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HURST REVIEW NCLEX-RN Readiness Exam 1, Hurst Practice Exam 2, Hurst Review Test # 3
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HURST REVIEW NCLEX-RN Readiness Exam 1, Hurst Practice Exam 2, Hurst Review Test # 3
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HURST REVIEW NCLEX-RN ReadinessExam 1, Hurst Practice Exam 2, Hurst
Review Test # 3,
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: 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 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. Five minutes would be longer than required to be
able to safely administer the medication.
4. 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. Ten minutes is much longer than required to be able
to safely administer the medication.
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 - 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.
4. Incorrect: Although the food in the stomach causes the pancreatic enzymes to
become activated in the pancreas due to the obstruction, the food is not considered an
irritant. Precipitating irritants are not a part of the pathophysiology occurring with
pancreatitis.
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., 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 zones should be on interior walls, no windows, and a strong concrete floor if
possible.
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. - 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 prevent a possible spread of an airborne infection to the
immunocompromised client.
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? - 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 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 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., 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.
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. 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.
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. No compensation has begun at this point.
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 - 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.
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