Hurst Review NCLEX RN Book | Latest
Review
1. The parents of a 4 year old child are concerned about whether the child will
adapt to the newborn baby they are expecting in two weeks. What
suggestions should the nurse make to assist with sibling adaptation?
Allow child to be one of the first to see the newborn.
Have child stay with parents during labor and delivery.
Arrange for one parent to spend time with the child while the other parent cares
for the newborn.
Provide a gift from the newborn to give to the child.
Have child care for a doll. - ANSWER 1., 3., 4., & 5: These are good
recommendations for the nurse to make to the parents in an effort to promote
sibling adaptation. Make the 4 year old part of the process as much as possible.
Demonstrate the importance of the child by allowing the child to see the baby
first. Provide personal time with the 4 year old. This shows that the 4 year old is
important to the family. The baby is providing a gift to the child which
promotes a bond between the two and demonstrates to the child that he or she is
important. Having a 4 year old care for a doll gets the child involved in caring
for another. The child can learn what a newborn needs both physically and
emotionally by imitating the parents.
Incorrect: This child is young and may not understand what is happening with
their mother during contractions and delivery. Does not promote sibling
adaptation. This is a 4 year old who would not understand what is going on
during labor and delivery. It can be very frightening to the child and does
nothing to support sibling adaptation.
2. 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?
Ask the UAP to put the client back in bed immediately.
Tell the UAP to take the BP in the opposite arm in 15 minutes.
Have the LPN/LVN administer the 0900 furosemide and enalapril now.
Ask the LPN/LVN to assess the client for pain. - ANSWER 3. 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.
Incorrect: This is an appropriate action, but does not address the problem of
lowering the client's blood pressure.
Incorrect: This is an appropriate action, but does not address the problem of
lowering the client's blood pressure.
Incorrect: This is an appropriate action, but does not address the problem of
lowering the client's blood pressure.
3. After reviewing the nursing notes on a client receiving a unit of packed red
blood cells, what action should the charge nurse take?
Decrease the transfusion rate to 50 mL/hour.
Assess the client for a transfusion reaction.
Check primary healthcare provider prescription for prescribed administration
time.
Stop the transfusion and send blood bag to the lab.
Exhibit:
,Nursing Notes:
1200: NS hung to y-tubing for administration of one unit of PRBCs. Initial vital
signs taken. Afebrile. Client informed of signs/symptoms of reactions to report.
Informed client that vital signs will be taken every 15 minutes for 1 hour.
1205: Unit of PRBCs checked with M. Nurse, RN as compatible. Unit #12345
hung via pump at 25 mL per hour.
1220: No signs/symptoms of reaction to blood transfusion. Vital signs stable.
Afebrile. IV rate increased to 50 mL per hour.
1620: PRBCs continue to infuse. IV rate increased to 125 mL per h - ANSWER
4. Correct: All blood from each unit of packed red blood cells must be
completed within a 4 hour time frame due to risk of hemolysis and bacterial
invasion. If the unit of blood is not completed in a 4 hour time frame, the blood
must be sent to the lab to be discarded. Keep in mind that the time frame for
administering platelets and fresh frozen plasma differs (20-30 min).
Incorrect: This blood has been hanging for 4 hours and must be discontinued.
Incorrect: The problem is that the blood has been hanging too long. It must be
taken down. There is no indication that a transfusion reaction is occurring.
Transfusion reaction symptoms include back pain, dark urine, chills, fainting or
dizziness, fever, flank pain, skin flushing, shortness of breath.
Incorrect: The problem is that the blood has been hanging too long. It must be
taken down. It cannot be hung for a longer period of time due to risk of
hemolysis and bacterial invasion.
4. A school nurse is teaching a group of preteens with acne how to care for the
skin. What points should the nurse include?
Wash face with soap and warm water.
Avoid using oily creams.
, Do not use cosmetics that block sebaceous gland ducts.
Do not squeeze lesions.
Clean face vigorously with a terry cloth. - ANSWER 1., 2., 3., & 4. Correct:
Washing the face frequently (at least twice a day) with mild soap or detergent
and warm water will remove oil, dirt, and bacteria which increase inflammatory
reactions and resulting acne. Oily creams and oil based cosmetics can block the
ducts of the sebaceous gland ducts and the hair follicles making the acne worse.
These should be avoided. Squeezing or picking at lesions will increase potential
for infection and scarring.
Incorrect: Clean face gently, as trauma during acne breakouts may worsen the
acne and cause scarring. When washing face, use hands, as terry cloth or other
scrubbing material may cause acne sores to rupture.
5. A client has sustained a major head injury as a result of a motor vehicle
accident. The emergency department nurse is assessing the client's
neurological status every 15 minutes. Which sign would the nurse recognize
as an early indicator of an increased intracranial pressure (ICP)?
Dilated and unresponsive pupils
Cheyne-Stokes respirations
Cushing's triad
Change in level of consciousness (LOC) - ANSWER 4. Correct: A change in
LOC is one of the earliest indicators of an elevated ICP.
Incorrect: Loss of pupillary reflexes is a late sign of increased ICP. Earlier
pupil changes would include gradual dilation and pupils become sluggish in
response to light.
Review
1. The parents of a 4 year old child are concerned about whether the child will
adapt to the newborn baby they are expecting in two weeks. What
suggestions should the nurse make to assist with sibling adaptation?
Allow child to be one of the first to see the newborn.
Have child stay with parents during labor and delivery.
Arrange for one parent to spend time with the child while the other parent cares
for the newborn.
Provide a gift from the newborn to give to the child.
Have child care for a doll. - ANSWER 1., 3., 4., & 5: These are good
recommendations for the nurse to make to the parents in an effort to promote
sibling adaptation. Make the 4 year old part of the process as much as possible.
Demonstrate the importance of the child by allowing the child to see the baby
first. Provide personal time with the 4 year old. This shows that the 4 year old is
important to the family. The baby is providing a gift to the child which
promotes a bond between the two and demonstrates to the child that he or she is
important. Having a 4 year old care for a doll gets the child involved in caring
for another. The child can learn what a newborn needs both physically and
emotionally by imitating the parents.
Incorrect: This child is young and may not understand what is happening with
their mother during contractions and delivery. Does not promote sibling
adaptation. This is a 4 year old who would not understand what is going on
during labor and delivery. It can be very frightening to the child and does
nothing to support sibling adaptation.
2. 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?
Ask the UAP to put the client back in bed immediately.
Tell the UAP to take the BP in the opposite arm in 15 minutes.
Have the LPN/LVN administer the 0900 furosemide and enalapril now.
Ask the LPN/LVN to assess the client for pain. - ANSWER 3. 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.
Incorrect: This is an appropriate action, but does not address the problem of
lowering the client's blood pressure.
Incorrect: This is an appropriate action, but does not address the problem of
lowering the client's blood pressure.
Incorrect: This is an appropriate action, but does not address the problem of
lowering the client's blood pressure.
3. After reviewing the nursing notes on a client receiving a unit of packed red
blood cells, what action should the charge nurse take?
Decrease the transfusion rate to 50 mL/hour.
Assess the client for a transfusion reaction.
Check primary healthcare provider prescription for prescribed administration
time.
Stop the transfusion and send blood bag to the lab.
Exhibit:
,Nursing Notes:
1200: NS hung to y-tubing for administration of one unit of PRBCs. Initial vital
signs taken. Afebrile. Client informed of signs/symptoms of reactions to report.
Informed client that vital signs will be taken every 15 minutes for 1 hour.
1205: Unit of PRBCs checked with M. Nurse, RN as compatible. Unit #12345
hung via pump at 25 mL per hour.
1220: No signs/symptoms of reaction to blood transfusion. Vital signs stable.
Afebrile. IV rate increased to 50 mL per hour.
1620: PRBCs continue to infuse. IV rate increased to 125 mL per h - ANSWER
4. Correct: All blood from each unit of packed red blood cells must be
completed within a 4 hour time frame due to risk of hemolysis and bacterial
invasion. If the unit of blood is not completed in a 4 hour time frame, the blood
must be sent to the lab to be discarded. Keep in mind that the time frame for
administering platelets and fresh frozen plasma differs (20-30 min).
Incorrect: This blood has been hanging for 4 hours and must be discontinued.
Incorrect: The problem is that the blood has been hanging too long. It must be
taken down. There is no indication that a transfusion reaction is occurring.
Transfusion reaction symptoms include back pain, dark urine, chills, fainting or
dizziness, fever, flank pain, skin flushing, shortness of breath.
Incorrect: The problem is that the blood has been hanging too long. It must be
taken down. It cannot be hung for a longer period of time due to risk of
hemolysis and bacterial invasion.
4. A school nurse is teaching a group of preteens with acne how to care for the
skin. What points should the nurse include?
Wash face with soap and warm water.
Avoid using oily creams.
, Do not use cosmetics that block sebaceous gland ducts.
Do not squeeze lesions.
Clean face vigorously with a terry cloth. - ANSWER 1., 2., 3., & 4. Correct:
Washing the face frequently (at least twice a day) with mild soap or detergent
and warm water will remove oil, dirt, and bacteria which increase inflammatory
reactions and resulting acne. Oily creams and oil based cosmetics can block the
ducts of the sebaceous gland ducts and the hair follicles making the acne worse.
These should be avoided. Squeezing or picking at lesions will increase potential
for infection and scarring.
Incorrect: Clean face gently, as trauma during acne breakouts may worsen the
acne and cause scarring. When washing face, use hands, as terry cloth or other
scrubbing material may cause acne sores to rupture.
5. A client has sustained a major head injury as a result of a motor vehicle
accident. The emergency department nurse is assessing the client's
neurological status every 15 minutes. Which sign would the nurse recognize
as an early indicator of an increased intracranial pressure (ICP)?
Dilated and unresponsive pupils
Cheyne-Stokes respirations
Cushing's triad
Change in level of consciousness (LOC) - ANSWER 4. Correct: A change in
LOC is one of the earliest indicators of an elevated ICP.
Incorrect: Loss of pupillary reflexes is a late sign of increased ICP. Earlier
pupil changes would include gradual dilation and pupils become sluggish in
response to light.
