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Hurst Review NCLEX-RN Readiness Test Bank – Complete
Practice Questions with Verified Answers & Rationales –
Updated 2025/2026 NCLEX Exam Prep
A 70 year old client was admitted to the vascular surgery unit during
the night shift with chronic hypertension. At 0830, the unlicensed
nursing assistant (UAP) reports that the client's BP is 198/94. What
would be the best action for the charge nurse to delegate at this time?
1. Ask the UAP to put the client back in bed immediately.
2. Tell the UAP to take the BP in the opposite arm in 15 minutes.
3. Have the LPN/LVN administer the 0900 furosemide and enalapril
now.
4. Ask the LPN/LVN to assess the client for pain. - ANSWER-3. Correct:
The nurse should recognize the need for measures to reduce the blood
pressure. Administering the client's blood pressure medicine is aimed
at correcting the problem. It is appropriate to administer the
medications at this time in relation to the time that the next dose is
due.
1. Incorrect: This is an appropriate action, but does not address the
problem of lowering the client's blood pressure.
2. Incorrect: This is an appropriate action, but does not address the
problem of lowering the client's blood pressure.
4. Incorrect: This is an appropriate action, but does not address the
problem of lowering the client's blood pressure.
,2|Page
A case manager is assessing an unresponsive client diagnosed with
terminal hepatic encephalopathy for equipment needs upon discharge
home for hospice care. Which equipment should the case manager
obtain for this client?
1. Alternating pressure mattress
2. Hospital bed
3. Walker
4. Suction equipment
5. Oxygen - ANSWER-1., 2., 4., & 5. Correct: An alternating pressure
mattress will help to prevent pressure ulcers. The risk of respiratory
compromise increases as the neurologic status deteriorates. A hospital
bed is needed so that the head of the client's bed can be elevated to 30
degrees to ease respirations and decrease the work of breathing. The
client with hepatic encephalopathy is unresponsive due to
accumulation of toxins and may need suctioning if unable to clear
secretions from the oropharynx. Hepatic encephalopathy frequently
has associated bleeding varices. The increasing ascites leads to
hypovolemia. Both of these conditions can result in hypoxemia for the
client at the end stages of liver disease; therefore, oxygen therapy is
provided.
3. Incorrect: As hepatic encephalopathy progresses and toxins
accumulate, the client lapses into a coma. Therefore, the unresponsive
client will not be ambulatory and would not need a walker.
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A child is being admitted with possible rheumatic fever. What
assessment data would be most important for the nurse to obtain from
the parent?
1. 102° F (38.89° C) temperature that started 2 days previously.
2. History of pharyngitis approximately 4 weeks ago.
3. Vomiting for 3 days.
4. A cough that started about 1 week earlier. - ANSWER-2. Correct:
Rheumatic fever is often the result of untreated or improperly treated
group A β-hemolytic streptococcal infections (GABHS), such as
pharyngitis. Therefore, the history of pharyngitis or upper respiratory
infection is a key assessment finding for establishing a diagnosis of
rheumatic fever. Subsequent development of rheumatic fever usually
occurs 2 to 6 weeks following the GABHS, so the assessment should
include a remote history of pharyngitis.
1. Incorrect: The fever with rheumatic fever is usually low grade and is
considered a minor manifestation of rheumatic fever.
3. Incorrect: Vomiting is not a commonly associated symptom with
rheumatic fever and is not considered a major manifestation of
rheumatic fever. Although the child may have a history of vomiting, this
finding would not be specific to rheumatic fever.
4. Incorrect: A cough is not an associated symptom of rheumatic fever.
The time frame for the development of rheumatic fever is not
appropriate if the cough started 1 week earlier, even if it had been
associated with an upper respiratory streptococcal infection.
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A client arrives in the emergency department after severely lacerating
the left hand with a knife. HR 96, BP 150/88, R 36. The client is
extremely anxious and crying uncontrollably. Based on this assessment,
the nurse should anticipate that this client is likely in which acid base
imbalance?
1. Respiratory acidosis
2. Respiratory alkalosis
3. Metabolic acidosis
4. Metabolic alkalosis - ANSWER-2. Correct: Hyperventilation due to
anxiety, pain, shock, severe infection, fever, liver failure can lead to
respiratory alkalosis. With each of these, the client loses too much CO2.
The reduction of CO2 creates an excessive loss of acid, resulting in an
alkalotic state. Since the problem is respiratory, it is respiratory
alkalosis.
1. Incorrect: This problem is respiratory, but there is excessive CO2 loss.
CO2 combines with water to form an acid. If too much of the CO2 is
lost, the result of the acid forming substance loss would be alkalosis-
Not acidosis.
3. Incorrect: The problem in this situation is respiratory in origin and
has acid loss. Therefore, it is not metabolic nor acidotic in nature.
4. Incorrect: The problem in this situation is the excessive loss of CO2
from the respiratory system secondary to hyperventilation. Although
Hurst Review NCLEX-RN Readiness Test Bank – Complete
Practice Questions with Verified Answers & Rationales –
Updated 2025/2026 NCLEX Exam Prep
A 70 year old client was admitted to the vascular surgery unit during
the night shift with chronic hypertension. At 0830, the unlicensed
nursing assistant (UAP) reports that the client's BP is 198/94. What
would be the best action for the charge nurse to delegate at this time?
1. Ask the UAP to put the client back in bed immediately.
2. Tell the UAP to take the BP in the opposite arm in 15 minutes.
3. Have the LPN/LVN administer the 0900 furosemide and enalapril
now.
4. Ask the LPN/LVN to assess the client for pain. - ANSWER-3. Correct:
The nurse should recognize the need for measures to reduce the blood
pressure. Administering the client's blood pressure medicine is aimed
at correcting the problem. It is appropriate to administer the
medications at this time in relation to the time that the next dose is
due.
1. Incorrect: This is an appropriate action, but does not address the
problem of lowering the client's blood pressure.
2. Incorrect: This is an appropriate action, but does not address the
problem of lowering the client's blood pressure.
4. Incorrect: This is an appropriate action, but does not address the
problem of lowering the client's blood pressure.
,2|Page
A case manager is assessing an unresponsive client diagnosed with
terminal hepatic encephalopathy for equipment needs upon discharge
home for hospice care. Which equipment should the case manager
obtain for this client?
1. Alternating pressure mattress
2. Hospital bed
3. Walker
4. Suction equipment
5. Oxygen - ANSWER-1., 2., 4., & 5. Correct: An alternating pressure
mattress will help to prevent pressure ulcers. The risk of respiratory
compromise increases as the neurologic status deteriorates. A hospital
bed is needed so that the head of the client's bed can be elevated to 30
degrees to ease respirations and decrease the work of breathing. The
client with hepatic encephalopathy is unresponsive due to
accumulation of toxins and may need suctioning if unable to clear
secretions from the oropharynx. Hepatic encephalopathy frequently
has associated bleeding varices. The increasing ascites leads to
hypovolemia. Both of these conditions can result in hypoxemia for the
client at the end stages of liver disease; therefore, oxygen therapy is
provided.
3. Incorrect: As hepatic encephalopathy progresses and toxins
accumulate, the client lapses into a coma. Therefore, the unresponsive
client will not be ambulatory and would not need a walker.
,3|Page
A child is being admitted with possible rheumatic fever. What
assessment data would be most important for the nurse to obtain from
the parent?
1. 102° F (38.89° C) temperature that started 2 days previously.
2. History of pharyngitis approximately 4 weeks ago.
3. Vomiting for 3 days.
4. A cough that started about 1 week earlier. - ANSWER-2. Correct:
Rheumatic fever is often the result of untreated or improperly treated
group A β-hemolytic streptococcal infections (GABHS), such as
pharyngitis. Therefore, the history of pharyngitis or upper respiratory
infection is a key assessment finding for establishing a diagnosis of
rheumatic fever. Subsequent development of rheumatic fever usually
occurs 2 to 6 weeks following the GABHS, so the assessment should
include a remote history of pharyngitis.
1. Incorrect: The fever with rheumatic fever is usually low grade and is
considered a minor manifestation of rheumatic fever.
3. Incorrect: Vomiting is not a commonly associated symptom with
rheumatic fever and is not considered a major manifestation of
rheumatic fever. Although the child may have a history of vomiting, this
finding would not be specific to rheumatic fever.
4. Incorrect: A cough is not an associated symptom of rheumatic fever.
The time frame for the development of rheumatic fever is not
appropriate if the cough started 1 week earlier, even if it had been
associated with an upper respiratory streptococcal infection.
, 4|Page
A client arrives in the emergency department after severely lacerating
the left hand with a knife. HR 96, BP 150/88, R 36. The client is
extremely anxious and crying uncontrollably. Based on this assessment,
the nurse should anticipate that this client is likely in which acid base
imbalance?
1. Respiratory acidosis
2. Respiratory alkalosis
3. Metabolic acidosis
4. Metabolic alkalosis - ANSWER-2. Correct: Hyperventilation due to
anxiety, pain, shock, severe infection, fever, liver failure can lead to
respiratory alkalosis. With each of these, the client loses too much CO2.
The reduction of CO2 creates an excessive loss of acid, resulting in an
alkalotic state. Since the problem is respiratory, it is respiratory
alkalosis.
1. Incorrect: This problem is respiratory, but there is excessive CO2 loss.
CO2 combines with water to form an acid. If too much of the CO2 is
lost, the result of the acid forming substance loss would be alkalosis-
Not acidosis.
3. Incorrect: The problem in this situation is respiratory in origin and
has acid loss. Therefore, it is not metabolic nor acidotic in nature.
4. Incorrect: The problem in this situation is the excessive loss of CO2
from the respiratory system secondary to hyperventilation. Although
