HURST REVIEW NCLEX-RN Readiness
Exam 1. Newest 2026-2027. Questions
& Correct Answers. Graded A
A 70 year old client was admitted to the vascular surgery unit during the
night shift with chronic hypertension. At 0830, the unlicensed nursing
assistant (UAP) reports that the client's BP is 198/94. What would be the
best action for the charge nurse to delegate at this time?
1. Ask the UAP to put the client back in bed immediately.
2. Tell the UAP to take the BP in the opposite arm in 15 minutes.
3. Have the LPN/LVN administer the 0900 furosemide and enalapril now.
4. Ask the LPN/LVN to assess the client for pain. - ANS3. Correct: The
nurse should recognize the need for measures to reduce the blood
pressure. Administering the client's blood pressure medicine is aimed at
correcting the problem. It is appropriate to administer the medications at
this time in relation to the time that the next dose is due.
1. Incorrect: This is an appropriate action, but does not address the
problem of lowering the client's blood pressure.
2. Incorrect: This is an appropriate action, but does not address the
problem of lowering the client's blood pressure.
1
,4. Incorrect: This is an appropriate action, but does not address the
problem of lowering the client's blood pressure.
A case manager is assessing an unresponsive client diagnosed with
terminal hepatic encephalopathy for equipment needs upon discharge
home for hospice care. Which equipment should the case manager obtain
for this client?
1. Alternating pressure mattress
2. Hospital bed
3. Walker
4. Suction equipment
5. Oxygen - ANS 1., 2., 4., & 5. Correct: An alternating pressure mattress
will help to prevent pressure ulcers. The risk of respiratory compromise
increases as the neurologic status deteriorates. A hospital bed is needed
so that the head of the client's bed can be elevated to 30 degrees to ease
respirations and decrease the work of breathing. The client with hepatic
encephalopathy is unresponsive due to accumulation of toxins and may
need suctioning if unable to clear secretions from the oropharynx. Hepatic
encephalopathy frequently has associated bleeding varices. The increasing
ascites leads to hypovolemia. Both of these conditions can result in
hypoxemia for the client at the end stages of liver disease; therefore,
oxygen therapy is provided.
3. Incorrect: As hepatic encephalopathy progresses and toxins accumulate,
the client lapses into a coma. Therefore, the unresponsive client will not be
ambulatory and would not need a walker.
2
,A child is being admitted with possible rheumatic fever. What assessment
data would be most important for the nurse to obtain from the parent?
1. 102° F (38.89° C) temperature that started 2 days previously.
2. History of pharyngitis approximately 4 weeks ago.
3. Vomiting for 3 days.
4. A cough that started about 1 week earlier. - ANS2. Correct: Rheumatic
fever is often the result of untreated or improperly treated group A β-
hemolytic streptococcal infections (GABHS), such as pharyngitis.
Therefore, the history of pharyngitis or upper respiratory infection is a key
assessment finding for establishing a diagnosis of rheumatic fever.
Subsequent development of rheumatic fever usually occurs 2 to 6 weeks
following the GABHS, so the assessment should include a remote history
of pharyngitis.
1. Incorrect: The fever with rheumatic fever is usually low grade and is
considered a minor manifestation of rheumatic fever.
3. Incorrect: Vomiting is not a commonly associated symptom with
rheumatic fever and is not considered a major manifestation of rheumatic
fever. Although the child may have a history of vomiting, this finding would
not be specific to rheumatic fever.
4. Incorrect: A cough is not an associated symptom of rheumatic fever. The
time frame for the development of rheumatic fever is not appropriate if the
cough started 1 week earlier, even if it had been associated with an upper
respiratory streptococcal infection.
3
, A client arrives in the emergency department after severely lacerating the
left hand with a knife. HR 96, BP 150/88, R 36. The client is extremely
anxious and crying uncontrollably. Based on this assessment, the nurse
should anticipate that this client is likely in which acid base imbalance?
1. Respiratory acidosis
2. Respiratory alkalosis
3. Metabolic acidosis
4. Metabolic alkalosis - ANS2. Correct: Hyperventilation due to anxiety,
pain, shock, severe infection, fever, liver failure can lead to respiratory
alkalosis. With each of these, the client loses too much CO2. The reduction
of CO2 creates an excessive loss of acid, resulting in an alkalotic state.
Since the problem is respiratory, it is respiratory alkalosis.
1. Incorrect: This problem is respiratory, but there is excessive CO2 loss.
CO2 combines with water to form an acid. If too much of the CO2 is lost,
the result of the acid forming substance loss would be alkalosis-Not
acidosis.
3. Incorrect: The problem in this situation is respiratory in origin and has
acid loss. Therefore, it is not metabolic nor acidotic in nature.
4. Incorrect: The problem in this situation is the excessive loss of CO2 from
the respiratory system secondary to hyperventilation. Although the CO2
loss creates an alkalotic state, it is respiratory, not metabolic in origin.
A client asked the nurse what could have caused them to develop right
sided heart failure? What would be the best response by the nurse?
4
Exam 1. Newest 2026-2027. Questions
& Correct Answers. Graded A
A 70 year old client was admitted to the vascular surgery unit during the
night shift with chronic hypertension. At 0830, the unlicensed nursing
assistant (UAP) reports that the client's BP is 198/94. What would be the
best action for the charge nurse to delegate at this time?
1. Ask the UAP to put the client back in bed immediately.
2. Tell the UAP to take the BP in the opposite arm in 15 minutes.
3. Have the LPN/LVN administer the 0900 furosemide and enalapril now.
4. Ask the LPN/LVN to assess the client for pain. - ANS3. Correct: The
nurse should recognize the need for measures to reduce the blood
pressure. Administering the client's blood pressure medicine is aimed at
correcting the problem. It is appropriate to administer the medications at
this time in relation to the time that the next dose is due.
1. Incorrect: This is an appropriate action, but does not address the
problem of lowering the client's blood pressure.
2. Incorrect: This is an appropriate action, but does not address the
problem of lowering the client's blood pressure.
1
,4. Incorrect: This is an appropriate action, but does not address the
problem of lowering the client's blood pressure.
A case manager is assessing an unresponsive client diagnosed with
terminal hepatic encephalopathy for equipment needs upon discharge
home for hospice care. Which equipment should the case manager obtain
for this client?
1. Alternating pressure mattress
2. Hospital bed
3. Walker
4. Suction equipment
5. Oxygen - ANS 1., 2., 4., & 5. Correct: An alternating pressure mattress
will help to prevent pressure ulcers. The risk of respiratory compromise
increases as the neurologic status deteriorates. A hospital bed is needed
so that the head of the client's bed can be elevated to 30 degrees to ease
respirations and decrease the work of breathing. The client with hepatic
encephalopathy is unresponsive due to accumulation of toxins and may
need suctioning if unable to clear secretions from the oropharynx. Hepatic
encephalopathy frequently has associated bleeding varices. The increasing
ascites leads to hypovolemia. Both of these conditions can result in
hypoxemia for the client at the end stages of liver disease; therefore,
oxygen therapy is provided.
3. Incorrect: As hepatic encephalopathy progresses and toxins accumulate,
the client lapses into a coma. Therefore, the unresponsive client will not be
ambulatory and would not need a walker.
2
,A child is being admitted with possible rheumatic fever. What assessment
data would be most important for the nurse to obtain from the parent?
1. 102° F (38.89° C) temperature that started 2 days previously.
2. History of pharyngitis approximately 4 weeks ago.
3. Vomiting for 3 days.
4. A cough that started about 1 week earlier. - ANS2. Correct: Rheumatic
fever is often the result of untreated or improperly treated group A β-
hemolytic streptococcal infections (GABHS), such as pharyngitis.
Therefore, the history of pharyngitis or upper respiratory infection is a key
assessment finding for establishing a diagnosis of rheumatic fever.
Subsequent development of rheumatic fever usually occurs 2 to 6 weeks
following the GABHS, so the assessment should include a remote history
of pharyngitis.
1. Incorrect: The fever with rheumatic fever is usually low grade and is
considered a minor manifestation of rheumatic fever.
3. Incorrect: Vomiting is not a commonly associated symptom with
rheumatic fever and is not considered a major manifestation of rheumatic
fever. Although the child may have a history of vomiting, this finding would
not be specific to rheumatic fever.
4. Incorrect: A cough is not an associated symptom of rheumatic fever. The
time frame for the development of rheumatic fever is not appropriate if the
cough started 1 week earlier, even if it had been associated with an upper
respiratory streptococcal infection.
3
, A client arrives in the emergency department after severely lacerating the
left hand with a knife. HR 96, BP 150/88, R 36. The client is extremely
anxious and crying uncontrollably. Based on this assessment, the nurse
should anticipate that this client is likely in which acid base imbalance?
1. Respiratory acidosis
2. Respiratory alkalosis
3. Metabolic acidosis
4. Metabolic alkalosis - ANS2. Correct: Hyperventilation due to anxiety,
pain, shock, severe infection, fever, liver failure can lead to respiratory
alkalosis. With each of these, the client loses too much CO2. The reduction
of CO2 creates an excessive loss of acid, resulting in an alkalotic state.
Since the problem is respiratory, it is respiratory alkalosis.
1. Incorrect: This problem is respiratory, but there is excessive CO2 loss.
CO2 combines with water to form an acid. If too much of the CO2 is lost,
the result of the acid forming substance loss would be alkalosis-Not
acidosis.
3. Incorrect: The problem in this situation is respiratory in origin and has
acid loss. Therefore, it is not metabolic nor acidotic in nature.
4. Incorrect: The problem in this situation is the excessive loss of CO2 from
the respiratory system secondary to hyperventilation. Although the CO2
loss creates an alkalotic state, it is respiratory, not metabolic in origin.
A client asked the nurse what could have caused them to develop right
sided heart failure? What would be the best response by the nurse?
4
