HURST REVIEW NCLEX RN READINESS EXAM 1: LATEST A+
QUESTIONS AND ANSWERS EDITION.
Which interventions should be included in the plan of care for an adult client with
constipation?
1. Allow adequate time for defecation.
2. Provide privacy for bowel elimination.
3. Suggest increasing fluid intake (unless contraindicated).
4. Encourage client to increase fiber in the diet.
5. Encourage the client to delay the urge to defecate until after a meal.
1., 2., 3. & 4. Correct: Clients should have ample time for defecation. Rushing the client
may lead to a client ignoring the urge. Since clients may be hesitant to have a bowel
movement in the presence of others, privacy should be provided. (The nurse may need
to stay with weak or disabled clients.) Increasing fluid intake will lead to softer stools.
This makes defecation easier. Fiber deficiencies may contribute to constipation. Fiber in
the diet adds bulk to the stools which help them pass more readily through the
intestines.
5. Incorrect: Ignoring the urge to defecate may increase the risk of constipation. Trying
to defecate after a meal when peristalsis is increased may be helpful; however, if the
urge occurs at other times, the client should go to the bathroom at that time to prevent
constipation.
The nurse is teaching a newly diagnosed diabetic about the action of regular
insulin. The nurse verifies that teaching has been successful when the client
verbalizes being at greatest risk for developing hypoglycemia at what time
following the 8:00 a.m. dose of regular insulin?
1. 8:30 AM
2. 11:00 AM
3. 1:30 PM
4. 4:00 PM
,2. Correct: 11:00 AM: Regular insulin peaks 2-3 hours after administration. Clients are
at greatest risk for hypoglycemia when insulin is at its peak.
1. Incorrect: 8:30 AM: Rapid acting insulin will begin peaking in 30 minutes.
3. Incorrect: 1:30 PM: Intermediate acting insulin begins peaking at 4 hours. So at 1:30
PM this would be a time of worry.
4. Incorrect: 4:00 PM: At 4 PM you would still be worried about intermediate acting
insulin. But you would also be worried about long acting insulin as well. Which starts to
peak at 6 hours.
How would the nurse determine the correct size oropharyngeal airway for a
client?
1. Select the same size as the little finger of the victim.
2. Measure from the tip of the lips to the epiglottis.
3. Determine the length from the earlobe to the xiphoid process.
4. Measure from the earlobe to the corner of the mouth.
4. Correct: An airway of proper size will extend from the corner of the client's mouth to
the tip of the earlobe on the same side of the client's face.
1. Incorrect: The size of the client's little finger does not determine the size of the oral
airway that should be used. This would result in an inappropriate size oropharyngeal
airway to be selected.
2. Incorrect: The epiglottis is an internal body part thus making it impossible to correctly
measure it. In addition, the measurement would not determine the appropriate size
oropharyngeal airway to use.
3. Incorrect: Measuring from the client's earlobe to the client's xiphoid process would
make the oral airway too long.
, A client has been taught guided imagery as a method to relieve pain. How should
the nurse first assess for pain relief after completion of guided imagery by the
client?
1. Assess vital signs
2. Use of pain intensity scale
3. Ask client to describe the pain
4. Observe ability to perform activities of daily living
2. Correct: The use of pain intensity scales is an easy and reliable method of
determining the client's pain intensity.
1. Incorrect: Although respiratory and heart rate may decrease with guided imagery and
pain reduction, the most objective measure is to ask the client to rate the pain.
3. Incorrect: First, ask the client if pain is present. If present, the client should be asked
to rate the pain. Once pain has been rated, the client should be asked to describe the
pain.
4. Incorrect: The client may be able to perform activities of daily living and still have
pain. Therefore, this would not be an accurate means of assessing pain relief.
A nurse is caring for a client who delivered a baby vaginally two hours ago. What
signs and symptoms of postpartum hemorrhage should the nurse report to the
primary healthcare provider?
1. Two blood clots the size of a dime.
2. Perineal pad saturation in 10 minutes.
3. Constant trickling of bright red blood from vagina.
4. Oliguria
5. Firm fundus
2., 3., & 4. Correct: Lochia should not exceed an amount that is needed to partially
saturate four to eight peripads daily, which is considered a moderate amount. Perineal
pad saturation in 15 minutes or less is considered excessive and is reason for
immediate concern. Saturation of a peripad in one hour is considered heavy. Also,
QUESTIONS AND ANSWERS EDITION.
Which interventions should be included in the plan of care for an adult client with
constipation?
1. Allow adequate time for defecation.
2. Provide privacy for bowel elimination.
3. Suggest increasing fluid intake (unless contraindicated).
4. Encourage client to increase fiber in the diet.
5. Encourage the client to delay the urge to defecate until after a meal.
1., 2., 3. & 4. Correct: Clients should have ample time for defecation. Rushing the client
may lead to a client ignoring the urge. Since clients may be hesitant to have a bowel
movement in the presence of others, privacy should be provided. (The nurse may need
to stay with weak or disabled clients.) Increasing fluid intake will lead to softer stools.
This makes defecation easier. Fiber deficiencies may contribute to constipation. Fiber in
the diet adds bulk to the stools which help them pass more readily through the
intestines.
5. Incorrect: Ignoring the urge to defecate may increase the risk of constipation. Trying
to defecate after a meal when peristalsis is increased may be helpful; however, if the
urge occurs at other times, the client should go to the bathroom at that time to prevent
constipation.
The nurse is teaching a newly diagnosed diabetic about the action of regular
insulin. The nurse verifies that teaching has been successful when the client
verbalizes being at greatest risk for developing hypoglycemia at what time
following the 8:00 a.m. dose of regular insulin?
1. 8:30 AM
2. 11:00 AM
3. 1:30 PM
4. 4:00 PM
,2. Correct: 11:00 AM: Regular insulin peaks 2-3 hours after administration. Clients are
at greatest risk for hypoglycemia when insulin is at its peak.
1. Incorrect: 8:30 AM: Rapid acting insulin will begin peaking in 30 minutes.
3. Incorrect: 1:30 PM: Intermediate acting insulin begins peaking at 4 hours. So at 1:30
PM this would be a time of worry.
4. Incorrect: 4:00 PM: At 4 PM you would still be worried about intermediate acting
insulin. But you would also be worried about long acting insulin as well. Which starts to
peak at 6 hours.
How would the nurse determine the correct size oropharyngeal airway for a
client?
1. Select the same size as the little finger of the victim.
2. Measure from the tip of the lips to the epiglottis.
3. Determine the length from the earlobe to the xiphoid process.
4. Measure from the earlobe to the corner of the mouth.
4. Correct: An airway of proper size will extend from the corner of the client's mouth to
the tip of the earlobe on the same side of the client's face.
1. Incorrect: The size of the client's little finger does not determine the size of the oral
airway that should be used. This would result in an inappropriate size oropharyngeal
airway to be selected.
2. Incorrect: The epiglottis is an internal body part thus making it impossible to correctly
measure it. In addition, the measurement would not determine the appropriate size
oropharyngeal airway to use.
3. Incorrect: Measuring from the client's earlobe to the client's xiphoid process would
make the oral airway too long.
, A client has been taught guided imagery as a method to relieve pain. How should
the nurse first assess for pain relief after completion of guided imagery by the
client?
1. Assess vital signs
2. Use of pain intensity scale
3. Ask client to describe the pain
4. Observe ability to perform activities of daily living
2. Correct: The use of pain intensity scales is an easy and reliable method of
determining the client's pain intensity.
1. Incorrect: Although respiratory and heart rate may decrease with guided imagery and
pain reduction, the most objective measure is to ask the client to rate the pain.
3. Incorrect: First, ask the client if pain is present. If present, the client should be asked
to rate the pain. Once pain has been rated, the client should be asked to describe the
pain.
4. Incorrect: The client may be able to perform activities of daily living and still have
pain. Therefore, this would not be an accurate means of assessing pain relief.
A nurse is caring for a client who delivered a baby vaginally two hours ago. What
signs and symptoms of postpartum hemorrhage should the nurse report to the
primary healthcare provider?
1. Two blood clots the size of a dime.
2. Perineal pad saturation in 10 minutes.
3. Constant trickling of bright red blood from vagina.
4. Oliguria
5. Firm fundus
2., 3., & 4. Correct: Lochia should not exceed an amount that is needed to partially
saturate four to eight peripads daily, which is considered a moderate amount. Perineal
pad saturation in 15 minutes or less is considered excessive and is reason for
immediate concern. Saturation of a peripad in one hour is considered heavy. Also,
