HURST READINESS EXAM 4 QUESTIONS AND ANSWERS | COMPLETE HURST
NCLEX READINESS EXAM 4 STUDY GUIDE 2026/2027
Which client must the nurse assign to a private room? You answered this question Correctly 1.
Primiparous client who delivered twins at 28 weeks gestation two days ago 2. Postpartum client on IV
Ampicillin and Gentamicin for chorioamnionitis 3. Postpartum client whose 2 hour old infant is being
worked up for sepsis 4. Postpartum client 32 hours after delivery with a temperature of 101º F (38.05 °
C) - ANS ✔✔Rationale Strategies 4. Correct: A temperature of 100.5° F (38.05° C) or greater in a client
more than 24 hours postpartum is likely an indication of infection. This client should be kept separate
from other mothers and babies. 1. Incorrect: The preterm twins are in the NICU and not in their
mother's room (a client with term twins would need a private room because of space considerations). 2.
Incorrect: Chorioamnionitis is not contagious. 3. Incorrect: The infant may have an infection and will
remain in the NICU. The mother is not infected.
Post thyroidectomy, the nurse assesses the client for complications by performing which assessment?
You answered this question Correctly 1. Perform blood glucose monitoring every 6 hours 2. Check for a
positive Chvostek's 3. Assess swallowing reflex 4. Monitor neck dressings for change in fit and comfort 5.
Administer desmopressin per nasal spray for urinary output (UOP) greater than 200 mL/hr - ANS
✔✔RationaleStrategies 2., 3., & 4. Correct: A positive Chvostek's and Trousseau's is indicative of tetany
(low calcium). This can occur when one or more of the parathyroids are accidently removed when the
thyroid is removed. A weak, raspy voice, swallowing difficulty, and impaired respiratory status can be
caused by nerve injury. Change in fit and comfort of the dressing can indicate possible neck swelling,
which can affect the airway. 1. Incorrect: A possible complication of a thyroidectomy is to remove one or
more parathyroid glands. The parathyroids' action is to regulate the serum calcium levels. The
parathyroid does not regulate the blood glucose levels. 5. Incorrect: The action of desmopressin is to
increase the reabsorption of water in the kidney. A decrease in vasopressin, (antidiuretic hormone) is not
a complication of a thyroidectomy.
A client diagnosed with pancreatitis becomes increasingly restless, confused and has pulled out the NG
tube and IV catheter. HR-128/min, BP 96/62. Oxygen saturation = 90%. Skin is cool and clammy to touch.
Prioritize the actions that the nurse should take. You answered this question IncorrectlyThe Correct
Order Initiate oxygen. Insert another IV line. Obtain blood sugar level. Insert NG tube. Repeat vital sign
checks Your Selected Order Repeat vital sign checks Initiate oxygen. Obtain blood sugar level. Insert NG
tube. Insert another IV line. - ANS ✔✔RationaleStrategies First, initiate oxygen. The client is anxious and
has tachycardia, signs of hypoxia. The BP is also low, so the client might be bleeding internally. If there is
a decreased circulating blood volume then there is less hemoglobin to carry oxygen, so increasing the
available oxygen will help the client until the problem is corrected. Second, get the IV started so fluid
resuscitation can continue.This increased volume will improve the blood pressure. More volume, more
pressure. The IV will also provide a port for needed medications. Third, check the client's blood sugar.
Since the pancreas is sick, insulin production can be decreased so glucose can go up. This is next in the
priority line of the available options. You have addressed air and circulation, so blood glucose would be
next. Fourth, insert the NG tube so that the client can be kept empty and dry and you can prevent
aspiration if the client starts vomiting. Last, recheck vital signs to assess effectiveness of your nursing
actions.
,What is the best instruction the nurse should provide when administering acetylsalicylic acid 81 mg to a
client experiencing severe, crushing chest pain radiating up the left jaw? You answered this question
Correctly 1. Chew the acetylsalicylic acid prior to swallowing. 2. Place the acetylsalicylic acid under the
tongue so that it can dissolve. 3. Swallow the acetylsalicylic acid tablet. 4. Insert the acetylsalicylic acid
between the cheek and gum for greater absorption. - ANS ✔✔RationaleStrategies 1. Correct:
Acetylsalicylic acid has been shown to decrease mortality and re-infarction rates after MI. The fastest
way to get the aspirin into the circulatory system is to have the client chew the acetylsalicylic acid prior
to swallowing. 2. Incorrect: Nitroglycerin is administered sublingual (SL) or buccal. Initially acetylsalicylic
acid is administered by chewing the tablet or swallowing the tablet. 3. Incorrect: If a solid dose pill is
prescribed, the pill should be chewed. Faster absorption is obtained from chewing, rather than
swallowing acetylsalicylic acid. 4. Incorrect: Nitroglycerin is administered SL or buccal. Initially
acetylsalicylic acid would be chewed to increase the absorption rate.
A client who has developed hypovolemic shock is receiving albumin. What assessment finding by the
nurse indicates that the albumin has been effective? You answered this question Correctly 1. Swelling in
the legs 2. Increase in uninary output 3. Proteinuria 4. Increase in waist measurement - ANS
✔✔RationaleStrategies 2. Correct: The action of albumin is to increase the serum albumin level. When
the albumin level increases there is a shift of fluid from extracellular to intracellular. This action will
result in an increase in urinary output. 1. Incorrect: This is a symptom of hypoalbuminemia. There is a
shift in the fluid from intracellular to extracellular. This results in the swelling of the legs. 3. Incorrect:
Hypoalbuminemia may cause damage to the kidneys. Proteinuria is indicative of renal disease or
damage. 4. Incorrect: There may be a increased accumulation of fluid in the abdomen. The ascites is due
to the decreased albumin level in the vascular space, which also causes damage to the liver.
A nurse is attempting to develop trust with a psychiatric client exhibiting concrete thinking. Which
nursing intervention would promote trust in this individual? You answered this question Incorrectly 1.
Attend an activity with the client who is reluctant to go alone. 2. Allow the client to break an insignificant
rule. 3. Consider client preferences when possible in decisions concerning care. 4. Provide a blanket
when the client is cold. 5. Provide food when the client is hungry. - ANS ✔✔RationaleStrategies 1., 3., 4.
& 5. Correct: Trust is demonstrated through nursing interventions that convey a sense of warmth and
care to the client. These interventions are initiated simply, concretely, and directed toward activities that
address the client's basic needs for physiological and psychological safety and security. Concrete thinking
focuses thought processes on specifics, rather than generalities, and immediate issues, rather than
eventual outcomes. Examples of nursing interventions that would promote trust in an individual who is
thinking concretely include such things as: providing a blanket when the client is cold, providing food
when the client is hungry, keeping promises, being honest, providing a written, structured schedule of
activities, attending activities with the client if he is reluctant to go alone, being consistent in adhering to
unit guidelines, and taking the client's preferences, requests, and opinions into consideration when
possible in decisions concerning care. 2. Incorrect: The client should be informed of all rules, simply and
clearly, with reasons for certain policies and rules. Be consistent and provide written, structured,
scheduled activities. Allowing a client to break a rule would not encourage them to think about the
outcomes of their actions.
A charge nurse is planning care for several clients on the unit. Which activities can the nurse safely
delegate to an unlicensed assistive personnel (UAP)? You answered this question Incorrectly 1.
Administer a nebulizer treatment to a client diagnosed with pneumonia. 2. Obtain vital signs on a
postoperative client who required naloxone 5 minutes ago. 3. Report a urinary output (UOP) less than 50
ml/hr on a post-op client. 4. Assist a client with obtaining a clean catch urine sample. 5. Remove an
,indwelling urinary catheter from a client. - ANS ✔✔RationaleStrategies 3., & 4. Correct: A UAP can report
the amount of UOP but cannot interpret it. A clean catch urine sample is a noninvasive procedure. The
UAP can assist the client to obtain the clean catch urinary sample. Both activities are the right person
and right task of delegation. 1. Incorrect: A UAP cannot administer medications. This is the wrong task
for an UAP. 2. Incorrect: The client received naloxone to reverse the action of an opioid medication. A
UAP should not be assigned to obtain vital signs on an unstable client. This is the wrong person to
perform removal of an indwelling urinary catheter. 5. Incorrect: A UAP cannot remove an indwelling
urinary catheter.
Which interventions should the nurse initiate to lessen acid reflux in a client diagnosed with
gastroesophagel reflux disease (GERD)? You answered this question Correctly 1. Provide small, frequent
meals. 2. Avoid carbonated beverages. 3. Administer omeprazole as prescribed. 4. Assist with smoking
cessation. 5. Place in left lateral position for 2 hours after eating. - ANS ✔✔RationaleStrategies 1., 2., 3.,
& 4. Correct: All of these actions are correct to help alleviate dyspepsia. When a client has GERD, the
stomach's contents reflux into the esophagus. Small frequent meals will decrease possible reflux by
decreasing the stomach content. Smoking can relax the lower muscle of the esophagus. Drinking a
carbonated drink may cause the stomach to expand. Both smoking and drinking a carbonated drink
increase the potential of reflux. The action of omeprazole is to reduce the acid that is produced in the
stomach. 5. Incorrect: The client should be positioned with the head of the bed (HOB) elevated for 2-3
hours after eating. This position will decrease the potential for esophageal reflux.
A nurse from the neonatal unit is transferred to the adult medical-surgical unit. Which client should the
charge nurse assign to the neonatal nurse? You answered this question Incorrectly 1. Undergoing surgery
for placement of a central venous catheter. 2. Diagnosed with leukemia, hospitalized for induction of
high-dose chemotherapy. 3. Receiving IV heparin for left leg thrombosis. 4. Admitted with a
cerebrovascular accident. - ANS ✔✔RationaleStrategies 1. Correct: This is the most stable client to give
to the nurse who was transferred from the neonatal unit. A neonatal nurse cares for central lines daily in
this specialty area and can transfer this knowledge to the adult client. 2. Incorrect: This is not a good
client for a neonatal nurse because knowledge of lab values, chemotherapy precautions, protective
isolation and chemotherapy drugs is required for the nurse in order to care for this client. 3. Incorrect:
This is not the best client for a neonatal nurse because thrombosis problems are not commonly seen in
the nursery. Monitoring clotting factors and being aware of signs and symptoms of pulmonary emboli
are essential for safe care of this client. 4. Incorrect: This client is very unstable and requires skilled
observation and assessment using the Glasgow Scale. This level of assessment is not utilized in a
neonatal unit.
A client with a history of increasing dyspnea over the past week comes to the emergency department.
After arterial blood gases (ABGs) are drawn, which information would be important for the nurse to
document? You answered this question Correctly 1. The client had not been NPO prior to the test. 2. The
client was on 2 L of oxygen by nasal canula. 3. Lung sounds are wet. 4. Client is sitting in upright position.
- ANS ✔✔RationaleStrategies 2. Correct: The fact that the client is on 2 L/min of oxygen will affect the
analysis of the ABG results. If the client is on oxygen, the partial pressure of oxygen (PO2) will be
elevated due to the increased inhaled oxygen. 1. Incorrect: Whether the client has eaten or been NPO
will not affect the evaluation of the ABG results. 3. Incorrect: An assessment of the client's lung sounds
must be performed for a client with a history of dyspnea. This assessment will not directly affect the
ABGs result. 4. Incorrect: The client's position will not directly affect the evaluation of the ABG results.
, The nurse is providing care to a client who has a large abdominal dressing. Which intervention is most
likely to reduce the risk of skin irritation due to frequent dressing changes? You answered this question
Correctly 1. Use a paper tape for adhering the dressing. 2. Use tape sparingly. 3. Secure the dressing with
Montgomery straps. 4. Change the dressing only if it becomes saturated with drainage. - ANS
✔✔RationaleStrategies 3. Correct: Montgomery straps will allow the dressing to be held in place without
the use of tape. The adhesive on the ends of the straps is the only adhesive used. 1. Incorrect: Paper
tape may be less irritating; however, with repeated changes, skin irritation is more likely. Montgomery
straps will decrease the repeated tape changes. 2. Incorrect: Use of the tape should be sufficient to
secure the dressing and applied in a way to allow mobility if placed over a joint. There still is an increase
of skin irritation from applying the tape. 4. Incorrect: The soiled dressing is a medium for bacteria
growth. The dressing should be changed as ordered or required.
A newborn in a neonatal unit is to receive penicillin G benzathine 50,000 units/kg intramuscularly (IM).
The newborn weighs 6 lbs (2.7 kg). The dispensed dose is 25,000 units per 1 mL. What should the nurse
do? You answered this question Incorrectly 1. Administer the drug intravenously (IV) since a large
volume is required. 2. Choose three injection sites and give the medication as prescribed. 3. Consult with
the pharmacy for a different medication concentration. 4. Read the available drug information to
determine how to administer the medication. - ANS ✔✔RationaleStrategies 3. Correct: The nurse must
consult with the pharmacy to receive further instructions. The dose is greater than the allowed volume
to be given IM, which warrants clarification by the pharmacy. 1. Incorrect: Since the drug is prescribed
IM, the route should not be changed to IV administration because this violates the prescription as
written. 2. Incorrect: The dose is greater than the allowed volume to be given IM, which warrants
clarification by the pharmacy. You want to avoid having to give three injections. 4. Incorrect: The concern
is not drug information or administration; it is the concentration, which can only be provided by the
pharmacy.
A nurse is preparing to conduct a presentation on barriers to therapeutic communication with clients
from a culture other than the nurse's culture. Which points should the nurse include in the
presentation? You answered this question Incorrectly 1. Lack of knowledge about a client's culture is a
major barrier to therapeutic communication. 2. Follow cultural beliefs when caring for all clients of that
particular culture. 3. Ethnocentrism facilitates therapeutic communication. 4. Do not touch the client
until you know what the cultural belief is about touching. 5. Adapt care to client's cultural needs and
preferences. - ANS ✔✔RationaleStrategies 1., 4. & 5. Correct: Nurses must understand and take into
consideration the cultural differences of their clients. Some cultures do not approve of touching or
shaking hands. By assessing the client's culture preference, the nurse is able to provide individualized
care. 2. Incorrect: Do not stereotype all clients of a certain culture. Ask questions. Allow for individuality.
To provide culturally competent care, the nurse must recognize individual preferences within the client's
culture. 3. Incorrect: Ethnocentrism is the belief that one's own culture and traditions are better than
those of another. It blocks therapeutic communication by allowing the nurse's biases and prejudices to
negatively influence the nursing care of the client.
A woman, diagnosed with an ectopic pregnancy, asks the nurse the purpose of receiving methotrexate.
What is the best reply for the nurse to make? You answered this question Correctly 1. "Methotrexate will
stop your bleeding." 2. "It will destroy fetal cells that got into your blood so that antibodies will not be
formed." 3. "This medication will stop the growth of the embryo to save your fallopian tube." 4. "Cervical
dilation is expected after receiving this medication." - ANS ✔✔RationaleStrategies 3. Correct: The
medical management of an ectopic pregnancy is to prescribe methotrexate. The action of methotrexate
is to stop the growth of the embryo in the fallopian tube. The embryo is reabsorbed and the fallopian
NCLEX READINESS EXAM 4 STUDY GUIDE 2026/2027
Which client must the nurse assign to a private room? You answered this question Correctly 1.
Primiparous client who delivered twins at 28 weeks gestation two days ago 2. Postpartum client on IV
Ampicillin and Gentamicin for chorioamnionitis 3. Postpartum client whose 2 hour old infant is being
worked up for sepsis 4. Postpartum client 32 hours after delivery with a temperature of 101º F (38.05 °
C) - ANS ✔✔Rationale Strategies 4. Correct: A temperature of 100.5° F (38.05° C) or greater in a client
more than 24 hours postpartum is likely an indication of infection. This client should be kept separate
from other mothers and babies. 1. Incorrect: The preterm twins are in the NICU and not in their
mother's room (a client with term twins would need a private room because of space considerations). 2.
Incorrect: Chorioamnionitis is not contagious. 3. Incorrect: The infant may have an infection and will
remain in the NICU. The mother is not infected.
Post thyroidectomy, the nurse assesses the client for complications by performing which assessment?
You answered this question Correctly 1. Perform blood glucose monitoring every 6 hours 2. Check for a
positive Chvostek's 3. Assess swallowing reflex 4. Monitor neck dressings for change in fit and comfort 5.
Administer desmopressin per nasal spray for urinary output (UOP) greater than 200 mL/hr - ANS
✔✔RationaleStrategies 2., 3., & 4. Correct: A positive Chvostek's and Trousseau's is indicative of tetany
(low calcium). This can occur when one or more of the parathyroids are accidently removed when the
thyroid is removed. A weak, raspy voice, swallowing difficulty, and impaired respiratory status can be
caused by nerve injury. Change in fit and comfort of the dressing can indicate possible neck swelling,
which can affect the airway. 1. Incorrect: A possible complication of a thyroidectomy is to remove one or
more parathyroid glands. The parathyroids' action is to regulate the serum calcium levels. The
parathyroid does not regulate the blood glucose levels. 5. Incorrect: The action of desmopressin is to
increase the reabsorption of water in the kidney. A decrease in vasopressin, (antidiuretic hormone) is not
a complication of a thyroidectomy.
A client diagnosed with pancreatitis becomes increasingly restless, confused and has pulled out the NG
tube and IV catheter. HR-128/min, BP 96/62. Oxygen saturation = 90%. Skin is cool and clammy to touch.
Prioritize the actions that the nurse should take. You answered this question IncorrectlyThe Correct
Order Initiate oxygen. Insert another IV line. Obtain blood sugar level. Insert NG tube. Repeat vital sign
checks Your Selected Order Repeat vital sign checks Initiate oxygen. Obtain blood sugar level. Insert NG
tube. Insert another IV line. - ANS ✔✔RationaleStrategies First, initiate oxygen. The client is anxious and
has tachycardia, signs of hypoxia. The BP is also low, so the client might be bleeding internally. If there is
a decreased circulating blood volume then there is less hemoglobin to carry oxygen, so increasing the
available oxygen will help the client until the problem is corrected. Second, get the IV started so fluid
resuscitation can continue.This increased volume will improve the blood pressure. More volume, more
pressure. The IV will also provide a port for needed medications. Third, check the client's blood sugar.
Since the pancreas is sick, insulin production can be decreased so glucose can go up. This is next in the
priority line of the available options. You have addressed air and circulation, so blood glucose would be
next. Fourth, insert the NG tube so that the client can be kept empty and dry and you can prevent
aspiration if the client starts vomiting. Last, recheck vital signs to assess effectiveness of your nursing
actions.
,What is the best instruction the nurse should provide when administering acetylsalicylic acid 81 mg to a
client experiencing severe, crushing chest pain radiating up the left jaw? You answered this question
Correctly 1. Chew the acetylsalicylic acid prior to swallowing. 2. Place the acetylsalicylic acid under the
tongue so that it can dissolve. 3. Swallow the acetylsalicylic acid tablet. 4. Insert the acetylsalicylic acid
between the cheek and gum for greater absorption. - ANS ✔✔RationaleStrategies 1. Correct:
Acetylsalicylic acid has been shown to decrease mortality and re-infarction rates after MI. The fastest
way to get the aspirin into the circulatory system is to have the client chew the acetylsalicylic acid prior
to swallowing. 2. Incorrect: Nitroglycerin is administered sublingual (SL) or buccal. Initially acetylsalicylic
acid is administered by chewing the tablet or swallowing the tablet. 3. Incorrect: If a solid dose pill is
prescribed, the pill should be chewed. Faster absorption is obtained from chewing, rather than
swallowing acetylsalicylic acid. 4. Incorrect: Nitroglycerin is administered SL or buccal. Initially
acetylsalicylic acid would be chewed to increase the absorption rate.
A client who has developed hypovolemic shock is receiving albumin. What assessment finding by the
nurse indicates that the albumin has been effective? You answered this question Correctly 1. Swelling in
the legs 2. Increase in uninary output 3. Proteinuria 4. Increase in waist measurement - ANS
✔✔RationaleStrategies 2. Correct: The action of albumin is to increase the serum albumin level. When
the albumin level increases there is a shift of fluid from extracellular to intracellular. This action will
result in an increase in urinary output. 1. Incorrect: This is a symptom of hypoalbuminemia. There is a
shift in the fluid from intracellular to extracellular. This results in the swelling of the legs. 3. Incorrect:
Hypoalbuminemia may cause damage to the kidneys. Proteinuria is indicative of renal disease or
damage. 4. Incorrect: There may be a increased accumulation of fluid in the abdomen. The ascites is due
to the decreased albumin level in the vascular space, which also causes damage to the liver.
A nurse is attempting to develop trust with a psychiatric client exhibiting concrete thinking. Which
nursing intervention would promote trust in this individual? You answered this question Incorrectly 1.
Attend an activity with the client who is reluctant to go alone. 2. Allow the client to break an insignificant
rule. 3. Consider client preferences when possible in decisions concerning care. 4. Provide a blanket
when the client is cold. 5. Provide food when the client is hungry. - ANS ✔✔RationaleStrategies 1., 3., 4.
& 5. Correct: Trust is demonstrated through nursing interventions that convey a sense of warmth and
care to the client. These interventions are initiated simply, concretely, and directed toward activities that
address the client's basic needs for physiological and psychological safety and security. Concrete thinking
focuses thought processes on specifics, rather than generalities, and immediate issues, rather than
eventual outcomes. Examples of nursing interventions that would promote trust in an individual who is
thinking concretely include such things as: providing a blanket when the client is cold, providing food
when the client is hungry, keeping promises, being honest, providing a written, structured schedule of
activities, attending activities with the client if he is reluctant to go alone, being consistent in adhering to
unit guidelines, and taking the client's preferences, requests, and opinions into consideration when
possible in decisions concerning care. 2. Incorrect: The client should be informed of all rules, simply and
clearly, with reasons for certain policies and rules. Be consistent and provide written, structured,
scheduled activities. Allowing a client to break a rule would not encourage them to think about the
outcomes of their actions.
A charge nurse is planning care for several clients on the unit. Which activities can the nurse safely
delegate to an unlicensed assistive personnel (UAP)? You answered this question Incorrectly 1.
Administer a nebulizer treatment to a client diagnosed with pneumonia. 2. Obtain vital signs on a
postoperative client who required naloxone 5 minutes ago. 3. Report a urinary output (UOP) less than 50
ml/hr on a post-op client. 4. Assist a client with obtaining a clean catch urine sample. 5. Remove an
,indwelling urinary catheter from a client. - ANS ✔✔RationaleStrategies 3., & 4. Correct: A UAP can report
the amount of UOP but cannot interpret it. A clean catch urine sample is a noninvasive procedure. The
UAP can assist the client to obtain the clean catch urinary sample. Both activities are the right person
and right task of delegation. 1. Incorrect: A UAP cannot administer medications. This is the wrong task
for an UAP. 2. Incorrect: The client received naloxone to reverse the action of an opioid medication. A
UAP should not be assigned to obtain vital signs on an unstable client. This is the wrong person to
perform removal of an indwelling urinary catheter. 5. Incorrect: A UAP cannot remove an indwelling
urinary catheter.
Which interventions should the nurse initiate to lessen acid reflux in a client diagnosed with
gastroesophagel reflux disease (GERD)? You answered this question Correctly 1. Provide small, frequent
meals. 2. Avoid carbonated beverages. 3. Administer omeprazole as prescribed. 4. Assist with smoking
cessation. 5. Place in left lateral position for 2 hours after eating. - ANS ✔✔RationaleStrategies 1., 2., 3.,
& 4. Correct: All of these actions are correct to help alleviate dyspepsia. When a client has GERD, the
stomach's contents reflux into the esophagus. Small frequent meals will decrease possible reflux by
decreasing the stomach content. Smoking can relax the lower muscle of the esophagus. Drinking a
carbonated drink may cause the stomach to expand. Both smoking and drinking a carbonated drink
increase the potential of reflux. The action of omeprazole is to reduce the acid that is produced in the
stomach. 5. Incorrect: The client should be positioned with the head of the bed (HOB) elevated for 2-3
hours after eating. This position will decrease the potential for esophageal reflux.
A nurse from the neonatal unit is transferred to the adult medical-surgical unit. Which client should the
charge nurse assign to the neonatal nurse? You answered this question Incorrectly 1. Undergoing surgery
for placement of a central venous catheter. 2. Diagnosed with leukemia, hospitalized for induction of
high-dose chemotherapy. 3. Receiving IV heparin for left leg thrombosis. 4. Admitted with a
cerebrovascular accident. - ANS ✔✔RationaleStrategies 1. Correct: This is the most stable client to give
to the nurse who was transferred from the neonatal unit. A neonatal nurse cares for central lines daily in
this specialty area and can transfer this knowledge to the adult client. 2. Incorrect: This is not a good
client for a neonatal nurse because knowledge of lab values, chemotherapy precautions, protective
isolation and chemotherapy drugs is required for the nurse in order to care for this client. 3. Incorrect:
This is not the best client for a neonatal nurse because thrombosis problems are not commonly seen in
the nursery. Monitoring clotting factors and being aware of signs and symptoms of pulmonary emboli
are essential for safe care of this client. 4. Incorrect: This client is very unstable and requires skilled
observation and assessment using the Glasgow Scale. This level of assessment is not utilized in a
neonatal unit.
A client with a history of increasing dyspnea over the past week comes to the emergency department.
After arterial blood gases (ABGs) are drawn, which information would be important for the nurse to
document? You answered this question Correctly 1. The client had not been NPO prior to the test. 2. The
client was on 2 L of oxygen by nasal canula. 3. Lung sounds are wet. 4. Client is sitting in upright position.
- ANS ✔✔RationaleStrategies 2. Correct: The fact that the client is on 2 L/min of oxygen will affect the
analysis of the ABG results. If the client is on oxygen, the partial pressure of oxygen (PO2) will be
elevated due to the increased inhaled oxygen. 1. Incorrect: Whether the client has eaten or been NPO
will not affect the evaluation of the ABG results. 3. Incorrect: An assessment of the client's lung sounds
must be performed for a client with a history of dyspnea. This assessment will not directly affect the
ABGs result. 4. Incorrect: The client's position will not directly affect the evaluation of the ABG results.
, The nurse is providing care to a client who has a large abdominal dressing. Which intervention is most
likely to reduce the risk of skin irritation due to frequent dressing changes? You answered this question
Correctly 1. Use a paper tape for adhering the dressing. 2. Use tape sparingly. 3. Secure the dressing with
Montgomery straps. 4. Change the dressing only if it becomes saturated with drainage. - ANS
✔✔RationaleStrategies 3. Correct: Montgomery straps will allow the dressing to be held in place without
the use of tape. The adhesive on the ends of the straps is the only adhesive used. 1. Incorrect: Paper
tape may be less irritating; however, with repeated changes, skin irritation is more likely. Montgomery
straps will decrease the repeated tape changes. 2. Incorrect: Use of the tape should be sufficient to
secure the dressing and applied in a way to allow mobility if placed over a joint. There still is an increase
of skin irritation from applying the tape. 4. Incorrect: The soiled dressing is a medium for bacteria
growth. The dressing should be changed as ordered or required.
A newborn in a neonatal unit is to receive penicillin G benzathine 50,000 units/kg intramuscularly (IM).
The newborn weighs 6 lbs (2.7 kg). The dispensed dose is 25,000 units per 1 mL. What should the nurse
do? You answered this question Incorrectly 1. Administer the drug intravenously (IV) since a large
volume is required. 2. Choose three injection sites and give the medication as prescribed. 3. Consult with
the pharmacy for a different medication concentration. 4. Read the available drug information to
determine how to administer the medication. - ANS ✔✔RationaleStrategies 3. Correct: The nurse must
consult with the pharmacy to receive further instructions. The dose is greater than the allowed volume
to be given IM, which warrants clarification by the pharmacy. 1. Incorrect: Since the drug is prescribed
IM, the route should not be changed to IV administration because this violates the prescription as
written. 2. Incorrect: The dose is greater than the allowed volume to be given IM, which warrants
clarification by the pharmacy. You want to avoid having to give three injections. 4. Incorrect: The concern
is not drug information or administration; it is the concentration, which can only be provided by the
pharmacy.
A nurse is preparing to conduct a presentation on barriers to therapeutic communication with clients
from a culture other than the nurse's culture. Which points should the nurse include in the
presentation? You answered this question Incorrectly 1. Lack of knowledge about a client's culture is a
major barrier to therapeutic communication. 2. Follow cultural beliefs when caring for all clients of that
particular culture. 3. Ethnocentrism facilitates therapeutic communication. 4. Do not touch the client
until you know what the cultural belief is about touching. 5. Adapt care to client's cultural needs and
preferences. - ANS ✔✔RationaleStrategies 1., 4. & 5. Correct: Nurses must understand and take into
consideration the cultural differences of their clients. Some cultures do not approve of touching or
shaking hands. By assessing the client's culture preference, the nurse is able to provide individualized
care. 2. Incorrect: Do not stereotype all clients of a certain culture. Ask questions. Allow for individuality.
To provide culturally competent care, the nurse must recognize individual preferences within the client's
culture. 3. Incorrect: Ethnocentrism is the belief that one's own culture and traditions are better than
those of another. It blocks therapeutic communication by allowing the nurse's biases and prejudices to
negatively influence the nursing care of the client.
A woman, diagnosed with an ectopic pregnancy, asks the nurse the purpose of receiving methotrexate.
What is the best reply for the nurse to make? You answered this question Correctly 1. "Methotrexate will
stop your bleeding." 2. "It will destroy fetal cells that got into your blood so that antibodies will not be
formed." 3. "This medication will stop the growth of the embryo to save your fallopian tube." 4. "Cervical
dilation is expected after receiving this medication." - ANS ✔✔RationaleStrategies 3. Correct: The
medical management of an ectopic pregnancy is to prescribe methotrexate. The action of methotrexate
is to stop the growth of the embryo in the fallopian tube. The embryo is reabsorbed and the fallopian
