2. Assist the client to void every 2 hours.
3. Introduce self upon interacting with the client.
4. Display a clock and calendar in the client's room.
5. Keep the client's television on during the day to distract the client. - CORRECT ANSWER-1, 2, 3, 4
A parent is discussing with the nurse about the behaviors of a 4-year-old child following the death
of a grandparent.
The nurse should understand that the child may be experiencing dysfunctional grieving if the
parent reports that the child
1. conducts mock funerals with stuffed animals
2. refuses to go to sleep at night
3. continues to talk about the grandparent coming to visit
4. asks to play with the grandparent while at the cemetery - CORRECT ANSWER-2. refuses to go to
sleep at night
, The nurse has taught a client who has been ordered a low-sodium diet about appropriate food
choices. Which of the following statements by the client would indicate a correct understanding of
the teaching?
1. "I will eat steamed, fresh broccoli with herbs and spices for an evening meal."
2. "I will add cottage cheese and other dairy products to my daily diet."
3. "I am glad I can still enjoy eating cereals, such as bran flakes with raisins."
4. "I am glad I can eat lean meats daily because I eat ham sandwiches for an afternoon meal." -
CORRECT ANSWER-1. "I will eat steamed, fresh broccoli with herbs and spices for an evening
meal."
Veggies are low sodium and herbs and spices are great substitutes for salt.
The nurse is caring for a client who had a left modified radical mastectomy. The client received
discharge instructions for performing range-of-motion (ROM) exercises on her left arm. Which of
the following, if reported by the client on her return visit to the clinic, would indicate to the nurse
that the instructions have been followed correctly?
1. regular squeezing of a tennis ball in her left hand
2. placing her left palm against a wall and "climbing" the wall with the left fingers
3. carrying light hand weights while walking 1 mile every other day
4. performing isometric exercises with both arms extended - CORRECT ANSWER-2. placing her left
palm against a wall and "climbing" the wall with the left fingers
The nurse is planning care for a client who has expressive aphasia after a left-sided stroke. Which
of the following statements by the client's spouse would indicate a correct understanding of the
client's communication abilities and interaction needs? Select all that apply.
1. "My spouse's response of 'fine' when asked how the day has been may or may not be what my
spouse meant
to communicate."
2. "I can anticipate what my spouse wants to say, so I complete my spouse's sentences to make
communication quicker."
3. "I will purchase a picture board to help my spouse express common needs, thoughts, and feelings
that are difficult to communicate."
4. "My spouse's angry response when we have a conversation makes me hesitant to try further
communication."
5. "I have arranged for my spouse to meet with a speech therapist twice each week to improve
communication skills." - CORRECT ANSWER-1,3,5
CORRECT ANSWERS WITH RATIONALES
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 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?
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. - CORRECT ANSWER-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
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 is teaching a client how to ambulate using crutches. Which of the following information
should the nurse include?
1. "Use your hands and arms to support your body weight."
2. "Wear slippers when ambulating with the crutches in your home."
3. "Maintain the crutches 12 in (30 cm) in front of your feet while standing."
4. "Adjust the hand grips of the crutches so that your elbows are fully extended." - CORRECT
ANSWER-1. "Use your hands and arms to support your body weight."
True! But watch out if it isn't 2-3 finger-widths, crutch paralysis can occur. s/s: paresis and
paresthesias in wrists and hands
Rationales:
2. Fall risk!
3. Should be 6 in. in front and 6 in. lateral
4. Elbows should be bent at 30 degree angle
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? Select all
that apply.
1. Establish a daily routine for the client.
2. Assist the client to void every 2 hours.
3. Introduce self upon interacting with the client.
4. Display a clock and calendar in the client's room.
5. Keep the client's television on during the day to distract the client. - CORRECT ANSWER-1, 2, 3, 4
A parent is discussing with the nurse about the behaviors of a 4-year-old child following the death
of a grandparent.
The nurse should understand that the child may be experiencing dysfunctional grieving if the
parent reports that the child
1. conducts mock funerals with stuffed animals
2. refuses to go to sleep at night
3. continues to talk about the grandparent coming to visit
4. asks to play with the grandparent while at the cemetery - CORRECT ANSWER-2. refuses to go to
sleep at night
, The nurse has taught a client who has been ordered a low-sodium diet about appropriate food
choices. Which of the following statements by the client would indicate a correct understanding of
the teaching?
1. "I will eat steamed, fresh broccoli with herbs and spices for an evening meal."
2. "I will add cottage cheese and other dairy products to my daily diet."
3. "I am glad I can still enjoy eating cereals, such as bran flakes with raisins."
4. "I am glad I can eat lean meats daily because I eat ham sandwiches for an afternoon meal." -
CORRECT ANSWER-1. "I will eat steamed, fresh broccoli with herbs and spices for an evening
meal."
Veggies are low sodium and herbs and spices are great substitutes for salt.
The nurse is caring for a client who had a left modified radical mastectomy. The client received
discharge instructions for performing range-of-motion (ROM) exercises on her left arm. Which of
the following, if reported by the client on her return visit to the clinic, would indicate to the nurse
that the instructions have been followed correctly?
1. regular squeezing of a tennis ball in her left hand
2. placing her left palm against a wall and "climbing" the wall with the left fingers
3. carrying light hand weights while walking 1 mile every other day
4. performing isometric exercises with both arms extended - CORRECT ANSWER-2. placing her left
palm against a wall and "climbing" the wall with the left fingers
The nurse is planning care for a client who has expressive aphasia after a left-sided stroke. Which
of the following statements by the client's spouse would indicate a correct understanding of the
client's communication abilities and interaction needs? Select all that apply.
1. "My spouse's response of 'fine' when asked how the day has been may or may not be what my
spouse meant
to communicate."
2. "I can anticipate what my spouse wants to say, so I complete my spouse's sentences to make
communication quicker."
3. "I will purchase a picture board to help my spouse express common needs, thoughts, and feelings
that are difficult to communicate."
4. "My spouse's angry response when we have a conversation makes me hesitant to try further
communication."
5. "I have arranged for my spouse to meet with a speech therapist twice each week to improve
communication skills." - CORRECT ANSWER-1,3,5
