HURST REVIEW NCLEX RN READINESS
EXAM 4 ADVANCED PATIENT CARE
PRIORITY SETTING 2026 COMPLETE STUDY
GUIDE AND SOLUTIONS
◉ The nurse is assessing pain after surgery in a 3 year old client
with a known developmental delay. Which pain scale should the
nurse use to assess this client's pain level?
a. CRIES scale
b. numeric scale
c. FLACC scale
d. FACES scale
Answer: c. FLACC scale
Rationale: The FLACC scale can be used for pediatric clients from age
2 months to 7 years and is appropriate when clients cannot
communicate their pain
◉ A client recently diagnosed with diabetes is sent home with a
prescription for subcutaneous insulin. What statement made by the
,client indicates that teaching has been effective regarding safe
needle disposal?
a. "I should wrap the needle in a paper towel and place in the trash."
b. "I should use a hospital issued biohazard container for all
needles."
c. "I may use any hard plastic container with a screw-on cap."
d. "I should take my needles to the nearest hospital for disposal."
Answer: c. "I may use any hard plastic container with a screw-on
cap."
Rationale: At home, an FDA approved sharps container is not
needed, however, needles, syringes, and sharps may be disposed of
in a hard plastic container. Clients should follow their community
guidelines for sharps container disposal. This protects the sanitation
engineers from injury by the sharps.
◉ The primary healthcare provider suspects the client has
tuberculosis (TB) and prescribes a Mantoux test. What precautions
should the nurse take when administering the Mantoux test?
a. don sterile gloves
b. place the client on reverse isolation
c. wear a particulate respirator
,d. obtain a consent form
e. initiate airborne precautions
Answer: c. wear a particulate respirator
e. initiate airborne precautions
Rationale: A disposable particulate respirator that fits snugly around
the face is needed. The client needs to be on acid-fast bacilli (AFB)
isolation precautions, not reverse isolation. Airborne precautions
include a private room with negative pressure and a minimum of 6
air exchanges per hour. Ultraviolet lamps and high efficiency
particulate air filters are also needed.
◉ A hysterical college student arrives in the emergency department
in bloody soiled clothing. The nursing assessment reveals facial
bruising and multiple contusions consistent with the client's report
of being raped. Which initial nursing intervention takes priority at
this time?
a. notify police of the alleged rape
b. allow the client privacy to wash self
c. remove clothing and bag for evidence
d. encourage client to express fears and anxiety
Answer: d. encourage client to express fears and anxiety
, Rationale: Although there are specific protocols that must be
followed when dealing with rape clients, it is important to
remember that this client had all control taken away during the
attack. The emotional effects of rape are as traumatizing as the
physical injuries. Allowing the client to first express emotions, such
as fear or anxiety, returns a small amount of control to a situation in
which the client has little or none.
◉ The nurse is caring for an adolescent client diagnosed with
depression. The client is prescribed fluoxetine. What is the best
response by the nurse when the client says, "What will this medicine
do to me?"
a. it will increase the level of serotonin in the brain
b. it will decrease the production of noradrenaline
c. it will lower your level of the brain hormone norepinephrine
d. it will balance blood glucose and dopamine levels in your head
Answer: a. it will increase the level of serotonin in the brain
Rationale: The action of fluoxetine is to increase the level of
serotonin in the central nervous system. There is a correlation
between a low level of serotonin and depression. The action of the
drug should be explained to the adolescent in a manner that will be
understood.
EXAM 4 ADVANCED PATIENT CARE
PRIORITY SETTING 2026 COMPLETE STUDY
GUIDE AND SOLUTIONS
◉ The nurse is assessing pain after surgery in a 3 year old client
with a known developmental delay. Which pain scale should the
nurse use to assess this client's pain level?
a. CRIES scale
b. numeric scale
c. FLACC scale
d. FACES scale
Answer: c. FLACC scale
Rationale: The FLACC scale can be used for pediatric clients from age
2 months to 7 years and is appropriate when clients cannot
communicate their pain
◉ A client recently diagnosed with diabetes is sent home with a
prescription for subcutaneous insulin. What statement made by the
,client indicates that teaching has been effective regarding safe
needle disposal?
a. "I should wrap the needle in a paper towel and place in the trash."
b. "I should use a hospital issued biohazard container for all
needles."
c. "I may use any hard plastic container with a screw-on cap."
d. "I should take my needles to the nearest hospital for disposal."
Answer: c. "I may use any hard plastic container with a screw-on
cap."
Rationale: At home, an FDA approved sharps container is not
needed, however, needles, syringes, and sharps may be disposed of
in a hard plastic container. Clients should follow their community
guidelines for sharps container disposal. This protects the sanitation
engineers from injury by the sharps.
◉ The primary healthcare provider suspects the client has
tuberculosis (TB) and prescribes a Mantoux test. What precautions
should the nurse take when administering the Mantoux test?
a. don sterile gloves
b. place the client on reverse isolation
c. wear a particulate respirator
,d. obtain a consent form
e. initiate airborne precautions
Answer: c. wear a particulate respirator
e. initiate airborne precautions
Rationale: A disposable particulate respirator that fits snugly around
the face is needed. The client needs to be on acid-fast bacilli (AFB)
isolation precautions, not reverse isolation. Airborne precautions
include a private room with negative pressure and a minimum of 6
air exchanges per hour. Ultraviolet lamps and high efficiency
particulate air filters are also needed.
◉ A hysterical college student arrives in the emergency department
in bloody soiled clothing. The nursing assessment reveals facial
bruising and multiple contusions consistent with the client's report
of being raped. Which initial nursing intervention takes priority at
this time?
a. notify police of the alleged rape
b. allow the client privacy to wash self
c. remove clothing and bag for evidence
d. encourage client to express fears and anxiety
Answer: d. encourage client to express fears and anxiety
, Rationale: Although there are specific protocols that must be
followed when dealing with rape clients, it is important to
remember that this client had all control taken away during the
attack. The emotional effects of rape are as traumatizing as the
physical injuries. Allowing the client to first express emotions, such
as fear or anxiety, returns a small amount of control to a situation in
which the client has little or none.
◉ The nurse is caring for an adolescent client diagnosed with
depression. The client is prescribed fluoxetine. What is the best
response by the nurse when the client says, "What will this medicine
do to me?"
a. it will increase the level of serotonin in the brain
b. it will decrease the production of noradrenaline
c. it will lower your level of the brain hormone norepinephrine
d. it will balance blood glucose and dopamine levels in your head
Answer: a. it will increase the level of serotonin in the brain
Rationale: The action of fluoxetine is to increase the level of
serotonin in the central nervous system. There is a correlation
between a low level of serotonin and depression. The action of the
drug should be explained to the adolescent in a manner that will be
understood.
