2
HURST REVIEW NCLEX-RN Readiness Exam 1 with accurate || || || || || || || ||
detailed answers ||
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 - ✔✔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.
|| || || ||
3. 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. || || ||
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. || ||
,2
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?
|| || ||
1. Relieve nausea
|| ||
2. Reduce pancreatic secretions
|| || ||
3. Control fluid and electrolyte imbalance
|| || || || ||
4. Remove the precipitating irritants - ✔✔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.
|| || || || || || || || || ||
3. Incorrect: Because gastric contents are removed, the NG tube to suction may lead to fluid
|| || || || || || || || || || || || || || || ||
and electrolyte disturbances rather than helping to control them.
|| || || || || || || ||
4. Incorrect: Although the food in the stomach causes the pancreatic enzymes to become
|| || || || || || || || || || || || || ||
activated in the pancreas due to the obstruction, the food is not considered an irritant.
|| || || || || || || || || || || || || || ||
Precipitating irritants are not a part of the pathophysiology occurring with pancreatitis.
|| || || || || || || || || || ||
The nurse is working with a committee at the local school to develop an emergency
|| || || || || || || || || || || || || || ||
preparedness plan for tornados. What should be included in the plan? || || || || || || || || || ||
1. Identification of safe zones.
|| || || ||
2. Methods for accounting for all people present in the building.
|| || || || || || || || || ||
,2
3. Warning system activation.
|| || ||
4. Identification of the gymnasium as the routine safe place.
|| || || || || || || || ||
5. Regular practice protocols. - ✔✔1., 2., 3. & 5. Correct: Everyone should be aware of safe
|| || || || || || || || || || || || || || || || ||
zones within the school. Personnel should be given this information and signs posted in
|| || || || || || || || || || || || || ||
safe zones. There must be systems in place to accurately determine the number of people in
|| || || || || || || || || || || || || || || ||
the building at any given time. There also must be a system in place to alert personnel and
|| || || || || || || || || || || || || || || || || ||
students of tornado warnings. Regular practice prepares everyone for an actual event.
|| || || || || || || || || || ||
4. Incorrect: Gymnasiums are not considered safe places due to wide expanse of roof. Safe
|| || || || || || || || || || || || || || ||
zones should be on interior walls, no windows, and a strong concrete floor if possible.
|| || || || || || || || || || || || || ||
What should a nurse teach family members prior to them entering the room of a client who
|| || || || || || || || || || || || || || || || ||
has agranulocytosis?
||
1. Meticulous hand washing is needed.
|| || || || ||
2. Do not visit if you have any infection.
|| || || || || || || ||
3. The client must wear a mask.
|| || || || || ||
4. Children under 12 may not visit.
|| || || || || ||
5. Flowers are not allowed in the room. - ✔✔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.
, 2
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?
|| || || || || || || || || || || || || ||
1. Are you having trouble sleeping at night?
|| || || || || || ||
2. Do you have periods of muscle jerking?
|| || || || || || ||
3. Are you having any sexual dysfunction?
|| || || || || ||
4. Is your mood improving? - ✔✔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 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? || || ||
1. Fever and shivering
|| || ||
2. Agitation
||
3. Decreased body temperature
|| || ||
HURST REVIEW NCLEX-RN Readiness Exam 1 with accurate || || || || || || || ||
detailed answers ||
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 - ✔✔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.
|| || || ||
3. 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. || || ||
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. || ||
,2
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?
|| || ||
1. Relieve nausea
|| ||
2. Reduce pancreatic secretions
|| || ||
3. Control fluid and electrolyte imbalance
|| || || || ||
4. Remove the precipitating irritants - ✔✔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.
|| || || || || || || || || ||
3. Incorrect: Because gastric contents are removed, the NG tube to suction may lead to fluid
|| || || || || || || || || || || || || || || ||
and electrolyte disturbances rather than helping to control them.
|| || || || || || || ||
4. Incorrect: Although the food in the stomach causes the pancreatic enzymes to become
|| || || || || || || || || || || || || ||
activated in the pancreas due to the obstruction, the food is not considered an irritant.
|| || || || || || || || || || || || || || ||
Precipitating irritants are not a part of the pathophysiology occurring with pancreatitis.
|| || || || || || || || || || ||
The nurse is working with a committee at the local school to develop an emergency
|| || || || || || || || || || || || || || ||
preparedness plan for tornados. What should be included in the plan? || || || || || || || || || ||
1. Identification of safe zones.
|| || || ||
2. Methods for accounting for all people present in the building.
|| || || || || || || || || ||
,2
3. Warning system activation.
|| || ||
4. Identification of the gymnasium as the routine safe place.
|| || || || || || || || ||
5. Regular practice protocols. - ✔✔1., 2., 3. & 5. Correct: Everyone should be aware of safe
|| || || || || || || || || || || || || || || || ||
zones within the school. Personnel should be given this information and signs posted in
|| || || || || || || || || || || || || ||
safe zones. There must be systems in place to accurately determine the number of people in
|| || || || || || || || || || || || || || || ||
the building at any given time. There also must be a system in place to alert personnel and
|| || || || || || || || || || || || || || || || || ||
students of tornado warnings. Regular practice prepares everyone for an actual event.
|| || || || || || || || || || ||
4. Incorrect: Gymnasiums are not considered safe places due to wide expanse of roof. Safe
|| || || || || || || || || || || || || || ||
zones should be on interior walls, no windows, and a strong concrete floor if possible.
|| || || || || || || || || || || || || ||
What should a nurse teach family members prior to them entering the room of a client who
|| || || || || || || || || || || || || || || || ||
has agranulocytosis?
||
1. Meticulous hand washing is needed.
|| || || || ||
2. Do not visit if you have any infection.
|| || || || || || || ||
3. The client must wear a mask.
|| || || || || ||
4. Children under 12 may not visit.
|| || || || || ||
5. Flowers are not allowed in the room. - ✔✔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.
, 2
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?
|| || || || || || || || || || || || || ||
1. Are you having trouble sleeping at night?
|| || || || || || ||
2. Do you have periods of muscle jerking?
|| || || || || || ||
3. Are you having any sexual dysfunction?
|| || || || || ||
4. Is your mood improving? - ✔✔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 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? || || ||
1. Fever and shivering
|| || ||
2. Agitation
||
3. Decreased body temperature
|| || ||
