HURST REVIEW NCLEX-RN Readiness Exam
2 Questions and Correct Answers (Verified
Answers) Plus Rationales
Which pain scale should the nurse use to monitor the pain
level of a 3-year old client after surgery?
1. Numerical scale
2. Verbal descriptive scale
3. Visual analog scale
4. FACES scale
4. Correct: Monitoring pain in children requires special
techniques. The nurse should use the FACES scale as a tool to
assess this client's pain level. Children as young as 3 years of
age can use the FACES scale to communicate their pain level to
the medical team. The scale has six faces ranging from smiling
face to sad, tearful face.
1. Incorrect: Not age appropriate. This scale uses numbers.
2. Incorrect: Not age appropriate. Young children may not
understand the word pain.
3. Incorrect: Not age appropriate. This scale requires reading.
Which tasks would be appropriate for the LPN/LVN to assign
to an unlicensed assistive personnel (UAP)? (SATA)
1. Ask the client diagnosed with dementia memory-testing
questions.
2. Collect the urinary output hourly on the client with renal
,disease.
3. Demonstrate pursed lipped breathing to the client who has
emphysema.
4. Give a tepid sponge bath to the client who has a fever.
5. Assess oxygen saturation on a client experiencing angina.
2., & 4. Correct: The UAP can obtain hourly urine output on
clients and can give a tepid sponge bath to a client. The LPN/VN
must know what tasks can be assigned to the UAP.
1. Incorrect: The nurse cannot delegate assessment, evaluation,
or teaching. This would be an assessment function for the RN to
perform.
3. Incorrect: The UAP cannot teach. Demonstration is a method of
teaching. This is an RN task.
5. Incorrect: The UAP cannot assess the client experiencing
angina. This is an RN task.
What nursing interventions should the nurse implement for a
client with Addison's disease? (SATA)
1. Administer potassium supplements as prescribed.
2. Assist the client to select foods high in sodium.
3. Administer Fludrocortisone as prescribed.
4. Monitor intake and output.
5. Record daily weight.
2., 3., 4. & 5. Correct: The client with Addison's disease needs
sodium due to low levels of aldosterone. Fludrocortisone is a
mineralocorticoid that the client will need to take for life. I&O and
daily weights are needed to monitor fluid status.
,1. Incorrect: Clients with Addison's disease lose sodium and
retain potassium, so this client does not need potassium.
A licensed practical nurse (LPN) is utilizing the nursing
process to care for assigned clients. Which nursing actions
should the LPN relate to the implementation step of the
nursing process? (SATA)
1. Collecting client data for a nursing history.
2. Reporting client response to a new medication.
3. Procuring equipment for a planned medical procedure.
4. Assigning client care activities to unlicensed assistive
personnel.
5. Delivering skilled nursing care according to an established
health care plan.
3., 4., & 5. Correct: The nurse should relate procuring medical
equipment, assigning client care activities, and delivering skilled
nursing care to the implementation step of the nursing process.
Implementation is the third step of the nursing process and
consists of delivering nursing care according to an established
health care plan and as assigned by the RN or other person(s)
authorized by law.
1. Incorrect: This is not the implementation step of the nursing
process. LPNs participate in the assessment step of the nursing
process by collecting client data for a nursing, psychological,
spiritual, and social histories, comparing the data collected to
normal values and findings.
2. Incorrect: This is not the implementation step of the nursing
process. LPNs participate in the nursing process by reporting
client responses to the RN or supervising healthcare provider.
, The primary healthcare provider prescribes nafcillin 0.6 gram
every 12 hours IM. Available is a vial labeled 200 mg per 1
mL. How many mL should the nurse give? Round your
answer to the nearest whole number.
Changing 0.6 g to mg equals 600 mg.
Then 200 mg : 1 mL = 600 mg : x mL
200x = 600
x=3
The nurse should reinforce which instructions given to the
unlicensed assistive personnel (UAP) about care needed to
reduce the risk of infection when a client has an indwelling
catheter? (SATA)
1. Check catheter for kinks in the tubing when the client is in
the bed or chair.
2. Disconnect the catheter from the bag when measuring
output.
3. Wash hands before providing personal care to the client.
4. Ensure that catheter remains secured to the thigh.
5. Make sure that the drainage bag is always below the level
of the bladder.
1., 3., 4. & 5. Correct: Tubing that becomes obstructed cannot
allow adequate urine flow. The urine flow occurs by gravity.
Adequate handwashing before providing care is one defense
against infection. Tension on the tubing may cause irritation and
subsequent infection. The bag should be below the level of the
bladder so that urine flows appropriately.
2. Incorrect: A closed drainage system should be maintained to
prevent entry of microorganisms. Disconnecting the catheter from
the bag would be incorrect and potentially cause harm to the
client.
2 Questions and Correct Answers (Verified
Answers) Plus Rationales
Which pain scale should the nurse use to monitor the pain
level of a 3-year old client after surgery?
1. Numerical scale
2. Verbal descriptive scale
3. Visual analog scale
4. FACES scale
4. Correct: Monitoring pain in children requires special
techniques. The nurse should use the FACES scale as a tool to
assess this client's pain level. Children as young as 3 years of
age can use the FACES scale to communicate their pain level to
the medical team. The scale has six faces ranging from smiling
face to sad, tearful face.
1. Incorrect: Not age appropriate. This scale uses numbers.
2. Incorrect: Not age appropriate. Young children may not
understand the word pain.
3. Incorrect: Not age appropriate. This scale requires reading.
Which tasks would be appropriate for the LPN/LVN to assign
to an unlicensed assistive personnel (UAP)? (SATA)
1. Ask the client diagnosed with dementia memory-testing
questions.
2. Collect the urinary output hourly on the client with renal
,disease.
3. Demonstrate pursed lipped breathing to the client who has
emphysema.
4. Give a tepid sponge bath to the client who has a fever.
5. Assess oxygen saturation on a client experiencing angina.
2., & 4. Correct: The UAP can obtain hourly urine output on
clients and can give a tepid sponge bath to a client. The LPN/VN
must know what tasks can be assigned to the UAP.
1. Incorrect: The nurse cannot delegate assessment, evaluation,
or teaching. This would be an assessment function for the RN to
perform.
3. Incorrect: The UAP cannot teach. Demonstration is a method of
teaching. This is an RN task.
5. Incorrect: The UAP cannot assess the client experiencing
angina. This is an RN task.
What nursing interventions should the nurse implement for a
client with Addison's disease? (SATA)
1. Administer potassium supplements as prescribed.
2. Assist the client to select foods high in sodium.
3. Administer Fludrocortisone as prescribed.
4. Monitor intake and output.
5. Record daily weight.
2., 3., 4. & 5. Correct: The client with Addison's disease needs
sodium due to low levels of aldosterone. Fludrocortisone is a
mineralocorticoid that the client will need to take for life. I&O and
daily weights are needed to monitor fluid status.
,1. Incorrect: Clients with Addison's disease lose sodium and
retain potassium, so this client does not need potassium.
A licensed practical nurse (LPN) is utilizing the nursing
process to care for assigned clients. Which nursing actions
should the LPN relate to the implementation step of the
nursing process? (SATA)
1. Collecting client data for a nursing history.
2. Reporting client response to a new medication.
3. Procuring equipment for a planned medical procedure.
4. Assigning client care activities to unlicensed assistive
personnel.
5. Delivering skilled nursing care according to an established
health care plan.
3., 4., & 5. Correct: The nurse should relate procuring medical
equipment, assigning client care activities, and delivering skilled
nursing care to the implementation step of the nursing process.
Implementation is the third step of the nursing process and
consists of delivering nursing care according to an established
health care plan and as assigned by the RN or other person(s)
authorized by law.
1. Incorrect: This is not the implementation step of the nursing
process. LPNs participate in the assessment step of the nursing
process by collecting client data for a nursing, psychological,
spiritual, and social histories, comparing the data collected to
normal values and findings.
2. Incorrect: This is not the implementation step of the nursing
process. LPNs participate in the nursing process by reporting
client responses to the RN or supervising healthcare provider.
, The primary healthcare provider prescribes nafcillin 0.6 gram
every 12 hours IM. Available is a vial labeled 200 mg per 1
mL. How many mL should the nurse give? Round your
answer to the nearest whole number.
Changing 0.6 g to mg equals 600 mg.
Then 200 mg : 1 mL = 600 mg : x mL
200x = 600
x=3
The nurse should reinforce which instructions given to the
unlicensed assistive personnel (UAP) about care needed to
reduce the risk of infection when a client has an indwelling
catheter? (SATA)
1. Check catheter for kinks in the tubing when the client is in
the bed or chair.
2. Disconnect the catheter from the bag when measuring
output.
3. Wash hands before providing personal care to the client.
4. Ensure that catheter remains secured to the thigh.
5. Make sure that the drainage bag is always below the level
of the bladder.
1., 3., 4. & 5. Correct: Tubing that becomes obstructed cannot
allow adequate urine flow. The urine flow occurs by gravity.
Adequate handwashing before providing care is one defense
against infection. Tension on the tubing may cause irritation and
subsequent infection. The bag should be below the level of the
bladder so that urine flows appropriately.
2. Incorrect: A closed drainage system should be maintained to
prevent entry of microorganisms. Disconnecting the catheter from
the bag would be incorrect and potentially cause harm to the
client.
