6/13/26, 12:38 NCLEX-RN
PM
NCLEX-RN Exam Prep 2026-2027 | 113 Verified Q&A
with Rationales | Maternity, Med-Surg, Pediatrics,
Infection Control & More | Nursing Licensure Review.
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 99.7F (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
Rationale:
1. Elevated temperature is normal during labor.
3. Increased respirations are normal during labor "pant-pant-blow" "hee-hee-
hoo" breathing pattern.
4. Contractions shouldn't be longer than 90 seconds, 60 seconds is okay and
normal. Second stage: 2-3 minutes apart, 60-90 seconds long, 10cm 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.
2. Placing a box of disposable face shields outside the client's room.
Rationale:
Varicella AKA chicken pox is an airborne precaution. Private, negative
pressure room, universal precautions (hand sanitizer in room) and placing a
surgical mask on client during transport are all correct interventions for
varicella.
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PM
2. Prepare for transcutaneous pacing.
& 5. Assess the client for angina.
Rationale:
1. Beta Blockers would further decrease HR.
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PM
2. External pacing stimulates the ventricles to pump at a set rate.
3. Valsalva maneuver would further decrease HR.
4. Chest compressions are for cardiac arrest.
5. Angina (Chest pain) can be caused by both tachycardia
(most common) and bradycardia (rare but can happen).
Therefore, assessment of angina is appropriate.
The nurse is caring for a client who reports feeling faint and is
experiencing the cardiac rhythm shown in the electrocardiogram
(ECG) strip below.
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.
1. Encourage the client to reminisce about happy memories.
Rationale:
1. Is correct because it is possible for AD patients to retain long-term memories.
2. Redirect is protocol for dementia. Don't confront, they can't learn.
3. AD is irreversible.
4. In the moderate AD, dementia has already progressed to where the patient
needs help with ADL's & planning daily activities. Asking them to plan can
frustrate them & cause distress. Structured, pleasant activities that consider the
person's likes & interests are the best.
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.
1. "Use your hands and arms to support your body
weight." Rationale:
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, 6/13/26, 12:38 NCLEX-RN
PM
1. Is true, but watch out if it isn't 2-3 finger-widths, because crutch paralysis
can occur. S/S: Paresis & Paresthesias in wrist & hands.
4/78
PM
NCLEX-RN Exam Prep 2026-2027 | 113 Verified Q&A
with Rationales | Maternity, Med-Surg, Pediatrics,
Infection Control & More | Nursing Licensure Review.
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 99.7F (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
Rationale:
1. Elevated temperature is normal during labor.
3. Increased respirations are normal during labor "pant-pant-blow" "hee-hee-
hoo" breathing pattern.
4. Contractions shouldn't be longer than 90 seconds, 60 seconds is okay and
normal. Second stage: 2-3 minutes apart, 60-90 seconds long, 10cm 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.
2. Placing a box of disposable face shields outside the client's room.
Rationale:
Varicella AKA chicken pox is an airborne precaution. Private, negative
pressure room, universal precautions (hand sanitizer in room) and placing a
surgical mask on client during transport are all correct interventions for
varicella.
1/78
,6/13/26, 12:38 NCLEX-RN
PM
2. Prepare for transcutaneous pacing.
& 5. Assess the client for angina.
Rationale:
1. Beta Blockers would further decrease HR.
2/78
,6/13/26, 12:38 NCLEX-RN
PM
2. External pacing stimulates the ventricles to pump at a set rate.
3. Valsalva maneuver would further decrease HR.
4. Chest compressions are for cardiac arrest.
5. Angina (Chest pain) can be caused by both tachycardia
(most common) and bradycardia (rare but can happen).
Therefore, assessment of angina is appropriate.
The nurse is caring for a client who reports feeling faint and is
experiencing the cardiac rhythm shown in the electrocardiogram
(ECG) strip below.
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.
1. Encourage the client to reminisce about happy memories.
Rationale:
1. Is correct because it is possible for AD patients to retain long-term memories.
2. Redirect is protocol for dementia. Don't confront, they can't learn.
3. AD is irreversible.
4. In the moderate AD, dementia has already progressed to where the patient
needs help with ADL's & planning daily activities. Asking them to plan can
frustrate them & cause distress. Structured, pleasant activities that consider the
person's likes & interests are the best.
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.
1. "Use your hands and arms to support your body
weight." Rationale:
3/78
, 6/13/26, 12:38 NCLEX-RN
PM
1. Is true, but watch out if it isn't 2-3 finger-widths, because crutch paralysis
can occur. S/S: Paresis & Paresthesias in wrist & hands.
4/78
