HURST REVIEW NCLEX EXAM LATEST UPDATED VERSION
COMPLETE ACTUAL EXAM QUESTIONS AND CORRECT
DETAILED ANSWERS (100% CORRECT VERIFIED ANSWERS) |
ALREADY GRADED A+ (BRAND NEW!!)
What clinical manifestation does the nurse expect to see in a client suspected of
having hypercalcemia?
1. Tachycardia
2. Positive Chvostek
3. Lethargy
4. Tachypnea
5. Decreased deep tendon reflexes - ANSWER: ANS: 3., 5.
3., & 5. Correct: Hypercalcemia is a condition in which the calcium level in blood is
above normal. Too much calcium in blood can weaken bones, create kidney stones,
and interfere with heart and brain function. Hypercalcemia is usually a result of
overactive parathyroid glands. Other causes include cancer, some medications, and
taking too much of calcium and vitamin D supplements. Signs and symptoms of
hypercalcemia range from nonexistent to severe. Lethargy and decreased deep
tendon reflexes are two manifestations of hypercalcemia.
1. Incorrect: Bradycardia rather than tachycardia is seen with hypercalcemia.
Remember - muscles are sedated.
2. Incorrect: A Negative Chvostek will be seen with hypercalcemia. It will be positive
in hypocalcemia.
4. Incorrect: Hypercalcemia will result in a decreased, rather than increased
respiratory rate.
A client has been admitted with a diagnosis of septic shock and has been successfully
intubated. The nurse performs and documents a rapid assessment. Which
information from the assessment requires the most immediate action by the nurse?
Vital Signs: Blood Pressure 92/54 mmHg, Heart Rate 116 bpm, Respiratory Rate 22
breaths/min, Temperature 103F (39.4C), Oxygen Saturation 91%.
Documentation: Heart tones irregular, distant. Face flushed and warm. Extremities
cool and mottled. Radial pulses faintly palpable. Pedal pulses non-palpable. Denies
chest pain. Endotracheal tube taped in place via oropharynx. Right anterior and
posterior lung sounds clear. Unable to hear left lung sounds. Grimaces with light
abdominal palpation over pelvic bone. Urine amber and cloudy with red streaks. 100
mL urine output in foley catheter bag. Opens eyes and moves to command. Pupils
equal, round, and react to light.
1. Lung assessment findi - ANSWER: ANS: 1.
1. Correct: Look at the clues: Endotracheal tube taped in place via oropharynx. Right
anterior and posterior lung sounds clear. Unable to hear left lung sounds. The ET
,tube is likely down in the right main stem bronchus. This means the left lung is not
being oxygenated.
2. Incorrect: The BP is above 90 systolic, so the vital organs are still being perfused.
The nurse will definitely keep monitoring, but this is not the priority.
3. Incorrect: The second priority is to treat the infection that is likely the cause of the
temperature elevation. But take care of that airway first.
4. Incorrect: This is the likely cause of the sepsis, but the priority is to fix the airway
problem.
Based on the results of the arterial blood gases (ABGs), what imbalance does the
nurse understand the client to be exhibiting?
ABGs:
pH - 7.35
PaO2 - 95%
PaCO2 - 49
HCO3 - 30
1. Respiratory acidosis compensated
2. Respiratory acidosis partially compensated
3. Metabolic acidosis compensated
4. Metabolic acidosis partially compensated - ANSWER: ANS: 1.
1. Correct: The pH is normal but is on the acidic side of normal. The PaCO2 is
elevated, causing acid formation. The HCO3 is alkalotic and is increased to buffer the
acid. The pH and PaCO2 match, so the original problem was respiratory acidosis, but
compensation has occurred since the pH is now normal.
2. Incorrect: The pH is normal but is on the acidic side of normal. The PaCO2 is acid.
The HCO3 is alkalotic. The pH and PaCO2 match, so the original problem was
respiratory acidosis, but compensation has occurred since the pH is now low.
3. Incorrect: The pH is normal but is on the acidic side of normal. The PaCO2 is acid.
The HCO3 is alkalotic. The pH and PaCO2 match, so the original problem was
respiratory acidosis, but compensation has occurred since the pH is now low.
4. Incorrect: The pH is normal but is on the acidic side of normal. The PaCO2 is acid.
The HCO3 is alkalotic. The pH and PaCO2 match, so the original problem was
respiratory acidosis, but compensation has occurred since the pH is now low.
The nurse is caring for a client in the emergency department with agitation, diarrhea,
and peripheral edema. Family reports client has a history of chronic renal damage
and has been taking a lot of antacids for indigestion. Which alterations in the arterial
blood gases would the nurse expect to find?
1. pH: 7.34, PaCO2: 48, HCO3: 29
2. pH: 7.50, PaCO2: 35, HCO3: 32
3. pH: 7.32, PaCO2: 36, HCO3: 20
4. pH: 7.42, PaCO2: 40, HCO3: 24 - ANSWER: ANS: 2.
2. Correct: Metabolic alkalosis may not show any symptoms. People with this type of
alkalosis more often complain of the underlying conditions that are causing it. These
can include vomiting, diarrhea, swelling in the lower legs, and fatigue. Severe cases
,of metabolic alkalosis can cause agitation, disorientation, seizures, and coma. So we
are looking for ABGs that indicate that this client is in metabolic alkalosis. A pH of
7.50 is higher than the normal pH value of 7.45, which indicates alkalosis. The PaCO2
is 35, which is on the low end of normal (34-45). The HCO3 is 32, which is higher than
the normal HCO3 of 26, which indicates alkalosis. So the Bicarb (Kidney chemical)
matches the pH. Metabolic alkalosis.
1. Incorrect: This is partially compensated respiratory acidosis. pH: 7.34 (acid),
PaCO2: 48 (acid), HCO3: 29 (alkaline)
3. Incorrect: This is metabolic acidosis. pH: 7.32 (acid), PaCO2: 36 (normal), HCO3: 20
(acid)
4. Incorrect: These are normal ABGs. pH: 7.42 (normal), PaCO2: 40 (normal), HCO3:
24 (normal)
Which signs and symptoms would concern the nurse if assessed in a client post
radical neck surgery?
1. Dysphagia
2. Facial numbness
3. Flushed and warm skin
4. Laryngeal stridor
5. Negative Chvostek's sign - ANSWER: ANS: 1., 2., 4.
1., 2., & 4. Correct: Dyspnea, facial numbness and laryngeal stridor are signs
indicating that muscles are rigid and tight due to a low calcium level. Some of the
parathyroids could have been removed resulting in hypocalcemia.
3. Incorrect: Flushed and warm skin would be seen with hypermagnesemia due to
vasodilation.
5. Incorrect: A negative Chvostek's sign is a good thing. It would be positive if the
calcium level is low.
An intravenous infusion of 0.9% normal saline is prescribed at a rate of 1000 mL in
12 hours. The tubing has a drop factor of 15. How many drops per minute (gtts/min)
are delivered? Round your answer to the nearest whole number.
Provide your answer using numbers and decimal points only. - ANSWER: ANS: 21
The formula used to calculate drop rates is the total number of milliliters divided by
the total number of minutes multiplied by the drop factor. In this circumstance, the
minutes portion must be figured first, that is, 12 hours equals 720 minutes. Then,
dividing 1000 by 720 equals 1.38888889. This is multiplied by the drop factor, which
is 15. Multiplying 15 by 1.38888889 equals 20.83, which rounds to 21.
A client arrives at the emergency department after being removed from a burning
building. The nurse suspects carbon monoxide poisoning when the client exhibits
which signs and symptoms?
1. Almond odor to breath
2. Blurred Vision
3. Dull headache
4. Excess salivation
5. Respirations 10 - ANSWER: ANS: 2., 3., 5.
, 2.,3. & 5. Correct: Not enough oxygen is getting to the vital organs, such as the brain
and heart, so blurred vision, a dull headache and respiratory depression can occur.
1. Incorrect: An almond odor to the breath is a manifestation of cyanide poisoning.
4. Incorrect: Excessive salivation can be seen with ingestion of acids or alkalis.
The client has pustules on the arm from intravenous drug abuse. The microbiology
laboratory informs the nurse that the client's cultures are growing methicillin-
resistant Staphylococcus aureus (MRSA). Which action would the nurse take?
1. Cover the pustules to prevent drainage.
2. Implement contact precautions immediately.
3. Instruct the client on the importance of hand hygiene.
4. Inform the client to wear a mask when ambulating in the hall.
5. Instruct visitors to wash hands before entering the client's room. - ANSWER: ANS:
1., 2., 3., 5.
1., 2., 3. & 5. Correct: The pustules should be covered with a dressing, because MRSA
is transmitted via contact! It is important that the nurse implement these
interventions in order to prevent the spread of infection. The number one way to
prevent the spread of infection is handwashing. That includes the client, staff, and
visitors. If the client refuses to follow instructions, then isolation precautions are
warranted.
4. Incorrect: The client is placed on contact precautions not droplet precautions. The
client would not need to wear a mask since the infection is not transmitted via the
respiratory system.
The nurse is caring for a client 8 hours post colectomy who is receiving 40%
humidified oxygen. ABG results are: pH= 7.30, pO2= 91, pCO2= 50, HCO3= 24. Based
on this information, which nursing action should the nurse initiate?
1. Reposition the client every 2 hours.
2. Request respiratory therapy to perform postural drainage and percussion.
3. Increase oxygen percentage.
4. Initiate incentive spirometry.
5. Assess mental status. - ANSWER: ANS: 1., 4., 5.
1., 4., & 5. Correct: If you had just a colectomy, would you be taking nice deep
breaths? No. So what would you be retaining? CO2, which makes your pCO2 go up
and your pH go down. These interventions will help improve gas exchange.
2. Incorrect: Requesting postural drainage and percussion form respiratory therapy
would not be the best nursing action to address the problem of retaining CO2.
3. Incorrect: How is oxygen going to help this client? It's not until they get rid of
what? CO2. And the only way to rid of the CO2 is coughing and deep breathing.
An agitated client arrives in the emergency department reporting fatigue, diarrhea,
and swelling in the legs. Current health history includes cirrhosis. Current
medications include spironolactone 25 mg by mouth every morning. What acid/base
imbalance does the nurse anticipate for this client?
1. Respiratory acidosis
2. Respiratory alkalosis
3. Metabolic acidosis
COMPLETE ACTUAL EXAM QUESTIONS AND CORRECT
DETAILED ANSWERS (100% CORRECT VERIFIED ANSWERS) |
ALREADY GRADED A+ (BRAND NEW!!)
What clinical manifestation does the nurse expect to see in a client suspected of
having hypercalcemia?
1. Tachycardia
2. Positive Chvostek
3. Lethargy
4. Tachypnea
5. Decreased deep tendon reflexes - ANSWER: ANS: 3., 5.
3., & 5. Correct: Hypercalcemia is a condition in which the calcium level in blood is
above normal. Too much calcium in blood can weaken bones, create kidney stones,
and interfere with heart and brain function. Hypercalcemia is usually a result of
overactive parathyroid glands. Other causes include cancer, some medications, and
taking too much of calcium and vitamin D supplements. Signs and symptoms of
hypercalcemia range from nonexistent to severe. Lethargy and decreased deep
tendon reflexes are two manifestations of hypercalcemia.
1. Incorrect: Bradycardia rather than tachycardia is seen with hypercalcemia.
Remember - muscles are sedated.
2. Incorrect: A Negative Chvostek will be seen with hypercalcemia. It will be positive
in hypocalcemia.
4. Incorrect: Hypercalcemia will result in a decreased, rather than increased
respiratory rate.
A client has been admitted with a diagnosis of septic shock and has been successfully
intubated. The nurse performs and documents a rapid assessment. Which
information from the assessment requires the most immediate action by the nurse?
Vital Signs: Blood Pressure 92/54 mmHg, Heart Rate 116 bpm, Respiratory Rate 22
breaths/min, Temperature 103F (39.4C), Oxygen Saturation 91%.
Documentation: Heart tones irregular, distant. Face flushed and warm. Extremities
cool and mottled. Radial pulses faintly palpable. Pedal pulses non-palpable. Denies
chest pain. Endotracheal tube taped in place via oropharynx. Right anterior and
posterior lung sounds clear. Unable to hear left lung sounds. Grimaces with light
abdominal palpation over pelvic bone. Urine amber and cloudy with red streaks. 100
mL urine output in foley catheter bag. Opens eyes and moves to command. Pupils
equal, round, and react to light.
1. Lung assessment findi - ANSWER: ANS: 1.
1. Correct: Look at the clues: Endotracheal tube taped in place via oropharynx. Right
anterior and posterior lung sounds clear. Unable to hear left lung sounds. The ET
,tube is likely down in the right main stem bronchus. This means the left lung is not
being oxygenated.
2. Incorrect: The BP is above 90 systolic, so the vital organs are still being perfused.
The nurse will definitely keep monitoring, but this is not the priority.
3. Incorrect: The second priority is to treat the infection that is likely the cause of the
temperature elevation. But take care of that airway first.
4. Incorrect: This is the likely cause of the sepsis, but the priority is to fix the airway
problem.
Based on the results of the arterial blood gases (ABGs), what imbalance does the
nurse understand the client to be exhibiting?
ABGs:
pH - 7.35
PaO2 - 95%
PaCO2 - 49
HCO3 - 30
1. Respiratory acidosis compensated
2. Respiratory acidosis partially compensated
3. Metabolic acidosis compensated
4. Metabolic acidosis partially compensated - ANSWER: ANS: 1.
1. Correct: The pH is normal but is on the acidic side of normal. The PaCO2 is
elevated, causing acid formation. The HCO3 is alkalotic and is increased to buffer the
acid. The pH and PaCO2 match, so the original problem was respiratory acidosis, but
compensation has occurred since the pH is now normal.
2. Incorrect: The pH is normal but is on the acidic side of normal. The PaCO2 is acid.
The HCO3 is alkalotic. The pH and PaCO2 match, so the original problem was
respiratory acidosis, but compensation has occurred since the pH is now low.
3. Incorrect: The pH is normal but is on the acidic side of normal. The PaCO2 is acid.
The HCO3 is alkalotic. The pH and PaCO2 match, so the original problem was
respiratory acidosis, but compensation has occurred since the pH is now low.
4. Incorrect: The pH is normal but is on the acidic side of normal. The PaCO2 is acid.
The HCO3 is alkalotic. The pH and PaCO2 match, so the original problem was
respiratory acidosis, but compensation has occurred since the pH is now low.
The nurse is caring for a client in the emergency department with agitation, diarrhea,
and peripheral edema. Family reports client has a history of chronic renal damage
and has been taking a lot of antacids for indigestion. Which alterations in the arterial
blood gases would the nurse expect to find?
1. pH: 7.34, PaCO2: 48, HCO3: 29
2. pH: 7.50, PaCO2: 35, HCO3: 32
3. pH: 7.32, PaCO2: 36, HCO3: 20
4. pH: 7.42, PaCO2: 40, HCO3: 24 - ANSWER: ANS: 2.
2. Correct: Metabolic alkalosis may not show any symptoms. People with this type of
alkalosis more often complain of the underlying conditions that are causing it. These
can include vomiting, diarrhea, swelling in the lower legs, and fatigue. Severe cases
,of metabolic alkalosis can cause agitation, disorientation, seizures, and coma. So we
are looking for ABGs that indicate that this client is in metabolic alkalosis. A pH of
7.50 is higher than the normal pH value of 7.45, which indicates alkalosis. The PaCO2
is 35, which is on the low end of normal (34-45). The HCO3 is 32, which is higher than
the normal HCO3 of 26, which indicates alkalosis. So the Bicarb (Kidney chemical)
matches the pH. Metabolic alkalosis.
1. Incorrect: This is partially compensated respiratory acidosis. pH: 7.34 (acid),
PaCO2: 48 (acid), HCO3: 29 (alkaline)
3. Incorrect: This is metabolic acidosis. pH: 7.32 (acid), PaCO2: 36 (normal), HCO3: 20
(acid)
4. Incorrect: These are normal ABGs. pH: 7.42 (normal), PaCO2: 40 (normal), HCO3:
24 (normal)
Which signs and symptoms would concern the nurse if assessed in a client post
radical neck surgery?
1. Dysphagia
2. Facial numbness
3. Flushed and warm skin
4. Laryngeal stridor
5. Negative Chvostek's sign - ANSWER: ANS: 1., 2., 4.
1., 2., & 4. Correct: Dyspnea, facial numbness and laryngeal stridor are signs
indicating that muscles are rigid and tight due to a low calcium level. Some of the
parathyroids could have been removed resulting in hypocalcemia.
3. Incorrect: Flushed and warm skin would be seen with hypermagnesemia due to
vasodilation.
5. Incorrect: A negative Chvostek's sign is a good thing. It would be positive if the
calcium level is low.
An intravenous infusion of 0.9% normal saline is prescribed at a rate of 1000 mL in
12 hours. The tubing has a drop factor of 15. How many drops per minute (gtts/min)
are delivered? Round your answer to the nearest whole number.
Provide your answer using numbers and decimal points only. - ANSWER: ANS: 21
The formula used to calculate drop rates is the total number of milliliters divided by
the total number of minutes multiplied by the drop factor. In this circumstance, the
minutes portion must be figured first, that is, 12 hours equals 720 minutes. Then,
dividing 1000 by 720 equals 1.38888889. This is multiplied by the drop factor, which
is 15. Multiplying 15 by 1.38888889 equals 20.83, which rounds to 21.
A client arrives at the emergency department after being removed from a burning
building. The nurse suspects carbon monoxide poisoning when the client exhibits
which signs and symptoms?
1. Almond odor to breath
2. Blurred Vision
3. Dull headache
4. Excess salivation
5. Respirations 10 - ANSWER: ANS: 2., 3., 5.
, 2.,3. & 5. Correct: Not enough oxygen is getting to the vital organs, such as the brain
and heart, so blurred vision, a dull headache and respiratory depression can occur.
1. Incorrect: An almond odor to the breath is a manifestation of cyanide poisoning.
4. Incorrect: Excessive salivation can be seen with ingestion of acids or alkalis.
The client has pustules on the arm from intravenous drug abuse. The microbiology
laboratory informs the nurse that the client's cultures are growing methicillin-
resistant Staphylococcus aureus (MRSA). Which action would the nurse take?
1. Cover the pustules to prevent drainage.
2. Implement contact precautions immediately.
3. Instruct the client on the importance of hand hygiene.
4. Inform the client to wear a mask when ambulating in the hall.
5. Instruct visitors to wash hands before entering the client's room. - ANSWER: ANS:
1., 2., 3., 5.
1., 2., 3. & 5. Correct: The pustules should be covered with a dressing, because MRSA
is transmitted via contact! It is important that the nurse implement these
interventions in order to prevent the spread of infection. The number one way to
prevent the spread of infection is handwashing. That includes the client, staff, and
visitors. If the client refuses to follow instructions, then isolation precautions are
warranted.
4. Incorrect: The client is placed on contact precautions not droplet precautions. The
client would not need to wear a mask since the infection is not transmitted via the
respiratory system.
The nurse is caring for a client 8 hours post colectomy who is receiving 40%
humidified oxygen. ABG results are: pH= 7.30, pO2= 91, pCO2= 50, HCO3= 24. Based
on this information, which nursing action should the nurse initiate?
1. Reposition the client every 2 hours.
2. Request respiratory therapy to perform postural drainage and percussion.
3. Increase oxygen percentage.
4. Initiate incentive spirometry.
5. Assess mental status. - ANSWER: ANS: 1., 4., 5.
1., 4., & 5. Correct: If you had just a colectomy, would you be taking nice deep
breaths? No. So what would you be retaining? CO2, which makes your pCO2 go up
and your pH go down. These interventions will help improve gas exchange.
2. Incorrect: Requesting postural drainage and percussion form respiratory therapy
would not be the best nursing action to address the problem of retaining CO2.
3. Incorrect: How is oxygen going to help this client? It's not until they get rid of
what? CO2. And the only way to rid of the CO2 is coughing and deep breathing.
An agitated client arrives in the emergency department reporting fatigue, diarrhea,
and swelling in the legs. Current health history includes cirrhosis. Current
medications include spironolactone 25 mg by mouth every morning. What acid/base
imbalance does the nurse anticipate for this client?
1. Respiratory acidosis
2. Respiratory alkalosis
3. Metabolic acidosis
