HURST REVIEW NCLEX-RN Readiness
Exam 1
2. Correct: The rate of IV administration should not exceed 50 mg/min. for adults and 1-3
mg/kg/min (or 50 mg/min, whichever is slower) in pediatric clients because of the risk of severe
hypotension and cardiac arrhythmias. So 100 mg can safely be delivered over a period of at
least 2 minutes.
1. Incorrect: The rate of IV administration should not exceed 50 mg/min. for adults and 1-3
mg/kg/min (or 50 mg/min, whichever is slower) in pediatric clients because of the risk of severe
hypotension and cardiac arrhythmias. So 100 mg can safely be delivered over a period of at
least 2 minutes. Giving this dose over only one minute could lead to these or other potential
harmful effects.
3. Incorrect: The rate of IV administration should not exceed 50 mg/min. for adults and 1-3
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mg/kg/min (or 50 mg/min, whichever is slower) in pediatric clients because of the risk of severe
hypotension and cardiac arrhythmias. So 100 mg can s - -The primary healthcare provider
has prescribed phenytoin 100 mg intravenous push (IVP) stat for an adult client. What is the
least amount of time that the nurse can safely administer this medication?
1. 1 minute
2. 2 minutes
3. 5 minutes
4. 10 minutes
2. Correct: In clients with pancreatitis, the pancreatic enzymes cannot exit the pancreas. These
enzymes, when activated, begin to digest the pancreas itself. The enzymes become activated in
the pancreas when fluid or food accumulates in the stomach. The goal in treating this client is to
stop the activation of the pancreatic enzymes. Treatment is focused on keeping the stomach
empty and dry. This allows the pancreas time to rest and heal. Note: Autodigestion (pancreas
digesting itself) is painful for the client and can lead to other problems such as bleeding.
1. Incorrect: The primary purpose of the NG tube to suction is to keep the stomach empty and
dry to decrease pancreatic enzyme production, not to relieve nausea.
3. Incorrect: Because gastric contents are removed, the NG tube to suction may lead to fluid
and electrolyte disturbances rather than helping to control them.
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4. Incorrect: Although the food in the - -A client, hospitalized with possible acute
pancreatitis secondary to chronic cholecystitis, has severe abdominal pain and nausea. The
client is kept NPO, an NG tube is inserted, and IV fluids are being administered. What is the
rationale for the client being NPO with an NG tube to low suction?
1. Relieve nausea
2. Reduce pancreatic secretions
,3. Control fluid and electrolyte imbalance
4. Remove the precipitating irritants
1., 2., 3. & 5. Correct: Everyone should be aware of safe zones within the school. Personnel
should be given this information and signs posted in safe zones. There must be systems in
place to accurately determine the number of people in the building at any given time. There also
must be a system in place to alert personnel and students of tornado warnings. Regular practice
prepares everyone for an actual event.
4. Incorrect: Gymnasiums are not considered safe places due to wide expanse of roof. Safe
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zones should be on interior walls, no windows, and a strong concrete floor if possible. -
-The nurse is working with a committee at the local school to develop an emergency
preparedness plan for tornados. What should be included in the plan?
1. Identification of safe zones.
2. Methods for accounting for all people present in the building.
3. Warning system activation.
4. Identification of the gymnasium as the routine safe place.
5. Regular practice protocols.
1., 2., 4., & 5. Correct: Protective isolation is needed for this client because of the presence of a
low white blood cell count. We are protecting the client from acquiring an infection. So any
visitors will need to have meticulous hand washing prior to entering. The visitor should not enter
if he or she has any type of infection. To decrease the risk of infection, small children should not
visit. Even the mildest symptom of infection could be detrimental to the client. Flowers have
bacteria and should not be brought into the room.
3. Incorrect: A mask must be worn by the visitor, not the client. The mask is worn by visitors to
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prevent a possible spread of an airborne infection to the immunocompromised client. -
-What should a nurse teach family members prior to them entering the room of a client
who has agranulocytosis?
1. Meticulous hand washing is needed.
2. Do not visit if you have any infection.
3. The client must wear a mask.
4. Children under 12 may not visit.
5. Flowers are not allowed in the room.
2. Correct: Myoclonus, high body temperature, shaking, chills, and mental confusion are some
of the symptoms of serotonin syndrome. This client may be having symptoms of this adverse
reaction which, if severe, can be fatal.
1. Incorrect: Sleep disturbances are common with depression. Selective serotonin reuptake
inhibitors (SSRIs) may cause insomnia; however, there is a more pertinent question needed for
assessment of this client. You should be concerned with the more serious or life-threatening
issue.
,3. Incorrect: Sexual dysfunction may occur with the SSRIs; however, the client is exhibiting
significant symptoms of an adverse reaction which would take priority.
4. Incorrect: The response to the SSRI medications is important; however, there is a more
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significant issue in this case. The possible serotonin syndrome is a serious situation that would
be the priority for the nurse to address. - -A client diagnosed with major depression has
been taking a selective serotonin reuptake inhibitor for the past 6 weeks. When visiting the
mental health center, the nurse discusses the medication and response with the client. The
nurse's assessment reveals that the client is confused about the date and about the prescribed
dosage of the medication. Which question would be most important for the nurse to ask to
further assess the situation?
1. Are you having trouble sleeping at night?
2. Do you have periods of muscle jerking?
3. Are you having any sexual dysfunction?
4. Is your mood improving?
1., 2. & 5. Correct: Serotonin syndrome is a group of symptoms that can result from the use of
certain serotonin reuptake inhibitors. These symptoms can range from mild to severe and
include high body temperature, agitation, increased reflexes, diaphoresis, tremors, dilated pupils
and diarrhea. The client is likely to experience shivering with fever. Increased heart rate and
blood pressure are also commonly experienced. More severe symptoms, including muscle
rigidity and seizures, can occur. If not treated, serotonin syndrome can be fatal.
3. Incorrect: Increased body temperature is expected as is increased diaphoresis.
4. Incorrect: Diarrhea, not constipation, is a symptom of serotonin syndrome. - ✅✅ -A client
diagnosed with serotonin syndrome is admitted to the unit. The nurse is familiar with this
adverse reaction to the serotonin reuptake inhibitors. Which symptoms can the nurse expect on
assessment?
1. Fever and shivering
2. Agitation
3. Decreased body temperature
4. Constipation
5. Increased heart rate
1. Correct: These ABGs are indicative of metabolic alkalosis. The pH is high, the pCO2 is within
normal limits and the bicarb is high (alkalosis). So, the excess Tums (calcium carbonate) could
have caused metabolic alkalosis.
2. Incorrect: The client is not hypoventilating and would not be in metabolic acidosis because he
ate 3 rolls of Tums which is a base. These ABGs are indicative of acidosis. The pH is low
(acidosis), the pCO2 is high (acidosis) and the bicarb is low (acidosis).
, 3. Incorrect: The client is not a long-term COPD client as these ABGs might suggest. These
ABGs are indicative of fully compensated respiratory acidosis. The pH is normal. The pCO2 is
high (as with chronic retention) and the bicarb is high to help compensate.
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4. Incorrect: These ABGs are the result of an acute ventilation problem. They are indicative of
respiratory acidosis. The pH is low, the pCO2 is high, and the bicarb is normal. N - -The
emergency department nurse is assessing a client who presents with severe epigastric pain.
The client reports that three rolls of calcium carbonate were consumed in the past eight hours to
treat the indigestion. Which blood gas report does the nurse associate with this situation?
1. pH - 7.49, pCO2 - 40, HCO3 - 30
2. pH - 7.32, pCO2 - 48, HCO3 - 20
3. pH - 7.38, pCO2 - 52, HCO3 - 32
4. pH - 7.29, pCO2 - 54, HCO3 - 26
1., 2. & 3. Correct: According to the current standards of Standard Precautions per the CDC, the
client with shingles should be placed on airborne precautions which require the use of a private
room with negative pressure airflow and a N-95 respirator mask.
4. Incorrect: A face shield is used when there is risk of splashing or spraying of blood or body
fluids. This is not required for airborne precautions.
5. Incorrect: Negative pressure is required in order to prevent the airborne infection from
spreading outside of the room. Positive pressure is used only in protective environments such
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as when immunocompromised clients require protection from potential infectious agents outside
of the room. - -Which prescriptions would the nurse recognize as being appropriate for the
client with shingles?
1. Private room
2. Negative pressure airflow
3. Respirator mask
4. Face Shield
5. Positive pressure room
Remember Maslow's hierarchy of needs will guide your assessment. First, Assess newborn's
airway and breathing. The most critical change that a newborn must make physiologically is the
initiation of breathing. The nurse should assess the newborn's crying. If the cry is weak, it may
indicate a respiratory disturbance. Other signs of respiratory compromise may include: stridor,
grunting, retractions, apnea or diminished breath sounds. Normal respiration are 30 - 60 breaths
a minute.
Second, Bulb suction excessive mucus. It is important to assure that the throat and nose are
kept clean of secretions to prevent respiratory distress.
