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NCLEX EXAM PREVIEW TEST BANK QUESTIONS, ANSWERS & RATIONALES 2024/2025
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NCLEX EXAM PREVIEW TEST BANK QUESTIONS, ANSWERS & RATIONALES 2024/2025
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NCLEX EXAM PREVIEWThe fee nurse has acquired a alternate-of-shift report on the subsequent clients in exertions.
The charge nurse must ask a team of workers member to first see the customer within the
1. First degree of labor who has an oral temperature of ninety nine.7° F (37.6° C)
2. First stage of labor whose contractions are taking place each 30 seconds
three. 2d level of hard work who has respirations of 26
4. Second level of exertions whose contractions are lasting for 60 seconds - ANS2. First
stage of labor whose contractions are going on each 30 seconds
Contractions must be now not than ninety secs and no nearer than 2 minutes (a hundred
and twenty secs)
ninety secs is the duration, 2 minutes is the frequency.
Rationale:
1. Elevated temp is ordinary for the duration of hard work
3. Increased resps are normal for the duration of labor "pant-pant-blow" "hee-hee-hoo"
breathing sample
4. Contractions should not be longer than ninety secs, 60 secs is k and regular
Second degree: 2-three minutes apart, 60-90 secs lengthy, 10 cm dilated, robust ache
The nurse is watching a staff member being concerned for a patron who has chickenpox.
Which of the subsequent actions via the staff member could require the nurse to intrude?
1. Setting the customer in a personal room with monitored poor air strain
2. Putting a field of disposable face shields out of doors the client's room
3. Putting an alcohol-based totally hand rub within the client's room for hand hygiene
four. Putting a surgical masks at the client in the course of delivery out of the customer's
room - ANS2. Putting a container of disposable face shields outdoor the client's room
disposable face mask are not suitable for airborne precautions
Rationale:
Varicella (chickenpox) is airborne precaution. Private, poor strain room, prevalent
precautions (hand sanitizer in room) and putting surgical mask on purchaser throughout
delivery are all accurate interventions for Varicilla.
The nurse is being concerned for a client who reviews feeling faint and is experiencing the
cardiac rhythm shown in the electrocardiogram (ECG) strip below.
- BRADYCARDIA (it's miles greater than five spaces apart, sinus rhythm)
Which of the following movements would be appropriate for the nurse to take? Select all that
apply:
1. Administer the patron's prescribed beta blocker.
2. Prepare for transcutaneous pacing.
Three. Instruct the consumer to perform the Valsalva maneuver.
4. Begin chest compressions.
Five. Assess the client for angina. - ANS2. Transcutaneous pacing
- outside pacing that stimulates the ventricles to pump at a set price
,five. Assess the consumer for angina
- Angina (Chest ache) may be caused by both tachycardia (most not unusual) and
bradycardia (uncommon however can manifest). Assessment of angina is suitable
Rationale:
1. Beta blocker could further decrease HR
3. Valsalva maneuver/Vagal stimulation could in addition decrease HR. (may be indicated for
sinus Tachy)
four. Chest compressions are for cardiac arrest
The nurse is planning take care of a purchaser with mild Alzheimer's ailment (AD).
Which of the following interventions ought to the nurse consist of within the client's plan of
care?
1. Encourage the purchaser to reminisce approximately satisfied recollections.
2. Confront the patron while irrelevant or agitated behaviors occur.
3. Administer to the consumer the cholinesterase inhibitor to opposite the course of AD.
Four. Provide the consumer with records approximately pastime selections inside the
morning so the customer can make plans for the day. - ANS1. Encourage the purchaser to
reminisce about glad reminiscences.
Its viable for AD sufferers to keep long-term reminiscences
Rationale:
2. Acknowledge feelings --> Redirect is protocol for Dementia. Don't confront; they can not
study
3. AD is irreversible
4. In mild AD, dementia has already advanced to wherein pt needs assist with ADLs and
planning each day activities. Asking them to plan can frustrate them and purpose distress.
STRUCTURED best activities that take into account the men and women likes and pastimes
are the nice.
The nurse is teaching a purchaser the way to ambulate using crutches. Which of the
following records should the nurse include?
1. "Use your palms and palms to help your frame weight."
2. "Wear slippers when ambulating with the crutches in your property."
three. "Maintain the crutches 12 in (30 cm) in the front of your feet whilst status."
4. "Adjust the hand grips of the crutches so that your elbows are fully extended." - ANS1.
"Use your hands and fingers to assist your frame weight."
True! But watch out if it is not 2-3 finger-widths, crutch paralysis can arise. S/s: paresis and
paresthesias in wrists and fingers
Rationales:
2. Fall risk!
3. Should be 6 in. In front and six in. Lateral
4. Elbows have to be bent at 30 degree angle
The nurse has taught a customer with more than one sclerosis (MS).
Which of the subsequent statements with the aid of the purchaser would indicate a correct
knowledge of the teaching?
, 1. "I will complete all of my family chores within the morning once I am properly rested."
2. "I have learned how to rub down my bladder to assist empty my bladder absolutely."
3. "I will take a hot bathtub in the evening to assist me relax if I have had a traumatic day at
work."
four. "I must assume the blurred vision to solve once I have received medications for several
weeks." - ANS4. "I must assume the blurred vision to solve after I have obtained medications
for several weeks."
MS reasons nerve harm and may bring about optic neuritis (vision loss, burry vision). In
maximum instances it resolves itself in four-12 weeks, but remedy (steroids) can accelerate
the procedure and solve it faster
Rationale:
1. MS patients ought to now not exert themselves an excessive amount of at one time.
Space out activities and permit time for rest.
2. Urinary retention is mainly handled by means of medication (bethanochol), and physical
games can aid with it however aren't the number one remedy
3. Hot temperatures are awful for MS and might worsen symptoms. Your nerves are already
fcked up and further warmness can pressure your frame into overdrive
The nurse has attended a workforce education software about being concerned for clients
who are receiving superb pressure mechanical air flow. Which of the following statements
via the nurse would imply a accurate expertise of the teaching?
1. "Clients ought to keep away from range-of-motion (ROM) physical activities until weaned
from ventilation."
2. "Clients may additionally develop strain ulcers and gastrointestinal bleeding."
three. "Clients could be chemically paralyzed to improve oxygenation."
4. "Clients will enjoy diuresis and polyuria." - ANS2. "Clients may additionally develop
pressure ulcers and gastrointestinal bleeding."
Rationale: Postive Pressure Ventilation may also purpose strain ulcers and GI bleeding due
to the fact
The price nurse have to switch a girl consumer from the clinical-surgical unit to the maternity
unit to make a bed available. It might be most appropriate for the nurse to switch the
consumer who's
1. 28 years vintage, had a proper mastectomy and has a closed-wound drainage device
2. 49 years old, has diabetes mellitus (kind 2) and has all started receiving insulin
three. 56 years vintage, has hepatitis C (HCV) and has been afebrile for twenty-four hours
4. 70 years antique, has a fractured left tibia and had an external fixation device carried out
48 hours ago - ANS3. 56 years old, has hepatitis C (HCV) and has been afebrile for 24
hours
The nurse has been made aware of the subsequent client situations. The nurse ought to first
verify the customer with:
1. Heart failure who has a productive cough and is nerve-racking
2. Regional enteritis (Crohn's disease) who is reporting cramping abdominal ache and
diarrhea
3. Idiopathic thrombocytopenic purpura (ITP) who has petechiae at the trunk and is reporting
heavy menses
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