HURST REVIEW NCLEX RN READINESS EXAM: LATEST A+
QUESTIONS AND ANSWERS EDITION.
Newborn with cleft lip, nurse should focus on which problem?
Impaired sucking and cannot effectively latch on to the mother's nipples.
What type of pain with the diagnosis of acute pancreatitis?
Severe pain in the mid-epigastric area radiating to the back. Sometimes it can radiate to
the chest, flank and lower abdomen.
Nurse is assessing patient need for as-needed opioid administration Patient is
arousable but tired and is falling asleep during conversation. This is:
#3 Pasero Opioid- Induced Sedation Scale (POSS)
S: Asleep but easily arousable
1: Alert and awake
2: Sleepy but easily aroused
3: Arousable but tired and falling asleep during conversations. This level is
unacceptable. Monitor respiratory status closely.
4: Little or no response to physical stimulation. Stop opioid and consider reversing with
naloxone.
What is stuporous?
Patient is unarousable except by painful stimulus (sternal rub)
What is partial thromboplastin time? warfarin/coumadin
30-45
What do you expect in an exacerbation of COPD?
An overinflated chest on the chest x-ray. There is loss of elasticity in the lungs leading
to congestion and hyper-elasticity of the lungs.
Judaism culture includes these wishes when client doesn't have much longer to
live:
They do not wish for the client to be taken off life-support, they would not like an
autopsy and cremation to be performed.
What medication prescription should the nurse anticipate for a client with
Generalized Anxiety Disorder?
,Buspirone- is a serotonergic agent that is efficacious in the treatment of anxiety. It takes
time to work (approximately 2-4 weeks).
What psychosocial interventions would be appropriate for a patient in the ICU
Use clocks and calendar, helps with orientation and reduce the patient's risk of
developing delirium.
How does amniocentesis work?
It is used to obtain a sample of amniotic fluid at 15-16 weeks of pregnancy. Tests are
carried out on this sample to check the health of the fetus and to check for
chromosomal mutations. Will be able to determine gender. Expect to have cramping
after this procedure, as this is the most common complaint.
It does not require IV sedation. It is an ultrasound guided test used in the detection of
fetal abnormalities. No medication will be given to stimulate contractions.
When can a patient with cardiac surgery have sexual activity again?
After exercise tolerance is assessed. Many physicians agree that a patient may return
to sexual activity if they can climb two flights of stairs without symptoms.
Risk factor for women to experience postpartum hemorrhage?
Dystocia- difficult birth
Placenta previa
What warrants immediate medical intervention and why for a client post stroke?
Fixed and dilated pupil- increase ICP. Notify physician immediately.
Difference between macule and papule
Macule- small patch of skin that is altered in color but is not elevated.
Papule- elevated, solid, palpable lesion that is <1 cm in diameter.
What assessment findings are consistent with eczema?
Erythema, pruritus and papules
What should the nurse prioritize when a patient has taken an overdose of aspirin?
Onset of pulmonary edema-
Maybe related to an increase in the permeability within the capillaries of the lung leading
to "protein leakage" and transduction of fluid in both renal and pulmonary tissues.
How should you handle the death of an Muslim client?
,Request all non-Muslims handling the body wear gloves. Most branches of the Islamic
faith request that the deceased body is handled only by Muslims of the same gender. If
no Muslims practitioners are available, then staff should wear gloves.
Why is morphine sulfate contraindicated among lactating women?
Is excreted in the breast milk.
When assessing a four month old male infant, the nurse correctly evaluates his
heart rate by performing which actions?
Auscultates the left 4th intercostal space for 60 seconds.
What action warrants intervention by the experienced nurse?
The nurse obtains green drainage from NG tube for culture. Typically yellow/green in
color due to the presence of bile. Sending these contents for culture may be
unnecessary worry for the patient and would not be appropriate since this is an
expected assessment.
What are loop diuretics and what can they cause?
They treat hypertension and work by making the kidneys pass out more fluid. A
complication is hypokalemia and patient may experience leg cramps. An increase in
urine output is a desired effect not a complication.
PPE for MRSA
contact precautions
gown and gloves
Vegan should be recommended what kind of vitamin?
B12
Hyperaldosteronism- what endocrine disorders cause an increased amount of
aldosterone?
Cushing's and Conn's syndrome
Aldosterone- steroid hormone, main role s to regulate salt and water in the body that
has an effect on blood pressure.
causes an increase secretion of adrenocorticotropic hormone (ACTH) from the pituitary
gland.
What type of client has the greatest risk for infection?
, A patient receiving TPN via central line. TPN is a risk factor as the high glucose content
makes the patient more likely to develop a bacterial or fungal infection.
How to calculate developmental milestones for patient born early/premature?
Add the months and subtract the months from the developmental age.
Patient born (now 6 months old) at 28 weeks is 12 weeks (3 months) early, so the RN
needs to subtract 3 months for appropriate developmental age-- developmental
milestone for 3 months old.
Patient is diagnosed with hypernatremia- what maintenance fluid would the nurse
expect to hang for this patient?
Dextrose-used to replace water losses due to hypernatremia and be an appropriate
maintenance fluid for this patient because it is an isotonic, contains free water with no
added sodium or electrolyte.
Patient told her GYNO that she forgot to take her pills for the past four days now?
What is the most appropriate instruction of the nurse:
When a client misses three or more pills in a row , she should throw out the rest of the
pack and start a new pack of pills the following Sunday. This nurse needs to inform her
to use extra protection until seven days after starting the new pack of pills.
An example of tertiary prevention care and services?
Physical rehab center in the community.
What is hyperalgesia and what is an appropriate nursing diagnosis for a client
affected with hyperalgesia?
at risk for abnormal and not reversible pain r/t hyperalgesia
increased sensitivity to painful stimuli
Lead to appearance of neuropathic pain that is not treatable and is irreversible if not
treated
Patient with PKU should avoid what kind of food
protein
What population prefer cremations than burying the remains of the diseased
person?
Hindus. The ashes are then spread over the holy river.
What is enoxaparin (Lovenox)?
QUESTIONS AND ANSWERS EDITION.
Newborn with cleft lip, nurse should focus on which problem?
Impaired sucking and cannot effectively latch on to the mother's nipples.
What type of pain with the diagnosis of acute pancreatitis?
Severe pain in the mid-epigastric area radiating to the back. Sometimes it can radiate to
the chest, flank and lower abdomen.
Nurse is assessing patient need for as-needed opioid administration Patient is
arousable but tired and is falling asleep during conversation. This is:
#3 Pasero Opioid- Induced Sedation Scale (POSS)
S: Asleep but easily arousable
1: Alert and awake
2: Sleepy but easily aroused
3: Arousable but tired and falling asleep during conversations. This level is
unacceptable. Monitor respiratory status closely.
4: Little or no response to physical stimulation. Stop opioid and consider reversing with
naloxone.
What is stuporous?
Patient is unarousable except by painful stimulus (sternal rub)
What is partial thromboplastin time? warfarin/coumadin
30-45
What do you expect in an exacerbation of COPD?
An overinflated chest on the chest x-ray. There is loss of elasticity in the lungs leading
to congestion and hyper-elasticity of the lungs.
Judaism culture includes these wishes when client doesn't have much longer to
live:
They do not wish for the client to be taken off life-support, they would not like an
autopsy and cremation to be performed.
What medication prescription should the nurse anticipate for a client with
Generalized Anxiety Disorder?
,Buspirone- is a serotonergic agent that is efficacious in the treatment of anxiety. It takes
time to work (approximately 2-4 weeks).
What psychosocial interventions would be appropriate for a patient in the ICU
Use clocks and calendar, helps with orientation and reduce the patient's risk of
developing delirium.
How does amniocentesis work?
It is used to obtain a sample of amniotic fluid at 15-16 weeks of pregnancy. Tests are
carried out on this sample to check the health of the fetus and to check for
chromosomal mutations. Will be able to determine gender. Expect to have cramping
after this procedure, as this is the most common complaint.
It does not require IV sedation. It is an ultrasound guided test used in the detection of
fetal abnormalities. No medication will be given to stimulate contractions.
When can a patient with cardiac surgery have sexual activity again?
After exercise tolerance is assessed. Many physicians agree that a patient may return
to sexual activity if they can climb two flights of stairs without symptoms.
Risk factor for women to experience postpartum hemorrhage?
Dystocia- difficult birth
Placenta previa
What warrants immediate medical intervention and why for a client post stroke?
Fixed and dilated pupil- increase ICP. Notify physician immediately.
Difference between macule and papule
Macule- small patch of skin that is altered in color but is not elevated.
Papule- elevated, solid, palpable lesion that is <1 cm in diameter.
What assessment findings are consistent with eczema?
Erythema, pruritus and papules
What should the nurse prioritize when a patient has taken an overdose of aspirin?
Onset of pulmonary edema-
Maybe related to an increase in the permeability within the capillaries of the lung leading
to "protein leakage" and transduction of fluid in both renal and pulmonary tissues.
How should you handle the death of an Muslim client?
,Request all non-Muslims handling the body wear gloves. Most branches of the Islamic
faith request that the deceased body is handled only by Muslims of the same gender. If
no Muslims practitioners are available, then staff should wear gloves.
Why is morphine sulfate contraindicated among lactating women?
Is excreted in the breast milk.
When assessing a four month old male infant, the nurse correctly evaluates his
heart rate by performing which actions?
Auscultates the left 4th intercostal space for 60 seconds.
What action warrants intervention by the experienced nurse?
The nurse obtains green drainage from NG tube for culture. Typically yellow/green in
color due to the presence of bile. Sending these contents for culture may be
unnecessary worry for the patient and would not be appropriate since this is an
expected assessment.
What are loop diuretics and what can they cause?
They treat hypertension and work by making the kidneys pass out more fluid. A
complication is hypokalemia and patient may experience leg cramps. An increase in
urine output is a desired effect not a complication.
PPE for MRSA
contact precautions
gown and gloves
Vegan should be recommended what kind of vitamin?
B12
Hyperaldosteronism- what endocrine disorders cause an increased amount of
aldosterone?
Cushing's and Conn's syndrome
Aldosterone- steroid hormone, main role s to regulate salt and water in the body that
has an effect on blood pressure.
causes an increase secretion of adrenocorticotropic hormone (ACTH) from the pituitary
gland.
What type of client has the greatest risk for infection?
, A patient receiving TPN via central line. TPN is a risk factor as the high glucose content
makes the patient more likely to develop a bacterial or fungal infection.
How to calculate developmental milestones for patient born early/premature?
Add the months and subtract the months from the developmental age.
Patient born (now 6 months old) at 28 weeks is 12 weeks (3 months) early, so the RN
needs to subtract 3 months for appropriate developmental age-- developmental
milestone for 3 months old.
Patient is diagnosed with hypernatremia- what maintenance fluid would the nurse
expect to hang for this patient?
Dextrose-used to replace water losses due to hypernatremia and be an appropriate
maintenance fluid for this patient because it is an isotonic, contains free water with no
added sodium or electrolyte.
Patient told her GYNO that she forgot to take her pills for the past four days now?
What is the most appropriate instruction of the nurse:
When a client misses three or more pills in a row , she should throw out the rest of the
pack and start a new pack of pills the following Sunday. This nurse needs to inform her
to use extra protection until seven days after starting the new pack of pills.
An example of tertiary prevention care and services?
Physical rehab center in the community.
What is hyperalgesia and what is an appropriate nursing diagnosis for a client
affected with hyperalgesia?
at risk for abnormal and not reversible pain r/t hyperalgesia
increased sensitivity to painful stimuli
Lead to appearance of neuropathic pain that is not treatable and is irreversible if not
treated
Patient with PKU should avoid what kind of food
protein
What population prefer cremations than burying the remains of the diseased
person?
Hindus. The ashes are then spread over the holy river.
What is enoxaparin (Lovenox)?
