1
NCLEX EXAM PREVIEW
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
, 2
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
2
, 3
- 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.
3
, 4
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 has taught a client with multiple sclerosis (MS).
Which of the following statements by the client would indicate a correct
understanding of the teaching?
1. "I will complete all of my household chores in the morning when I am
well rested."
2. "I have learned how to massage my bladder to help empty my
bladder completely."
3. "I will take a hot bath in the evening to help me relax if I have had a
stressful day at work."
4
NCLEX EXAM PREVIEW
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
, 2
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
2
, 3
- 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.
3
, 4
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 has taught a client with multiple sclerosis (MS).
Which of the following statements by the client would indicate a correct
understanding of the teaching?
1. "I will complete all of my household chores in the morning when I am
well rested."
2. "I have learned how to massage my bladder to help empty my
bladder completely."
3. "I will take a hot bath in the evening to help me relax if I have had a
stressful day at work."
4
