NCLEX EXAM PREVIEW
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1. The charge nurse has received a 2. first stage of labor whose contrac-
change-of-shift report on the following clients tions are occurring every 30 seconds
in labor. The charge nurse should ask a staff Contractions should be no longer than
member to first see the client in the 90 secs and no closer than 2 mins (120
1. first stage of labor who has an oral temper- secs)
ature of 99.7° F (37.6° C) 90 secs is the duration, 2 mins is the
2. first stage of labor whose contractions are frequency.
occurring every 30 seconds
3. second stage of labor who has respirations Rationale:
of 26 1. Elevated temp is normal during la-
4. second stage of labor whose contractions bor
are lasting for 60 seconds 3. Increased resps are nor-
mal during labor "pant-pant-blow"
"hee-hee-hoo" breathing pattern
4. Contractions shouldn't be longer
than 90 secs, 60 secs is okay and nor-
mal
Second stage: 2-3 mins apart, 60-90
secs long, 10 cm dilated, strong pain
2. The nurse is observing a staff member caring 2. placing a box of disposable face
for a client who has chickenpox. shields outside the client's room
Which of the following actions by the staff disposable face masks are not suitable
member would require the nurse to inter- for airborne precautions
vene?
1. placing the client in a private room with Rationale:
monitored negative air pressure Varicella (chickenpox) is airborne pre-
2. placing a box of disposable face shields out- caution. Private, negative pressure
side the client's room room, universal precautions (hand
3. placing an alcohol-based hand rub in the sanitizer in room) and placing surgical
client's room for hand hygiene mask on client during transport are all
correct interventions for Varicilla.
, NCLEX EXAM PREVIEW
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4. placing a surgical mask on the client during
transport out of the client's room
3. The nurse is caring for a client who reports 2. transcutaneous pacing
feeling faint and is experiencing the cardiac - external pacing that stimulates the
rhythm shown in the electrocardiogram (ECG) ventricles to pump at a set rate
strip below. 5. Assess the client for angina
- BRADYCARDIA (it is more than 5 spaces - Angina (Chest pain) can be caused by
apart, sinus rhythm) both tachycardia (most common) and
Which of the following actions would be ap- bradycardia (rare but can happen). As-
propriate for the nurse to take? Select all that sessment of angina is appropriate
apply:
1. Administer the client's prescribed beta Rationale:
blocker. 1. Beta blocker would further decrease
2. Prepare for transcutaneous pacing. HR
3. Instruct the client to perform the Valsalva 3. Valsalva maneuver/Vagal stimula-
maneuver. tion would further decrease HR. (can
4. Begin chest compressions. be indicated for sinus Tachy)
5. Assess the client for angina. 4. Chest compressions are for cardiac
arrest
4. The nurse is planning care for a client with 1. Encourage the client to reminisce
moderate Alzheimer's disease (AD). about happy memories.
Which of the following interventions should Its possible for AD patients to retain
the nurse include in the client's plan of care? long-term memories
1. Encourage the client to reminisce about
happy memories. Rationale:
2. Confront the client when inappropriate or 2. Acknowledge feelings --> Redirect is
agitated behaviors occur. protocol for Dementia. Don't confront;
3. Administer to the client the cholinesterase they can't learn
inhibitor to reverse the course of AD. 3. AD is irreversible
4. Provide the client with information about 4. In moderate AD, dementia has al-
, NCLEX EXAM PREVIEW
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activity choices in the morning so the client ready progressed to where pt needs
can make plans for the day. help with ADLs and planning daily ac-
tivities. Asking them to plan can frus-
trate them and cause distress.
STRUCTURED pleasant activities that
consider the persons likes and inter-
ests are the best.
5. The nurse is teaching a client how to ambulate 1. "Use your hands and arms to sup-
using crutches. Which of the following infor- port your body weight."
mation should the nurse include? True! But watch out if it isn't 2-3 fin-
1. "Use your hands and arms to support your ger-widths, crutch paralysis can occur.
body weight." s/s: paresis and paresthesias in wrists
2. "Wear slippers when ambulating with the and hands
crutches in your home."
3. "Maintain the crutches 12 in (30 cm) in front Rationales:
of your feet while standing." 2. Fall risk!
4. "Adjust the hand grips of the crutches so 3. Should be 6 in. in front and 6 in.
that your elbows are fully extended." lateral
4. Elbows should be bent at 30 degree
angle
6. The nurse has taught a client with multiple 4. "I should expect the blurred vision
sclerosis (MS). to resolve after I have received med-
Which of the following statements by the ications for several weeks."
client would indicate a correct understanding MS causes nerve damage and can re-
of the teaching? sult in optic neuritis (vision loss, bur-
1. "I will complete all of my household chores ry vision). In most cases it resolves
in the morning when I am well rested." itself in 4-12 weeks, but medication
2. "I have learned how to massage my bladder (steroids) can speed up the process
to help empty my bladder completely." and resolve it quicker
3. "I will take a hot bath in the evening to help
, NCLEX EXAM PREVIEW
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me relax if I have had a stressful day at work." Rationale:
4. "I should expect the blurred vision to re- 1. MS patients should not exert them-
solve after I have received medications for selves too much at one time. Space out
several weeks." activities and allow time for rest.
2. Urinary retention is primarily treated
by medication (bethanochol), and ex-
ercises can aid with it but are not the
primary treatment
3. Hot temperatures are bad for
MS and can worsen symptoms. Your
nerves are already fcked up and extra
heat can stress your body into over-
drive
7. The nurse has attended a staff education pro- 2. "Clients may develop stress ulcers
gram about caring for clients who are re- and gastrointestinal bleeding."
ceiving positive pressure mechanical ventila- Rationale: Postive Pressure Ventilation
tion. Which of the following statements by the may cause stress ulcers and GI bleed-
nurse would indicate a correct understanding ing because
of the teaching?
1. "Clients should avoid range-of-motion
(ROM) exercises until weaned from ventila-
tion."
2. "Clients may develop stress ulcers and gas-
trointestinal bleeding."
3. "Clients will be chemically paralyzed to im-
prove oxygenation."
4. "Clients will experience diuresis and
polyuria."
8. The charge nurse must transfer a female 3. 56 years old, has hepatitis C (HCV)
client from the medical-surgical unit to the and has been afebrile for 24 hours
Study online at https://quizlet.com/_ditdjx
1. The charge nurse has received a 2. first stage of labor whose contrac-
change-of-shift report on the following clients tions are occurring every 30 seconds
in labor. The charge nurse should ask a staff Contractions should be no longer than
member to first see the client in the 90 secs and no closer than 2 mins (120
1. first stage of labor who has an oral temper- secs)
ature of 99.7° F (37.6° C) 90 secs is the duration, 2 mins is the
2. first stage of labor whose contractions are frequency.
occurring every 30 seconds
3. second stage of labor who has respirations Rationale:
of 26 1. Elevated temp is normal during la-
4. second stage of labor whose contractions bor
are lasting for 60 seconds 3. Increased resps are nor-
mal during labor "pant-pant-blow"
"hee-hee-hoo" breathing pattern
4. Contractions shouldn't be longer
than 90 secs, 60 secs is okay and nor-
mal
Second stage: 2-3 mins apart, 60-90
secs long, 10 cm dilated, strong pain
2. The nurse is observing a staff member caring 2. placing a box of disposable face
for a client who has chickenpox. shields outside the client's room
Which of the following actions by the staff disposable face masks are not suitable
member would require the nurse to inter- for airborne precautions
vene?
1. placing the client in a private room with Rationale:
monitored negative air pressure Varicella (chickenpox) is airborne pre-
2. placing a box of disposable face shields out- caution. Private, negative pressure
side the client's room room, universal precautions (hand
3. placing an alcohol-based hand rub in the sanitizer in room) and placing surgical
client's room for hand hygiene mask on client during transport are all
correct interventions for Varicilla.
, NCLEX EXAM PREVIEW
Study online at https://quizlet.com/_ditdjx
4. placing a surgical mask on the client during
transport out of the client's room
3. The nurse is caring for a client who reports 2. transcutaneous pacing
feeling faint and is experiencing the cardiac - external pacing that stimulates the
rhythm shown in the electrocardiogram (ECG) ventricles to pump at a set rate
strip below. 5. Assess the client for angina
- BRADYCARDIA (it is more than 5 spaces - Angina (Chest pain) can be caused by
apart, sinus rhythm) both tachycardia (most common) and
Which of the following actions would be ap- bradycardia (rare but can happen). As-
propriate for the nurse to take? Select all that sessment of angina is appropriate
apply:
1. Administer the client's prescribed beta Rationale:
blocker. 1. Beta blocker would further decrease
2. Prepare for transcutaneous pacing. HR
3. Instruct the client to perform the Valsalva 3. Valsalva maneuver/Vagal stimula-
maneuver. tion would further decrease HR. (can
4. Begin chest compressions. be indicated for sinus Tachy)
5. Assess the client for angina. 4. Chest compressions are for cardiac
arrest
4. The nurse is planning care for a client with 1. Encourage the client to reminisce
moderate Alzheimer's disease (AD). about happy memories.
Which of the following interventions should Its possible for AD patients to retain
the nurse include in the client's plan of care? long-term memories
1. Encourage the client to reminisce about
happy memories. Rationale:
2. Confront the client when inappropriate or 2. Acknowledge feelings --> Redirect is
agitated behaviors occur. protocol for Dementia. Don't confront;
3. Administer to the client the cholinesterase they can't learn
inhibitor to reverse the course of AD. 3. AD is irreversible
4. Provide the client with information about 4. In moderate AD, dementia has al-
, NCLEX EXAM PREVIEW
Study online at https://quizlet.com/_ditdjx
activity choices in the morning so the client ready progressed to where pt needs
can make plans for the day. help with ADLs and planning daily ac-
tivities. Asking them to plan can frus-
trate them and cause distress.
STRUCTURED pleasant activities that
consider the persons likes and inter-
ests are the best.
5. The nurse is teaching a client how to ambulate 1. "Use your hands and arms to sup-
using crutches. Which of the following infor- port your body weight."
mation should the nurse include? True! But watch out if it isn't 2-3 fin-
1. "Use your hands and arms to support your ger-widths, crutch paralysis can occur.
body weight." s/s: paresis and paresthesias in wrists
2. "Wear slippers when ambulating with the and hands
crutches in your home."
3. "Maintain the crutches 12 in (30 cm) in front Rationales:
of your feet while standing." 2. Fall risk!
4. "Adjust the hand grips of the crutches so 3. Should be 6 in. in front and 6 in.
that your elbows are fully extended." lateral
4. Elbows should be bent at 30 degree
angle
6. The nurse has taught a client with multiple 4. "I should expect the blurred vision
sclerosis (MS). to resolve after I have received med-
Which of the following statements by the ications for several weeks."
client would indicate a correct understanding MS causes nerve damage and can re-
of the teaching? sult in optic neuritis (vision loss, bur-
1. "I will complete all of my household chores ry vision). In most cases it resolves
in the morning when I am well rested." itself in 4-12 weeks, but medication
2. "I have learned how to massage my bladder (steroids) can speed up the process
to help empty my bladder completely." and resolve it quicker
3. "I will take a hot bath in the evening to help
, NCLEX EXAM PREVIEW
Study online at https://quizlet.com/_ditdjx
me relax if I have had a stressful day at work." Rationale:
4. "I should expect the blurred vision to re- 1. MS patients should not exert them-
solve after I have received medications for selves too much at one time. Space out
several weeks." activities and allow time for rest.
2. Urinary retention is primarily treated
by medication (bethanochol), and ex-
ercises can aid with it but are not the
primary treatment
3. Hot temperatures are bad for
MS and can worsen symptoms. Your
nerves are already fcked up and extra
heat can stress your body into over-
drive
7. The nurse has attended a staff education pro- 2. "Clients may develop stress ulcers
gram about caring for clients who are re- and gastrointestinal bleeding."
ceiving positive pressure mechanical ventila- Rationale: Postive Pressure Ventilation
tion. Which of the following statements by the may cause stress ulcers and GI bleed-
nurse would indicate a correct understanding ing because
of the teaching?
1. "Clients should avoid range-of-motion
(ROM) exercises until weaned from ventila-
tion."
2. "Clients may develop stress ulcers and gas-
trointestinal bleeding."
3. "Clients will be chemically paralyzed to im-
prove oxygenation."
4. "Clients will experience diuresis and
polyuria."
8. The charge nurse must transfer a female 3. 56 years old, has hepatitis C (HCV)
client from the medical-surgical unit to the and has been afebrile for 24 hours
