HURST REVIEW NCLEX RN READINESS EXAM 1: LATEST A+
QUESTIONS AND ANSWERS EDITION.
What medication should the nurse anticipate giving to a client in preterm labor to
stimulate maturation of the baby's lungs?
1. Magnesium sulfate
2. Terbutaline
3. Methotrexate
4. Betamethasone
4. Correct: Betamethasone is used to stimulate maturation of the baby's lungs in case
preterm birth occurs. This medication is given to help prevent respiratory distress
syndrome (RDS) by improving storage and secretion of surfactant that helps to keep the
alveoli from collapsing.
1. Incorrect: Magnesium sulfate is given to stop preterm labor, however, if delivery is
imminent, then Betamethasone should be given to stimulate maturation of the baby's
lungs.
2. Incorrect: Terbutaline is contraindicated in preterm labor, however, if delivery is
imminent, then Betamethasone should be given to stimulate maturation of the baby's
lungs.
3. Incorrect: Methotrexate is used to stop the growth of the embryo in ectopic pregnancy
so that the fallopian tube can be saved. It is not an agent used in the management of
preterm labor.
Which client could the charge nurse assign to an LPN/VN?
1. Eight year old in diabetic ketoacidosis (DKA)
2. Six year old in sickle cell crisis
3. Two month old with dehydration
4. Five year old in skeletal traction
,4. Correct: The fracture would be most appropriate for an LPN/VN and is within the
scope of practice. This LPN/VN would need minimal assistance from the RN. Possibly,
the other clients could have intravenous fluid (IVF) needs and medications that would
require skill from an RN.
1. Incorrect: The child with DKA is in metabolic acidosis. The child is also at risk for
other problems such as dehydration and electrolyte disturbances. Therefore, the child
will need close observation and the RN's assessment skills.
2. Incorrect: IV fluid management is crucial for clients in a sickle cell crisis Assessment
of the child's cardiovascular status, tissue perfusion and neuro status are priorities. Pain
management is also very important in these clients. Therefore, the child with sickle cell
will need close observation and the RN's assessment skills.
3. Incorrect: The baby with dehydration will need close observation and the RN's
assessment skills, including monitoring for impending shock. Renal function and
electrolyte levels should be monitored closely. The care of the child will likely involve IV
fluids.
Which statement made by a client post-thyroidectomy would require further
investigation by the nurse?
1. "I have a tingling feeling of my fingers."
2. "It hurts when I move my head."
3. "I feel pressure in my arm when you take my blood pressure."
4. "My legs are weak."
1. Correct. After this procedure the nurse should worry about the possibility of some of
the parathyroids being accidentally removed with resulting hypoparathyroidism.
Hypoparathyroidism results in hypocalcemia. Signs and symptoms include tingling,
burning, or numbness of lips, fingers, and toes. The muscles may become tight and
rigid, and seizures can result.
2. Incorrect. Pain is expected here. The incision is at the base of the neck, so
,movement of the head would increase the pain.
3. Incorrect. The sensation of pressure in the arm is considered normal when the BP is
being measured. You worry if you see carpal spasm (+ Trousseau's) which is indicative
of neuromuscular excitability caused by hypocalcemia secondary to the inadvertent
removal of some of the parathyroids.
4. Incorrect. Weak/flaccid extremities would be seen with hyperparathyroidism. In this
case, we are concerned that the parathyroids may have been removed, resulting in
hypoparathyroidism. The weakness in the legs is apparently from a different cause.
However, the signs of possible hypoparathyroidism would be the priority to investigate.
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?
1. Allow child to be one of the first to see the newborn.
2. Have child stay with parents during labor and delivery.
3. Arrange for one parent to spend time with the child while the other parent cares
for the newborn.
4. Provide a gift from the newborn to give to the child.
5. Have child care for a doll.
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.
2. 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.
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.
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.
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.
4. Incorrect: This is an appropriate action, but does not address the problem of lowering
the client's blood pressure.
After reviewing the nursing notes on a client receiving a unit of packed red blood
cells, what action should the charge nurse take?
1. Decrease the transfusion rate to 50 mL/hour.
2. Assess the client for a transfusion reaction.
3. Check primary healthcare provider prescription for prescribed administration
time.
4. Stop the transfusion and send blood bag to the lab.
QUESTIONS AND ANSWERS EDITION.
What medication should the nurse anticipate giving to a client in preterm labor to
stimulate maturation of the baby's lungs?
1. Magnesium sulfate
2. Terbutaline
3. Methotrexate
4. Betamethasone
4. Correct: Betamethasone is used to stimulate maturation of the baby's lungs in case
preterm birth occurs. This medication is given to help prevent respiratory distress
syndrome (RDS) by improving storage and secretion of surfactant that helps to keep the
alveoli from collapsing.
1. Incorrect: Magnesium sulfate is given to stop preterm labor, however, if delivery is
imminent, then Betamethasone should be given to stimulate maturation of the baby's
lungs.
2. Incorrect: Terbutaline is contraindicated in preterm labor, however, if delivery is
imminent, then Betamethasone should be given to stimulate maturation of the baby's
lungs.
3. Incorrect: Methotrexate is used to stop the growth of the embryo in ectopic pregnancy
so that the fallopian tube can be saved. It is not an agent used in the management of
preterm labor.
Which client could the charge nurse assign to an LPN/VN?
1. Eight year old in diabetic ketoacidosis (DKA)
2. Six year old in sickle cell crisis
3. Two month old with dehydration
4. Five year old in skeletal traction
,4. Correct: The fracture would be most appropriate for an LPN/VN and is within the
scope of practice. This LPN/VN would need minimal assistance from the RN. Possibly,
the other clients could have intravenous fluid (IVF) needs and medications that would
require skill from an RN.
1. Incorrect: The child with DKA is in metabolic acidosis. The child is also at risk for
other problems such as dehydration and electrolyte disturbances. Therefore, the child
will need close observation and the RN's assessment skills.
2. Incorrect: IV fluid management is crucial for clients in a sickle cell crisis Assessment
of the child's cardiovascular status, tissue perfusion and neuro status are priorities. Pain
management is also very important in these clients. Therefore, the child with sickle cell
will need close observation and the RN's assessment skills.
3. Incorrect: The baby with dehydration will need close observation and the RN's
assessment skills, including monitoring for impending shock. Renal function and
electrolyte levels should be monitored closely. The care of the child will likely involve IV
fluids.
Which statement made by a client post-thyroidectomy would require further
investigation by the nurse?
1. "I have a tingling feeling of my fingers."
2. "It hurts when I move my head."
3. "I feel pressure in my arm when you take my blood pressure."
4. "My legs are weak."
1. Correct. After this procedure the nurse should worry about the possibility of some of
the parathyroids being accidentally removed with resulting hypoparathyroidism.
Hypoparathyroidism results in hypocalcemia. Signs and symptoms include tingling,
burning, or numbness of lips, fingers, and toes. The muscles may become tight and
rigid, and seizures can result.
2. Incorrect. Pain is expected here. The incision is at the base of the neck, so
,movement of the head would increase the pain.
3. Incorrect. The sensation of pressure in the arm is considered normal when the BP is
being measured. You worry if you see carpal spasm (+ Trousseau's) which is indicative
of neuromuscular excitability caused by hypocalcemia secondary to the inadvertent
removal of some of the parathyroids.
4. Incorrect. Weak/flaccid extremities would be seen with hyperparathyroidism. In this
case, we are concerned that the parathyroids may have been removed, resulting in
hypoparathyroidism. The weakness in the legs is apparently from a different cause.
However, the signs of possible hypoparathyroidism would be the priority to investigate.
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?
1. Allow child to be one of the first to see the newborn.
2. Have child stay with parents during labor and delivery.
3. Arrange for one parent to spend time with the child while the other parent cares
for the newborn.
4. Provide a gift from the newborn to give to the child.
5. Have child care for a doll.
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.
2. 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.
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.
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.
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.
4. Incorrect: This is an appropriate action, but does not address the problem of lowering
the client's blood pressure.
After reviewing the nursing notes on a client receiving a unit of packed red blood
cells, what action should the charge nurse take?
1. Decrease the transfusion rate to 50 mL/hour.
2. Assess the client for a transfusion reaction.
3. Check primary healthcare provider prescription for prescribed administration
time.
4. Stop the transfusion and send blood bag to the lab.
