NCLEX EXAM PREVIEW / ACTUAL QUESTIONS & CORRECT ANSWERS
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Course
NCLEX
Institution
NCLEX
NCLEX EXAM PREVIEW / ACTUAL QUESTIONS & CORRECT ANSWERS WITH RATIONALES (NEWEST 2025). 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 temper...
NCLEX EXAM PREVIEW / ACTUAL QUESTIONS &
CORRECT ANSWERS WITH RATIONALES (NEWEST
2025).
Terms in this set (110)
The charge nurse has 2. first stage of labor whose contractions are occurring every
received a change-of-shift 30 seconds
report on the following Contractions should be no longer than 90 secs and no closer
clients in labor. The charge than 2 mins (120 secs)
nurse should ask a staff 90 secs is the duration, 2 mins is the frequency.
member to first see the client
in the Rationale:
1. first stage of labor 1. Elevated temp is normal during labor
whohas an oral temperature 3. Increased resps are normal during labor "pantpant-blow"
of "hee-hee-hoo" breathing pattern
99.7° F (37.6° C) 4. Contractions shouldn't be longer than 90 secs, 60 secs is okay
2. first stage of and normal
laborwhose contractions are Second stage: 2-3 mins apart, 60-90 secs long, 10 cm dilated,
strong pain
occurring every 30 seconds
3. second stage of
laborwho has respirations of
26 4. second stage of labor
whose contractions are
lasting for 60 seconds
,The nurse is observing a staff 2. placing a box of disposable face shields outside the
member caring for a client client's room disposable face masks are not suitable for
who has chickenpox. airborne precautions
Which of the following actions
by the staff member would Rationale:
require the nurse to Varicella (chickenpox) is airborne precaution. Private, negative
intervene? pressure room, universal precautions (hand sanitizer in room)
and placing surgical mask on client during transport are all
1. placing the client in correct interventions for Varicilla.
aprivate room with monitored
negative air pressure
2. placing a box
ofdisposable face shields
outside the client's room 3.
placing an alcoholbased 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
,The nurse is caring for a 2. transcutaneous pacing
client who reports feeling - external pacing that stimulates the ventricles to pump at a
faint and is experiencing the set rate
cardiac rhythm shown in the 5. Assess the client for angina
electrocardiogram (ECG) - Angina (Chest pain) can be caused by both tachycardia
strip below. - BRADYCARDIA (most common) and bradycardia (rare but can happen).
(it is more than 5 spaces Assessment of angina is appropriate
apart, sinus rhythm)
Which of the following Rationale:
actions would be 1. Beta blocker would further decrease HR
appropriate for the nurse to 3. Valsalva maneuver/Vagal stimulation would further
decrease HR. (can be indicated for sinus Tachy) 4. Chest
take? Select all that apply: compressions are for cardiac arrest
1. Administer the
client'sprescribed beta
blocker.
2. Prepare
fortranscutaneous pacing.
3. Instruct the client to
perform the Valsalva
maneuver.
4. Begin
chestcompressions.
5. Assess the client
forangina.
, The nurse is planning care 1. Encourage the client to reminisce about happymemories.
for a client with moderate Its possible for AD patients to retain long-term memories
Alzheimer's disease (AD).
Which of the following Rationale:
interventions should the 2. Acknowledge feelings --> Redirect is protocol for
nurse include in the client's Dementia. Don't confront; they can't learn
plan of care? 3. AD is irreversible
1. Encourage the client 4. In moderate AD, dementia has already progressedto where pt
toreminisce about happy needs help with ADLs and planning daily activities. Asking them to
memories. plan can frustrate them and cause distress.
2. Confront the STRUCTURED pleasant activities that consider the persons likes
and interests are the best.
clientwhen inappropriate or
agitated behaviors occur.
3. Administer to the
clientthe cholinesterase
inhibitor to reverse the
course of AD.
4. Provide the client
withinformation about
activity choices in the
morning so the client can
make plans for the day.
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