Hurst NCLEX Test Taking Strategy Questions
1. The nurs is providing post-operative care to a craniotomy patient. Diabetes insipidus is
suspected when the patient’s urine output suddenly increases significantly. Which action
takeshighest priority?
o 1. Monitoring urine output
o 2. Checking pulse
o 3. Checking blood pressure
o 4. Assessing level of consciousness
Rationale:
3. Correct: This is the best answer because we are “worried” this patient is going into
SHOCK. So…..you better be checking a BP. This is a time where checking the BP is
appropriate. If we “assume the worst” I better check a blood pressure. It could have dropped
out the bottom.
1. Incorrect: Continuing to monitor U/O is important but I need to find out if they are already
shocky.
2. Incorrect: Checking the pulse is a good thing, but, not as important as checking the BP.
4. Incorrect: If my patient is going into shock the highest priority is to assess the BP.
2. The patient is being treated for fluid volume deficit. Which is an expected outcome
ofsuccessful treatment?
o 1. Resolution of orthostatic hypotension
o 2. Maintenance of weight loss
o 3. Compliance with sodium restricted diet
o 4. Maintenance of serum Na above 148 mEq
Rationale:
1. Correct: When you are in a fluid volume deficit your blood pressure goes down when you
stand up and it’s called orthostatic hypotension. Successful treatment would resolve this.
2. Incorrect: When I have lost a lot of volume, my weight goes down, so if I am better, my
weight should go up.
3. Incorrect: Who needs to adhere to dietary sodium restrictions? People who are in fluid volume
excess.
4. Incorrect: If your serum sodium is above 148, hypernatremia is the same thing as dehydration,
Day 4 1
,so this means that you are still sick.
2 Day 4
,3. The nurs in the intensive care unit is caring for a patient receiving hemodynamic monitoring.
When planning for a patient’s care, which nursing diagnoses associated with hemodynamic
monitoring may be utilized by the nurs? Select all that apply.
1. Decreased cardiac output
2. Fluid volume deficit
3. Fluid volume excess
4. Ineffective tissue perfusion
5. Ineffective airway
Rationale:
1., 2., 3. & 4. Correct: Nursing diagnoses, associated with hemodynamic monitoring, that may be
utilized by the nurs include decreased cardiac output, fluid volume deficit, fluid volume excess,
and ineffective tissue perfusion. These nursing diagnoses relate to the pathophysiologic
processes that alter one of the four hemodynamic mechanisms that support normal
cardiovascular function: preload, afterload, heart rate, and contractility.
5. Incorrect: Ineffective Airway would not be associated with hemodynamic monitoring.
4. The nurs is caring for a patient that has two IV access sites. One is a 20 gauge antecubital
peripheral IV that was started yesterday for blood and has normal saline (NS) at keep vein open
rate. The other is a double lumen central line catheter with one port for Total Parental Nutrition
and the other is used for blood samples. Where is the best site for the nurs to administer 20 mEq
of potassium chloride (KCL) in 100 mL of normal saline(NS) over 4 hours?
o 1. Central line port that is being used for lab draws
o 2. Same line with the Total Parental Nutrition
o 3. Large bore antecubital
o 4. Start another peripheral IV
Rationale:
1. Correct: Yes- K is very hard on the veins, give it through the central line.
2. Incorrect: No, never put anything through a line with Total Parental Nutrition.
3. Incorrect: Second best choice- but it will burn.
4. Incorrect: No, a central line is needed.
Day 4 3
, 5. The nurs is caring for a patient that has metabolic acidosis secondary to acute renal failure.
What is the initial patient response to this problem?
o 1. Respiratory rate increases to blow off acid.
o 2. Respiratory rate decreases to conserve acid and buffer the kidneys response.
o 3. Kidneys will excrete hydrogen and retain bicarb.
o 4. Sodium will shift to cells and buffer the hydrogens.
Rationale:
1. Correct: Yes, acute renal failure causes metabolic acidosis and the body is trying to breathe
faster to blow off some acid. The respiratory response is fast.
2. Incorrect: No, the patient’s respiratory rate is fast, not slow.
3. Incorrect: This will happen, later. Did not we say about 48 hours? Not initial response.
4. Incorrect: Sodium is extracellular electrolyte, not an intracellular electrolyte.
6. The patient presents to the emergency department with nausea, vomiting and anorexia for
thelast few days. An EKG on admission reveals an arrhythmia. Which electrolytes imbalance
is suspected?
o 1. Hypercalcemia
o 2. Hypokalemia
o 3. Hypermagnesemia
o 4. Hyponatremia
Rationale:
2. Correct: The patient has been vomiting so the electrolytes losses are potassium, hydrogen
andchloride. The anorexia further complicates the condition because we get potassium from
the foods we eat. The one electrolyte we worry about with arrhythmias is potassium.
1. Incorrect: What has calcium got to do with nausea and vomiting? Nothing
3. Incorrect: Magnesium is loss through the lower GI tract and Hypermagnesemia is not related
to dysrhythmias.
4. Incorrect: The loss of sodium is related to diarrhea.
4 Day 4
1. The nurs is providing post-operative care to a craniotomy patient. Diabetes insipidus is
suspected when the patient’s urine output suddenly increases significantly. Which action
takeshighest priority?
o 1. Monitoring urine output
o 2. Checking pulse
o 3. Checking blood pressure
o 4. Assessing level of consciousness
Rationale:
3. Correct: This is the best answer because we are “worried” this patient is going into
SHOCK. So…..you better be checking a BP. This is a time where checking the BP is
appropriate. If we “assume the worst” I better check a blood pressure. It could have dropped
out the bottom.
1. Incorrect: Continuing to monitor U/O is important but I need to find out if they are already
shocky.
2. Incorrect: Checking the pulse is a good thing, but, not as important as checking the BP.
4. Incorrect: If my patient is going into shock the highest priority is to assess the BP.
2. The patient is being treated for fluid volume deficit. Which is an expected outcome
ofsuccessful treatment?
o 1. Resolution of orthostatic hypotension
o 2. Maintenance of weight loss
o 3. Compliance with sodium restricted diet
o 4. Maintenance of serum Na above 148 mEq
Rationale:
1. Correct: When you are in a fluid volume deficit your blood pressure goes down when you
stand up and it’s called orthostatic hypotension. Successful treatment would resolve this.
2. Incorrect: When I have lost a lot of volume, my weight goes down, so if I am better, my
weight should go up.
3. Incorrect: Who needs to adhere to dietary sodium restrictions? People who are in fluid volume
excess.
4. Incorrect: If your serum sodium is above 148, hypernatremia is the same thing as dehydration,
Day 4 1
,so this means that you are still sick.
2 Day 4
,3. The nurs in the intensive care unit is caring for a patient receiving hemodynamic monitoring.
When planning for a patient’s care, which nursing diagnoses associated with hemodynamic
monitoring may be utilized by the nurs? Select all that apply.
1. Decreased cardiac output
2. Fluid volume deficit
3. Fluid volume excess
4. Ineffective tissue perfusion
5. Ineffective airway
Rationale:
1., 2., 3. & 4. Correct: Nursing diagnoses, associated with hemodynamic monitoring, that may be
utilized by the nurs include decreased cardiac output, fluid volume deficit, fluid volume excess,
and ineffective tissue perfusion. These nursing diagnoses relate to the pathophysiologic
processes that alter one of the four hemodynamic mechanisms that support normal
cardiovascular function: preload, afterload, heart rate, and contractility.
5. Incorrect: Ineffective Airway would not be associated with hemodynamic monitoring.
4. The nurs is caring for a patient that has two IV access sites. One is a 20 gauge antecubital
peripheral IV that was started yesterday for blood and has normal saline (NS) at keep vein open
rate. The other is a double lumen central line catheter with one port for Total Parental Nutrition
and the other is used for blood samples. Where is the best site for the nurs to administer 20 mEq
of potassium chloride (KCL) in 100 mL of normal saline(NS) over 4 hours?
o 1. Central line port that is being used for lab draws
o 2. Same line with the Total Parental Nutrition
o 3. Large bore antecubital
o 4. Start another peripheral IV
Rationale:
1. Correct: Yes- K is very hard on the veins, give it through the central line.
2. Incorrect: No, never put anything through a line with Total Parental Nutrition.
3. Incorrect: Second best choice- but it will burn.
4. Incorrect: No, a central line is needed.
Day 4 3
, 5. The nurs is caring for a patient that has metabolic acidosis secondary to acute renal failure.
What is the initial patient response to this problem?
o 1. Respiratory rate increases to blow off acid.
o 2. Respiratory rate decreases to conserve acid and buffer the kidneys response.
o 3. Kidneys will excrete hydrogen and retain bicarb.
o 4. Sodium will shift to cells and buffer the hydrogens.
Rationale:
1. Correct: Yes, acute renal failure causes metabolic acidosis and the body is trying to breathe
faster to blow off some acid. The respiratory response is fast.
2. Incorrect: No, the patient’s respiratory rate is fast, not slow.
3. Incorrect: This will happen, later. Did not we say about 48 hours? Not initial response.
4. Incorrect: Sodium is extracellular electrolyte, not an intracellular electrolyte.
6. The patient presents to the emergency department with nausea, vomiting and anorexia for
thelast few days. An EKG on admission reveals an arrhythmia. Which electrolytes imbalance
is suspected?
o 1. Hypercalcemia
o 2. Hypokalemia
o 3. Hypermagnesemia
o 4. Hyponatremia
Rationale:
2. Correct: The patient has been vomiting so the electrolytes losses are potassium, hydrogen
andchloride. The anorexia further complicates the condition because we get potassium from
the foods we eat. The one electrolyte we worry about with arrhythmias is potassium.
1. Incorrect: What has calcium got to do with nausea and vomiting? Nothing
3. Incorrect: Magnesium is loss through the lower GI tract and Hypermagnesemia is not related
to dysrhythmias.
4. Incorrect: The loss of sodium is related to diarrhea.
4 Day 4
