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Hurst Review Exam 2 | Readiness Assessment
2026/2027 | Comprehensive Q&A | Verified
NCLEX Prep
Which pain scale should the nurse use to monitor the pain level of a 3-year old client
after surgery?
1. Numerical scale
2. Verbal descriptive scale
3. Visual analog scale
4. FACES scale
4. Correct: Monitoring pain in children requires special techniques. The nurse should
use the FACES scale as a tool to assess this client's pain level. Children as young as 3
years of age can use the FACES scale to communicate their pain level to the medical
team. The scale has six faces ranging from smiling face to sad, tearful face.
1. Incorrect: Not age appropriate. This scale uses numbers.
2. Incorrect: Not age appropriate. Young children may not understand the word pain.
3. Incorrect: Not age appropriate. This scale requires reading.
Which tasks would be appropriate for the LPN/LVN to assign to an unlicensed assistive
personnel (UAP)? (SATA)
1. Ask the client diagnosed with dementia memory-testing questions.
2. Collect the urinary output hourly on the client with renal disease.
3. Demonstrate pursed lipped breathing to the client who has emphysema.
4. Give a tepid sponge bath to the client who has a fever.
5. Assess oxygen saturation on a client experiencing angina.
2., & 4. Correct: The UAP can obtain hourly urine output on clients and can give a tepid
sponge bath to a client. The LPN/VN must know what tasks can be assigned to the UAP.
1. Incorrect: The nurse cannot delegate assessment, evaluation, or teaching. This would
be an assessment function for the RN to perform.
3. Incorrect: The UAP cannot teach. Demonstration is a method of teaching. This is an
RN task.
5. Incorrect: The UAP cannot assess the client experiencing angina. This is an RN task.
What nursing interventions should the nurse implement for a client with Addison's
disease? (SATA)
1. Administer potassium supplements as prescribed.
,2. Assist the client to select foods high in sodium.
3. Administer Fludrocortisone as prescribed.
4. Monitor intake and output.
5. Record daily weight.
2., 3., 4. & 5. Correct: The client with Addison's disease needs sodium due to low levels
of aldosterone. Fludrocortisone is a mineralocorticoid that the client will need to take
for life. I&O and daily weights are needed to monitor fluid status.
1. Incorrect: Clients with Addison's disease lose sodium and retain potassium, so this
client does not need potassium.
A licensed practical nurse (LPN) is utilizing the nursing process to care for assigned
clients. Which nursing actions should the LPN relate to the implementation step of the
nursing process? (SATA)
1. Collecting client data for a nursing history.
2. Reporting client response to a new medication.
3. Procuring equipment for a planned medical procedure.
4. Assigning client care activities to unlicensed assistive personnel.
5. Delivering skilled nursing care according to an established health care plan.
3., 4., & 5. Correct: The nurse should relate procuring medical equipment, assigning
client care activities, and delivering skilled nursing care to the implementation step of
the nursing process. Implementation is the third step of the nursing process and
consists of delivering nursing care according to an established health care plan and as
assigned by the RN or other person(s) authorized by law.
1. Incorrect: This is not the implementation step of the nursing process. LPNs
participate in the assessment step of the nursing process by collecting client data for a
nursing, psychological, spiritual, and social histories, comparing the data collected to
normal values and findings.
2. Incorrect: This is not the implementation step of the nursing process. LPNs
participate in the nursing process by reporting client responses to the RN or supervising
healthcare provider.
The primary healthcare provider prescribes nafcillin 0.6 gram every 12 hours IM.
Available is a vial labeled 200 mg per 1 mL. How many mL should the nurse give?
Round your answer to the nearest whole number.
Changing 0.6 g to mg equals 600 mg.
Then 200 mg : 1 mL = 600 mg : x mL
200x = 600
x=3
The nurse should reinforce which instructions given to the unlicensed assistive
personnel (UAP) about care needed to reduce the risk of infection when a client has an
indwelling catheter? (SATA)
1. Check catheter for kinks in the tubing when the client is in the bed or chair.
2. Disconnect the catheter from the bag when measuring output.
3. Wash hands before providing personal care to the client.
4. Ensure that catheter remains secured to the thigh.
5. Make sure that the drainage bag is always below the level of the bladder.
,1., 3., 4. & 5. Correct: Tubing that becomes obstructed cannot allow adequate urine flow.
The urine flow occurs by gravity. Adequate handwashing before providing care is one
defense against infection. Tension on the tubing may cause irritation and subsequent
infection. The bag should be below the level of the bladder so that urine flows
appropriately.
2. Incorrect: A closed drainage system should be maintained to prevent entry of
microorganisms. Disconnecting the catheter from the bag would be incorrect and
potentially cause harm to the client.
What should the nurse document after a client has died? (SATA)
1. Time of death
2. Who pronounced the death
3. Disposition of personal articles
4. Destination of body
5. Primary healthcare provider's prescriptions
6. Time body left facility
1., 2., 3., 4., & 6. Correct: All of these are correct options that should be documented. In
addition to these things, the nurse should also document consideration of and
preparation for organ donation, family notified and decisions made, and location of
identification tags.
5. Incorrect: The primary healthcare provider's prescriptions do not need to be
documented after a client dies.
The client states, "I really do not want to have surgery. I have told my children this, but
they still want me to go through with the surgery. I do not know what to do." What is the
best response for the nurse as client advocate?
1. "Your children are concerned about you. The surgery is the best thing for your health."
2. "You have some genuine concerns about the surgery, and you feel as if your children
are not addressing your concerns. You and your family will need to resolve this before
you go to surgery."
3. "I can contact your primary healthcare provider so that you can discuss your concerns
regarding surgery."
4. "You have some genuine concerns about the surgery, and you feel as if your children
are not addressing your concerns. Tell me more about your concerns."
4. Correct: The nurse has a duty to advocate for the client if there is a discrepancy
between the care or proposed care and the client's wishes regarding treatment. It is
important to acknowledge the client's feelings and to demonstrate compassion and a
willingness to understand. This presents an opportunity for additional communication
to help answer some of the client's questions or set up a client-family conference with
the client, the client's family, and the primary healthcare provider.
1. Incorrect: When the nurse agrees with the client's children, the nurse ignores the
client's feelings and does not address the issue of the client's treatment wishes.
2. Incorrect: When the nurse restates the client's comment without investigating the
client's concerns, the issue goes unresolved.
3. Incorrect: Offering only to contact the primary healthcare provider is an incomplete
solution and hints of the nurse not taking responsibility to investigate the client's
, concerns. The client may be uncomfortable addressing concerns with the primary
healthcare provider before resolving the issue of treatment wishes with family members.
The nurse makes selections from the hospital menu for a client who is confused and
suspicious of others. Which menu choice is best?
1. Ham and vegetable casserole
2. Cheese and crackers
3. Caffeine free tea
4. Packaged sugar free Jell-O
4. Correct: A client who is suspicious of others needs foods that are packaged and can
see them opened.
1. Incorrect: A client who is suspicious of others needs to be able to identify the
ingredients in the food that is being eaten. A casserole contains many ingredients, and
the client may fear that something has been added to the food.
2. Incorrect: Finger foods are best for clients that are manic.
3. Incorrect: Drinks and foods with no caffeine are okay for the confused and suspicious
client, but this menu choice is not the best choice from the list here.
A nurse has reinforced teaching to a client about home dressing changes using a clean
technique. Which statement made by a client indicates to the nurse that the client
understands this technique?
1. "The wound should be cleaned using a washcloth, soap, and water."
2. "Povidone-iodine should be applied to the wound with each dressing change."
3. "It is important that I wash my hands using soap and water before removing my
dressing."
4. "I will use sterile gloves to clean my wound and change the dressings."
3. Correct: Clean technique requires washing hands with soap and water prior to
removing the dressing.
1. Incorrect: The wound should be cleaned with 4x4's and sterile water. Soap can be very
drying to the wound. A washcloth may not be clean as it has been sitting in a cabinet.
2. Incorrect: Povidone-iodine is harsh and damages healthy tissue, so should not be
applied to the wound.
4. Incorrect: Sterile gloves are not needed when using clean technique. Clean gloves may
be used.
When caring for a client on bedrest, which interventions should the nurse implement to
decrease the risk of deep vein thrombosis? (SATA)
1. Apply compression hose.
2. Place pillow under knees while supine.
3. Assist client to perform active foot and leg exercises.
4. Place client on intermittent pneumatic compression device.
5. Assess extremities for negative Homan's sign.
1., 3., & 4. Correct. The client will need compression or compression hose and/or
Hurst Review Exam 2 | Readiness Assessment
2026/2027 | Comprehensive Q&A | Verified
NCLEX Prep
Which pain scale should the nurse use to monitor the pain level of a 3-year old client
after surgery?
1. Numerical scale
2. Verbal descriptive scale
3. Visual analog scale
4. FACES scale
4. Correct: Monitoring pain in children requires special techniques. The nurse should
use the FACES scale as a tool to assess this client's pain level. Children as young as 3
years of age can use the FACES scale to communicate their pain level to the medical
team. The scale has six faces ranging from smiling face to sad, tearful face.
1. Incorrect: Not age appropriate. This scale uses numbers.
2. Incorrect: Not age appropriate. Young children may not understand the word pain.
3. Incorrect: Not age appropriate. This scale requires reading.
Which tasks would be appropriate for the LPN/LVN to assign to an unlicensed assistive
personnel (UAP)? (SATA)
1. Ask the client diagnosed with dementia memory-testing questions.
2. Collect the urinary output hourly on the client with renal disease.
3. Demonstrate pursed lipped breathing to the client who has emphysema.
4. Give a tepid sponge bath to the client who has a fever.
5. Assess oxygen saturation on a client experiencing angina.
2., & 4. Correct: The UAP can obtain hourly urine output on clients and can give a tepid
sponge bath to a client. The LPN/VN must know what tasks can be assigned to the UAP.
1. Incorrect: The nurse cannot delegate assessment, evaluation, or teaching. This would
be an assessment function for the RN to perform.
3. Incorrect: The UAP cannot teach. Demonstration is a method of teaching. This is an
RN task.
5. Incorrect: The UAP cannot assess the client experiencing angina. This is an RN task.
What nursing interventions should the nurse implement for a client with Addison's
disease? (SATA)
1. Administer potassium supplements as prescribed.
,2. Assist the client to select foods high in sodium.
3. Administer Fludrocortisone as prescribed.
4. Monitor intake and output.
5. Record daily weight.
2., 3., 4. & 5. Correct: The client with Addison's disease needs sodium due to low levels
of aldosterone. Fludrocortisone is a mineralocorticoid that the client will need to take
for life. I&O and daily weights are needed to monitor fluid status.
1. Incorrect: Clients with Addison's disease lose sodium and retain potassium, so this
client does not need potassium.
A licensed practical nurse (LPN) is utilizing the nursing process to care for assigned
clients. Which nursing actions should the LPN relate to the implementation step of the
nursing process? (SATA)
1. Collecting client data for a nursing history.
2. Reporting client response to a new medication.
3. Procuring equipment for a planned medical procedure.
4. Assigning client care activities to unlicensed assistive personnel.
5. Delivering skilled nursing care according to an established health care plan.
3., 4., & 5. Correct: The nurse should relate procuring medical equipment, assigning
client care activities, and delivering skilled nursing care to the implementation step of
the nursing process. Implementation is the third step of the nursing process and
consists of delivering nursing care according to an established health care plan and as
assigned by the RN or other person(s) authorized by law.
1. Incorrect: This is not the implementation step of the nursing process. LPNs
participate in the assessment step of the nursing process by collecting client data for a
nursing, psychological, spiritual, and social histories, comparing the data collected to
normal values and findings.
2. Incorrect: This is not the implementation step of the nursing process. LPNs
participate in the nursing process by reporting client responses to the RN or supervising
healthcare provider.
The primary healthcare provider prescribes nafcillin 0.6 gram every 12 hours IM.
Available is a vial labeled 200 mg per 1 mL. How many mL should the nurse give?
Round your answer to the nearest whole number.
Changing 0.6 g to mg equals 600 mg.
Then 200 mg : 1 mL = 600 mg : x mL
200x = 600
x=3
The nurse should reinforce which instructions given to the unlicensed assistive
personnel (UAP) about care needed to reduce the risk of infection when a client has an
indwelling catheter? (SATA)
1. Check catheter for kinks in the tubing when the client is in the bed or chair.
2. Disconnect the catheter from the bag when measuring output.
3. Wash hands before providing personal care to the client.
4. Ensure that catheter remains secured to the thigh.
5. Make sure that the drainage bag is always below the level of the bladder.
,1., 3., 4. & 5. Correct: Tubing that becomes obstructed cannot allow adequate urine flow.
The urine flow occurs by gravity. Adequate handwashing before providing care is one
defense against infection. Tension on the tubing may cause irritation and subsequent
infection. The bag should be below the level of the bladder so that urine flows
appropriately.
2. Incorrect: A closed drainage system should be maintained to prevent entry of
microorganisms. Disconnecting the catheter from the bag would be incorrect and
potentially cause harm to the client.
What should the nurse document after a client has died? (SATA)
1. Time of death
2. Who pronounced the death
3. Disposition of personal articles
4. Destination of body
5. Primary healthcare provider's prescriptions
6. Time body left facility
1., 2., 3., 4., & 6. Correct: All of these are correct options that should be documented. In
addition to these things, the nurse should also document consideration of and
preparation for organ donation, family notified and decisions made, and location of
identification tags.
5. Incorrect: The primary healthcare provider's prescriptions do not need to be
documented after a client dies.
The client states, "I really do not want to have surgery. I have told my children this, but
they still want me to go through with the surgery. I do not know what to do." What is the
best response for the nurse as client advocate?
1. "Your children are concerned about you. The surgery is the best thing for your health."
2. "You have some genuine concerns about the surgery, and you feel as if your children
are not addressing your concerns. You and your family will need to resolve this before
you go to surgery."
3. "I can contact your primary healthcare provider so that you can discuss your concerns
regarding surgery."
4. "You have some genuine concerns about the surgery, and you feel as if your children
are not addressing your concerns. Tell me more about your concerns."
4. Correct: The nurse has a duty to advocate for the client if there is a discrepancy
between the care or proposed care and the client's wishes regarding treatment. It is
important to acknowledge the client's feelings and to demonstrate compassion and a
willingness to understand. This presents an opportunity for additional communication
to help answer some of the client's questions or set up a client-family conference with
the client, the client's family, and the primary healthcare provider.
1. Incorrect: When the nurse agrees with the client's children, the nurse ignores the
client's feelings and does not address the issue of the client's treatment wishes.
2. Incorrect: When the nurse restates the client's comment without investigating the
client's concerns, the issue goes unresolved.
3. Incorrect: Offering only to contact the primary healthcare provider is an incomplete
solution and hints of the nurse not taking responsibility to investigate the client's
, concerns. The client may be uncomfortable addressing concerns with the primary
healthcare provider before resolving the issue of treatment wishes with family members.
The nurse makes selections from the hospital menu for a client who is confused and
suspicious of others. Which menu choice is best?
1. Ham and vegetable casserole
2. Cheese and crackers
3. Caffeine free tea
4. Packaged sugar free Jell-O
4. Correct: A client who is suspicious of others needs foods that are packaged and can
see them opened.
1. Incorrect: A client who is suspicious of others needs to be able to identify the
ingredients in the food that is being eaten. A casserole contains many ingredients, and
the client may fear that something has been added to the food.
2. Incorrect: Finger foods are best for clients that are manic.
3. Incorrect: Drinks and foods with no caffeine are okay for the confused and suspicious
client, but this menu choice is not the best choice from the list here.
A nurse has reinforced teaching to a client about home dressing changes using a clean
technique. Which statement made by a client indicates to the nurse that the client
understands this technique?
1. "The wound should be cleaned using a washcloth, soap, and water."
2. "Povidone-iodine should be applied to the wound with each dressing change."
3. "It is important that I wash my hands using soap and water before removing my
dressing."
4. "I will use sterile gloves to clean my wound and change the dressings."
3. Correct: Clean technique requires washing hands with soap and water prior to
removing the dressing.
1. Incorrect: The wound should be cleaned with 4x4's and sterile water. Soap can be very
drying to the wound. A washcloth may not be clean as it has been sitting in a cabinet.
2. Incorrect: Povidone-iodine is harsh and damages healthy tissue, so should not be
applied to the wound.
4. Incorrect: Sterile gloves are not needed when using clean technique. Clean gloves may
be used.
When caring for a client on bedrest, which interventions should the nurse implement to
decrease the risk of deep vein thrombosis? (SATA)
1. Apply compression hose.
2. Place pillow under knees while supine.
3. Assist client to perform active foot and leg exercises.
4. Place client on intermittent pneumatic compression device.
5. Assess extremities for negative Homan's sign.
1., 3., & 4. Correct. The client will need compression or compression hose and/or
