***HURST REVIEW NCLEX-RN
READINESS EXAM 1*** QUESTIONS AND
CORRECT VERIFIED ANSWERS
TheA2primaryA2healthcareA2providerA2hasA2prescribedA2phenytoinA2100A2mgA2intravenousA
2pushA2(IVP)A2statA2forA2anA2adultA2client.A2WhatA2isA2theA2leastA2amountA2ofA2timeA2thatA2t
heA2nurseA2canA2safelyA2administerA2thisA2medication?
1.A21A2minute
2.A22A2minutes
3.A25A2minutes
4.A210A2minutesA2-A2Ans--
A22.A2Correct:A2TheA2rateA2ofA2IVA2administrationA2shouldA2notA2exceedA250A2mg/
min.A2forA2adultsA2andA21-3A2mg/kg/minA2(orA250A2mg/
min,A2whicheverA2isA2slower)A2inA2pediatricA2clientsA2becauseA2ofA2theA2riskA2ofA2severeA2h
ypotensionA2andA2cardiacA2arrhythmias.A2SoA2100A2mgA2canA2safelyA2beA2deliveredA2over
A2aA2periodA2ofA2atA2leastA22A2minutes.
1.A2Incorrect:A2TheA2rateA2ofA2IVA2administrationA2shouldA2notA2exceedA250A2mg/
min.A2forA2adultsA2andA21-3A2mg/kg/minA2(orA250A2mg/
min,A2whicheverA2isA2slower)A2inA2pediatricA2clientsA2becauseA2ofA2theA2riskA2ofA2severeA2h
ypotensionA2andA2cardiacA2arrhythmias.A2SoA2100A2mgA2canA2safelyA2beA2deliveredA2over
A2aA2periodA2ofA2atA2leastA22A2minutes.A2GivingA2thisA2doseA2overA2onlyA2oneA2minuteA2coul
dA2leadA2toA2theseA2orA2otherA2potentialA2harmfulA2effects.A2
3.A2Incorrect:A2TheA2rateA2ofA2IVA2administrationA2shouldA2notA2exceedA250A2mg/
min.A2forA2adultsA2andA21-3A2mg/kg/minA2(orA250A2mg/
min,A2whicheverA2isA2slower)A2inA2pediatricA2clientsA2becauseA2ofA2theA2riskA2ofA2severeA2h
ypotensionA2andA2cardiacA2arrhythmias.A2SoA2100A2mgA2canA2safelyA2beA2deliveredA2over
A2aA2periodA2ofA2atA2leastA22A2minutes.A2FiveA2minutesA2wouldA2beA2longerA2thanA2required
A2toA2beA2ableA2toA2safelyA2administerA2theA2medication.A2
4.A2Incorrect:A2TheA2rateA2ofA2IVA2administrationA2shouldA2notA2exceedA250A2mg/
min.A2forA2adultsA2andA21-3A2mg/kg/minA2(orA250A2mg/
min,A2whicheverA2isA2slower)A2inA2pediatricA2clientsA2becauseA2ofA2theA2riskA2ofA2severeA2h
ypotensionA2andA2cardiacA2arrhythmias.A2SoA2100A2mgA2canA2safelyA2beA2deliveredA2over
A2aA2periodA2ofA2atA2leastA22A2minutes.A2TenA2minutesA2isA2muchA2longerA2thanA2requiredA2
toA2beA2ableA2toA2safelyA2administerA2theA2medication.
AA2client,A2hospitalizedA2withA2possibleA2acuteA2pancreatitisA2secondaryA2toA2chronicA2cho
lecystitis,A2hasA2severeA2abdominalA2painA2andA2nausea.A2TheA2clientA2isA2keptA2NPO,A2a
nA2NGA2tubeA2isA2inserted,A2andA2IVA2fluidsA2areA2beingA2administered.A2WhatA2isA2theA2rat
ionaleA2forA2theA2clientA2beingA2NPOA2withA2anA2NGA2tubeA2toA2lowA2suction?
1.A2RelieveA2nausea
2.A2ReduceA2pancreaticA2secretions
,3.A2ControlA2fluidA2andA2electrolyteA2imbalance
4.A2RemoveA2theA2precipitatingA2irritantsA2-A2Ans--
A22.A2Correct:A2InA2clientsA2withA2pancreatitis,A2theA2pancreaticA2enzymesA2cannotA2exitA2t
heA2pancreas.A2TheseA2enzymes,A2whenA2activated,A2beginA2toA2digestA2theA2pancreasA2i
tself.A2TheA2enzymesA2becomeA2activatedA2inA2theA2pancreasA2whenA2fluidA2orA2foodA2acc
umulatesA2inA2theA2stomach.A2TheA2goalA2inA2treatingA2thisA2clientA2isA2toA2stopA2theA2activ
ationA2ofA2theA2pancreaticA2enzymes.A2TreatmentA2isA2focusedA2onA2keepingA2theA2stoma
chA2emptyA2andA2dry.A2ThisA2allowsA2theA2pancreasA2timeA2toA2restA2andA2heal.A2Note:A2A
utodigestionA2(pancreasA2digestingA2itself)A2isA2painfulA2forA2theA2clientA2andA2canA2leadA2t
oA2otherA2problemsA2suchA2asA2bleeding.
1.A2Incorrect:A2TheA2primaryA2purposeA2ofA2theA2NGA2tubeA2toA2suctionA2isA2toA2keepA2theA
2stomachA2emptyA2andA2dryA2toA2decreaseA2pancreaticA2enzymeA2production,A2notA2toA2re
lieveA2nausea.
3.A2Incorrect:A2BecauseA2gastricA2contentsA2areA2removed,A2theA2NGA2tubeA2toA2suctionA2
mayA2leadA2toA2fluidA2andA2electrolyteA2disturbancesA2ratherA2thanA2helpingA2toA2controlA2t
hem.
4.A2Incorrect:A2AlthoughA2theA2foodA2inA2theA2stomachA2causesA2theA2pancreaticA2enzyme
sA2toA2becomeA2activatedA2inA2theA2pancreasA2dueA2toA2theA2obstruction,A2theA2foodA2isA2n
otA2consideredA2anA2irritant.A2PrecipitatingA2irritantsA2areA2notA2aA2partA2ofA2theA2pathophy
siologyA2occurringA2withA2pancreatitis.
TheA2nurseA2isA2workingA2withA2aA2committeeA2atA2theA2localA2schoolA2toA2developA2anA2e
mergencyA2preparednessA2planA2forA2tornados.A2WhatA2shouldA2beA2includedA2inA2theA2pl
an?
1.A2IdentificationA2ofA2safeA2zones.
2.A2MethodsA2forA2accountingA2forA2allA2peopleA2presentA2inA2theA2building.
3.A2WarningA2systemA2activation.
4.A2IdentificationA2ofA2theA2gymnasiumA2asA2theA2routineA2safeA2place.
5.A2RegularA2practiceA2protocols.A2-A2Ans--
A21.,A22.,A23.A2&A25.A2Correct:A2EveryoneA2shouldA2beA2awareA2ofA2safeA2zonesA2withinA2th
eA2school.A2PersonnelA2shouldA2beA2givenA2thisA2informationA2andA2signsA2postedA2inA2saf
eA2zones.A2ThereA2mustA2beA2systemsA2inA2placeA2toA2accuratelyA2determineA2theA2numb
erA2ofA2peopleA2inA2theA2buildingA2atA2anyA2givenA2time.A2ThereA2alsoA2mustA2beA2aA2syste
mA2inA2placeA2toA2alertA2personnelA2andA2studentsA2ofA2tornadoA2warnings.A2RegularA2pra
cticeA2preparesA2everyoneA2forA2anA2actualA2event.
4.A2Incorrect:A2GymnasiumsA2areA2notA2consideredA2safeA2placesA2dueA2toA2wideA2expans
eA2ofA2roof.A2SafeA2zonesA2shouldA2beA2onA2interiorA2walls,A2noA2windows,A2andA2aA2stron
gA2concreteA2floorA2ifA2possible.
WhatA2shouldA2aA2nurseA2teachA2familyA2membersA2priorA2toA2themA2enteringA2theA2roomA
2ofA2aA2clientA2whoA2hasA2agranulocytosis?
1.A2MeticulousA2handA2washingA2isA2needed.
,2.A2DoA2notA2visitA2ifA2youA2haveA2anyA2infection.
3.A2TheA2clientA2mustA2wearA2aA2mask.
4.A2ChildrenA2underA212A2mayA2notA2visit.
5.A2FlowersA2areA2notA2allowedA2inA2theA2room.A2-A2Ans--
A21.,A22.,A24.,A2&A25.A2Correct:A2ProtectiveA2isolationA2isA2neededA2forA2thisA2clientA2becaus
eA2ofA2theA2presenceA2ofA2aA2lowA2whiteA2bloodA2cellA2count.A2WeA2areA2protectingA2theA2cl
ientA2fromA2acquiringA2anA2infection.A2SoA2anyA2visitorsA2willA2needA2toA2haveA2meticulous
A2handA2washingA2priorA2toA2entering.A2TheA2visitorA2shouldA2notA2enterA2ifA2heA2orA2sheA2h
asA2anyA2typeA2ofA2infection.A2ToA2decreaseA2theA2riskA2ofA2infection,A2smallA2childrenA2sh
ouldA2notA2visit.A2EvenA2theA2mildestA2symptomA2ofA2infectionA2couldA2beA2detrimentalA2toA
2theA2client.A2FlowersA2haveA2bacteriaA2andA2shouldA2notA2beA2broughtA2intoA2theA2room.
3.A2Incorrect:A2AA2maskA2mustA2beA2wornA2byA2theA2visitor,A2notA2theA2client.A2TheA2maskA
2isA2wornA2byA2visitorsA2toA2preventA2aA2possibleA2spreadA2ofA2anA2airborneA2infectionA2toA2
theA2immunocompromisedA2client.
AA2clientA2diagnosedA2withA2majorA2depressionA2hasA2beenA2takingA2aA2selectiveA2seroton
inA2reuptakeA2inhibitorA2forA2theA2pastA26A2weeks.A2WhenA2visitingA2theA2mentalA2healthA2c
enter,A2theA2nurseA2discussesA2theA2medicationA2andA2responseA2withA2theA2client.A2TheA2
nurse'sA2assessmentA2revealsA2thatA2theA2clientA2isA2confusedA2aboutA2theA2dateA2andA2a
boutA2theA2prescribedA2dosageA2ofA2theA2medication.A2WhichA2questionA2wouldA2beA2most
A2importantA2forA2theA2nurseA2toA2askA2toA2furtherA2assessA2theA2situation?
1.A2AreA2youA2havingA2troubleA2sleepingA2atA2night?
2.A2DoA2youA2haveA2periodsA2ofA2muscleA2jerking?
3.A2AreA2youA2havingA2anyA2sexualA2dysfunction?
4.A2IsA2yourA2moodA2improving?A2-A2Ans--
A22.A2Correct:A2Myoclonus,A2highA2bodyA2temperature,A2shaking,A2chills,A2andA2mentalA2co
nfusionA2areA2someA2ofA2theA2symptomsA2ofA2serotoninA2syndrome.A2ThisA2clientA2mayA2b
eA2havingA2symptomsA2ofA2thisA2adverseA2reactionA2which,A2ifA2severe,A2canA2beA2fatal.
1.A2Incorrect:A2SleepA2disturbancesA2areA2commonA2withA2depression.A2SelectiveA2seroto
ninA2reuptakeA2inhibitorsA2(SSRIs)A2mayA2causeA2insomnia;A2however,A2thereA2isA2aA2mor
eA2pertinentA2questionA2neededA2forA2assessmentA2ofA2thisA2client.A2YouA2shouldA2beA2co
ncernedA2withA2theA2moreA2seriousA2orA2life-threateningA2issue.
3.A2Incorrect:A2SexualA2dysfunctionA2mayA2occurA2withA2theA2SSRIs;A2however,A2theA2clie
ntA2isA2exhibitingA2significantA2symptomsA2ofA2anA2adverseA2reactionA2whichA2wouldA2take
A2priority.
4.A2Incorrect:A2TheA2responseA2toA2theA2SSRIA2medicationsA2isA2important;A2however,A2th
ereA2isA2aA2moreA2significantA2issueA2inA2thisA2case.A2TheA2possibleA2serotoninA2syndrome
A2isA2aA2seriousA2situationA2thatA2wouldA2beA2theA2priorityA2forA2theA2nurseA2toA2address.
AA2clientA2diagnosedA2withA2serotoninA2syndromeA2isA2admittedA2toA2theA2unit.A2TheA2nurs
eA2isA2familiarA2withA2thisA2adverseA2reactionA2toA2theA2serotoninA2reuptakeA2inhibitors.A2W
hichA2symptomsA2canA2theA2nurseA2expectA2onA2assessment?
, 1.A2FeverA2andA2shivering
2.A2Agitation
3.A2DecreasedA2bodyA2temperature
4.A2Constipation
5.A2IncreasedA2heartA2rateA2-A2Ans--
A21.,A22.A2&A25.A2Correct:A2SerotoninA2syndromeA2isA2aA2groupA2ofA2symptomsA2thatA2canA2
resultA2fromA2theA2useA2ofA2certainA2serotoninA2reuptakeA2inhibitors.A2TheseA2symptomsA2
canA2rangeA2fromA2mildA2toA2severeA2andA2includeA2highA2bodyA2temperature,A2agitation,A
2increasedA2reflexes,A2diaphoresis,A2tremors,A2dilatedA2pupilsA2andA2diarrhea.A2TheA2clien
tA2isA2likelyA2toA2experienceA2shiveringA2withA2fever.A2IncreasedA2heartA2rateA2andA2bloodA
2pressureA2areA2alsoA2commonlyA2experienced.A2MoreA2severeA2symptoms,A2includingA2
muscleA2rigidityA2andA2seizures,A2canA2occur.A2IfA2notA2treated,A2serotoninA2syndromeA2ca
nA2beA2fatal.A2
3.A2Incorrect:A2IncreasedA2bodyA2temperatureA2isA2expectedA2asA2isA2increasedA2diaphore
sis.
4.A2Incorrect:A2Diarrhea,A2notA2constipation,A2isA2aA2symptomA2ofA2serotoninA2syndrome.
TheA2emergencyA2departmentA2nurseA2isA2assessingA2aA2clientA2whoA2presentsA2withA2se
vereA2epigastricA2pain.A2TheA2clientA2reportsA2thatA2threeA2rollsA2ofA2calciumA2carbonateA2
wereA2consumedA2inA2theA2pastA2eightA2hoursA2toA2treatA2theA2indigestion.A2WhichA2bloodA
2gasA2reportA2doesA2theA2nurseA2associateA2withA2thisA2situation?
1.A2pHA2-A27.49,A2pCO2A2-A240,A2HCO3A2-A230
2.A2pHA2-A27.32,A2pCO2A2-A248,A2HCO3A2-A220
3.A2pHA2-A27.38,A2pCO2A2-A252,A2HCO3A2-A232
4.A2pHA2-A27.29,A2pCO2A2-A254,A2HCO3A2-A226A2-A2Ans--
A21.A2Correct:A2TheseA2ABGsA2areA2indicativeA2ofA2metabolicA2alkalosis.A2TheA2pHA2isA2hig
h,A2theA2pCO2A2isA2withinA2normalA2limitsA2andA2theA2bicarbA2isA2highA2(alkalosis).A2So,A2th
eA2excessA2TumsA2(calciumA2carbonate)A2couldA2haveA2causedA2metabolicA2alkalosis.
2.A2Incorrect:A2TheA2clientA2isA2notA2hypoventilatingA2andA2wouldA2notA2beA2inA2metabolicA2
acidosisA2becauseA2heA2ateA23A2rollsA2ofA2TumsA2whichA2isA2aA2base.A2TheseA2ABGsA2are
A2indicativeA2ofA2acidosis.A2TheA2pHA2isA2lowA2(acidosis),A2theA2pCO2A2isA2highA2(acidosis)
A2andA2theA2bicarbA2isA2lowA2(acidosis).
3.A2Incorrect:A2TheA2clientA2isA2notA2aA2long-
termA2COPDA2clientA2asA2theseA2ABGsA2mightA2suggest.A2TheseA2ABGsA2areA2indicativeA
2ofA2fullyA2compensatedA2respiratoryA2acidosis.A2TheA2pHA2isA2normal.A2TheA2pCO2A2isA2h
ighA2(asA2withA2chronicA2retention)A2andA2theA2bicarbA2isA2highA2toA2helpA2compensate.
4.A2Incorrect:A2TheseA2ABGsA2areA2theA2resultA2ofA2anA2acuteA2ventilationA2problem.A2The
yA2areA2indicativeA2ofA2respiratoryA2acidosis.A2TheA2pHA2isA2low,A2theA2pCO2A2isA2high,A2a
ndA2theA2bicarbA2isA2normal.A2NoA2compensationA2hasA2begunA2atA2thisA2point.
READINESS EXAM 1*** QUESTIONS AND
CORRECT VERIFIED ANSWERS
TheA2primaryA2healthcareA2providerA2hasA2prescribedA2phenytoinA2100A2mgA2intravenousA
2pushA2(IVP)A2statA2forA2anA2adultA2client.A2WhatA2isA2theA2leastA2amountA2ofA2timeA2thatA2t
heA2nurseA2canA2safelyA2administerA2thisA2medication?
1.A21A2minute
2.A22A2minutes
3.A25A2minutes
4.A210A2minutesA2-A2Ans--
A22.A2Correct:A2TheA2rateA2ofA2IVA2administrationA2shouldA2notA2exceedA250A2mg/
min.A2forA2adultsA2andA21-3A2mg/kg/minA2(orA250A2mg/
min,A2whicheverA2isA2slower)A2inA2pediatricA2clientsA2becauseA2ofA2theA2riskA2ofA2severeA2h
ypotensionA2andA2cardiacA2arrhythmias.A2SoA2100A2mgA2canA2safelyA2beA2deliveredA2over
A2aA2periodA2ofA2atA2leastA22A2minutes.
1.A2Incorrect:A2TheA2rateA2ofA2IVA2administrationA2shouldA2notA2exceedA250A2mg/
min.A2forA2adultsA2andA21-3A2mg/kg/minA2(orA250A2mg/
min,A2whicheverA2isA2slower)A2inA2pediatricA2clientsA2becauseA2ofA2theA2riskA2ofA2severeA2h
ypotensionA2andA2cardiacA2arrhythmias.A2SoA2100A2mgA2canA2safelyA2beA2deliveredA2over
A2aA2periodA2ofA2atA2leastA22A2minutes.A2GivingA2thisA2doseA2overA2onlyA2oneA2minuteA2coul
dA2leadA2toA2theseA2orA2otherA2potentialA2harmfulA2effects.A2
3.A2Incorrect:A2TheA2rateA2ofA2IVA2administrationA2shouldA2notA2exceedA250A2mg/
min.A2forA2adultsA2andA21-3A2mg/kg/minA2(orA250A2mg/
min,A2whicheverA2isA2slower)A2inA2pediatricA2clientsA2becauseA2ofA2theA2riskA2ofA2severeA2h
ypotensionA2andA2cardiacA2arrhythmias.A2SoA2100A2mgA2canA2safelyA2beA2deliveredA2over
A2aA2periodA2ofA2atA2leastA22A2minutes.A2FiveA2minutesA2wouldA2beA2longerA2thanA2required
A2toA2beA2ableA2toA2safelyA2administerA2theA2medication.A2
4.A2Incorrect:A2TheA2rateA2ofA2IVA2administrationA2shouldA2notA2exceedA250A2mg/
min.A2forA2adultsA2andA21-3A2mg/kg/minA2(orA250A2mg/
min,A2whicheverA2isA2slower)A2inA2pediatricA2clientsA2becauseA2ofA2theA2riskA2ofA2severeA2h
ypotensionA2andA2cardiacA2arrhythmias.A2SoA2100A2mgA2canA2safelyA2beA2deliveredA2over
A2aA2periodA2ofA2atA2leastA22A2minutes.A2TenA2minutesA2isA2muchA2longerA2thanA2requiredA2
toA2beA2ableA2toA2safelyA2administerA2theA2medication.
AA2client,A2hospitalizedA2withA2possibleA2acuteA2pancreatitisA2secondaryA2toA2chronicA2cho
lecystitis,A2hasA2severeA2abdominalA2painA2andA2nausea.A2TheA2clientA2isA2keptA2NPO,A2a
nA2NGA2tubeA2isA2inserted,A2andA2IVA2fluidsA2areA2beingA2administered.A2WhatA2isA2theA2rat
ionaleA2forA2theA2clientA2beingA2NPOA2withA2anA2NGA2tubeA2toA2lowA2suction?
1.A2RelieveA2nausea
2.A2ReduceA2pancreaticA2secretions
,3.A2ControlA2fluidA2andA2electrolyteA2imbalance
4.A2RemoveA2theA2precipitatingA2irritantsA2-A2Ans--
A22.A2Correct:A2InA2clientsA2withA2pancreatitis,A2theA2pancreaticA2enzymesA2cannotA2exitA2t
heA2pancreas.A2TheseA2enzymes,A2whenA2activated,A2beginA2toA2digestA2theA2pancreasA2i
tself.A2TheA2enzymesA2becomeA2activatedA2inA2theA2pancreasA2whenA2fluidA2orA2foodA2acc
umulatesA2inA2theA2stomach.A2TheA2goalA2inA2treatingA2thisA2clientA2isA2toA2stopA2theA2activ
ationA2ofA2theA2pancreaticA2enzymes.A2TreatmentA2isA2focusedA2onA2keepingA2theA2stoma
chA2emptyA2andA2dry.A2ThisA2allowsA2theA2pancreasA2timeA2toA2restA2andA2heal.A2Note:A2A
utodigestionA2(pancreasA2digestingA2itself)A2isA2painfulA2forA2theA2clientA2andA2canA2leadA2t
oA2otherA2problemsA2suchA2asA2bleeding.
1.A2Incorrect:A2TheA2primaryA2purposeA2ofA2theA2NGA2tubeA2toA2suctionA2isA2toA2keepA2theA
2stomachA2emptyA2andA2dryA2toA2decreaseA2pancreaticA2enzymeA2production,A2notA2toA2re
lieveA2nausea.
3.A2Incorrect:A2BecauseA2gastricA2contentsA2areA2removed,A2theA2NGA2tubeA2toA2suctionA2
mayA2leadA2toA2fluidA2andA2electrolyteA2disturbancesA2ratherA2thanA2helpingA2toA2controlA2t
hem.
4.A2Incorrect:A2AlthoughA2theA2foodA2inA2theA2stomachA2causesA2theA2pancreaticA2enzyme
sA2toA2becomeA2activatedA2inA2theA2pancreasA2dueA2toA2theA2obstruction,A2theA2foodA2isA2n
otA2consideredA2anA2irritant.A2PrecipitatingA2irritantsA2areA2notA2aA2partA2ofA2theA2pathophy
siologyA2occurringA2withA2pancreatitis.
TheA2nurseA2isA2workingA2withA2aA2committeeA2atA2theA2localA2schoolA2toA2developA2anA2e
mergencyA2preparednessA2planA2forA2tornados.A2WhatA2shouldA2beA2includedA2inA2theA2pl
an?
1.A2IdentificationA2ofA2safeA2zones.
2.A2MethodsA2forA2accountingA2forA2allA2peopleA2presentA2inA2theA2building.
3.A2WarningA2systemA2activation.
4.A2IdentificationA2ofA2theA2gymnasiumA2asA2theA2routineA2safeA2place.
5.A2RegularA2practiceA2protocols.A2-A2Ans--
A21.,A22.,A23.A2&A25.A2Correct:A2EveryoneA2shouldA2beA2awareA2ofA2safeA2zonesA2withinA2th
eA2school.A2PersonnelA2shouldA2beA2givenA2thisA2informationA2andA2signsA2postedA2inA2saf
eA2zones.A2ThereA2mustA2beA2systemsA2inA2placeA2toA2accuratelyA2determineA2theA2numb
erA2ofA2peopleA2inA2theA2buildingA2atA2anyA2givenA2time.A2ThereA2alsoA2mustA2beA2aA2syste
mA2inA2placeA2toA2alertA2personnelA2andA2studentsA2ofA2tornadoA2warnings.A2RegularA2pra
cticeA2preparesA2everyoneA2forA2anA2actualA2event.
4.A2Incorrect:A2GymnasiumsA2areA2notA2consideredA2safeA2placesA2dueA2toA2wideA2expans
eA2ofA2roof.A2SafeA2zonesA2shouldA2beA2onA2interiorA2walls,A2noA2windows,A2andA2aA2stron
gA2concreteA2floorA2ifA2possible.
WhatA2shouldA2aA2nurseA2teachA2familyA2membersA2priorA2toA2themA2enteringA2theA2roomA
2ofA2aA2clientA2whoA2hasA2agranulocytosis?
1.A2MeticulousA2handA2washingA2isA2needed.
,2.A2DoA2notA2visitA2ifA2youA2haveA2anyA2infection.
3.A2TheA2clientA2mustA2wearA2aA2mask.
4.A2ChildrenA2underA212A2mayA2notA2visit.
5.A2FlowersA2areA2notA2allowedA2inA2theA2room.A2-A2Ans--
A21.,A22.,A24.,A2&A25.A2Correct:A2ProtectiveA2isolationA2isA2neededA2forA2thisA2clientA2becaus
eA2ofA2theA2presenceA2ofA2aA2lowA2whiteA2bloodA2cellA2count.A2WeA2areA2protectingA2theA2cl
ientA2fromA2acquiringA2anA2infection.A2SoA2anyA2visitorsA2willA2needA2toA2haveA2meticulous
A2handA2washingA2priorA2toA2entering.A2TheA2visitorA2shouldA2notA2enterA2ifA2heA2orA2sheA2h
asA2anyA2typeA2ofA2infection.A2ToA2decreaseA2theA2riskA2ofA2infection,A2smallA2childrenA2sh
ouldA2notA2visit.A2EvenA2theA2mildestA2symptomA2ofA2infectionA2couldA2beA2detrimentalA2toA
2theA2client.A2FlowersA2haveA2bacteriaA2andA2shouldA2notA2beA2broughtA2intoA2theA2room.
3.A2Incorrect:A2AA2maskA2mustA2beA2wornA2byA2theA2visitor,A2notA2theA2client.A2TheA2maskA
2isA2wornA2byA2visitorsA2toA2preventA2aA2possibleA2spreadA2ofA2anA2airborneA2infectionA2toA2
theA2immunocompromisedA2client.
AA2clientA2diagnosedA2withA2majorA2depressionA2hasA2beenA2takingA2aA2selectiveA2seroton
inA2reuptakeA2inhibitorA2forA2theA2pastA26A2weeks.A2WhenA2visitingA2theA2mentalA2healthA2c
enter,A2theA2nurseA2discussesA2theA2medicationA2andA2responseA2withA2theA2client.A2TheA2
nurse'sA2assessmentA2revealsA2thatA2theA2clientA2isA2confusedA2aboutA2theA2dateA2andA2a
boutA2theA2prescribedA2dosageA2ofA2theA2medication.A2WhichA2questionA2wouldA2beA2most
A2importantA2forA2theA2nurseA2toA2askA2toA2furtherA2assessA2theA2situation?
1.A2AreA2youA2havingA2troubleA2sleepingA2atA2night?
2.A2DoA2youA2haveA2periodsA2ofA2muscleA2jerking?
3.A2AreA2youA2havingA2anyA2sexualA2dysfunction?
4.A2IsA2yourA2moodA2improving?A2-A2Ans--
A22.A2Correct:A2Myoclonus,A2highA2bodyA2temperature,A2shaking,A2chills,A2andA2mentalA2co
nfusionA2areA2someA2ofA2theA2symptomsA2ofA2serotoninA2syndrome.A2ThisA2clientA2mayA2b
eA2havingA2symptomsA2ofA2thisA2adverseA2reactionA2which,A2ifA2severe,A2canA2beA2fatal.
1.A2Incorrect:A2SleepA2disturbancesA2areA2commonA2withA2depression.A2SelectiveA2seroto
ninA2reuptakeA2inhibitorsA2(SSRIs)A2mayA2causeA2insomnia;A2however,A2thereA2isA2aA2mor
eA2pertinentA2questionA2neededA2forA2assessmentA2ofA2thisA2client.A2YouA2shouldA2beA2co
ncernedA2withA2theA2moreA2seriousA2orA2life-threateningA2issue.
3.A2Incorrect:A2SexualA2dysfunctionA2mayA2occurA2withA2theA2SSRIs;A2however,A2theA2clie
ntA2isA2exhibitingA2significantA2symptomsA2ofA2anA2adverseA2reactionA2whichA2wouldA2take
A2priority.
4.A2Incorrect:A2TheA2responseA2toA2theA2SSRIA2medicationsA2isA2important;A2however,A2th
ereA2isA2aA2moreA2significantA2issueA2inA2thisA2case.A2TheA2possibleA2serotoninA2syndrome
A2isA2aA2seriousA2situationA2thatA2wouldA2beA2theA2priorityA2forA2theA2nurseA2toA2address.
AA2clientA2diagnosedA2withA2serotoninA2syndromeA2isA2admittedA2toA2theA2unit.A2TheA2nurs
eA2isA2familiarA2withA2thisA2adverseA2reactionA2toA2theA2serotoninA2reuptakeA2inhibitors.A2W
hichA2symptomsA2canA2theA2nurseA2expectA2onA2assessment?
, 1.A2FeverA2andA2shivering
2.A2Agitation
3.A2DecreasedA2bodyA2temperature
4.A2Constipation
5.A2IncreasedA2heartA2rateA2-A2Ans--
A21.,A22.A2&A25.A2Correct:A2SerotoninA2syndromeA2isA2aA2groupA2ofA2symptomsA2thatA2canA2
resultA2fromA2theA2useA2ofA2certainA2serotoninA2reuptakeA2inhibitors.A2TheseA2symptomsA2
canA2rangeA2fromA2mildA2toA2severeA2andA2includeA2highA2bodyA2temperature,A2agitation,A
2increasedA2reflexes,A2diaphoresis,A2tremors,A2dilatedA2pupilsA2andA2diarrhea.A2TheA2clien
tA2isA2likelyA2toA2experienceA2shiveringA2withA2fever.A2IncreasedA2heartA2rateA2andA2bloodA
2pressureA2areA2alsoA2commonlyA2experienced.A2MoreA2severeA2symptoms,A2includingA2
muscleA2rigidityA2andA2seizures,A2canA2occur.A2IfA2notA2treated,A2serotoninA2syndromeA2ca
nA2beA2fatal.A2
3.A2Incorrect:A2IncreasedA2bodyA2temperatureA2isA2expectedA2asA2isA2increasedA2diaphore
sis.
4.A2Incorrect:A2Diarrhea,A2notA2constipation,A2isA2aA2symptomA2ofA2serotoninA2syndrome.
TheA2emergencyA2departmentA2nurseA2isA2assessingA2aA2clientA2whoA2presentsA2withA2se
vereA2epigastricA2pain.A2TheA2clientA2reportsA2thatA2threeA2rollsA2ofA2calciumA2carbonateA2
wereA2consumedA2inA2theA2pastA2eightA2hoursA2toA2treatA2theA2indigestion.A2WhichA2bloodA
2gasA2reportA2doesA2theA2nurseA2associateA2withA2thisA2situation?
1.A2pHA2-A27.49,A2pCO2A2-A240,A2HCO3A2-A230
2.A2pHA2-A27.32,A2pCO2A2-A248,A2HCO3A2-A220
3.A2pHA2-A27.38,A2pCO2A2-A252,A2HCO3A2-A232
4.A2pHA2-A27.29,A2pCO2A2-A254,A2HCO3A2-A226A2-A2Ans--
A21.A2Correct:A2TheseA2ABGsA2areA2indicativeA2ofA2metabolicA2alkalosis.A2TheA2pHA2isA2hig
h,A2theA2pCO2A2isA2withinA2normalA2limitsA2andA2theA2bicarbA2isA2highA2(alkalosis).A2So,A2th
eA2excessA2TumsA2(calciumA2carbonate)A2couldA2haveA2causedA2metabolicA2alkalosis.
2.A2Incorrect:A2TheA2clientA2isA2notA2hypoventilatingA2andA2wouldA2notA2beA2inA2metabolicA2
acidosisA2becauseA2heA2ateA23A2rollsA2ofA2TumsA2whichA2isA2aA2base.A2TheseA2ABGsA2are
A2indicativeA2ofA2acidosis.A2TheA2pHA2isA2lowA2(acidosis),A2theA2pCO2A2isA2highA2(acidosis)
A2andA2theA2bicarbA2isA2lowA2(acidosis).
3.A2Incorrect:A2TheA2clientA2isA2notA2aA2long-
termA2COPDA2clientA2asA2theseA2ABGsA2mightA2suggest.A2TheseA2ABGsA2areA2indicativeA
2ofA2fullyA2compensatedA2respiratoryA2acidosis.A2TheA2pHA2isA2normal.A2TheA2pCO2A2isA2h
ighA2(asA2withA2chronicA2retention)A2andA2theA2bicarbA2isA2highA2toA2helpA2compensate.
4.A2Incorrect:A2TheseA2ABGsA2areA2theA2resultA2ofA2anA2acuteA2ventilationA2problem.A2The
yA2areA2indicativeA2ofA2respiratoryA2acidosis.A2TheA2pHA2isA2low,A2theA2pCO2A2isA2high,A2a
ndA2theA2bicarbA2isA2normal.A2NoA2compensationA2hasA2begunA2atA2thisA2point.
