HURST REVIEW NCLEX RN READINESS EXAM 1
ACTUAL QUESTIONS AND CORRECT
ANSWERS
◉ 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.
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..
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..
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?.
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.
ACTUAL QUESTIONS AND CORRECT
ANSWERS
◉ 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.
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..
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..
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?.
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.
