HURST REVIEW NCLEX-RN Readiness Exam 1|125 Questions and Answers Latest Update 2024Guarant, Exams of Nursing

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HURST REVIEW NCLEX-RN Readiness Exam 1|

Questions and Answers Latest Update

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The primary healthcare provider has prescribed phenytoin 100 mg intravenous push (IVP) stat for an adult client. What is the least amount of time that the nurse can safely administer this medication?

1. 1 minute
2. 2 minutes
3. 5 minutes

4. 10 minutes - Correct answer 2. Correct: The rate of IV administration

should not exceed 50 mg/min. for adults and 1-3 mg/kg/min (or 50 mg/min, whichever is slower) in pediatric clients because of the risk of severe hypotension and cardiac arrhythmias. So 100 mg can safely be delivered over a period of at least 2 minutes.

1. Incorrect: The rate of IV administration should not exceed 50 mg/min. for adults and 1-3 mg/kg/min (or 50 mg/min, whichever is slower) in pediatric clients because of the risk of severe hypotension and cardiac arrhythmias. So 100 mg can safely be delivered over a period of at least 2 minutes. Giving this dose over only one minute could lead to these or other potential harmful effects.
2. Incorrect: The rate of IV administration should not exceed 50 mg/min. for adults and 1-3 mg/kg/min (or 50 mg/min, whichever is slower) in pediatric clients because of the risk of severe hypotension and cardiac arrhythmias. So 100 mg can safely be delivered over a period of at least 2 minutes. Five minutes would be longer than required to be able to safely administer the medication.

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4. Incorrect: The rate of IV administration should not exceed 50 mg/min. for adults and 1-3 mg/kg/min (or 50 mg/min, whichever is slower) in pediatric clients because of the risk of severe hypotension and cardiac arrhythmias. So 100 mg can safely be delivered over a period of at least 2 minutes. Ten minutes is much longer than required to be able to safely administer the medication. A client, hospitalized with possible acute pancreatitis secondary to chronic cholecystitis, has severe abdominal pain and nausea. The client is kept NPO, an NG tube is inserted, and IV fluids are being administered. What is the rationale for the client being NPO with an NG tube to low suction?
5. Relieve nausea
6. Reduce pancreatic secretions
7. Control fluid and electrolyte imbalance

4. Remove the precipitating irritants - Correct answer 2. Correct: In clients

with pancreatitis, the pancreatic enzymes cannot exit the pancreas. These enzymes, when activated, begin to digest the pancreas itself. The enzymes become activated in the pancreas when fluid or food accumulates in the stomach. The goal in treating this client is to stop the activation of the pancreatic enzymes. Treatment is focused on keeping the stomach empty and dry. This allows the pancreas time to rest and heal. Note: Autodigestion (pancreas digesting itself) is painful for the client and can lead to other problems such as bleeding.

1. Incorrect: The primary purpose of the NG tube to suction is to keep the stomach empty and dry to decrease pancreatic enzyme production, not to relieve nausea.
2. Incorrect: Because gastric contents are removed, the NG tube to suction may lead to fluid and electrolyte disturbances rather than helping to control them.

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5. Flowers are not allowed in the room. - Correct answer 1., 2., 4., & 5.

Correct: Protective isolation is needed for this client because of the presence of a low white blood cell count. We are protecting the client from acquiring an infection. So any visitors will need to have meticulous hand washing prior to entering. The visitor should not enter if he or she has any type of infection. To decrease the risk of infection, small children should not visit. Even the mildest symptom of infection could be detrimental to the client. Flowers have bacteria and should not be brought into the room.

3. Incorrect: A mask must be worn by the visitor, not the client. The mask is worn by visitors to prevent a possible spread of an airborne infection to the immunocompromised client. A client diagnosed with major depression has been taking a selective serotonin reuptake inhibitor for the past 6 weeks. When visiting the mental health center, the nurse discusses the medication and response with the client. The nurse's assessment reveals that the client is confused about the date and about the prescribed dosage of the medication. Which question would be most important for the nurse to ask to further assess the situation?
4. Are you having trouble sleeping at night?
5. Do you have periods of muscle jerking?
6. Are you having any sexual dysfunction?

4. Is your mood improving? - Correct answer 2. Correct: Myoclonus, high

body temperature, shaking, chills, and mental confusion are some of the symptoms of serotonin syndrome. This client may be having symptoms of this adverse reaction which, if severe, can be fatal.

1. Incorrect: Sleep disturbances are common with depression. Selective serotonin reuptake inhibitors (SSRIs) may cause insomnia; however, there is a more

[Date] pertinent question needed for assessment of this client. You should be concerned with the more serious or life-threatening issue.

3. Incorrect: Sexual dysfunction may occur with the SSRIs; however, the client is exhibiting significant symptoms of an adverse reaction which would take priority.
4. Incorrect: The response to the SSRI medications is important; however, there is a more significant issue in this case. The possible serotonin syndrome is a serious situation that would be the priority for the nurse to address. A client diagnosed with serotonin syndrome is admitted to the unit. The nurse is familiar with this adverse reaction to the serotonin reuptake inhibitors. Which symptoms can the nurse expect on assessment?
5. Fever and shivering
6. Agitation
7. Decreased body temperature
8. Constipation

5. Increased heart rate - Correct answer 1., 2. & 5. Correct: Serotonin

syndrome is a group of symptoms that can result from the use of certain serotonin reuptake inhibitors. These symptoms can range from mild to severe and include high body temperature, agitation, increased reflexes, diaphoresis, tremors, dilated pupils and diarrhea. The client is likely to experience shivering with fever. Increased heart rate and blood pressure are also commonly experienced. More severe symptoms, including muscle rigidity and seizures, can occur. If not treated, serotonin syndrome can be fatal.

3. Incorrect: Increased body temperature is expected as is increased diaphoresis.

[Date] Which prescriptions would the nurse recognize as being appropriate for the client with shingles?

1. Private room
2. Negative pressure airflow
3. Respirator mask
4. Face Shield

5. Positive pressure room - Correct answer 1., 2. & 3. Correct: According to

the current standards of Standard Precautions per the CDC, the client with shingles should be placed on airborne precautions which require the use of a private room with negative pressure airflow and a N-95 respirator mask.

4. Incorrect: A face shield is used when there is risk of splashing or spraying of blood or body fluids. This is not required for airborne precautions.
5. Incorrect: Negative pressure is required in order to prevent the airborne infection from spreading outside of the room. Positive pressure is used only in protective environments such as when immunocompromised clients require protection from potential infectious agents outside of the room. A healthy newborn has just been delivered and placed in the care of the nurse. What nursing actions should the nurse initiate? Place in the correct priority order. Assess newborn's airway and breathing. Bulb suction excessive mucus. Assess newborn's heart rate.

[Date] Place identification bands on newborn and mom.

Administer sterile ophthalmic ointment containing 0.5% erythromycin. - Correct

answer Remember Maslow's hierarchy of needs will guide your assessment.

First, Assess newborn's airway and breathing. The most critical change that a newborn must make physiologically is the initiation of breathing. The nurse should assess the newborn's crying. If the cry is weak, it may indicate a respiratory disturbance. Other signs of respiratory compromise may include: stridor, grunting, retractions, apnea or diminished breath sounds. Normal respiration are 30 - 60 breaths a minute. Second, Bulb suction excessive mucus. It is important to assure that the throat and nose are kept clean of secretions to prevent respiratory distress. Third, Assess newborn's heart rate. If there is no respiratory distress, the nurse continues the assessment by checking the heart rate and other vital signs. Fourth, Place identification bands on newborn and mom. These are critical for ensuring babies and moms will be appropriately matched at all times but does not take priority over respiration and circulation. Fifth, Administer sterile ophthalmic ointment containing 0.5% erythromycin. This is a legally required prophylactic eye treatment to prevent Neisseria gonorrhea. However, this would never be a priority over Maslow's hierarchy of needs. What information should a nurse include when educating a client regarding buccal administration of a medication?

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5. Moon face - Correct answer 2., 3. & 5. Correct: Decreased wound healing is

a side effect with prolonged steroid use due to the immunosuppressive effects. All steroid medications, such as prednisone, can lead to sodium retention which then leads to dose related fluid retention. Hypertension is seen due to this fluid and sodium retention. Cushingoid appearance (moon face) is a side effect that is created from the abnormal redistribution of fat from prolonged steroid use.

1. Incorrect: Within one month after corticosteroid administration, weight gain is seen rather than weight loss.
2. Incorrect: Facial and body hair increase with prolonged steroid use. This excessive growth of body hair, known as hirsutism, is one of the numerous potential side effects of prednisone. A nurse is at highest risk for blood-borne exposure during which situation?
3. When removing a needle from the syringe.
4. While placing a suture needle into the self-locking forceps.
5. Prior to inserting the intravenous (IV) line, the client moves causing a needle stick to the nurse.

4. A clean needle sticks the nurse through blood-soiled gloves. - Correct

answer 4. Correct: A clean needle that moves through blood-soiled gloves to

stick the nurse is considered to be potentially contaminated and results in a blood-borne exposure. All other answers are considered a clean stick.

1. Incorrect: This is considered a clean stick. The needle is sterile initially and has not been contaminated prior to removal of the needle from the syringe.

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2. Incorrect: This is considered a clean stick since the suture needle has not been inserted into the client prior to the needle stick.
3. Incorrect: This is considered a clean stick. The IV insertion device is sterile and has not been contaminated since it was not inserted into the client. A new nurse is preparing to give a medication to a nine month old client. After checking a drug reference book, the nurse crushes the tablet and mixes it into 3 ounces of applesauce. The new nurse proceeds to the client's room. What priority action should the supervising nurse take?
4. Tell the new nurse to recheck the drug reference book before administering the medication.
5. Suggest that the new nurse reconsider the client's developmental needs.
6. Check the prescription order and the client dose.

4. Observe the new nurse administer the medication. - Correct answer 2.

Correct: Mixing medication with applesauce is appropriate in some circumstances, but the volume of 3 ounces is excessive for a nine month old. The nurse will want to make sure the client gets all of the medication. Additionally, applesauce may or may not have been introduced into the diet, and it is inappropriate to introduce a new food during an illness.

1. Incorrect: There is nothing in the stem about a problem with the medication dose or route.
2. Incorrect: There is nothing in the stem about a problem with the medication dose or route.

[Date] The family member of a schizophrenic client asks the nurse why the client is receiving chlorpromazine and benztropine. What is the best response by the nurse?

1. The chlorpromazine makes the benztropine more effective so a smaller dose of both drugs can be used.
2. Benztropine is given to treat the side effects produced by the chlorpromazine.
3. Chlorpromazine is used for severe hiccups that can occur with the use of benztropine.
4. Chlorpromazine is used for psychosis and benztropine is used for preventing

agranulocytosis. - Correct answer 2. Correct: Benztropine is used to treat

parkinsonism of various causes and drug-induced extrapyramidal reactions seen with chlorpromazine, which is an antipsychotic agent. Extrapyramidal symptoms are neurologic disturbances in the area of the brain that controls motor coordination. This disruption can cause symptoms that mimic Parkinson's disease, including stiffness, rigidity, tremor, drooling and the classic "mask like" facial expression. These symptoms can be treated and are reversible using such medications as benztropine.

1. Incorrect: Chlorpromazine does not potentiate the effects of benztropine, so dosage regulation is not appropriate. 3 Incorrect: Chlorpromazine can be used for severe hiccups, but the hiccups are not the result of using benztropine. Chlorpromazine is also used for psychosis in the schizophrenic client.
2. Incorrect: Benztropine is not used to prevent agranulocytosis.

[Date] A nurse is planning to provide information regarding suicide to a high school assembly. What information should the nurse include?

1. Do not keep secrets for the suicidal person.
2. Express concern for a person expressing thoughts of suicide.
3. Teens often don't mean what they say, so only take suicide seriously if grades are dropping as well.
4. Inform group of suicide intervention sources.

5. Do not leave a suicidal person alone. - Correct answer 1., 2., 4. & 5.

Correct: If a person reveals that suicide is being considered, this should never be kept secret. Help should be sought for the person immediately. It is also important to be direct and non-secretive with suicidal clients. It is appropriate to express concern for their thoughts. The use of empathy, warmth and concern indicates to the client that their feelings are being understood and viewed as real, which helps to build trust with the client. Resources for assistance are important to include in all health teaching programs. The teens need to know what resources are readily available if someone is considering suicide. The client contemplating suicide should not be left alone. This is for the client's safety until further assistance can be obtained

3. Incorrect: Most clients who commit suicide have told at least one person that they were contemplating suicide before thy actually committed the act. Therefore, suicidal comments should be considered important risk factors that require evaluation, and all comments should be taken seriously. Anyone expressing suicidal feelings needs immediate attention. The nurse is caring for a client who was admitted to the hospital following a severe motor vehicle crash (MVC) in which the client was trapped in the car for several hours. The client is being closely monitored for the development of renal failure. Which assessment finding would warrant immediate reporting?
4. Creatinine 1.1 mg/dl (97.24 mmol/L)

[Date] Captopril should not be taken during pregnancy because serious harm (possibly fatal) to the unborn baby can result when taken during pregnancy.

1. Incorrect: Captopril should not be taken during pregnancy because serious harm (possibly fatal) to the unborn baby can result when taken during pregnancy.
2. Incorrect: Captopril should not be taken during pregnancy because serious harm (possibly fatal) to the unborn baby can result when taken during pregnancy.
3. Incorrect: Captopril should not be taken during pregnancy because serious harm (possibly fatal) to the unborn baby can result when taken during pregnancy. The problem being presented in the stem is not related to general prevention of neural tube defects. Folic acid would not prevent the harm to the fetus caused by captopril. A client diagnosed with glomerulonephritis presents with generalized malaise, weight gain, generalized edema, and flank pain. The primary healthcare provider prescribes antibiotics and strict bedrest. What is the best explanation to give the client regarding the strict bedrest prescription?
4. Promotes diuresis
5. Prevents injury
6. Promotes rest

4. Stimulates RBC production - Correct answer 1. Correct: Bedrest and the

supine position promote diuresis. When the client is supine, there is a gradual shift of fluids away from the legs toward the thorax, abdomen and head. This increased volume causes the right atrium of the heart to stretch and release ANP, which leads to diuresis: renal blood flow increases due to vasodilation, and aldosterone and ADH secretion are inhibited.

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2. Incorrect: Bedrest can keep the client from falling and injuring self; however, that is not why it has been prescribed.
3. Incorrect: Promotion of rest is good, but this is not why the primary healthcare provider prescribed it. Simply promoting does not help improve the symptoms listed. The reason the client needs bedrest should focus on relieving the symptoms listed in the stem.
4. Incorrect: No relationship between bedrest and red blood cell production exists. A newly admitted client with schizophrenia has an unkempt appearance and needs to attend to personal hygiene. Which statement by the nurse is most therapeutic?
5. A shower will make you feel better.
6. It is time to take a shower.
7. Have you thought about taking a shower?

4. I need you to take a shower. - Correct answer 2. Correct: Schizophrenia is a

thought disorder. Many clients with schizophrenia are concrete thinkers and have difficulty making decisions. The nurse needs to be direct, clear and concise in communicating with the client. This is a direct, clear and concise statement that guides the client to perform the needed activity.

1. Incorrect: Many clients with schizophrenia are concrete thinkers. The nurse needs to be direct, clear and concise in communicating with the client. The client may not comprehend how the shower improves the overall sense of well-being and would remain reluctant to take the shower.

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2. Incorrect: This client is experiencing chest pain and is thus considered unstable and should be cared for by the RN.
3. Incorrect: This client has s/s that could indicate sepsis, so is considered unstable and should not be assigned to the LPN/LVN. While examining a client's health history, which data indicates to the nurse that the client is at increased risk for developing cancer?
4. Family history
5. Alcohol consumption
6. Spicy diet
7. Human papillomavirus

5. Tobacco use - Correct answer 1., 2., 4., & 5. Correct: Family history of

cancer increases the risk for having the same type of cancer. Alcohol and tobacco use increase the risk of cancer. When used together, they have a synergistic effect. Human papillomavirus (HPV) increases the risk of cervical, head, and neck cancers.

3. Incorrect: Although there are some dietary factors associated with cancer development, a spicy diet does not necessarily increase the risk of cancer. A nurse is caring for a client admitted with chronic fatigue and weakness. During the physical assessment, the nurse notes jaundiced sclera, abdominal distension, swelling in the legs and ankles, and bruises in various stages of healing throughout the body. What nursing interventions should the nurse initiate?
4. Measure abdomen

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2. Monitor intake and output
3. Obtain daily weight
4. Place on fall precautions
5. Provide three meals per day

6. Dangle legs - Correct answer 1., 2., 3., & 4. Correct: The symptoms

presented are indicative of liver disease. Measuring abdominal girth will monitor for accumulating ascitic fluid. Clients with liver disease have fluid volume problems, so daily weight and I&O are indicated. This client is at risk for injury related to chronic fatigue and weakness, so fall prevention is indicated. The client may need help eating if fatigue is severe.

5. Incorrect: Poor tolerance to larger meals may be due to abdominal distension and ascites. Clients should eat smaller, more frequent meals (6/day). The recommended diet is high calorie and low sodium with protein regulated based on liver function. Between meal snacks should be provided.
6. Incorrect: Elevating legs enhances venous return and reduces edema in extremities. Dangling the leg would cause the fluid in the lower extremities to accumulate more. A client experiencing chest pain is prescribed an intravenous infusion of nitroglycerin. After the infusion is initiated, the occurrence of which symptom would prompt the nurse to discontinue the nitroglycerin?
7. Frontal headache
8. Orthostatic hypotension
9. Decrease in intensity of chest pain

4. Cool, clammy skin - Correct answer 4. Correct: This assessment finding of

cool, clammy skin is an indication of decreased cardiac output that could be the