- | Page
NCLEX EXAM PREVIEW WITH
100% CORRECT ANSWERS
Question :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
first stage of labor who has an oral temperature of
99.7° F (37.6° C)
first stage of labor whose contractions are occurring every 30 seconds
second stage of labor who has respirations of 26
second stage of labor whose contractions are lasting for 60 seconds
- | Page
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:
Elevated temp is normal during labor
Increased resps are normal during labor "pant-pant- blow" "hee-hee-hoo" breathing pattern
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
- | Page
Question :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?
placing the client in a private room with monitored negative air pressure
placing a box of disposable face shields outside the client's room
placing an alcohol-based hand rub in the client's room for hand hygiene
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
- | Page
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.
Question :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