***HURST REVIEW NCLEX-RN
READINESS EXAM 1***
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.admi
nister.this.medication?
1..1.minute
2..2.minutes
3..5.minutes
4..10.minutes.-.ans✔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.effect
s..
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,.h
as.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.t
ube.to.low.suction?
1..Relieve.nausea
2..Reduce.pancreatic.secretions
3..Control.fluid.and.electrolyte.imbalance
4..Remove.the.precipitating.irritants.-.ans✔2..Correct:.In.clients.with.pancreatitis,.the.pancr
eatic.enzymes.cannot.exit.the.pancreas..These.enzymes,.when.activated,.begin.to.digest.t
he.pancreas.itself..The.enzymes.become.activated.in.the.pancreas.when.fluid.or.food.accu
mulates.in.the.stomach..The.goal.in.treating.this.client.is.to.stop.the.activation.of.the.pancre
atic.enzymes..Treatment.is.focused.on.keeping.the.stomach.empty.and.dry..This.allows.th
e.pancreas.time.to.rest.and.heal..Note:.Autodigestion.
(pancreas.digesting.itself).is.painful.for.the.client.and.can.lead.to.other.problems.such.as.bl
eeding.
1..Incorrect:.The.primary.purpose.of.the.NG.tube.to.suction.is.to.keep.the.stomach.empty.a
nd.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.flui
d.and.electrolyte.disturbances.rather.than.helping.to.control.them.
4..Incorrect:.Although.the.food.in.the.stomach.causes.the.pancreatic.enzymes.to.become.a
ctivated.in.the.pancreas.due.to.the.obstruction,.the.food.is.not.considered.an.irritant..Precip
itating.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.prepar
edness.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..-.ans✔1.,.2.,.3..&.5..Correct:.Everyone.should.be.aware.of.sa
fe.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.an
d.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..Saf
e.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..-.ans✔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.prote
cting.the.client.from.acquiring.an.infection..So.any.visitors.will.need.to.have.meticulous.han
d.washing.prior.to.entering..The.visitor.should.not.enter.if.he.or.she.has.any.type.of.infectio
n..To.decrease.the.risk.of.infection,.small.children.should.not.visit..Even.the.mildest.sympto
m.of.infection.could.be.detrimental.to.the.client..Flowers.have.bacteria.and.should.not.be.br
ought.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.in
hibitor.for.the.past.6.weeks..When.visiting.the.mental.health.center,.the.nurse.discusses.th
e.medication.and.response.with.the.client..The.nurse's.assessment.reveals.that.the.client.i
s.confused.about.the.date.and.about.the.prescribed.dosage.of.the.medication..Which.ques
tion.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?.-.ans✔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.reuptak
e.inhibitors.
(SSRIs).may.cause.insomnia;.however,.there.is.a.more.pertinent.question.needed.for.asse
ssment.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.w
ould.be.the.priority.for.the.nurse.to.address.
A.client.diagnosed.with.serotonin.syndrome.is.admitted.to.the.unit..The.nurse.is.familiar.wit
h.this.adverse.reaction.to.the.serotonin.reuptake.inhibitors..Which.symptoms.can.the.nurs
e.expect.on.assessment?
1..Fever.and.shivering
2..Agitation
3..Decreased.body.temperature
4..Constipation
5..Increased.heart.rate.-.ans✔1.,.2..&.5..Correct:.Serotonin.syndrome.is.a.group.of.sympto
ms.that.can.result.from.the.use.of.certain.serotonin.reuptake.inhibitors..These.symptoms.c
, an.range.from.mild.to.severe.and.include.high.body.temperature,.agitation,.increased.refle
xes,.diaphoresis,.tremors,.dilated.pupils.and.diarrhea..The.client.is.likely.to.experience.shi
vering.with.fever..Increased.heart.rate.and.blood.pressure.are.also.commonly.experienced
..More.severe.symptoms,.including.muscle.rigidity.and.seizures,.can.occur..If.not.treated,.s
erotonin.syndrome.can.be.fatal..
3..Incorrect:.Increased.body.temperature.is.expected.as.is.increased.diaphoresis.
4..Incorrect:.Diarrhea,.not.constipation,.is.a.symptom.of.serotonin.syndrome.
The.emergency.department.nurse.is.assessing.a.client.who.presents.with.severe.epigastri
c.pain..The.client.reports.that.three.rolls.of.calcium.carbonate.were.consumed.in.the.past.ei
ght.hours.to.treat.the.indigestion..Which.blood.gas.report.does.the.nurse.associate.with.thi
s.situation?
1..pH.-.7.49,.pCO2.-.40,.HCO3.-.30
2..pH.-.7.32,.pCO2.-.48,.HCO3.-.20
3..pH.-.7.38,.pCO2.-.52,.HCO3.-.32
4..pH.-.7.29,.pCO2.-.54,.HCO3.-.26.-.ans✔1..Correct:.These.ABGs.are.indicative.of.metabo
lic.alkalosis..The.pH.is.high,.the.pCO2.is.within.normal.limits.and.the.bicarb.is.high.
(alkalosis)..So,.the.excess.Tums.
(calcium.carbonate).could.have.caused.metabolic.alkalosis.
2..Incorrect:.The.client.is.not.hypoventilating.and.would.not.be.in.metabolic.acidosis.becau
se.he.ate.3.rolls.of.Tums.which.is.a.base..These.ABGs.are.indicative.of.acidosis..The.pH.is.
low.(acidosis),.the.pCO2.is.high.(acidosis).and.the.bicarb.is.low.(acidosis).
3..Incorrect:.The.client.is.not.a.long-
term.COPD.client.as.these.ABGs.might.suggest..These.ABGs.are.indicative.of.fully.compe
nsated.respiratory.acidosis..The.pH.is.normal..The.pCO2.is.high.
(as.with.chronic.retention).and.the.bicarb.is.high.to.help.compensate.
4..Incorrect:.These.ABGs.are.the.result.of.an.acute.ventilation.problem..They.are.indicative
.of.respiratory.acidosis..The.pH.is.low,.the.pCO2.is.high,.and.the.bicarb.is.normal..No.comp
ensation.has.begun.at.this.point.
Which.prescriptions.would.the.nurse.recognize.as.being.appropriate.for.the.client.with.shin
gles?
1..Private.room
2..Negative.pressure.airflow
3..Respirator.mask
4..Face.Shield
5..Positive.pressure.room.-.ans✔1.,.2..&.3..Correct:.According.to.the.current.standards.of.S
tandard.Precautions.per.the.CDC,.the.client.with.shingles.should.be.placed.on.airborne.pre
cautions.which.require.the.use.of.a.private.room.with.negative.pressure.airflow.and.a.N-
95.respirator.mask.
READINESS EXAM 1***
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.admi
nister.this.medication?
1..1.minute
2..2.minutes
3..5.minutes
4..10.minutes.-.ans✔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.effect
s..
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,.h
as.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.t
ube.to.low.suction?
1..Relieve.nausea
2..Reduce.pancreatic.secretions
3..Control.fluid.and.electrolyte.imbalance
4..Remove.the.precipitating.irritants.-.ans✔2..Correct:.In.clients.with.pancreatitis,.the.pancr
eatic.enzymes.cannot.exit.the.pancreas..These.enzymes,.when.activated,.begin.to.digest.t
he.pancreas.itself..The.enzymes.become.activated.in.the.pancreas.when.fluid.or.food.accu
mulates.in.the.stomach..The.goal.in.treating.this.client.is.to.stop.the.activation.of.the.pancre
atic.enzymes..Treatment.is.focused.on.keeping.the.stomach.empty.and.dry..This.allows.th
e.pancreas.time.to.rest.and.heal..Note:.Autodigestion.
(pancreas.digesting.itself).is.painful.for.the.client.and.can.lead.to.other.problems.such.as.bl
eeding.
1..Incorrect:.The.primary.purpose.of.the.NG.tube.to.suction.is.to.keep.the.stomach.empty.a
nd.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.flui
d.and.electrolyte.disturbances.rather.than.helping.to.control.them.
4..Incorrect:.Although.the.food.in.the.stomach.causes.the.pancreatic.enzymes.to.become.a
ctivated.in.the.pancreas.due.to.the.obstruction,.the.food.is.not.considered.an.irritant..Precip
itating.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.prepar
edness.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..-.ans✔1.,.2.,.3..&.5..Correct:.Everyone.should.be.aware.of.sa
fe.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.an
d.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..Saf
e.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..-.ans✔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.prote
cting.the.client.from.acquiring.an.infection..So.any.visitors.will.need.to.have.meticulous.han
d.washing.prior.to.entering..The.visitor.should.not.enter.if.he.or.she.has.any.type.of.infectio
n..To.decrease.the.risk.of.infection,.small.children.should.not.visit..Even.the.mildest.sympto
m.of.infection.could.be.detrimental.to.the.client..Flowers.have.bacteria.and.should.not.be.br
ought.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.in
hibitor.for.the.past.6.weeks..When.visiting.the.mental.health.center,.the.nurse.discusses.th
e.medication.and.response.with.the.client..The.nurse's.assessment.reveals.that.the.client.i
s.confused.about.the.date.and.about.the.prescribed.dosage.of.the.medication..Which.ques
tion.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?.-.ans✔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.reuptak
e.inhibitors.
(SSRIs).may.cause.insomnia;.however,.there.is.a.more.pertinent.question.needed.for.asse
ssment.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.w
ould.be.the.priority.for.the.nurse.to.address.
A.client.diagnosed.with.serotonin.syndrome.is.admitted.to.the.unit..The.nurse.is.familiar.wit
h.this.adverse.reaction.to.the.serotonin.reuptake.inhibitors..Which.symptoms.can.the.nurs
e.expect.on.assessment?
1..Fever.and.shivering
2..Agitation
3..Decreased.body.temperature
4..Constipation
5..Increased.heart.rate.-.ans✔1.,.2..&.5..Correct:.Serotonin.syndrome.is.a.group.of.sympto
ms.that.can.result.from.the.use.of.certain.serotonin.reuptake.inhibitors..These.symptoms.c
, an.range.from.mild.to.severe.and.include.high.body.temperature,.agitation,.increased.refle
xes,.diaphoresis,.tremors,.dilated.pupils.and.diarrhea..The.client.is.likely.to.experience.shi
vering.with.fever..Increased.heart.rate.and.blood.pressure.are.also.commonly.experienced
..More.severe.symptoms,.including.muscle.rigidity.and.seizures,.can.occur..If.not.treated,.s
erotonin.syndrome.can.be.fatal..
3..Incorrect:.Increased.body.temperature.is.expected.as.is.increased.diaphoresis.
4..Incorrect:.Diarrhea,.not.constipation,.is.a.symptom.of.serotonin.syndrome.
The.emergency.department.nurse.is.assessing.a.client.who.presents.with.severe.epigastri
c.pain..The.client.reports.that.three.rolls.of.calcium.carbonate.were.consumed.in.the.past.ei
ght.hours.to.treat.the.indigestion..Which.blood.gas.report.does.the.nurse.associate.with.thi
s.situation?
1..pH.-.7.49,.pCO2.-.40,.HCO3.-.30
2..pH.-.7.32,.pCO2.-.48,.HCO3.-.20
3..pH.-.7.38,.pCO2.-.52,.HCO3.-.32
4..pH.-.7.29,.pCO2.-.54,.HCO3.-.26.-.ans✔1..Correct:.These.ABGs.are.indicative.of.metabo
lic.alkalosis..The.pH.is.high,.the.pCO2.is.within.normal.limits.and.the.bicarb.is.high.
(alkalosis)..So,.the.excess.Tums.
(calcium.carbonate).could.have.caused.metabolic.alkalosis.
2..Incorrect:.The.client.is.not.hypoventilating.and.would.not.be.in.metabolic.acidosis.becau
se.he.ate.3.rolls.of.Tums.which.is.a.base..These.ABGs.are.indicative.of.acidosis..The.pH.is.
low.(acidosis),.the.pCO2.is.high.(acidosis).and.the.bicarb.is.low.(acidosis).
3..Incorrect:.The.client.is.not.a.long-
term.COPD.client.as.these.ABGs.might.suggest..These.ABGs.are.indicative.of.fully.compe
nsated.respiratory.acidosis..The.pH.is.normal..The.pCO2.is.high.
(as.with.chronic.retention).and.the.bicarb.is.high.to.help.compensate.
4..Incorrect:.These.ABGs.are.the.result.of.an.acute.ventilation.problem..They.are.indicative
.of.respiratory.acidosis..The.pH.is.low,.the.pCO2.is.high,.and.the.bicarb.is.normal..No.comp
ensation.has.begun.at.this.point.
Which.prescriptions.would.the.nurse.recognize.as.being.appropriate.for.the.client.with.shin
gles?
1..Private.room
2..Negative.pressure.airflow
3..Respirator.mask
4..Face.Shield
5..Positive.pressure.room.-.ans✔1.,.2..&.3..Correct:.According.to.the.current.standards.of.S
tandard.Precautions.per.the.CDC,.the.client.with.shingles.should.be.placed.on.airborne.pre
cautions.which.require.the.use.of.a.private.room.with.negative.pressure.airflow.and.a.N-
95.respirator.mask.
