NCLEX-RN READINESS EXAM 1
Questions and Answers
1.The primary healthcare provider has prescribed phenytoin 100 mg
intra- venous push (IVP) stat for an adult client. What is the least amount
of time that the nurse can safely administer this medication?
1.1 minute
2. 2 minutes
3. 5 minutes
4. 10 minutes: 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 effects.
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
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148
,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.
2.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: 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 o
keeping the stomach empty and dry. This allows the pancreas time to
2/
148
,rest and heal. Note: Autodigestion (pancreas digesting itself) is painful fo
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, th
food is not considered an irritant. Precipitating irritants are not a part of
the pathophysiology occurring with pancreatitis.
3.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.: 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
3/
148
, 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.
4. 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.: 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.
4/
148
Questions and Answers
1.The primary healthcare provider has prescribed phenytoin 100 mg
intra- venous push (IVP) stat for an adult client. What is the least amount
of time that the nurse can safely administer this medication?
1.1 minute
2. 2 minutes
3. 5 minutes
4. 10 minutes: 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 effects.
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
1/
148
,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.
2.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: 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 o
keeping the stomach empty and dry. This allows the pancreas time to
2/
148
,rest and heal. Note: Autodigestion (pancreas digesting itself) is painful fo
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, th
food is not considered an irritant. Precipitating irritants are not a part of
the pathophysiology occurring with pancreatitis.
3.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.: 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
3/
148
, 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.
4. 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.: 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.
4/
148
