HURST REVIEW NCLEX-RN Readiness Exam 1***,
Hurst Practice Exam 2, Hurst Review Test # 3, Hurst
Review Test #2, Hurst Readiness Exam 3, Hurst
(Readiness Exam #4), Hurst (Readiness Exam #3),
Hurst 1, HESI 8, HESI 7, HESI Exit 2 leigh_love_life
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 - ANSWER -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 - ANSWER -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 as when immunocompromised clients require protection from
potential infectious agents outside of the room.
A healthy newborn has just been delivered and placed in the care of the nurse.
What nursing actions should the nurse initiate?
Place in the correct priority order.
Assess newborn's airway and breathing.
Bulb suction excessive mucus.
Assess newborn's heart rate.
Place identification bands on newborn and mom.
Administer sterile ophthalmic ointment containing 0.5% erythromycin. -
ANSWER -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.
Third, Assess newborn's heart rate. If there is no respiratory distress, the nurse
continues the assessment by checking the heart rate and other vital signs.
,Fourth, Place identification bands on newborn and mom. These are critical for
ensuring babies and moms will be appropriately matched at all times but does not
take priority over respiration and circulation.
Fifth, Administer sterile ophthalmic ointment containing 0.5% erythromycin. This
is a legally required prophylactic eye treatment to prevent Neisseria gonorrhea.
However, this would never be a priority over Maslow's hierarchy of needs.
What information should a nurse include when educating a client regarding buccal
administration of a medication?
1. This route allows the medication to get into the bloodstream faster than the oral
route.
2. Stinging may occur after placing the medication in the cheek.
3. If swallowed, the medication may be inactivated by gastric secretions.
4. The buccal dose of medication will need to be increased from the oral dose.
5. Remove the tablet from buccal area after 15 seconds. - ANSWER -1., 2., & 3.
Correct: These are correct statements about buccal administration of medication.
Buccal administration involves the medication being placed between the gums and
cheek, where it dissolves and becomes absorbed into the bloodstream. The cheek
area has many capillaries that allow the medication to be absorbed quickly without
having to pass through the digestive system. The degree of stinging experienced
depends on the medication being administered. Some effects of certain medications
can be lessened by digestive processes.
4. Incorrect: When given by the buccal route, the medication does not go through
the digestive system. This means that the medication is not metabolized through
the liver, and thus a lower dose can be used.
5. Incorrect: Placement should be maintained until the tablet is dissolved in order
to get the dosage and effects desired.
Which signs and symptoms would the nurse expect to see in a client who has
taken prednisone for two months?
1. Weight loss
2. Decreased wound healing
3. Hypertension
4. Decreased facial hair
5. Moon face - ANSWER -2., 3. & 5. Correct: Decreased wound healing is a side
effect with prolonged steroid use due to the immunosuppressive effects. All steroid
medications, such as prednisone, can lead to sodium retention which then leads to
, dose related fluid retention. Hypertension is seen due to this fluid and sodium
retention. Cushingoid appearance (moon face) is a side effect that is created from
the abnormal redistribution of fat from prolonged steroid use.
1. Incorrect: Within one month after corticosteroid administration, weight gain is
seen rather than weight loss.
4. Incorrect: Facial and body hair increase with prolonged steroid use. This
excessive growth of body hair, known as hirsutism, is one of the numerous
potential side effects of prednisone.
A nurse is at highest risk for blood-borne exposure during which situation?
1. When removing a needle from the syringe.
2. While placing a suture needle into the self-locking forceps.
3. Prior to inserting the intravenous (IV) line, the client moves causing a needle
stick to the nurse.
4. A clean needle sticks the nurse through blood-soiled gloves. - ANSWER -4.
Correct: A clean needle that moves through blood-soiled gloves to stick the nurse
is considered to be potentially contaminated and results in a blood-borne exposure.
All other ANSWERs are considered a clean stick.
1. Incorrect: This is considered a clean stick. The needle is sterile initially and has
not been contaminated prior to removal of the needle from the syringe.
2. Incorrect: This is considered a clean stick since the suture needle has not been
inserted into the client prior to the needle stick.
3. Incorrect: This is considered a clean stick. The IV insertion device is sterile and
has not been contaminated since it was not inserted into the client.
A new nurse is preparing to give a medication to a nine month old client. After
checking a drug reference book, the nurse crushes the tablet and mixes it into 3
ounces of applesauce. The new nurse proceeds to the client's room. What priority
action should the supervising nurse take?
1. Tell the new nurse to recheck the drug reference book before administering the
medication.
2. Suggest that the new nurse reconsider the client's developmental needs.
3. Check the prescription order and the client dose.
4. Observe the new nurse administer the medication. - ANSWER -2. Correct:
Mixing medication with applesauce is appropriate in some circumstances, but the
Hurst Practice Exam 2, Hurst Review Test # 3, Hurst
Review Test #2, Hurst Readiness Exam 3, Hurst
(Readiness Exam #4), Hurst (Readiness Exam #3),
Hurst 1, HESI 8, HESI 7, HESI Exit 2 leigh_love_life
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 - ANSWER -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 - ANSWER -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 as when immunocompromised clients require protection from
potential infectious agents outside of the room.
A healthy newborn has just been delivered and placed in the care of the nurse.
What nursing actions should the nurse initiate?
Place in the correct priority order.
Assess newborn's airway and breathing.
Bulb suction excessive mucus.
Assess newborn's heart rate.
Place identification bands on newborn and mom.
Administer sterile ophthalmic ointment containing 0.5% erythromycin. -
ANSWER -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.
Third, Assess newborn's heart rate. If there is no respiratory distress, the nurse
continues the assessment by checking the heart rate and other vital signs.
,Fourth, Place identification bands on newborn and mom. These are critical for
ensuring babies and moms will be appropriately matched at all times but does not
take priority over respiration and circulation.
Fifth, Administer sterile ophthalmic ointment containing 0.5% erythromycin. This
is a legally required prophylactic eye treatment to prevent Neisseria gonorrhea.
However, this would never be a priority over Maslow's hierarchy of needs.
What information should a nurse include when educating a client regarding buccal
administration of a medication?
1. This route allows the medication to get into the bloodstream faster than the oral
route.
2. Stinging may occur after placing the medication in the cheek.
3. If swallowed, the medication may be inactivated by gastric secretions.
4. The buccal dose of medication will need to be increased from the oral dose.
5. Remove the tablet from buccal area after 15 seconds. - ANSWER -1., 2., & 3.
Correct: These are correct statements about buccal administration of medication.
Buccal administration involves the medication being placed between the gums and
cheek, where it dissolves and becomes absorbed into the bloodstream. The cheek
area has many capillaries that allow the medication to be absorbed quickly without
having to pass through the digestive system. The degree of stinging experienced
depends on the medication being administered. Some effects of certain medications
can be lessened by digestive processes.
4. Incorrect: When given by the buccal route, the medication does not go through
the digestive system. This means that the medication is not metabolized through
the liver, and thus a lower dose can be used.
5. Incorrect: Placement should be maintained until the tablet is dissolved in order
to get the dosage and effects desired.
Which signs and symptoms would the nurse expect to see in a client who has
taken prednisone for two months?
1. Weight loss
2. Decreased wound healing
3. Hypertension
4. Decreased facial hair
5. Moon face - ANSWER -2., 3. & 5. Correct: Decreased wound healing is a side
effect with prolonged steroid use due to the immunosuppressive effects. All steroid
medications, such as prednisone, can lead to sodium retention which then leads to
, dose related fluid retention. Hypertension is seen due to this fluid and sodium
retention. Cushingoid appearance (moon face) is a side effect that is created from
the abnormal redistribution of fat from prolonged steroid use.
1. Incorrect: Within one month after corticosteroid administration, weight gain is
seen rather than weight loss.
4. Incorrect: Facial and body hair increase with prolonged steroid use. This
excessive growth of body hair, known as hirsutism, is one of the numerous
potential side effects of prednisone.
A nurse is at highest risk for blood-borne exposure during which situation?
1. When removing a needle from the syringe.
2. While placing a suture needle into the self-locking forceps.
3. Prior to inserting the intravenous (IV) line, the client moves causing a needle
stick to the nurse.
4. A clean needle sticks the nurse through blood-soiled gloves. - ANSWER -4.
Correct: A clean needle that moves through blood-soiled gloves to stick the nurse
is considered to be potentially contaminated and results in a blood-borne exposure.
All other ANSWERs are considered a clean stick.
1. Incorrect: This is considered a clean stick. The needle is sterile initially and has
not been contaminated prior to removal of the needle from the syringe.
2. Incorrect: This is considered a clean stick since the suture needle has not been
inserted into the client prior to the needle stick.
3. Incorrect: This is considered a clean stick. The IV insertion device is sterile and
has not been contaminated since it was not inserted into the client.
A new nurse is preparing to give a medication to a nine month old client. After
checking a drug reference book, the nurse crushes the tablet and mixes it into 3
ounces of applesauce. The new nurse proceeds to the client's room. What priority
action should the supervising nurse take?
1. Tell the new nurse to recheck the drug reference book before administering the
medication.
2. Suggest that the new nurse reconsider the client's developmental needs.
3. Check the prescription order and the client dose.
4. Observe the new nurse administer the medication. - ANSWER -2. Correct:
Mixing medication with applesauce is appropriate in some circumstances, but the
