HURST REVIEW NCLEX-RN Readiness Exam 1
Questions With Correct Answers
The |primary |healthcare |provider |has |prescribed |phenytoin |100 |mg |intravenous |push |(IVP) |stat |
for |an |adult |client. |What |is |the |least |amount |of |time |that |the |nurse |can |safely |administer |this |
medication?
1. |1 |minute
2. |2 |minutes
3. |5 |minutes
4. |10 |minutes |- |CORRECT |ANSWER✔✔-2. |Correct: |The |rate |of |IV |administration |should |not |
exceed |50 |mg/min. |for |adults |and |1-3 |mg/kg/min |(or |50 |mg/min, |whichever |is |slower) |in |
pediatric |clients |because |of |the |risk |of |severe |hypotension |and |cardiac |arrhythmias. |So |100 |
mg |can |safely |be |delivered |over |a |period |of |at |least |2 |minutes.
1. |Incorrect: |The |rate |of |IV |administration |should |not |exceed |50 |mg/min. |for |adults |and |1-3 |
mg/kg/min |(or |50 |mg/min, |whichever |is |slower) |in |pediatric |clients |because |of |the |risk |of |
severe |hypotension |and |cardiac |arrhythmias. |So |100 |mg |can |safely |be |delivered |over |a |period |
of |at |least |2 |minutes. |Giving |this |dose |over |only |one |minute |could |lead |to |these |or |other |
potential |harmful |effects. |
3. |Incorrect: |The |rate |of |IV |administration |should |not |exceed |50 |mg/min. |for |adults |and |1-3 |
mg/kg/min |(or |50 |mg/min, |whichever |is |slower) |in |pediatric |clients |because |of |the |risk |of |
severe |hypotension |and |cardiac |arrhythmias. |So |100 |mg |can |safely |be |delivered |over |a |period |
of |at |least |2 |minutes. |Five |minutes |would |be |longer |than |required |to |be |able |to |safely |
administer |the |medication. |
4. |Incorrect: |The |rate |of |IV |administration |should |not |exceed |50 |mg/min. |for |adults |and |1-3 |
mg/kg/min |(or |50 |mg/min, |whichever |is |slower) |in |pediatric |clients |because |of |the |risk |of |
severe |hypotension |and |cardiac |arrhythmias. |So |100 |mg |can |safely |be |delivered |over |a |period |
,of |at |least |2 |minutes. |Ten |minutes |is |much |longer |than |required |to |be |able |to |safely |
administer |the |medication.
A |client, |hospitalized |with |possible |acute |pancreatitis |secondary |to |chronic |cholecystitis, |has |
severe |abdominal |pain |and |nausea. |The |client |is |kept |NPO, |an |NG |tube |is |inserted, |and |IV |
fluids |are |being |administered. |What |is |the |rationale |for |the |client |being |NPO |with |an |NG |tube |
to |low |suction?
1. |Relieve |nausea
2. |Reduce |pancreatic |secretions
3. |Control |fluid |and |electrolyte |imbalance
4. |Remove |the |precipitating |irritants |- |CORRECT |ANSWER✔✔-2. |Correct: |In |clients |with |
pancreatitis, |the |pancreatic |enzymes |cannot |exit |the |pancreas. |These |enzymes, |when |
activated, |begin |to |digest |the |pancreas |itself. |The |enzymes |become |activated |in |the |pancreas |
when |fluid |or |food |accumulates |in |the |stomach. |The |goal |in |treating |this |client |is |to |stop |the |
activation |of |the |pancreatic |enzymes. |Treatment |is |focused |on |keeping |the |stomach |empty |
and |dry. |This |allows |the |pancreas |time |to |rest |and |heal. |Note: |Autodigestion |(pancreas |
digesting |itself) |is |painful |for |the |client |and |can |lead |to |other |problems |such |as |bleeding.
1. |Incorrect: |The |primary |purpose |of |the |NG |tube |to |suction |is |to |keep |the |stomach |empty |
and |dry |to |decrease |pancreatic |enzyme |production, |not |to |relieve |nausea.
3. |Incorrect: |Because |gastric |contents |are |removed, |the |NG |tube |to |suction |may |lead |to |fluid |
and |electrolyte |disturbances |rather |than |helping |to |control |them.
4. |Incorrect: |Although |the |food |in |the |stomach |causes |the |pancreatic |enzymes |to |become |
activated |in |the |pancreas |due |to |the |obstruction, |the |food |is |not |considered |an |irritant. |
Precipitating |irritants |are |not |a |part |of |the |pathophysiology |occurring |with |pancreatitis.
The |nurse |is |working |with |a |committee |at |the |local |school |to |develop |an |emergency |
preparedness |plan |for |tornados. |What |should |be |included |in |the |plan?
1. |Identification |of |safe |zones.
,2. |Methods |for |accounting |for |all |people |present |in |the |building.
3. |Warning |system |activation.
4. |Identification |of |the |gymnasium |as |the |routine |safe |place.
5. |Regular |practice |protocols. |- |CORRECT |ANSWER✔✔-1., |2., |3. |& |5. |Correct: |Everyone |should |
be |aware |of |safe |zones |within |the |school. |Personnel |should |be |given |this |information |and |
signs |posted |in |safe |zones. |There |must |be |systems |in |place |to |accurately |determine |the |
number |of |people |in |the |building |at |any |given |time. |There |also |must |be |a |system |in |place |to |
alert |personnel |and |students |of |tornado |warnings. |Regular |practice |prepares |everyone |for |an |
actual |event.
4. |Incorrect: |Gymnasiums |are |not |considered |safe |places |due |to |wide |expanse |of |roof. |Safe |
zones |should |be |on |interior |walls, |no |windows, |and |a |strong |concrete |floor |if |possible.
What |should |a |nurse |teach |family |members |prior |to |them |entering |the |room |of |a |client |who |
has |agranulocytosis?
1. |Meticulous |hand |washing |is |needed.
2. |Do |not |visit |if |you |have |any |infection.
3. |The |client |must |wear |a |mask.
4. |Children |under |12 |may |not |visit.
5. |Flowers |are |not |allowed |in |the |room. |- |CORRECT |ANSWER✔✔-1., |2., |4., |& |5. |Correct: |
Protective |isolation |is |needed |for |this |client |because |of |the |presence |of |a |low |white |blood |cell
|count. |We |are |protecting |the |client |from |acquiring |an |infection. |So |any |visitors |will |need |to |
have |meticulous |hand |washing |prior |to |entering. |The |visitor |should |not |enter |if |he |or |she |has |
any |type |of |infection. |To |decrease |the |risk |of |infection, |small |children |should |not |visit. |Even |
the |mildest |symptom |of |infection |could |be |detrimental |to |the |client. |Flowers |have |bacteria |
and |should |not |be |brought |into |the |room.
3. |Incorrect: |A |mask |must |be |worn |by |the |visitor, |not |the |client. |The |mask |is |worn |by |visitors |
to |prevent |a |possible |spread |of |an |airborne |infection |to |the |immunocompromised |client.
, A |client |diagnosed |with |major |depression |has |been |taking |a |selective |serotonin |reuptake |
inhibitor |for |the |past |6 |weeks. |When |visiting |the |mental |health |center, |the |nurse |discusses |the
|medication |and |response |with |the |client. |The |nurse's |assessment |reveals |that |the |client |is |
confused |about |the |date |and |about |the |prescribed |dosage |of |the |medication. |Which |question |
would |be |most |important |for |the |nurse |to |ask |to |further |assess |the |situation?
1. |Are |you |having |trouble |sleeping |at |night?
2. |Do |you |have |periods |of |muscle |jerking?
3. |Are |you |having |any |sexual |dysfunction?
4. |Is |your |mood |improving? |- |CORRECT |ANSWER✔✔-2. |Correct: |Myoclonus, |high |body |
temperature, |shaking, |chills, |and |mental |confusion |are |some |of |the |symptoms |of |serotonin |
syndrome. |This |client |may |be |having |symptoms |of |this |adverse |reaction |which, |if |severe, |can |
be |fatal.
1. |Incorrect: |Sleep |disturbances |are |common |with |depression. |Selective |serotonin |reuptake |
inhibitors |(SSRIs) |may |cause |insomnia; |however, |there |is |a |more |pertinent |question |needed |
for |assessment |of |this |client. |You |should |be |concerned |with |the |more |serious |or |life-
threatening |issue.
3. |Incorrect: |Sexual |dysfunction |may |occur |with |the |SSRIs; |however, |the |client |is |exhibiting |
significant |symptoms |of |an |adverse |reaction |which |would |take |priority.
4. |Incorrect: |The |response |to |the |SSRI |medications |is |important; |however, |there |is |a |more |
significant |issue |in |this |case. |The |possible |serotonin |syndrome |is |a |serious |situation |that |would
|be |the |priority |for |the |nurse |to |address.
A |client |diagnosed |with |serotonin |syndrome |is |admitted |to |the |unit. |The |nurse |is |familiar |with |
this |adverse |reaction |to |the |serotonin |reuptake |inhibitors. |Which |symptoms |can |the |nurse |
expect |on |assessment?
1. |Fever |and |shivering
2. |Agitation
3. |Decreased |body |temperature
Questions With Correct Answers
The |primary |healthcare |provider |has |prescribed |phenytoin |100 |mg |intravenous |push |(IVP) |stat |
for |an |adult |client. |What |is |the |least |amount |of |time |that |the |nurse |can |safely |administer |this |
medication?
1. |1 |minute
2. |2 |minutes
3. |5 |minutes
4. |10 |minutes |- |CORRECT |ANSWER✔✔-2. |Correct: |The |rate |of |IV |administration |should |not |
exceed |50 |mg/min. |for |adults |and |1-3 |mg/kg/min |(or |50 |mg/min, |whichever |is |slower) |in |
pediatric |clients |because |of |the |risk |of |severe |hypotension |and |cardiac |arrhythmias. |So |100 |
mg |can |safely |be |delivered |over |a |period |of |at |least |2 |minutes.
1. |Incorrect: |The |rate |of |IV |administration |should |not |exceed |50 |mg/min. |for |adults |and |1-3 |
mg/kg/min |(or |50 |mg/min, |whichever |is |slower) |in |pediatric |clients |because |of |the |risk |of |
severe |hypotension |and |cardiac |arrhythmias. |So |100 |mg |can |safely |be |delivered |over |a |period |
of |at |least |2 |minutes. |Giving |this |dose |over |only |one |minute |could |lead |to |these |or |other |
potential |harmful |effects. |
3. |Incorrect: |The |rate |of |IV |administration |should |not |exceed |50 |mg/min. |for |adults |and |1-3 |
mg/kg/min |(or |50 |mg/min, |whichever |is |slower) |in |pediatric |clients |because |of |the |risk |of |
severe |hypotension |and |cardiac |arrhythmias. |So |100 |mg |can |safely |be |delivered |over |a |period |
of |at |least |2 |minutes. |Five |minutes |would |be |longer |than |required |to |be |able |to |safely |
administer |the |medication. |
4. |Incorrect: |The |rate |of |IV |administration |should |not |exceed |50 |mg/min. |for |adults |and |1-3 |
mg/kg/min |(or |50 |mg/min, |whichever |is |slower) |in |pediatric |clients |because |of |the |risk |of |
severe |hypotension |and |cardiac |arrhythmias. |So |100 |mg |can |safely |be |delivered |over |a |period |
,of |at |least |2 |minutes. |Ten |minutes |is |much |longer |than |required |to |be |able |to |safely |
administer |the |medication.
A |client, |hospitalized |with |possible |acute |pancreatitis |secondary |to |chronic |cholecystitis, |has |
severe |abdominal |pain |and |nausea. |The |client |is |kept |NPO, |an |NG |tube |is |inserted, |and |IV |
fluids |are |being |administered. |What |is |the |rationale |for |the |client |being |NPO |with |an |NG |tube |
to |low |suction?
1. |Relieve |nausea
2. |Reduce |pancreatic |secretions
3. |Control |fluid |and |electrolyte |imbalance
4. |Remove |the |precipitating |irritants |- |CORRECT |ANSWER✔✔-2. |Correct: |In |clients |with |
pancreatitis, |the |pancreatic |enzymes |cannot |exit |the |pancreas. |These |enzymes, |when |
activated, |begin |to |digest |the |pancreas |itself. |The |enzymes |become |activated |in |the |pancreas |
when |fluid |or |food |accumulates |in |the |stomach. |The |goal |in |treating |this |client |is |to |stop |the |
activation |of |the |pancreatic |enzymes. |Treatment |is |focused |on |keeping |the |stomach |empty |
and |dry. |This |allows |the |pancreas |time |to |rest |and |heal. |Note: |Autodigestion |(pancreas |
digesting |itself) |is |painful |for |the |client |and |can |lead |to |other |problems |such |as |bleeding.
1. |Incorrect: |The |primary |purpose |of |the |NG |tube |to |suction |is |to |keep |the |stomach |empty |
and |dry |to |decrease |pancreatic |enzyme |production, |not |to |relieve |nausea.
3. |Incorrect: |Because |gastric |contents |are |removed, |the |NG |tube |to |suction |may |lead |to |fluid |
and |electrolyte |disturbances |rather |than |helping |to |control |them.
4. |Incorrect: |Although |the |food |in |the |stomach |causes |the |pancreatic |enzymes |to |become |
activated |in |the |pancreas |due |to |the |obstruction, |the |food |is |not |considered |an |irritant. |
Precipitating |irritants |are |not |a |part |of |the |pathophysiology |occurring |with |pancreatitis.
The |nurse |is |working |with |a |committee |at |the |local |school |to |develop |an |emergency |
preparedness |plan |for |tornados. |What |should |be |included |in |the |plan?
1. |Identification |of |safe |zones.
,2. |Methods |for |accounting |for |all |people |present |in |the |building.
3. |Warning |system |activation.
4. |Identification |of |the |gymnasium |as |the |routine |safe |place.
5. |Regular |practice |protocols. |- |CORRECT |ANSWER✔✔-1., |2., |3. |& |5. |Correct: |Everyone |should |
be |aware |of |safe |zones |within |the |school. |Personnel |should |be |given |this |information |and |
signs |posted |in |safe |zones. |There |must |be |systems |in |place |to |accurately |determine |the |
number |of |people |in |the |building |at |any |given |time. |There |also |must |be |a |system |in |place |to |
alert |personnel |and |students |of |tornado |warnings. |Regular |practice |prepares |everyone |for |an |
actual |event.
4. |Incorrect: |Gymnasiums |are |not |considered |safe |places |due |to |wide |expanse |of |roof. |Safe |
zones |should |be |on |interior |walls, |no |windows, |and |a |strong |concrete |floor |if |possible.
What |should |a |nurse |teach |family |members |prior |to |them |entering |the |room |of |a |client |who |
has |agranulocytosis?
1. |Meticulous |hand |washing |is |needed.
2. |Do |not |visit |if |you |have |any |infection.
3. |The |client |must |wear |a |mask.
4. |Children |under |12 |may |not |visit.
5. |Flowers |are |not |allowed |in |the |room. |- |CORRECT |ANSWER✔✔-1., |2., |4., |& |5. |Correct: |
Protective |isolation |is |needed |for |this |client |because |of |the |presence |of |a |low |white |blood |cell
|count. |We |are |protecting |the |client |from |acquiring |an |infection. |So |any |visitors |will |need |to |
have |meticulous |hand |washing |prior |to |entering. |The |visitor |should |not |enter |if |he |or |she |has |
any |type |of |infection. |To |decrease |the |risk |of |infection, |small |children |should |not |visit. |Even |
the |mildest |symptom |of |infection |could |be |detrimental |to |the |client. |Flowers |have |bacteria |
and |should |not |be |brought |into |the |room.
3. |Incorrect: |A |mask |must |be |worn |by |the |visitor, |not |the |client. |The |mask |is |worn |by |visitors |
to |prevent |a |possible |spread |of |an |airborne |infection |to |the |immunocompromised |client.
, A |client |diagnosed |with |major |depression |has |been |taking |a |selective |serotonin |reuptake |
inhibitor |for |the |past |6 |weeks. |When |visiting |the |mental |health |center, |the |nurse |discusses |the
|medication |and |response |with |the |client. |The |nurse's |assessment |reveals |that |the |client |is |
confused |about |the |date |and |about |the |prescribed |dosage |of |the |medication. |Which |question |
would |be |most |important |for |the |nurse |to |ask |to |further |assess |the |situation?
1. |Are |you |having |trouble |sleeping |at |night?
2. |Do |you |have |periods |of |muscle |jerking?
3. |Are |you |having |any |sexual |dysfunction?
4. |Is |your |mood |improving? |- |CORRECT |ANSWER✔✔-2. |Correct: |Myoclonus, |high |body |
temperature, |shaking, |chills, |and |mental |confusion |are |some |of |the |symptoms |of |serotonin |
syndrome. |This |client |may |be |having |symptoms |of |this |adverse |reaction |which, |if |severe, |can |
be |fatal.
1. |Incorrect: |Sleep |disturbances |are |common |with |depression. |Selective |serotonin |reuptake |
inhibitors |(SSRIs) |may |cause |insomnia; |however, |there |is |a |more |pertinent |question |needed |
for |assessment |of |this |client. |You |should |be |concerned |with |the |more |serious |or |life-
threatening |issue.
3. |Incorrect: |Sexual |dysfunction |may |occur |with |the |SSRIs; |however, |the |client |is |exhibiting |
significant |symptoms |of |an |adverse |reaction |which |would |take |priority.
4. |Incorrect: |The |response |to |the |SSRI |medications |is |important; |however, |there |is |a |more |
significant |issue |in |this |case. |The |possible |serotonin |syndrome |is |a |serious |situation |that |would
|be |the |priority |for |the |nurse |to |address.
A |client |diagnosed |with |serotonin |syndrome |is |admitted |to |the |unit. |The |nurse |is |familiar |with |
this |adverse |reaction |to |the |serotonin |reuptake |inhibitors. |Which |symptoms |can |the |nurse |
expect |on |assessment?
1. |Fever |and |shivering
2. |Agitation
3. |Decreased |body |temperature
