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HURST REVIEW NCLEX-RN Readiness
Exam 1 Q/A 2022/2023
Question: 1
Which assessments will provide the nurse with the most information regarding a client's neurologic function?
You answered this question Incorrectly
1. Level of consciousness
2. Doll's eyes reflex
3. Babinski reflex
4. Reaction to painful stimuli
5. Verbal ability
Rationale:
1. & 5. Correct: Yes! The most important and subtle changes are related to the client's level of consciousness, verbal ability, orientation, and
ability to move to command.
2. Incorrect: No, only helps with the determination of brain death.
3. Incorrect: Identifies diseases of the brain and spinal cord.
4. Incorrect: This should be last resort.
Question: 2
Which client should the nurse recognize as being at greatest risk for the development of cancer?
You answered this question Incorrectly
1. Smoker for 30 plus years
2. Body builder taking steroids and using tanning salons
3. Newborn with multiple birth defects
4. Older individual with acquired immunodeficiency syndrome
Rationale:
4. Correct: Cancer has a high incidence in the immune deficiency client and in the older adult! This one is highest.
1. Incorrect: Not highest, but known environmental carcinogen.
2. Incorrect: Not highest, but known environmental carcinogen.
3. Incorrect: No, birth defects are not a risk factor for cancer.
Question: 3
first-attempt success and A+ Grade
,Created by AnswersCOM@stuvia 2026/01/09 Page 2 of 231
A client is admitted to the medical unit with persistent vomiting. The client complains of weakness and leg cramps. The wife states that he is
irritable. The primary healthcare provider has prescribed lab work and blood gases. Based on this assessment the nurse anticipates which
acid base imbalance?
You answered this question Correctly
1. Respiratory acidosis
2. Respiratory alkalosis
3. Metabolic acidosis
4. Metabolic alkalosis
Rationale:
4. Correct: Symptoms of alkalosis are often due to associated potassium loss and may include irritability, weakness, and
cramping. Excessive vomiting eliminates gastric acid and potassium, leading to metabolic alkalosis.
1. Incorrect: Not respiratory related acid-base imbalance
2. Incorrect: Not respiratory related acid-base imbalance
3. Incorrect: Not acidosis. There is loss of gastric acid and K with persistent vomiting.
Question: 4
A client diagnosed with depression asks the nurse, “What is causing me to be depressed so often?” What is the best response by the nurse?
You answered this question Incorrectly
1. There are a number of reasons that may contribute to depression, such as a
decreased level of chemicals in your brain.
2. You experience depression because of your elevated levels of thyroid hormones.
3. The primary healthcare provider will have to explain to you what is causing your
depression.
4. Tell me what you think causes you to be depressed?
Rationale:
1. Correct: Decreased levels of norepinephrine, dopamine, and serotonin are neurotransmitter implications for depression.
2. Incorrect: Elevated levels of thyroid hormones are thought to contribute to panic disorder.
3. Incorrect: The nurse can discuss this with the client.
4. Incorrect: This statement may allow for dialog, but does not answer the client's question.
Question: 5
The nurse has just received a client from the special procedures lab for a liver biopsy. What is the position of choice for this client post
procedure?
You answered this question Correctly
1. Fowlers
2. Right side
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3. Left side
4. Prone
Rationale:
2. Correct: Position client on the liver to hold pressure and stop bleeding.
1. Incorrect: No, this will not help control the bleeding.
3. Incorrect: Oops, the liver is on the right, not the left.
4. Incorrect: No, we don’t turn client onto abdomen.
Question: 6
A client arrives in the emergency department after severely lacerating the left hand with a knife. HR 96, BP 150/88, R36. The client is
extremely anxious and crying uncontrollably. Based on this assessment, the nurse should anticipate that this client is likely in which acid
base imbalance?
You answered this question Incorrectly
1. Respiratory acidosis
2. Respiratory alkalosis
3. Metabolic acidosis
4. Metabolic alkalosis
Rationale:
2. Correct: Hyperventilation due to anxiety, pain, shock, severe infection, fever, liver failure can lead to respiratory alkalosis. With each of
these, the client has an increased CO2 loss.
1. Incorrect: Not acidosis
3. Incorrect: Not metabolic
4. Incorrect: Not metabolic
Question: 7
What signs or symptoms should the nurse assess for when monitoring a client who has a brain injury?
You answered this question Incorrectly
1. Increased pulse
2. Glasgow coma score of 15
3. BP 150/60
4. Papilledema
5. Projectile vomiting
first-attempt success and A+ Grade
, Created by AnswersCOM@stuvia 2026/01/09 Page 4 of 231
Rationale:
3. , 4. & 5. Correct: The pulse pressure of 150/60 is 90 (greater than 40 is a sign of increased ICP). Signs of increased intracranial pressure
also include papilledema, elevated systolic pressure, wide pulse pressure, decreased pulse, and slow respirations. Projectile vomiting is
classically associated with increased ICP.
1. Incorrect: Decreased pulse, not increased pulse.
2. Incorrect: A score of 15 is the best score a person can get.
Question:
The nurse is caring for a client diagnosed with heart failure who has developed pulmonary edema. Which findings best indicate that the
medications are having a therapeutic effect?
Exhibit You answered this question Incorrectly
1. Respiratory rate of 34/min
2. Blood pressure 90/50
3. Urine output of 100 mL over the last hour
4. Apical heart rate of 96/min
5. Blood pressure of 160/90
6. Respiratory rate of 24
Rationale:
3. , 4., 5., & 6. Correct. The heart rate has decreased to within normal range. The blood pressure has decreased, and the urine output has
increased.
1. Incorrect. The respiratory rate is still too high, so the pulmonary edema has not resolved.
2. Incorrect. The blood pressure is too low. We worry when the blood pressure gets to 90 systolic.
Question: 9
The nurse is caring for a client with possible hepatic failure. The nurse asks the client to sign a permit for a procedure. The nurse recalls the
client's admission signature is legible, however, now observes a jerky, illegible signature. How should the nurse document this handwriting
change?
You answered this question Incorrectly
1. Fetor
2. Ataxia
3. Apraxia
4. Asterixis
Rationale:
4. Correct: Yes the liver flap, abnormal muscle tremor, is usually found in clients with diseases of the liver.
first-attempt success and A+ Grade
HURST REVIEW NCLEX-RN Readiness
Exam 1 Q/A 2022/2023
Question: 1
Which assessments will provide the nurse with the most information regarding a client's neurologic function?
You answered this question Incorrectly
1. Level of consciousness
2. Doll's eyes reflex
3. Babinski reflex
4. Reaction to painful stimuli
5. Verbal ability
Rationale:
1. & 5. Correct: Yes! The most important and subtle changes are related to the client's level of consciousness, verbal ability, orientation, and
ability to move to command.
2. Incorrect: No, only helps with the determination of brain death.
3. Incorrect: Identifies diseases of the brain and spinal cord.
4. Incorrect: This should be last resort.
Question: 2
Which client should the nurse recognize as being at greatest risk for the development of cancer?
You answered this question Incorrectly
1. Smoker for 30 plus years
2. Body builder taking steroids and using tanning salons
3. Newborn with multiple birth defects
4. Older individual with acquired immunodeficiency syndrome
Rationale:
4. Correct: Cancer has a high incidence in the immune deficiency client and in the older adult! This one is highest.
1. Incorrect: Not highest, but known environmental carcinogen.
2. Incorrect: Not highest, but known environmental carcinogen.
3. Incorrect: No, birth defects are not a risk factor for cancer.
Question: 3
first-attempt success and A+ Grade
,Created by AnswersCOM@stuvia 2026/01/09 Page 2 of 231
A client is admitted to the medical unit with persistent vomiting. The client complains of weakness and leg cramps. The wife states that he is
irritable. The primary healthcare provider has prescribed lab work and blood gases. Based on this assessment the nurse anticipates which
acid base imbalance?
You answered this question Correctly
1. Respiratory acidosis
2. Respiratory alkalosis
3. Metabolic acidosis
4. Metabolic alkalosis
Rationale:
4. Correct: Symptoms of alkalosis are often due to associated potassium loss and may include irritability, weakness, and
cramping. Excessive vomiting eliminates gastric acid and potassium, leading to metabolic alkalosis.
1. Incorrect: Not respiratory related acid-base imbalance
2. Incorrect: Not respiratory related acid-base imbalance
3. Incorrect: Not acidosis. There is loss of gastric acid and K with persistent vomiting.
Question: 4
A client diagnosed with depression asks the nurse, “What is causing me to be depressed so often?” What is the best response by the nurse?
You answered this question Incorrectly
1. There are a number of reasons that may contribute to depression, such as a
decreased level of chemicals in your brain.
2. You experience depression because of your elevated levels of thyroid hormones.
3. The primary healthcare provider will have to explain to you what is causing your
depression.
4. Tell me what you think causes you to be depressed?
Rationale:
1. Correct: Decreased levels of norepinephrine, dopamine, and serotonin are neurotransmitter implications for depression.
2. Incorrect: Elevated levels of thyroid hormones are thought to contribute to panic disorder.
3. Incorrect: The nurse can discuss this with the client.
4. Incorrect: This statement may allow for dialog, but does not answer the client's question.
Question: 5
The nurse has just received a client from the special procedures lab for a liver biopsy. What is the position of choice for this client post
procedure?
You answered this question Correctly
1. Fowlers
2. Right side
first-attempt success and A+ Grade
,Created by AnswersCOM@stuvia 2026/01/09 Page 3 of 231
3. Left side
4. Prone
Rationale:
2. Correct: Position client on the liver to hold pressure and stop bleeding.
1. Incorrect: No, this will not help control the bleeding.
3. Incorrect: Oops, the liver is on the right, not the left.
4. Incorrect: No, we don’t turn client onto abdomen.
Question: 6
A client arrives in the emergency department after severely lacerating the left hand with a knife. HR 96, BP 150/88, R36. The client is
extremely anxious and crying uncontrollably. Based on this assessment, the nurse should anticipate that this client is likely in which acid
base imbalance?
You answered this question Incorrectly
1. Respiratory acidosis
2. Respiratory alkalosis
3. Metabolic acidosis
4. Metabolic alkalosis
Rationale:
2. Correct: Hyperventilation due to anxiety, pain, shock, severe infection, fever, liver failure can lead to respiratory alkalosis. With each of
these, the client has an increased CO2 loss.
1. Incorrect: Not acidosis
3. Incorrect: Not metabolic
4. Incorrect: Not metabolic
Question: 7
What signs or symptoms should the nurse assess for when monitoring a client who has a brain injury?
You answered this question Incorrectly
1. Increased pulse
2. Glasgow coma score of 15
3. BP 150/60
4. Papilledema
5. Projectile vomiting
first-attempt success and A+ Grade
, Created by AnswersCOM@stuvia 2026/01/09 Page 4 of 231
Rationale:
3. , 4. & 5. Correct: The pulse pressure of 150/60 is 90 (greater than 40 is a sign of increased ICP). Signs of increased intracranial pressure
also include papilledema, elevated systolic pressure, wide pulse pressure, decreased pulse, and slow respirations. Projectile vomiting is
classically associated with increased ICP.
1. Incorrect: Decreased pulse, not increased pulse.
2. Incorrect: A score of 15 is the best score a person can get.
Question:
The nurse is caring for a client diagnosed with heart failure who has developed pulmonary edema. Which findings best indicate that the
medications are having a therapeutic effect?
Exhibit You answered this question Incorrectly
1. Respiratory rate of 34/min
2. Blood pressure 90/50
3. Urine output of 100 mL over the last hour
4. Apical heart rate of 96/min
5. Blood pressure of 160/90
6. Respiratory rate of 24
Rationale:
3. , 4., 5., & 6. Correct. The heart rate has decreased to within normal range. The blood pressure has decreased, and the urine output has
increased.
1. Incorrect. The respiratory rate is still too high, so the pulmonary edema has not resolved.
2. Incorrect. The blood pressure is too low. We worry when the blood pressure gets to 90 systolic.
Question: 9
The nurse is caring for a client with possible hepatic failure. The nurse asks the client to sign a permit for a procedure. The nurse recalls the
client's admission signature is legible, however, now observes a jerky, illegible signature. How should the nurse document this handwriting
change?
You answered this question Incorrectly
1. Fetor
2. Ataxia
3. Apraxia
4. Asterixis
Rationale:
4. Correct: Yes the liver flap, abnormal muscle tremor, is usually found in clients with diseases of the liver.
first-attempt success and A+ Grade
