HURST REVIEW NCLEX RN READINESS EXAM 1
COMPREHENSIVE TEST PAPER QUESTIONS
AND SOLUTIONS
◉ 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 volume of 3 ounces is
excessive for a nine month old. The nurse will want to make sure the
client gets all of the medication. Additionally, applesauce may or may
not have been introduced into the diet, and it is inappropriate to
introduce a new food during an illness.
1. Incorrect: There is nothing in the stem about a problem with the
medication dose or route.
, 3. Incorrect: There is nothing in the stem about a problem with the
medication dose or route.
4. Incorrect: This is an appropriate action. However, it is not the
priority over ensuring that the new nurse knows how to
appropriately prepare the medication for this client.
◉ An adult client has just returned to the nursing care unit following
a gastroscopy. Which intervention should the nurse include on the
plan of care?
1. Vital sign checks every 15 min x 4
2. Supine position for 6 hours
3. NPO until return of gag reflex
4. Irrigate NG tube every 2 hours
5. Raise four side rails.
Answer: 1., & 3. Correct: Vital signs post procedure are important to
monitor for any post-procedure complications such as bleeding or
any signs of respiratory compromise. VS are checked frequently for
the first hour post procedure. Any client who has a scope inserted
down the throat and has received numbing medication in the back of
the throat to depress the gag reflex should be kept NPO until the gag
reflex returns.
2. Incorrect: Supine position for 6 hours is contraindicated. The HOB
should be elevated. In the event the client vomits, he/she is less
COMPREHENSIVE TEST PAPER QUESTIONS
AND SOLUTIONS
◉ 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 volume of 3 ounces is
excessive for a nine month old. The nurse will want to make sure the
client gets all of the medication. Additionally, applesauce may or may
not have been introduced into the diet, and it is inappropriate to
introduce a new food during an illness.
1. Incorrect: There is nothing in the stem about a problem with the
medication dose or route.
, 3. Incorrect: There is nothing in the stem about a problem with the
medication dose or route.
4. Incorrect: This is an appropriate action. However, it is not the
priority over ensuring that the new nurse knows how to
appropriately prepare the medication for this client.
◉ An adult client has just returned to the nursing care unit following
a gastroscopy. Which intervention should the nurse include on the
plan of care?
1. Vital sign checks every 15 min x 4
2. Supine position for 6 hours
3. NPO until return of gag reflex
4. Irrigate NG tube every 2 hours
5. Raise four side rails.
Answer: 1., & 3. Correct: Vital signs post procedure are important to
monitor for any post-procedure complications such as bleeding or
any signs of respiratory compromise. VS are checked frequently for
the first hour post procedure. Any client who has a scope inserted
down the throat and has received numbing medication in the back of
the throat to depress the gag reflex should be kept NPO until the gag
reflex returns.
2. Incorrect: Supine position for 6 hours is contraindicated. The HOB
should be elevated. In the event the client vomits, he/she is less
