HURST REVIEW NCLEX-RN Readiness
Exam 2 Questions with Complete
Answers with Rationales
The public health nurse is planning to participate in local forums regarding the placement of a factory
that is known to produce pollution through discharge of chemical by-products into the air. What actions
demonstrate ethical nursing practice in the public health arena?
1. Speaking up for the underrepresented, such as the poor and uneducated persons
3. Requesting that forums be held throughout the community at various times of the day or evening.
4. Asking for information regarding the health status of people in other factory locations.
5. Requesting information from individuals in areas where the factories are currently located.
Which assignment would be most appropriate for the charge nurse to assign to the LPN/VN in the Labor,
Delivery, Recovery and Postpartum Unit (LDRP)?
1. Primipara needing assistance with breastfeeding.
3. Primipara who is two days post op cesarean section.
A nurse is calling the primary healthcare provider about a client who is experiencing dyspnea and chest
pain two days post total knee replacement. Which statements by the nurse are appropriate according to
the communication tool SBAR (Situation, Background, Assessment and Recommendation)?
2. "Jane Doe is having increasing dyspnea and is reporting chest pain."
,3. "Jane Doe had a total knee replacement two days ago. Pulse is 120, BP 128/54, Resp 32. She is
restless."
4. "From my assessment, I think she may be having a cardiac event or a pulmonary embolism."
5. "I recommend that you see the client immediately and that we start oxygen stat. Do you agree?"
Which tasks would be appropriate for the nurse to assign to an LPN/VN?
1. Changing a colostomy bag.
2. Administer antibiotic via intravenous piggyback (IVPB).
5. Check for urinary retention.
6. Remove wound sutures.
A 13 year old, found unresponsive in the park, is brought into the emergency department. The nurse
sees a medical alert bracelet stating "Diabetic", and notes a fruity smell to the breath. There are no
family members available to obtain consent for treatment and an attempt to call them has been
unsuccessful. What action should the nurse take?
2. Begin treatment by inserting two large bore IVs of Normal Saline.
The nurse is working at the triage station. Which client should the nurse triage first?
2. A client with a cast on the right leg who states, "My right leg is killing me and nothing I do makes it
stop hurting. "
A quality assurance (QA) manager plans to evaluate performance improvement regarding the
implementation of fall precautions for at risk clients. What steps should the QA manager include in this
evaluation?
1. Chart review for fall precaution documentation.
2. Direct observation of unit staff.
,4. Identify at risk clients on unit.
5. Make unannounced visits to the unit for evaluating staff performance.
The nurse is performing the admission assessment on a client who is having a breast augmentation.
Which client information would be most important for the nurse to report to the surgeon before
surgery?
3. Client's last menstrual period was 8 weeks ago.
The charge nurse has received report from the emergency department about a client diagnosed with
Cushing's disease being admitted to the unit. Which client in a semi-private room would be appropriate
for the charge nurse to have this client share?
3. Client who has a fractured hip.
Which pediatric client should the nurse see first?
3. Three year old with wheezes in right lower lobe.
What is priority for the nurse to determine about a client who is scheduled for a tubal ligation in the
outpatient surgical center?
3. Client's plan for transportation and care at home.
A case manager is assessing an unresponsive client diagnosed with terminal hepatic encephalopathy to
determine equipment needs upon discharge to home for hospice care. Which equipment should the
case manager obtain for this client?
1. Alternating pressure mattress
2. Hospital bed
4. Suction equipment
, 5. Oxygen
Which client must the nurse assign to a private room?
4. Postpartum client 32 hours after delivery with a temperature of 101º F (38.05 ° C)
Which client requires immediate intervention by the nurse?
3. Client with a fractured femur reporting sharp chest pain of 4/10.
Which nursing tasks can the RN delegate to an unlicensed assistive personnel (UAP)?
2. Obtain blood pressure of client diagnosed with nephrotic syndrome.
4. Document the intake and output of a client in acute renal failure.
6. Perform perineal care of a client who has urinary incontinence.
A client tells the nurse, "I am dying from cancer. I have told my primary healthcare provider that I do not
want to be revived if my heart stops beating or I stop breathing." What action should the nurse take first
to assure that the client's request is respected?
1. Ensure a do-not-resuscitate prescription has been provided.
A homebound client lives alone, has a history of poorly controlled diabetes, and has an open wound on
the left heel. The home health nurse is concerned about the client's condition and the possible need for
a referral. Which intervention should the nurse initiate for this client?
1. Ask the primary healthcare provider to prescribe a diabetes educator consult.
Exam 2 Questions with Complete
Answers with Rationales
The public health nurse is planning to participate in local forums regarding the placement of a factory
that is known to produce pollution through discharge of chemical by-products into the air. What actions
demonstrate ethical nursing practice in the public health arena?
1. Speaking up for the underrepresented, such as the poor and uneducated persons
3. Requesting that forums be held throughout the community at various times of the day or evening.
4. Asking for information regarding the health status of people in other factory locations.
5. Requesting information from individuals in areas where the factories are currently located.
Which assignment would be most appropriate for the charge nurse to assign to the LPN/VN in the Labor,
Delivery, Recovery and Postpartum Unit (LDRP)?
1. Primipara needing assistance with breastfeeding.
3. Primipara who is two days post op cesarean section.
A nurse is calling the primary healthcare provider about a client who is experiencing dyspnea and chest
pain two days post total knee replacement. Which statements by the nurse are appropriate according to
the communication tool SBAR (Situation, Background, Assessment and Recommendation)?
2. "Jane Doe is having increasing dyspnea and is reporting chest pain."
,3. "Jane Doe had a total knee replacement two days ago. Pulse is 120, BP 128/54, Resp 32. She is
restless."
4. "From my assessment, I think she may be having a cardiac event or a pulmonary embolism."
5. "I recommend that you see the client immediately and that we start oxygen stat. Do you agree?"
Which tasks would be appropriate for the nurse to assign to an LPN/VN?
1. Changing a colostomy bag.
2. Administer antibiotic via intravenous piggyback (IVPB).
5. Check for urinary retention.
6. Remove wound sutures.
A 13 year old, found unresponsive in the park, is brought into the emergency department. The nurse
sees a medical alert bracelet stating "Diabetic", and notes a fruity smell to the breath. There are no
family members available to obtain consent for treatment and an attempt to call them has been
unsuccessful. What action should the nurse take?
2. Begin treatment by inserting two large bore IVs of Normal Saline.
The nurse is working at the triage station. Which client should the nurse triage first?
2. A client with a cast on the right leg who states, "My right leg is killing me and nothing I do makes it
stop hurting. "
A quality assurance (QA) manager plans to evaluate performance improvement regarding the
implementation of fall precautions for at risk clients. What steps should the QA manager include in this
evaluation?
1. Chart review for fall precaution documentation.
2. Direct observation of unit staff.
,4. Identify at risk clients on unit.
5. Make unannounced visits to the unit for evaluating staff performance.
The nurse is performing the admission assessment on a client who is having a breast augmentation.
Which client information would be most important for the nurse to report to the surgeon before
surgery?
3. Client's last menstrual period was 8 weeks ago.
The charge nurse has received report from the emergency department about a client diagnosed with
Cushing's disease being admitted to the unit. Which client in a semi-private room would be appropriate
for the charge nurse to have this client share?
3. Client who has a fractured hip.
Which pediatric client should the nurse see first?
3. Three year old with wheezes in right lower lobe.
What is priority for the nurse to determine about a client who is scheduled for a tubal ligation in the
outpatient surgical center?
3. Client's plan for transportation and care at home.
A case manager is assessing an unresponsive client diagnosed with terminal hepatic encephalopathy to
determine equipment needs upon discharge to home for hospice care. Which equipment should the
case manager obtain for this client?
1. Alternating pressure mattress
2. Hospital bed
4. Suction equipment
, 5. Oxygen
Which client must the nurse assign to a private room?
4. Postpartum client 32 hours after delivery with a temperature of 101º F (38.05 ° C)
Which client requires immediate intervention by the nurse?
3. Client with a fractured femur reporting sharp chest pain of 4/10.
Which nursing tasks can the RN delegate to an unlicensed assistive personnel (UAP)?
2. Obtain blood pressure of client diagnosed with nephrotic syndrome.
4. Document the intake and output of a client in acute renal failure.
6. Perform perineal care of a client who has urinary incontinence.
A client tells the nurse, "I am dying from cancer. I have told my primary healthcare provider that I do not
want to be revived if my heart stops beating or I stop breathing." What action should the nurse take first
to assure that the client's request is respected?
1. Ensure a do-not-resuscitate prescription has been provided.
A homebound client lives alone, has a history of poorly controlled diabetes, and has an open wound on
the left heel. The home health nurse is concerned about the client's condition and the possible need for
a referral. Which intervention should the nurse initiate for this client?
1. Ask the primary healthcare provider to prescribe a diabetes educator consult.
