HURST READINESS EXAM 3 QUESTIONS AND ANSWERS | COMPLETE HURST
NCLEX-RN READINESS EXAM 3 STUDY GUIDE 2026/2027
Which menu selection by the client diagnosed with nephrotic syndrome indicates that teaching of
proper diet was understood? You answered this question Correctly 1. Pancakes with whipped butter,
syrup, bacon, apple juice 2. Scrambled eggs, sliced turkey, biscuit, whole milk 3. Grits, fresh fruit, toast,
coffee 4. Bagel with jelly, hash browns, tea - ✔✔Rationale
2. Correct: Client needs low sodium and increased proteins. 1. Incorrect: This selection is too high in
sodium and fats. 3. Incorrect: This selection has no protein. Remember, nephrotic syndrome is the
exception to the rule of limiting protein. These clients need increased protein to compensate for the
large loss of protein in the urine. 4. Incorrect: This selection has no protein. Remember, nephrotic
syndrome is the exception to the rule of limiting protein. These clients need increased protein to
compensate for the large loss of protein in the urine.
Following a total hip replacement, the nurse provides discharge teaching to the client. The nurse knows
that teaching was effective when the client states which activities are safe to perform? You answered this
question Correctly 1. Using an abduction pillow while sleeping 2. Crossing the legs 3. Using a toilet
extender 4. Showering rather than taking a bath 5. Tying shoes - ✔✔RationaleStrategies 1., 3., & 4.
Correct: The client should use an abduction pillow to keep hip in proper alignment and prevent hip
dislocation. A toilet extender keeps the hip in proper alignment and prevents hip dislocation. Showering
rather than sitting in a tub will prevent flexion of the hip. 2. Incorrect: Crossing the leg can pop the hip
out of place and prevent total healing and success with the replacement. 5. Incorrect: To tie shoes, the
client has to bend over which can pop the hip out of place. The client would need to have shoes that do
not require tying or have someone do it for them.
What risk factors should the nurse include when conducting a class about type 2 diabetes mellitus? You
answered this question Correctly 1. Fat distribution greater in abdomen than in hips. 2. Being
underweight. 3. Having type 1 diabetes as a child increases risk for type 2 diabetes. 4. Caucasians are
more likely to develop type 2 diabetes than Hispanics. 5. Polycystic ovary syndrome. -
✔✔RationaleStrategies 1., & 5. Correct: If the body stores fat primarily in the abdomen, risk of type 2
diabetes is greater than if body stores fat elsewhere, such as hips and thighs. Women with polycystic
ovary syndrome have increased risk of diabetes. 2. Incorrect: Being overweight is a primary risk factor for
type 2 diabetes. The more fatty tissue, the more resistant cells become to insulin. 3. Incorrect: A type 1
diabetic will remain a type 1 diabetic. 4. Incorrect: African Americans, Hispanics, American Indians, and
Asian Americans are more likely to develop type 2 diabetes than Caucasians are.
The nurse is caring for a client following spinal surgery. The client is placed on methylprednisolone. What
additional drug therapy would the nurse expect to be prescribed with methylprednisolone? You
answered this question Correctly 1. Pantoprazole 2. Phenytoin 3. Imipramine HCI 4. Aminocaproic acid -
✔✔RationaleStrategies 1. Correct: A potential side effect of methylprednisolone is a peptic ulcer. The
primary healthcare provider will prescribe a proton pump inhibitor or H2 blocker to prevent this side
effect. 2. Incorrect: Phenytoin is an anticonvulsant. Seizures are not a side effect of methylprednisolone.
3. Incorrect: Imipramine HCI is an antidepressant which is not routinely given with methylprednisolone
(Although mood changes can occur with steroid administration, anti-depressants are not routinely
given). 4. Incorrect: Aminocaproic acid is given when clients are bleeding. Bleeding is not a side effect of
methylprednisolone.
,In what order, after initially washing hands, should the nurse change a dressing on an infected abdominal
surgical wound that has a Penrose drain and a large amount of purulent drainage? Place in priority order
from first to last. You answered this question CorrectlyThe Correct Order Apply clean gloves. Remove
soiled dressings. Discard soiled dressings and clean gloves in red bag. Don sterile gloves. Clean surgical
wound with moistened sterile 4x4's. Clean around Penrose drain using a circular pattern inside to
outside. Place dry, sterile 4x4's over surgical wound and Penrose drain. Apply abdominal dressing pad.
Your Selected Order Apply clean gloves. Remove soiled dressings. Discard soiled dressings and clean
gloves in red bag. Don sterile gloves. Clean surgical wound with moistened sterile 4x4's. Clean around
Penrose drain using a circular pattern inside to outside. Place dry, sterile 4x4's over surgical wound and -
✔✔RationaleStrategies First, apply clean gloves. Second, remove soiled dressings. Third, discard soiled
dressings and clean gloves in red bag. Fourth, don sterile gloves. Fifth, clean surgical wound with
moistened sterile 4x4's. Sixth, clean around Penrose drain using circular pattern inside to outside.
Seventh, place dry, sterile 4x4's over surgical wound and Penrose drain. Eighth, apply abdominal dressing
pad.
A client diagnosed with schizophrenia who is taking monthly haloperidol injections develops slurred
speech, shuffling gait and drooling. Which prescribed PRN medication would the nurse administer? You
answered this question Incorrectly 1. Lorazepam 2. Atropine 3. Benztropine 4. Chlorpromazine -
✔✔RationaleStrategies 3. Correct: These signs and symptoms are reflective of pseudoparkinsonism, a
form of extrapyramidal side effects which are side effects of the haloperidol. An anticholinergic agent
maybe used for treatment. This is an anticholinergic agent that may be used for extrapyramidal side
effects. 1. Incorrect: This is a sedative/hypnotic or antianxiety agent. It is not used for treatment of
extrapyramidal side effects. 2. Incorrect: This is an anticholinergic agent, but not one commonly used to
treat pseudoparkinsonism, a form of extrapyramidal side effects. It is commonly used to treat
arrhythmias and preoperatively to decrease secretions. 4. Incorrect: This is another antipsychotic
medication.
A nurse is caring for a client who reports fatigue, weight loss, afternoon fevers, night sweats, cough, and
hemoptysis. What interventions should the nurse initiate? You answered this question Correctly 1. Wear
an N95 respirator when caring for client. 2. Restrict fluid intake to 500 mL per day. 3. Position client in
semi-Fowler's position. 4. Place client in a negative pressure airflow room. 5. Do not allow visitors for 48
hours. - ✔✔RationaleStrategies 1., 3. & 4. Correct: The nurse should suspect that the client is suffering
from tuberculosis. Early pulmonary TB is asymptomatic. When the bacterial load increases, nonspecific
symptoms of fatigue, weight loss, afternoon fevers, and night sweats may set in. As disease advances,
cough, sputum production, and hemoptysis may appear. This client has the classic symptoms of TB and
should be placed on airborne precautions. N95 respirator ensures that the nurse does not inhale the TB
organism. Placing in a semi-Fowler's position reduces the work of breathing. 2. Incorrect: Unless
contraindicated, 3-4 liters of fluid is needed per day to liquefy secretions. 5. Incorrect: Visitors are
allowed if standard and airborne precautions are followed.
Which task should the nurse perform first? You answered this question Correctly 1. Suctioning the
tracheostomy. 2. Changing a colostomy bag that is leaking. 3. Performing an admission assessment on a
client. 4. Administering pain medication to a postoperative client. - ✔✔RationaleStrategies 1. Correct:
The tracheostomy tube must be suctioned to keep the client's airway open. Suctioning the tracheostomy
should take priority. Remember, airway first. 2. Incorrect: The client may be uncomfortable from the
colostomy bag leaking. This task can be delegated. The suctioning of the client does not have priority
over airway. 3. Incorrect: Important, but not priority over airway. There is no indication from the
,question that the new client is in distress. The priority intervention is to maintain the airway. 4. Incorrect:
Important, but it does not take priority over airway.
A nurse is caring for a client hospitalized with Guillain-Barre syndrome. Which is the most important
nursing measure to include in the nursing care plan for this client? You answered this question Correctly
1. Observation and support of ventilation 2. Insertion of indwelling urinary catheter 3. Nasogastric
suctioning 4. Frequent assessments of level of consciousness - ✔✔RationaleStrategies 1. Correct:
Guillain-Barre syndrome is an acquired inflammatory disease that results in demyelinization of the
peripheral nerves. It is usually ascending in nature and can lead to respiratory paresis or paralysis. 2.
Incorrect: Insertion of an indwelling urinary catheter may in fact be necessary but does not prioritize
higher than support of ventilation. 3. Incorrect: Nasogastric suctioning is not a need identified with
Guillain-Barre syndrome. Guillain-Barre does not affect the LOC. 4. Incorrect: The client's cognitive
function remains intact, and there is no data in the stem of the question that indicates otherwise;
therefore, ventilation is the priority.
The nurse recognizes that treatment has been successful in resolving fluid volume excess based on which
assessment findings? You answered this question Correctly 1. Continued lethargy 2. Heart rate 112/min
3. Decreasing shortness of breath 4. BP 114/78 5. Increased thirst - ✔✔RationaleStrategies 3. & 4.
Correct: Urinary output should increase with decreasing shortness of breath as hydration is corrected,
and BP should be normal. 1. Incorrect: Level of consciousness (LOC) should improve with perfusion to
the brain. 2. Incorrect: Heart rate should decrease if hydration is corrected. 5. Incorrect: Thirst level
should be decreased if hydration is corrected.
The oncoming nurse has just received report and is preparing to make initial rounds. Which postpartum
client should the nurse see first? You answered this question Correctly 1. A primipara 6 hours
postpartum saturating one peripad every two hours 2. A multigravida 1 hour postpartum and reporting
intense perineal pain 3. A primigravida 12 hours postpartum with the uterine fundus at the umbilicus 4.
A multigravida 72 hours postpartum with a brownish pink lochia discharge. - ✔✔RationaleStrategies 2.
Correct: Intense perineal pain is a symptom of a perineal hematoma which is a medical emergency. 1.
Incorrect: Expected findings for the postpartum period are described here. This is a normal peripad
saturation and does not indicate a problem. 3. Incorrect: Expected findings for the postpartum period
are described here. This is the proper position of the fundus 12 hours postpartum. 4. Incorrect: Expected
findings for the postpartum period are described here also. A client postpartal 72 hours should have a
brownish pink lochia discharge.
The primary healthcare provider prescribes glycopyrrolate 0.2 mg IM thirty minutes prior to
electroconvulsive therapy (ECT). What should be the nurse's response when the client asks why this drug
is being given? You answered this question Incorrectly 1. "The action of the medication is complex." 2.
"This drug will prevent you from having a seizure." 3. "This medication will relax your muscles so that you
do not break a bone." 4. "Glycopyrrolate will decrease stomach secretions." - ✔✔RationaleStrategies 4.
Correct: Glycopyrrolate is an anticholinergic. Glycopyrrolate blocks the activity of acetylcholine which
reduces secretions in the mouth, throat, airway, and stomach. It is used prior to procedures to decrease
the risk of aspiration. 1. Incorrect: The client has a right to be told the reason the drug is given. This is a
nontherapeutic communication response. The nurse should not refuse the client's desire to understand
their medications. 2. Incorrect: Glycopyrrolate blocks the secretions in the mouth, throat, airway and
stomach. The medication does not prevent the client having a seizure. The ECT will induce a seizure,
which is the desire. 3. Incorrect: This is not the drug's purpose so this would be incorrect information to
give to the client.
, The nurse is searching for information about the nursing care of a client receiving an experimental drug
for the treatment of obesity. Which database is most likely to address this issue? You answered this
question Correctly 1. Cumulative Index for Nursing and Allied Health Literature (CINAHL) 2. Cochrane
Library 3. Health and Wellness Resource Center 4. MEDLINE - ✔✔RationaleStrategies 1. Correct: The
Cumulative Index for Nursing and Allied Health Literature (CINAHL) is a source for reviewing nursing and
allied health information. It is also located in other healthcare data bases. 2. Incorrect: Cochrane Library
includes evidence based medicine databases. 3. Incorrect: The Health and Wellness Resource Center
provides access to a variety of journal articles, magazines, and pamphlets. 4. Incorrect: MEDLINE is one
of the major sources for biomedical information.
A client comes to the clinic reporting palpitations, as well as nausea and vomiting while taking
metronidazole. The nurse notes that the client is flushed and has a heart rate of 118 bpm. Based on this
information, what is the most important question for the nurse to ask the client? You answered this
question Correctly 1. "Do you take metronidazole on an empty stomach?" 2. "Are you using any products
that contain alcohol?" 3. "How long have you had these symptoms?" 4. "What other medications are you
currently taking?" - ✔✔RationaleStrategies 2. Correct: Flushing, nausea and vomiting, palpitations,
tachycardia, psychosis are signs of disulfiram-type reaction seen when using products containing alcohol
(cologne, after shave lotion, or path splashes) or ingesting alcohol products while taking metronidazole.
1. Incorrect: Although it is preferable to take metronidazole on an empty stomach, this is not the most
important question to ask at this time. 3. Incorrect: How long the client has had these symptoms is not
as important as whether the client is using any alcohol containing products. 4. Incorrect: Although the
nurse needs to know what other medications the client is taking, it is not as important as knowing if the
client is using any alcohol containing products.
A case manager is evaluating a client diagnosed with hemiplegia due to a cerebral vascular accident who
will need assistive devices upon discharge. Which devices should the case manager include for this
client? You answered this question Correctly 1. Dinner plate food guards 2. Transfer belt 3. Raised toilet
seat 4. Long handled shoe horn 5. Wide grip eating utensils 6. Button closures on clothes -
✔✔RationaleStrategies 1., 2., 3., 4., & 5. Correct: The goal is to promote self-care by the client as much
as possible. The case manager should evaluate the need for assistive devices to help with eating,
bathing, dressing, and ambulating. The dinner plate food guard will prevent food from being pushed off
the plate. The transfer belt will provide safety for the client to get into a chair or back in bed. A raised
toilet seat makes it easier for the client to sit on the toilet without falling. The long-handled shoe horn
allows the client to put on shoes without assistance. Wide grip utensils accommodate a weak grip. 6.
Incorrect: It is hard for someone with hemiplegia to use buttons. Velcro fasteners are best.
The nurse is caring for a Native American client who has returned to the surgical floor following
abdominal surgery. The nurse is concerned about the level of discomfort that the client is experiencing.
Which comment is the nurse likely to hear upon assessment? You answered this question Correctly 1.
"The pain is getting worse. I can't stand it." 2. "I need something for pain as soon as possible." 3. "I hope
that the pain will go away soon." 4. "I am doing okay. The pain is not bad." - ✔✔RationaleStrategies 4.
Correct: The Native American client is likely to be quiet and less expressive of pain. Native Americans
tend to tolerate high levels of pain. 1. Incorrect: This comment is likely to come from the dominant
American culture where pain is considered something to be treated. 2. Incorrect: Native Americans tend
to tolerate high levels of pain. Abdominal surgery usually results in sensations of pain for most people. 3.
Incorrect: The Native American client is likely to be very quiet about the pain being experienced.
NCLEX-RN READINESS EXAM 3 STUDY GUIDE 2026/2027
Which menu selection by the client diagnosed with nephrotic syndrome indicates that teaching of
proper diet was understood? You answered this question Correctly 1. Pancakes with whipped butter,
syrup, bacon, apple juice 2. Scrambled eggs, sliced turkey, biscuit, whole milk 3. Grits, fresh fruit, toast,
coffee 4. Bagel with jelly, hash browns, tea - ✔✔Rationale
2. Correct: Client needs low sodium and increased proteins. 1. Incorrect: This selection is too high in
sodium and fats. 3. Incorrect: This selection has no protein. Remember, nephrotic syndrome is the
exception to the rule of limiting protein. These clients need increased protein to compensate for the
large loss of protein in the urine. 4. Incorrect: This selection has no protein. Remember, nephrotic
syndrome is the exception to the rule of limiting protein. These clients need increased protein to
compensate for the large loss of protein in the urine.
Following a total hip replacement, the nurse provides discharge teaching to the client. The nurse knows
that teaching was effective when the client states which activities are safe to perform? You answered this
question Correctly 1. Using an abduction pillow while sleeping 2. Crossing the legs 3. Using a toilet
extender 4. Showering rather than taking a bath 5. Tying shoes - ✔✔RationaleStrategies 1., 3., & 4.
Correct: The client should use an abduction pillow to keep hip in proper alignment and prevent hip
dislocation. A toilet extender keeps the hip in proper alignment and prevents hip dislocation. Showering
rather than sitting in a tub will prevent flexion of the hip. 2. Incorrect: Crossing the leg can pop the hip
out of place and prevent total healing and success with the replacement. 5. Incorrect: To tie shoes, the
client has to bend over which can pop the hip out of place. The client would need to have shoes that do
not require tying or have someone do it for them.
What risk factors should the nurse include when conducting a class about type 2 diabetes mellitus? You
answered this question Correctly 1. Fat distribution greater in abdomen than in hips. 2. Being
underweight. 3. Having type 1 diabetes as a child increases risk for type 2 diabetes. 4. Caucasians are
more likely to develop type 2 diabetes than Hispanics. 5. Polycystic ovary syndrome. -
✔✔RationaleStrategies 1., & 5. Correct: If the body stores fat primarily in the abdomen, risk of type 2
diabetes is greater than if body stores fat elsewhere, such as hips and thighs. Women with polycystic
ovary syndrome have increased risk of diabetes. 2. Incorrect: Being overweight is a primary risk factor for
type 2 diabetes. The more fatty tissue, the more resistant cells become to insulin. 3. Incorrect: A type 1
diabetic will remain a type 1 diabetic. 4. Incorrect: African Americans, Hispanics, American Indians, and
Asian Americans are more likely to develop type 2 diabetes than Caucasians are.
The nurse is caring for a client following spinal surgery. The client is placed on methylprednisolone. What
additional drug therapy would the nurse expect to be prescribed with methylprednisolone? You
answered this question Correctly 1. Pantoprazole 2. Phenytoin 3. Imipramine HCI 4. Aminocaproic acid -
✔✔RationaleStrategies 1. Correct: A potential side effect of methylprednisolone is a peptic ulcer. The
primary healthcare provider will prescribe a proton pump inhibitor or H2 blocker to prevent this side
effect. 2. Incorrect: Phenytoin is an anticonvulsant. Seizures are not a side effect of methylprednisolone.
3. Incorrect: Imipramine HCI is an antidepressant which is not routinely given with methylprednisolone
(Although mood changes can occur with steroid administration, anti-depressants are not routinely
given). 4. Incorrect: Aminocaproic acid is given when clients are bleeding. Bleeding is not a side effect of
methylprednisolone.
,In what order, after initially washing hands, should the nurse change a dressing on an infected abdominal
surgical wound that has a Penrose drain and a large amount of purulent drainage? Place in priority order
from first to last. You answered this question CorrectlyThe Correct Order Apply clean gloves. Remove
soiled dressings. Discard soiled dressings and clean gloves in red bag. Don sterile gloves. Clean surgical
wound with moistened sterile 4x4's. Clean around Penrose drain using a circular pattern inside to
outside. Place dry, sterile 4x4's over surgical wound and Penrose drain. Apply abdominal dressing pad.
Your Selected Order Apply clean gloves. Remove soiled dressings. Discard soiled dressings and clean
gloves in red bag. Don sterile gloves. Clean surgical wound with moistened sterile 4x4's. Clean around
Penrose drain using a circular pattern inside to outside. Place dry, sterile 4x4's over surgical wound and -
✔✔RationaleStrategies First, apply clean gloves. Second, remove soiled dressings. Third, discard soiled
dressings and clean gloves in red bag. Fourth, don sterile gloves. Fifth, clean surgical wound with
moistened sterile 4x4's. Sixth, clean around Penrose drain using circular pattern inside to outside.
Seventh, place dry, sterile 4x4's over surgical wound and Penrose drain. Eighth, apply abdominal dressing
pad.
A client diagnosed with schizophrenia who is taking monthly haloperidol injections develops slurred
speech, shuffling gait and drooling. Which prescribed PRN medication would the nurse administer? You
answered this question Incorrectly 1. Lorazepam 2. Atropine 3. Benztropine 4. Chlorpromazine -
✔✔RationaleStrategies 3. Correct: These signs and symptoms are reflective of pseudoparkinsonism, a
form of extrapyramidal side effects which are side effects of the haloperidol. An anticholinergic agent
maybe used for treatment. This is an anticholinergic agent that may be used for extrapyramidal side
effects. 1. Incorrect: This is a sedative/hypnotic or antianxiety agent. It is not used for treatment of
extrapyramidal side effects. 2. Incorrect: This is an anticholinergic agent, but not one commonly used to
treat pseudoparkinsonism, a form of extrapyramidal side effects. It is commonly used to treat
arrhythmias and preoperatively to decrease secretions. 4. Incorrect: This is another antipsychotic
medication.
A nurse is caring for a client who reports fatigue, weight loss, afternoon fevers, night sweats, cough, and
hemoptysis. What interventions should the nurse initiate? You answered this question Correctly 1. Wear
an N95 respirator when caring for client. 2. Restrict fluid intake to 500 mL per day. 3. Position client in
semi-Fowler's position. 4. Place client in a negative pressure airflow room. 5. Do not allow visitors for 48
hours. - ✔✔RationaleStrategies 1., 3. & 4. Correct: The nurse should suspect that the client is suffering
from tuberculosis. Early pulmonary TB is asymptomatic. When the bacterial load increases, nonspecific
symptoms of fatigue, weight loss, afternoon fevers, and night sweats may set in. As disease advances,
cough, sputum production, and hemoptysis may appear. This client has the classic symptoms of TB and
should be placed on airborne precautions. N95 respirator ensures that the nurse does not inhale the TB
organism. Placing in a semi-Fowler's position reduces the work of breathing. 2. Incorrect: Unless
contraindicated, 3-4 liters of fluid is needed per day to liquefy secretions. 5. Incorrect: Visitors are
allowed if standard and airborne precautions are followed.
Which task should the nurse perform first? You answered this question Correctly 1. Suctioning the
tracheostomy. 2. Changing a colostomy bag that is leaking. 3. Performing an admission assessment on a
client. 4. Administering pain medication to a postoperative client. - ✔✔RationaleStrategies 1. Correct:
The tracheostomy tube must be suctioned to keep the client's airway open. Suctioning the tracheostomy
should take priority. Remember, airway first. 2. Incorrect: The client may be uncomfortable from the
colostomy bag leaking. This task can be delegated. The suctioning of the client does not have priority
over airway. 3. Incorrect: Important, but not priority over airway. There is no indication from the
,question that the new client is in distress. The priority intervention is to maintain the airway. 4. Incorrect:
Important, but it does not take priority over airway.
A nurse is caring for a client hospitalized with Guillain-Barre syndrome. Which is the most important
nursing measure to include in the nursing care plan for this client? You answered this question Correctly
1. Observation and support of ventilation 2. Insertion of indwelling urinary catheter 3. Nasogastric
suctioning 4. Frequent assessments of level of consciousness - ✔✔RationaleStrategies 1. Correct:
Guillain-Barre syndrome is an acquired inflammatory disease that results in demyelinization of the
peripheral nerves. It is usually ascending in nature and can lead to respiratory paresis or paralysis. 2.
Incorrect: Insertion of an indwelling urinary catheter may in fact be necessary but does not prioritize
higher than support of ventilation. 3. Incorrect: Nasogastric suctioning is not a need identified with
Guillain-Barre syndrome. Guillain-Barre does not affect the LOC. 4. Incorrect: The client's cognitive
function remains intact, and there is no data in the stem of the question that indicates otherwise;
therefore, ventilation is the priority.
The nurse recognizes that treatment has been successful in resolving fluid volume excess based on which
assessment findings? You answered this question Correctly 1. Continued lethargy 2. Heart rate 112/min
3. Decreasing shortness of breath 4. BP 114/78 5. Increased thirst - ✔✔RationaleStrategies 3. & 4.
Correct: Urinary output should increase with decreasing shortness of breath as hydration is corrected,
and BP should be normal. 1. Incorrect: Level of consciousness (LOC) should improve with perfusion to
the brain. 2. Incorrect: Heart rate should decrease if hydration is corrected. 5. Incorrect: Thirst level
should be decreased if hydration is corrected.
The oncoming nurse has just received report and is preparing to make initial rounds. Which postpartum
client should the nurse see first? You answered this question Correctly 1. A primipara 6 hours
postpartum saturating one peripad every two hours 2. A multigravida 1 hour postpartum and reporting
intense perineal pain 3. A primigravida 12 hours postpartum with the uterine fundus at the umbilicus 4.
A multigravida 72 hours postpartum with a brownish pink lochia discharge. - ✔✔RationaleStrategies 2.
Correct: Intense perineal pain is a symptom of a perineal hematoma which is a medical emergency. 1.
Incorrect: Expected findings for the postpartum period are described here. This is a normal peripad
saturation and does not indicate a problem. 3. Incorrect: Expected findings for the postpartum period
are described here. This is the proper position of the fundus 12 hours postpartum. 4. Incorrect: Expected
findings for the postpartum period are described here also. A client postpartal 72 hours should have a
brownish pink lochia discharge.
The primary healthcare provider prescribes glycopyrrolate 0.2 mg IM thirty minutes prior to
electroconvulsive therapy (ECT). What should be the nurse's response when the client asks why this drug
is being given? You answered this question Incorrectly 1. "The action of the medication is complex." 2.
"This drug will prevent you from having a seizure." 3. "This medication will relax your muscles so that you
do not break a bone." 4. "Glycopyrrolate will decrease stomach secretions." - ✔✔RationaleStrategies 4.
Correct: Glycopyrrolate is an anticholinergic. Glycopyrrolate blocks the activity of acetylcholine which
reduces secretions in the mouth, throat, airway, and stomach. It is used prior to procedures to decrease
the risk of aspiration. 1. Incorrect: The client has a right to be told the reason the drug is given. This is a
nontherapeutic communication response. The nurse should not refuse the client's desire to understand
their medications. 2. Incorrect: Glycopyrrolate blocks the secretions in the mouth, throat, airway and
stomach. The medication does not prevent the client having a seizure. The ECT will induce a seizure,
which is the desire. 3. Incorrect: This is not the drug's purpose so this would be incorrect information to
give to the client.
, The nurse is searching for information about the nursing care of a client receiving an experimental drug
for the treatment of obesity. Which database is most likely to address this issue? You answered this
question Correctly 1. Cumulative Index for Nursing and Allied Health Literature (CINAHL) 2. Cochrane
Library 3. Health and Wellness Resource Center 4. MEDLINE - ✔✔RationaleStrategies 1. Correct: The
Cumulative Index for Nursing and Allied Health Literature (CINAHL) is a source for reviewing nursing and
allied health information. It is also located in other healthcare data bases. 2. Incorrect: Cochrane Library
includes evidence based medicine databases. 3. Incorrect: The Health and Wellness Resource Center
provides access to a variety of journal articles, magazines, and pamphlets. 4. Incorrect: MEDLINE is one
of the major sources for biomedical information.
A client comes to the clinic reporting palpitations, as well as nausea and vomiting while taking
metronidazole. The nurse notes that the client is flushed and has a heart rate of 118 bpm. Based on this
information, what is the most important question for the nurse to ask the client? You answered this
question Correctly 1. "Do you take metronidazole on an empty stomach?" 2. "Are you using any products
that contain alcohol?" 3. "How long have you had these symptoms?" 4. "What other medications are you
currently taking?" - ✔✔RationaleStrategies 2. Correct: Flushing, nausea and vomiting, palpitations,
tachycardia, psychosis are signs of disulfiram-type reaction seen when using products containing alcohol
(cologne, after shave lotion, or path splashes) or ingesting alcohol products while taking metronidazole.
1. Incorrect: Although it is preferable to take metronidazole on an empty stomach, this is not the most
important question to ask at this time. 3. Incorrect: How long the client has had these symptoms is not
as important as whether the client is using any alcohol containing products. 4. Incorrect: Although the
nurse needs to know what other medications the client is taking, it is not as important as knowing if the
client is using any alcohol containing products.
A case manager is evaluating a client diagnosed with hemiplegia due to a cerebral vascular accident who
will need assistive devices upon discharge. Which devices should the case manager include for this
client? You answered this question Correctly 1. Dinner plate food guards 2. Transfer belt 3. Raised toilet
seat 4. Long handled shoe horn 5. Wide grip eating utensils 6. Button closures on clothes -
✔✔RationaleStrategies 1., 2., 3., 4., & 5. Correct: The goal is to promote self-care by the client as much
as possible. The case manager should evaluate the need for assistive devices to help with eating,
bathing, dressing, and ambulating. The dinner plate food guard will prevent food from being pushed off
the plate. The transfer belt will provide safety for the client to get into a chair or back in bed. A raised
toilet seat makes it easier for the client to sit on the toilet without falling. The long-handled shoe horn
allows the client to put on shoes without assistance. Wide grip utensils accommodate a weak grip. 6.
Incorrect: It is hard for someone with hemiplegia to use buttons. Velcro fasteners are best.
The nurse is caring for a Native American client who has returned to the surgical floor following
abdominal surgery. The nurse is concerned about the level of discomfort that the client is experiencing.
Which comment is the nurse likely to hear upon assessment? You answered this question Correctly 1.
"The pain is getting worse. I can't stand it." 2. "I need something for pain as soon as possible." 3. "I hope
that the pain will go away soon." 4. "I am doing okay. The pain is not bad." - ✔✔RationaleStrategies 4.
Correct: The Native American client is likely to be quiet and less expressive of pain. Native Americans
tend to tolerate high levels of pain. 1. Incorrect: This comment is likely to come from the dominant
American culture where pain is considered something to be treated. 2. Incorrect: Native Americans tend
to tolerate high levels of pain. Abdominal surgery usually results in sensations of pain for most people. 3.
Incorrect: The Native American client is likely to be very quiet about the pain being experienced.
