HURST REVIEW NCLEX-RN READINESS EXAM 1-Study Guide
Questions And Answers Verified 100% Correct
A client experiencing chest pain is prescribed an intravenous infusion of nitroglycerin. After the infusion
is initiated, the occurrence of which symptom would prompt the nurse to discontinue the nitroglycerin?
1. Frontal headache
2. Orthostatic hypotension
3. Decrease in intensity of chest pain
4. Cool, clammy skin
4. Correct: This assessment finding of cool, clammy skin is an indication of decreased cardiac output that
could be the result of too much vasodilatation. Cardiac output could continue to decrease if the
nitroglycerin is not discontinued.
1. Incorrect: A headache is an expected common side effect of nitroglycerin administration. The
headache is treated with medication.
2. Incorrect: A decrease in blood pressure when rising from a supine or sitting position is a
common effect of the vasodilatation that occurs with the administration of nitroglycerin. The client
should be advised to change positions slowly.
3. Incorrect: The decrease in the intensity of the client's chest pain is the desired outcome of the
nitroglycerin administration.
During an assessment interview with a client, what alternative healing modalities should the nurse
inquire about?
1. "Tell me about your use of teas, herbs, and vitamins."
2. "What traditional or folk remedies are used in your family?"
3. "Do you meditate, pray, or use relaxation techniques for healing purposes?"
4. "What prescription medications are you taking?"
5. "What alternative therapies have you used?"
1., 2., 3., & 5. Correct: These are all inquiries the nurse should make when conducting an assessment
interview in order to find out about alternative healing modalities. Alternative or complementary
medicine is used to describe over 1800 therapies practiced around the world. Approximately 65 to 80%
of the world's population use non-conventional (alternative) healing modalities. These alternative
healing modalities can be such things as: Natural products (herbs, dietary supplements, etc.) mind and
body practices (yoga, mediation, prayer, etc.), folk remedies and other non-traditional practices.
4. Incorrect: Prescription medications would be part of traditional, western medicine. Although the
nurse needs to find out what prescription medications are being taken, it is not part of alternative
medicine.
,The nurse in the emergency department suspects that a client's lesion is caused by anthrax. What
assessment question is most important?
1. Have you traveled out of the United States recently?
2. Have you recently worked with any farm animals or any animal-skin products?
3. Have you experienced any gastrointestinal upset recently?
4. Have you eaten any home-canned foods recently?
2. Correct: Cutaneous anthrax may be contracted by working with contaminated animal-skin products.
Anthrax is found in nature and commonly infects wild and domestic hoofed animals.
1. Incorrect: Cutaneous anthrax is also found in the United States, so asking about travel abroad would
not be necessary.
3. Incorrect: Cutaneous anthrax can be contracted by spores entering cuts or abrasions in the skin. This
is cutaneous anthrax that causes edema, itching and macule or papule formation, resulting in
ulceration. Ingestion of anthrax can cause GI symptoms such as nausea and vomiting, abdominal pain,
and bloody diarrhea. Inhalation of anthrax may result in flu-like symptoms that progress to severe
respiratory distress.
4. Incorrect: This question would be appropriate if botulism were suspected in a client.
When preparing a client for surgery, the nurse realizes the operative permit has not been signed. The
client tells the nurse he understands the procedure, but received his preoperative medication
approximately 10 minutes ago. What would be the appropriate action by the nurse?
1. Have the client sign the permit, as he verbalizes understanding.
2. Witness the form after having the client sign it.
3. Have his wife sign the form as she witnessed his statement that he understands.
4. Call the surgical area and explain that the surgery will have to be cancelled.
4. Correct: The client must sign the operative permit or any other legal document prior to taking
preoperative drugs that can affect judgment and decision-making capacity.
1. Incorrect: The client's verbal understanding does not override the fact that he has received
medication that can alter thought processes and decision-making.
2. Incorrect: Witnessing would not make this document legal. The consent would not be valid
because the client has already received the pain medication that could alter the thought process.
3. Incorrect: When a client is of legal age (unless an emancipated minor) and of sound mind, it
would be inappropriate for the spouse to sign the form for surgery. In order to be valid it must be the
client who signs it, unless there is a legal power of attorney, durable power of attorney, or healthcare
surrogate.
A child is being admitted with possible rheumatic fever. What assessment data would be most important
for the nurse to obtain from the parent?
1. 102° F (38.89° C) temperature that started 2 days previously.
,2. History of pharyngitis approximately 4 weeks ago.
3. Vomiting for 3 days.
4. A cough that started about 1 week earlier.
2. Correct: Rheumatic fever is often the result of untreated or improperly treated group A β-hemolytic
streptococcal infections (GABHS), such as pharyngitis. Therefore, the history of pharyngitis or upper
respiratory infection is a key assessment finding for establishing a diagnosis of rheumatic fever.
Subsequent development of rheumatic fever usually occurs 2 to 6 weeks following the GABHS, so the
assessment should include a remote history of pharyngitis.
1. Incorrect: The fever with rheumatic fever is usually low grade and is considered a minor manifestation
of rheumatic fever.
3. Incorrect: Vomiting is not a commonly associated symptom with rheumatic fever and is not
considered a major manifestation of rheumatic fever. Although the child may have a history of vomiting,
this finding would not be specific to rheumatic fever.
4. Incorrect: A cough is not an associated symptom of rheumatic fever. The time frame for the
development of rheumatic fever is not appropriate if the cough started 1 week earlier, even if it had
been associated with an upper respiratory streptococcal infection.
The primary healthcare provider has prescribed phenytoin 100 mg intravenous push (IVP) stat through a
non-tunneled central venous catheter lumen with no other medication or fluid infusing. In what order
should the nurse administer this prescription?
Cleanse access port
Connect 10 mL normal saline to access port
Gently aspirate for blood
Flush saline using push-pause method
Administer phenytoin
Flush with normal saline, then with heparin
Proper administration of medication through a non-tunneled central venous catheter:
First, cleanse the access port. Failure to cleanse the port first would increase the risk of infection from
contamination when the port is accessed.
Second, connect 10 mL normal saline to access port. This 10 mL syringe will be connected to first check
patency and then for flushing prior to medication administration. At least 10 mL of normal saline is used
to flush central lines.
Third, gently aspirate for blood.
Fourth, flush saline using push-pause method. This method is utilized to help clear the catheter of blood
or drugs that could potentially adhere to the internal surface of the central line catheter. This creation of
, turbulent flow from pausing then pushing causes swirling of the fluid and theoretically removes blood
and medications from the walls of the catheter, which reduces the risk of occlusion in the catheter.
Fifth, administer phenytoin.
Sixth, flush with normal saline, then with heparin. Standard flushing solutions used most frequently for
central venous access devices include normal saline and/or heparinized sodium chloride. Low dose
heparin flushes are generally used to fill the lumen of the central line between use in order to prevent
thrombus formation and maintain patency of the catheter for a longer period of time.
An elderly male, diagnosed with chronic renal failure and depression, lives alone. Which question should
the home health nurse ask first when assessing this client?
1. Have you had suicidal thoughts in the past?
2. How are you feeling today?
3. Have you had thoughts of harming yourself?
4. Do you have guns in your home?
3. Correct: Suicide assessment should begin with direct questions about the presence of suicidal
thinking. The nurse should recognize that elderly men are at higher risk for committing suicide,
especially those with a history of depression, chronic illness and isolation.
1. Incorrect: This question should be asked, but only after determining if suicidal thinking is present.
2. Incorrect: This question could be an introductory question to establish rapport, but it is not direct
enough to use in suicide assessment.
4. Incorrect: This question should be asked if the client is considering using gun as a method of suicide or
if he has a history of suicide attempts with a gun.
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.
Questions And Answers Verified 100% Correct
A client experiencing chest pain is prescribed an intravenous infusion of nitroglycerin. After the infusion
is initiated, the occurrence of which symptom would prompt the nurse to discontinue the nitroglycerin?
1. Frontal headache
2. Orthostatic hypotension
3. Decrease in intensity of chest pain
4. Cool, clammy skin
4. Correct: This assessment finding of cool, clammy skin is an indication of decreased cardiac output that
could be the result of too much vasodilatation. Cardiac output could continue to decrease if the
nitroglycerin is not discontinued.
1. Incorrect: A headache is an expected common side effect of nitroglycerin administration. The
headache is treated with medication.
2. Incorrect: A decrease in blood pressure when rising from a supine or sitting position is a
common effect of the vasodilatation that occurs with the administration of nitroglycerin. The client
should be advised to change positions slowly.
3. Incorrect: The decrease in the intensity of the client's chest pain is the desired outcome of the
nitroglycerin administration.
During an assessment interview with a client, what alternative healing modalities should the nurse
inquire about?
1. "Tell me about your use of teas, herbs, and vitamins."
2. "What traditional or folk remedies are used in your family?"
3. "Do you meditate, pray, or use relaxation techniques for healing purposes?"
4. "What prescription medications are you taking?"
5. "What alternative therapies have you used?"
1., 2., 3., & 5. Correct: These are all inquiries the nurse should make when conducting an assessment
interview in order to find out about alternative healing modalities. Alternative or complementary
medicine is used to describe over 1800 therapies practiced around the world. Approximately 65 to 80%
of the world's population use non-conventional (alternative) healing modalities. These alternative
healing modalities can be such things as: Natural products (herbs, dietary supplements, etc.) mind and
body practices (yoga, mediation, prayer, etc.), folk remedies and other non-traditional practices.
4. Incorrect: Prescription medications would be part of traditional, western medicine. Although the
nurse needs to find out what prescription medications are being taken, it is not part of alternative
medicine.
,The nurse in the emergency department suspects that a client's lesion is caused by anthrax. What
assessment question is most important?
1. Have you traveled out of the United States recently?
2. Have you recently worked with any farm animals or any animal-skin products?
3. Have you experienced any gastrointestinal upset recently?
4. Have you eaten any home-canned foods recently?
2. Correct: Cutaneous anthrax may be contracted by working with contaminated animal-skin products.
Anthrax is found in nature and commonly infects wild and domestic hoofed animals.
1. Incorrect: Cutaneous anthrax is also found in the United States, so asking about travel abroad would
not be necessary.
3. Incorrect: Cutaneous anthrax can be contracted by spores entering cuts or abrasions in the skin. This
is cutaneous anthrax that causes edema, itching and macule or papule formation, resulting in
ulceration. Ingestion of anthrax can cause GI symptoms such as nausea and vomiting, abdominal pain,
and bloody diarrhea. Inhalation of anthrax may result in flu-like symptoms that progress to severe
respiratory distress.
4. Incorrect: This question would be appropriate if botulism were suspected in a client.
When preparing a client for surgery, the nurse realizes the operative permit has not been signed. The
client tells the nurse he understands the procedure, but received his preoperative medication
approximately 10 minutes ago. What would be the appropriate action by the nurse?
1. Have the client sign the permit, as he verbalizes understanding.
2. Witness the form after having the client sign it.
3. Have his wife sign the form as she witnessed his statement that he understands.
4. Call the surgical area and explain that the surgery will have to be cancelled.
4. Correct: The client must sign the operative permit or any other legal document prior to taking
preoperative drugs that can affect judgment and decision-making capacity.
1. Incorrect: The client's verbal understanding does not override the fact that he has received
medication that can alter thought processes and decision-making.
2. Incorrect: Witnessing would not make this document legal. The consent would not be valid
because the client has already received the pain medication that could alter the thought process.
3. Incorrect: When a client is of legal age (unless an emancipated minor) and of sound mind, it
would be inappropriate for the spouse to sign the form for surgery. In order to be valid it must be the
client who signs it, unless there is a legal power of attorney, durable power of attorney, or healthcare
surrogate.
A child is being admitted with possible rheumatic fever. What assessment data would be most important
for the nurse to obtain from the parent?
1. 102° F (38.89° C) temperature that started 2 days previously.
,2. History of pharyngitis approximately 4 weeks ago.
3. Vomiting for 3 days.
4. A cough that started about 1 week earlier.
2. Correct: Rheumatic fever is often the result of untreated or improperly treated group A β-hemolytic
streptococcal infections (GABHS), such as pharyngitis. Therefore, the history of pharyngitis or upper
respiratory infection is a key assessment finding for establishing a diagnosis of rheumatic fever.
Subsequent development of rheumatic fever usually occurs 2 to 6 weeks following the GABHS, so the
assessment should include a remote history of pharyngitis.
1. Incorrect: The fever with rheumatic fever is usually low grade and is considered a minor manifestation
of rheumatic fever.
3. Incorrect: Vomiting is not a commonly associated symptom with rheumatic fever and is not
considered a major manifestation of rheumatic fever. Although the child may have a history of vomiting,
this finding would not be specific to rheumatic fever.
4. Incorrect: A cough is not an associated symptom of rheumatic fever. The time frame for the
development of rheumatic fever is not appropriate if the cough started 1 week earlier, even if it had
been associated with an upper respiratory streptococcal infection.
The primary healthcare provider has prescribed phenytoin 100 mg intravenous push (IVP) stat through a
non-tunneled central venous catheter lumen with no other medication or fluid infusing. In what order
should the nurse administer this prescription?
Cleanse access port
Connect 10 mL normal saline to access port
Gently aspirate for blood
Flush saline using push-pause method
Administer phenytoin
Flush with normal saline, then with heparin
Proper administration of medication through a non-tunneled central venous catheter:
First, cleanse the access port. Failure to cleanse the port first would increase the risk of infection from
contamination when the port is accessed.
Second, connect 10 mL normal saline to access port. This 10 mL syringe will be connected to first check
patency and then for flushing prior to medication administration. At least 10 mL of normal saline is used
to flush central lines.
Third, gently aspirate for blood.
Fourth, flush saline using push-pause method. This method is utilized to help clear the catheter of blood
or drugs that could potentially adhere to the internal surface of the central line catheter. This creation of
, turbulent flow from pausing then pushing causes swirling of the fluid and theoretically removes blood
and medications from the walls of the catheter, which reduces the risk of occlusion in the catheter.
Fifth, administer phenytoin.
Sixth, flush with normal saline, then with heparin. Standard flushing solutions used most frequently for
central venous access devices include normal saline and/or heparinized sodium chloride. Low dose
heparin flushes are generally used to fill the lumen of the central line between use in order to prevent
thrombus formation and maintain patency of the catheter for a longer period of time.
An elderly male, diagnosed with chronic renal failure and depression, lives alone. Which question should
the home health nurse ask first when assessing this client?
1. Have you had suicidal thoughts in the past?
2. How are you feeling today?
3. Have you had thoughts of harming yourself?
4. Do you have guns in your home?
3. Correct: Suicide assessment should begin with direct questions about the presence of suicidal
thinking. The nurse should recognize that elderly men are at higher risk for committing suicide,
especially those with a history of depression, chronic illness and isolation.
1. Incorrect: This question should be asked, but only after determining if suicidal thinking is present.
2. Incorrect: This question could be an introductory question to establish rapport, but it is not direct
enough to use in suicide assessment.
4. Incorrect: This question should be asked if the client is considering using gun as a method of suicide or
if he has a history of suicide attempts with a gun.
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.
