Hurst NCLEX Exam with Accurate
Solutions
NCLEX hospital . . . - correct answer-is perfect and you only care for client on screen
Priority questions - correct answer-which one is the Killer answer? *NOTE: Pain isn't a
priority and expected problems related to conditions-like kidney stones positive for
hematuria and 8/10 pain-not priority over other conditions
Call physician when - correct answer-only if not a nursing intervention available
Never pick an answer - correct answer-*that isn't the least invasive * that isn't client
focused
*that doesn't allow client to speak or rushes their complaint off *puts off work to
someone else *if you're down to 2, pick the killer answer *has long-term consequences *
don't delay care/treatment
report what to next shift nurse - correct answer-something "new" or "different" or
"possible"
like illnesses can be put in - correct answer-same room
if you have no baseline in question - correct answer-assume normal limits
elevate _______ and dangle _______ - correct answer-elevate veins and dangle
arteries. E goes with E and A goes with A
any fluid problem, daily do what - correct answer-I&O and weights
with pacemaker always worry when - correct answer-rate is decreased
Mg or calcium problem, think what first - correct answer-muscles
restless client think what first - correct answer-hypoxia
always limit protein with kidney clients except which - correct answer-those with
nephrotic syndrome
first sign of respiratory acidosis - correct answer-hypoxia possibly
remember with SIADH - correct answer-too many letters, too much water
,"Soggy Sid"
aldosterone, think - correct answer-sodium and water, releases K
Al likes to swim in saltwater
ADH - correct answer-H20
(three letters/three digits)
remember what about traction - correct answer-never release unless you have order
from dr to do so
when you see polyuria, think what first - correct answer-shock first
when you see fluid retention, think what first - correct answer-heart problems
what should you ALWAYS assume - correct answer-the worst * you always have
something to worry about
if you see "assessment" or "evaluation" in stem - correct answer-think signs and
symptoms
don't ever use what in a nursing diagnosis - correct answer-a medical diagnosis
less volume ____ pressure
and more volume _____ pressure - correct answer-less volume, less pressure
more volume, more pressure
if problem is in kidneys - correct answer-HCO3 will be affected
if problem in lungs - correct answer-CO2 will be affected
when triaging, emergent means:
urgent means:
non-urgent means - correct answer-emergent is lift threatening
urgent is stable on arrival but needing timely attention
non-urgent is stable and not in immediate need of ER treatment
when you see words like always, never, total . . . - correct answer-don't ever choose
them! They're too limiting. Look for things like might or maybe or sometimes!
arrythmias are not big deal unless what - correct answer-they affect cardiac output
Remember order of Maslow's - correct answer-Biological and physiological needs,
safety, belonging and love needs, esteem needs and then self-actualization needs like
personal growth and fulfillment
,what tasks can NAP be assigned - correct answer-stable patients (could be complex
also) and tasks that are routine, simple, repetitive, everyday activities that don't require
nursing judgment such as feeding, hygiene, ambulation
LVNs can be delegated tasks BUT . . . - correct answer-R.N. still is accountable and
responsible for it
assignment - correct answer-the work you must get accomplished during your shift
RN to RN assignments transfer - correct answer-responsibility and accountability
with delegation, you can transfer - correct answer-the responsibility but not the
accountability.
Supervision - correct answer-guidance and direction, oversight and eval by the RN to
see that delegated task is accomplished.
What specific things do you have to tell the person you are delegating to? - correct
answer-You must make sure exactly which task you've assigned them, which should be
done first, etc., and any other tasks you need completed and when. Give CLEAR
directions indicating what ranges you want reported to you.
after task is completed, check what - correct answer-&Was task done properly?* If not,
provide teaching.
*Was the task done in the proper timeframe?* Will the delay affect client safety? *Were
the client's needs met?* Did the task change and require higher level of education?
Maybe you should do the task!
don't assume someone is competent to do something just because of what - correct
answer-Their job description. It's our job to find out our staff's strength and weakness.
If we identify a weakness of our NAP, what do we do to remedy that? - correct answer-
Teach, teach, teach and DOCUMENT WHAT WE TAUGHT -- it's our responsibility
when we get a nurse from another unit to our floor, what do we consider them - correct
answer-a brand new nurse. Cannot handle any specialized care.
Most important thing we can do before we start our new job - correct answer-
malpractice insurance
If a staff member performs your assigned tasks which were not delegated to them and a
problem occurs, what do you do - correct answer-Teach, teach, teach and document
what you taught. ALWAYS fill out an incident report and then go home and document
the incident for yourself. The hospital will protect its interests and you need to protect
yours.
, what can LVNs help us with - correct answer-Stable clients only. Can handle data
collection but never the actual steps in nursing process. They can implement tasks on
careplan and SPECIFIC tasks for us on our unstable client. Can't start but can remove
IVs
RN must do what - correct answer-Admission history. If someone else does it for you,
NEVER sign off on the form until you have validated the data.
A new admit is considered stable or unstable? - correct answer-Unstable and is our
PRIORITY CLIENT!!! BUT DON'T FORGET that a client that's been on our floor can be
COMPLEX AND STABLE at the same time.
Admission height and weight is whose responsibility - correct answer-OUR
RESPONSIBILITY (Basis for all drug calculations)
In delegating, we should always keep in mind - correct answer-Right task,
circumstances, person, direction, supervision AND evaluation. We are the manager of
client care and we should be thinking cost-effective, too
why could we not assign a client with abdominal pain scheduled for a CT scan - correct
answer-At this point client has not been diagnosed whether stable or unstable
What should be always be ready to do with our assigned clients - correct answer-Re-
evaluate and re-assign care as the client's needs or the nursing team's abilities change
If assigned task doesn't meet expectations - correct answer-RN must step in and teach.
Give credit and praise when due. Offer observations and share concerns and ask for
their feedback, too.
Standard precautions for - correct answer-HIV, MRSA or VRSA (but contact if more
severe), tetanus, E Coli, mono (from 2nd day), impetigo (from 2nd day), lyme disease,
thrush
airborne and contact - correct answer-varicella and disseminated shingles
contact - correct answer-RSV, head lice (with isolation up to 24 hours), rotavirus,
impetigo (for 24 hours), CDIF (MUST WASH WITH SOAP AND WATER)
droplet - correct answer-pertussis, mumps (for 9 days), seasonal influenza, mono for 24
hours, rubella,
airborne - correct answer-TB with pulmonary involvement
think thyroid think what - correct answer-iodine
disease related to hyperthyroidism - correct answer-Graves disease
Solutions
NCLEX hospital . . . - correct answer-is perfect and you only care for client on screen
Priority questions - correct answer-which one is the Killer answer? *NOTE: Pain isn't a
priority and expected problems related to conditions-like kidney stones positive for
hematuria and 8/10 pain-not priority over other conditions
Call physician when - correct answer-only if not a nursing intervention available
Never pick an answer - correct answer-*that isn't the least invasive * that isn't client
focused
*that doesn't allow client to speak or rushes their complaint off *puts off work to
someone else *if you're down to 2, pick the killer answer *has long-term consequences *
don't delay care/treatment
report what to next shift nurse - correct answer-something "new" or "different" or
"possible"
like illnesses can be put in - correct answer-same room
if you have no baseline in question - correct answer-assume normal limits
elevate _______ and dangle _______ - correct answer-elevate veins and dangle
arteries. E goes with E and A goes with A
any fluid problem, daily do what - correct answer-I&O and weights
with pacemaker always worry when - correct answer-rate is decreased
Mg or calcium problem, think what first - correct answer-muscles
restless client think what first - correct answer-hypoxia
always limit protein with kidney clients except which - correct answer-those with
nephrotic syndrome
first sign of respiratory acidosis - correct answer-hypoxia possibly
remember with SIADH - correct answer-too many letters, too much water
,"Soggy Sid"
aldosterone, think - correct answer-sodium and water, releases K
Al likes to swim in saltwater
ADH - correct answer-H20
(three letters/three digits)
remember what about traction - correct answer-never release unless you have order
from dr to do so
when you see polyuria, think what first - correct answer-shock first
when you see fluid retention, think what first - correct answer-heart problems
what should you ALWAYS assume - correct answer-the worst * you always have
something to worry about
if you see "assessment" or "evaluation" in stem - correct answer-think signs and
symptoms
don't ever use what in a nursing diagnosis - correct answer-a medical diagnosis
less volume ____ pressure
and more volume _____ pressure - correct answer-less volume, less pressure
more volume, more pressure
if problem is in kidneys - correct answer-HCO3 will be affected
if problem in lungs - correct answer-CO2 will be affected
when triaging, emergent means:
urgent means:
non-urgent means - correct answer-emergent is lift threatening
urgent is stable on arrival but needing timely attention
non-urgent is stable and not in immediate need of ER treatment
when you see words like always, never, total . . . - correct answer-don't ever choose
them! They're too limiting. Look for things like might or maybe or sometimes!
arrythmias are not big deal unless what - correct answer-they affect cardiac output
Remember order of Maslow's - correct answer-Biological and physiological needs,
safety, belonging and love needs, esteem needs and then self-actualization needs like
personal growth and fulfillment
,what tasks can NAP be assigned - correct answer-stable patients (could be complex
also) and tasks that are routine, simple, repetitive, everyday activities that don't require
nursing judgment such as feeding, hygiene, ambulation
LVNs can be delegated tasks BUT . . . - correct answer-R.N. still is accountable and
responsible for it
assignment - correct answer-the work you must get accomplished during your shift
RN to RN assignments transfer - correct answer-responsibility and accountability
with delegation, you can transfer - correct answer-the responsibility but not the
accountability.
Supervision - correct answer-guidance and direction, oversight and eval by the RN to
see that delegated task is accomplished.
What specific things do you have to tell the person you are delegating to? - correct
answer-You must make sure exactly which task you've assigned them, which should be
done first, etc., and any other tasks you need completed and when. Give CLEAR
directions indicating what ranges you want reported to you.
after task is completed, check what - correct answer-&Was task done properly?* If not,
provide teaching.
*Was the task done in the proper timeframe?* Will the delay affect client safety? *Were
the client's needs met?* Did the task change and require higher level of education?
Maybe you should do the task!
don't assume someone is competent to do something just because of what - correct
answer-Their job description. It's our job to find out our staff's strength and weakness.
If we identify a weakness of our NAP, what do we do to remedy that? - correct answer-
Teach, teach, teach and DOCUMENT WHAT WE TAUGHT -- it's our responsibility
when we get a nurse from another unit to our floor, what do we consider them - correct
answer-a brand new nurse. Cannot handle any specialized care.
Most important thing we can do before we start our new job - correct answer-
malpractice insurance
If a staff member performs your assigned tasks which were not delegated to them and a
problem occurs, what do you do - correct answer-Teach, teach, teach and document
what you taught. ALWAYS fill out an incident report and then go home and document
the incident for yourself. The hospital will protect its interests and you need to protect
yours.
, what can LVNs help us with - correct answer-Stable clients only. Can handle data
collection but never the actual steps in nursing process. They can implement tasks on
careplan and SPECIFIC tasks for us on our unstable client. Can't start but can remove
IVs
RN must do what - correct answer-Admission history. If someone else does it for you,
NEVER sign off on the form until you have validated the data.
A new admit is considered stable or unstable? - correct answer-Unstable and is our
PRIORITY CLIENT!!! BUT DON'T FORGET that a client that's been on our floor can be
COMPLEX AND STABLE at the same time.
Admission height and weight is whose responsibility - correct answer-OUR
RESPONSIBILITY (Basis for all drug calculations)
In delegating, we should always keep in mind - correct answer-Right task,
circumstances, person, direction, supervision AND evaluation. We are the manager of
client care and we should be thinking cost-effective, too
why could we not assign a client with abdominal pain scheduled for a CT scan - correct
answer-At this point client has not been diagnosed whether stable or unstable
What should be always be ready to do with our assigned clients - correct answer-Re-
evaluate and re-assign care as the client's needs or the nursing team's abilities change
If assigned task doesn't meet expectations - correct answer-RN must step in and teach.
Give credit and praise when due. Offer observations and share concerns and ask for
their feedback, too.
Standard precautions for - correct answer-HIV, MRSA or VRSA (but contact if more
severe), tetanus, E Coli, mono (from 2nd day), impetigo (from 2nd day), lyme disease,
thrush
airborne and contact - correct answer-varicella and disseminated shingles
contact - correct answer-RSV, head lice (with isolation up to 24 hours), rotavirus,
impetigo (for 24 hours), CDIF (MUST WASH WITH SOAP AND WATER)
droplet - correct answer-pertussis, mumps (for 9 days), seasonal influenza, mono for 24
hours, rubella,
airborne - correct answer-TB with pulmonary involvement
think thyroid think what - correct answer-iodine
disease related to hyperthyroidism - correct answer-Graves disease
