HURST REVIEW NCLEX-RN Readiness Exam 1 Questions and Answers 2024, Exams of Nursing

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HURST REVIEW NCLEX-RN Readiness Exam

1 Questions and Answers 2024

Question: 1

Which assessments will provide the nurse with the most information regarding a client's neurologic function?

You answered this question Incorrectly

1. Level of consciousness

2. Doll's eyes reflex

3. Babinski reflex

4. Reaction to painful stimuli

5. Verbal ability

Rationale:

1. & 5. Correct: Yes! The most important and subtle changes are related to the client's level of consciousness, verbal ability, orientation, and ability to move to command.
2. Incorrect: No, only helps with the determination of brain death.
3. Incorrect: Identifies diseases of the brain and spinal cord.
4. Incorrect: This should be last resort.

Question: 2

Which client should the nurse recognize as being at greatest risk for the development of cancer?

You answered this question Incorrectly

1. Smoker for 30 plus years

2. Body builder taking steroids and using tanning salons

3. Newborn with multiple birth defects

4. Older individual with acquired immunodeficiency syndrome

Rationale:

4. Correct: Cancer has a high incidence in the immune deficiency client and in the older adult! This one is highest.
5. Incorrect: Not highest, but known environmental carcinogen.
6. Incorrect: Not highest, but known environmental carcinogen.
7. Incorrect: No, birth defects are not a risk factor for cancer.

Question: 3

3. Left side

4. Prone

Rationale:

2. Correct: Position client on the liver to hold pressure and stop bleeding.
3. Incorrect: No, this will not help control the bleeding.
4. Incorrect: Oops, the liver is on the right, not the left.
5. Incorrect: No, we don’t turn client onto abdomen.

Question: 6

A client arrives in the emergency department after severely lacerating the left hand with a knife. HR 96, BP 150/88, R36. 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?

You answered this question Incorrectly

1. Respiratory acidosis

2. Respiratory alkalosis

3. Metabolic acidosis

4. Metabolic alkalosis

Rationale:

2. Correct: Hyperventilation due to anxiety, pain, shock, severe infection, fever, liver failure can lead to respiratory alkalosis. With each of these, the client has an increased CO^2 loss.
3. Incorrect: Not acidosis
4. Incorrect: Not metabolic
5. Incorrect: Not metabolic

Question: 7

What signs or symptoms should the nurse assess for when monitoring a client who has a brain injury?

You answered this question Incorrectly

1. Increased pulse

2. Glasgow coma score of 15

3. BP 150/

4. Papilledema

5. Projectile vomiting

Rationale:

3., 4. & 5. Correct: The pulse pressure of 150/60 is 90 (greater than 40 is a sign of increased ICP). Signs of increased intracranial pressure also include papilledema, elevated systolic pressure, wide pulse pressure, decreased pulse, and slow respirations. Projectile vomiting is classically associated with increased ICP.

1. Incorrect: Decreased pulse, not increased pulse.
2. Incorrect: A score of 15 is the best score a person can get.

Question:

The nurse is caring for a client diagnosed with heart failure who has developed pulmonary edema. Which findings best indicate that the medications are having a therapeutic effect?

Exhibit You answered this question Incorrectly

1. Respiratory rate of 34/min

2. Blood pressure 90/

3. Urine output of 100 mL over the last hour

4. Apical heart rate of 96/min

5. Blood pressure of 160/

6. Respiratory rate of 24

Rationale:

3. , 4., 5., & 6. Correct. The heart rate has decreased to within normal range. The blood pressure has decreased, and the urine output has increased.
4. Incorrect. The respiratory rate is still too high, so the pulmonary edema has not resolved.
5. Incorrect. The blood pressure is too low. We worry when the blood pressure gets to 90 systolic.

Question: 9

The nurse is caring for a client with possible hepatic failure. The nurse asks the client to sign a permit for a procedure. The nurse recalls the client's admission signature is legible, however, now observes a jerky, illegible signature. How should the nurse document this handwriting change?

You answered this question Incorrectly

1. Fetor

2. Ataxia

3. Apraxia

4. Asterixis

Rationale:

4. Correct: Yes the liver flap, abnormal muscle tremor, is usually found in clients with diseases of the liver.

4. Incorrect: Splitting occurs when a person cannot stand the thought that someone might have both good and bad aspects, so they polarize their view of that person as someone who is "all good" or "all bad."

Question: 12

The emergency responders enter the emergency department with a client in cardiac arrest. One of the responders is performing chest compressions. What is the best assessment for the nurse to determine if the responder is compressing with enough force and depth?

You answered this question Correctly

1. Dilated pupils after 1 minute of CPR

2. Presence of a carotid pulse with each compression

3. Cardiac rhythm on the monitor

4. Rise and fall of client's chest with ventilations

Rationale:

2. Correct: If chest compressions are being given with enough force and depth, a pulse will be felt with each compression.
3. Incorrect: Dilated pupils are a neurological sign. Pupils should constrict if CPR is effective.
4. Incorrect: The cardiac rhythm reflects the electrical activity of the heart. It does not indicate effective cardiac compressions with CPR.
5. Incorrect: Responsiveness is a neurological check. It determines if the client responds to stimuli. Responsiveness is documented as alert, responds to verbal stimuli, and responds to painful stimuli or unresponsive.

Question: 13

The nurse is caring for a client with deep vein thrombosis. The client has been treated with intravenous heparin for one week. The primary healthcare provider plans to change the medication to warfarin sodium. The nurse understands which approach would be appropriate?

You answered this question Correctly

1. Begin the warfarin sodium and stop the heparin simultaneously.

2. Stop the heparin 24 hours, then begin the warfarin sodium.

3. Begin the warfarin sodium before stopping the heparin.

4. Stop the heparin, wait for the coagulation studies to reach the control value,

and begin the warfarin sodium.

Rationale:

3. Correct: Warfarin sodium is initiated while the client remains on heparin. This is done so the client remains adequately anticoagulated during the transition from IV heparin to warfarin sodium.
4. Incorrect: Warfarin sodium’s onset of action is 36 hours to 3 days. If heparin were stopped and warfarin sodium initiated there would be a lag of time wherein the client would be at increased risk for clotting.
5. Incorrect: Warfarin sodium’s onset of action is 36 hours to 3 days, which would be lag time with increased risk for clotting.
6. Incorrect: Client would not be adequately antiocoagulated and at increased risk for clotting.

Question: 14

A client has been diagnosed with genital herpes. Which comment indicates understanding of the disease and prevention of the spread of the disease?

You answered this question Correctly

1. "I can be treated and then no one else is at risk."

2. "Using condoms will keep my sex partner from acquiring the disease."

3. "If I have no sores, I am not contagious to anyone."

4. "My sex partner should be tested because we have not always used condoms."

Rationale:

4. Correct: The sex partner may become infected even if using a condom. The condom does not always cover all lesions. Condoms do however reduce the likelihood of getting /transmitting the disease.
5. Incorrect: Sex partners can acquire the disease even if no open sores are present. Treatment manages outbreaks, but does not cure the disease.
6. Incorrect: Condoms decrease the risk.
7. Incorrect: Sex partners may get the disease even if no open sores are present; therefore, they should be tested for the disease.

Question: 15

The nurse is performing a non-stress test on an anxious pregnant client who has lots of questions. What does the non- stress test tell the nurse?

You answered this question Correctly

1. That the baby is going to be a boy or girl

2. The baby is doing well and the placenta is providing enough oxygen at this time

3. That the baby's heart is healthy and there are no birth defects

4. That the mother is strong enough to undergo vaginal delivery

Rationale:

2. Correct: Yes, gives information about the placenta, uterus, and oxygenation.
3. Incorrect: No, the sex is not determined by this test.
4. Incorrect: No, we can’t determine birth defects from a non-stress test.
5. Incorrect: No, we can't determine if the mother is strong enough to undergo vaginal delivery from a non-stress test.

Question:

The nurse is caring for a client with a Mantoux tuberculin skin test to be read. Which assessment finding would best indicate a positive test?

You answered this question Correctly

1. Formation of a vesicle that is at least 6 mm in diameter

2. A sharply demarcated region of erythema

3. PICC lines do not have to be replaced as often as a peripheral IV

line.

4. PICC lines provide the same risk of infection than a peripheral IV line.

5. PICC lines do not need to be flushed as frequently.

6. PICC placement decreases the need for skin puncture when blood sampling

is needed.

Rationale:

1., 2., 3., & 6. Correct: Peripheral IV lines must be changed every 72-96 hours. PICC lines may remain in place for a year or more. A PICC can be cared for at home by home care nurses, client family members, or in outpatient clinics. TPN cannot be administered via a peripheral line since it is hypertonic. PICC lines offer a lower chance for infection than a peripheral line.

4. Incorrect: PICC lines are long lasting, so the risk of infection from changing sites is eliminated. Additionally, sterile technique is used for insertion, with sterile dressing changes.
5. Incorrect: Both peripheral and central lines need to be flushed to maintain patency.

Question:

The nurse is preparing for a dressing change on a full thickness burn to the flank area. The wound care instructions include irrigating the wound with each dressing change. What should the nurse use to irrigate the wound?

You answered this question Incorrectly

1. Sterile saline

2. Distilled water

3. Betadine scrub

4. Tap water

Rationale:

1. Correct: Must use sterile saline to irrigate a full thickness burn.
2. Incorrect: This is not a sterile solution.
3. Incorrect: This should not be used for irrigation as further tissue damage can occur.
4. Incorrect: This is not a sterile solution.

Question: 20

The nurse is caring for a client on the psychiatric unit with a diagnosis of obsessive-compulsive disorder. The client has frequent hand washing rituals. Which nursing interventions would be advisable for this client?

You answered this question Incorrectly

1. Allow time for ritual.

2. Provide positive reinforcement for nonritualistic behavior.

3. Provide a flexible schedule for the client.

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4. Remove all soap and water sources from the client's environment.

5. Create a regular schedule for taking client to bathroom.

Rationale:

1., 2. & 5. Correct: Initially meet the clients dependency needs as required to keep anxiety from escalating. Rituals may interfere with client elimination needs. Establishing a regular schedule may prevent constipation.

3. Incorrect: A structured schedule is needed for this client.
4. Incorrect: Sudden and complete elimination of all avenues for dependency would create intense anxiety on the part of the client.

Question:

The nurse is caring for a newly admitted diabetic client. The initial assessment reveals that the client is unresponsive, BP is 98/64, Resp 38, HR 100, T 97.2ºF/36.2ºC. The nurse notes a fruity smell on the client’s breath. The nurse recognizes that the client is in which acid-base imbalance?

You answered this question Correctly

1. Respiratory acidosis

2. Respiratory alkalosis

3. Metabolic acidosis

4. Metabolic alkalosis

Rationale:

3. Correct: Kussmaul respirations occur due to excess ketones in the body causing metabolic acidosis. A diabetic client who is unresponsive with fruity ketone breath is assumed to be in acidosis. The respiratory rate indicates that the lungs are trying to fix the metabolic acidosis with Kussmaul breathing.
4. Incorrect: Not respiratory. Ketone breath indicates a metabolic problem.
5. Incorrect: Not respiratory. We are worried about ketoacidosis.
6. Incorrect: Not alkalosis. We are worried about ketoacidosis.

Question:

The lactation consultant is preparing to make rounds on the breastfeeding clients on the LDRP. Which client should the consultant see first?

You answered this question Correctly

1. The mother who is nursing her newborn every 2-3 hours for 15-20 minutes at a

time.

2. The mother who stated that her newborn sucks in short bursts and has audible

swallowing.

3. The mother who reported blisters on her nipples and pain whenever the

newborn latches on.

4. The mother who stated that her baby was so good that she has to wake him for

each feeding.

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1. Incorrect: Rate of administration is not an indicator for an implantable port and chemotherapeutic agents are administered at a slower rate than most IV medications.
2. Incorrect: Infection is a concern for any implantable device.
3. Incorrect: Rate of absorption is not affected by the type of central line or implantable IV port.

Question: 25

In what position should the nurse place a client post intracranial surgery?

You answered this question Correctly

1. Head of bed elevated 30 degrees

2. Supine

3. Dorsal recumbent

4. Recovery position

Rationale:

1. Correct: HOB elevated up 30-40 degrees will help keep ICP from increasing and facilitate respirations. The other positions will increase ICP. Remember to keep head in neutral position.
2. Incorrect: May increase ICP
3. Incorrect: May increase ICP. Client is flat on back with one pillow under head; knees flexed and separated and feet flat on bed.
4. Incorrect: May increase ICP. Side lying. Key is to keep HOB elevated.

Question:

A client admitted to the psychiatric unit after a suicide attempt is placed on suicide precautions. Which nursing interventions would be appropriate?

You answered this question Incorrectly

1. Assign the client to a private room.

2. Make rounds to assess the client at regular intervals.

3. Secure a promise that the client will seek out staff when feeling suicidal.

4. Closely supervise the client during meals.

5. Formulate a no harm contract for the client to sign.

Rationale:

3., 4. & 5. Correct: These are all appropriate interventions. Close supervision is also necessary during medication administration. Increased feelings of self-worth may be experienced when the client feels accepted unconditionally regardless of thoughts or behavior. Additionally, remove harmful objects from the client’s access, such as sharp objects, straps, belts, ties, glass items, and alcohol.

1. Incorrect: Clients should not be left alone for long periods of time. It is best not to place in a private room. Be sure to place close to the nurse’s station.
2. Incorrect: Make rounds at frequent, irregular intervals to avoid predictability.

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Question:

The nurse is caring for a burn client 48 hours after the burn occurred. What would be the nurse’s priority assessment?

You answered this question Correctly

1. Measure the abdominal girth.

2. Administer pain medication.

3. Auscultate the lungs every 2 hours.

4. Inspect the burn for infection.

Rationale:

3 Correct: After 48 hours the fluid in the interstitial spaces will begin to shift back into the vascular space and can lead to fluid volume excess. Excess fluid can back up into the lungs, which takes priority.

1. Incorrect: No indication of need to measure abdominal girth
2. Incorrect: Not priority over pulmonary function
3. Incorrect: Not priority over pulmonary function

Question:

The parents of a 5 year old child have recently had a new baby and want to discuss their 5 year old's recent bedwetting. The parents report that the child had been dry all night for about 8 months, and now has started wetting the bed again. What should the nurse tell the parents is the most likely reason for this change?

You answered this question Correctly

1. There is a new baby in the house.

2. The child may have poor urination habits.

3. There may be a problem with the urinary system.

4. The child has been participating in sports.

Rationale:

1. Correct: The child may be feeling stressed by the addition of the new baby and less attention from the parents.
2. Incorrect: The child has been “dry” for 8 months, so there seems to be some change to the normal routine.
3. Incorrect: Enuresis is not considered a problem at this age, particularly nocturnal enuresis.
4. Incorrect: Stress may contribute to nocturnal enuresis. Further assessment data are needed before one could conclude that this change presents a problem.

Question:

The nurse is preparing a client for a renal biopsy. Which is most important for the nurse to assess prior to this procedure?

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3. Stricture formation

4. Impaired immunologic response to infectious microorganisms

Rationale:

2. Correct: Clients who suffer from Crohn’s disease are at risk for developing fistulas, and an abscess can result from the fistula.
3. Incorrect: Perianal irritation from frequent diarrhea can occur, but irritation does not result in an infection.
4. Incorrect: Stricture formation is a complication, however, these s/s indicate an abscess.
5. Incorrect: Impaired immunologic response is not associated with Crohn’s disease.

Question:

The nurse is caring for a group of clients on the chemotherapy infusion unit. What is the major barrier of chemotherapy success in treating cancer clients?

You answered this question Incorrectly

1. Inadequate knowledge of the side effects of chemotherapy

2. Difficulty obtaining an IV access

3. The development of alopecia

4. Toxicity to normal tissues

Rationale:

4. Correct: Chemotherapy is toxic to both cancerous and non-cancerous cells. Widespread destruction of non- concancerous “normal” cells can limit the use of chemotherapeutic agents.
5. Incorrect: Inadequate knowledge can be addressed and is not considered a major barrier for chemotherapy treatment.
6. Incorrect: Implantable ports are most often used for chemotherapy administration and eliminate the difficulty of obtaining a repeated peripheral IV site.
7. Incorrect: Alopecia is an adverse effect of chemotherapy but does not affect the success of chemotherapeutic agents.

Question:

Prior to signing a consent form for surgery, the client states, "I am not sure that I understand the possible risks for this surgery, and what the alternative treatments are." What should the nurse do?

You answered this question Correctly

1. Encourage the client to sign the form, and then ask the primary healthcare

provider to talk with the client.

2. Tell the client that it is not unusual to have questions about surgery.

3. Inform the primary healthcare provider that the client has concerns and is not

ready to sign the consent.

4. Answer the questions for the client.

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Rationale:

3. Correct: The nurse should call the primary healthcare provider. Further discussion with the client is warranted. The client has the right to make informed decisions, and should not be encouraged to sign the form without further discussion.
4. Incorrect: The client has the right to make informed decisions. The client should not sign until all questions are answered.
5. Incorrect: Recognizes client concerns, but does not take care of problem.
6. Incorrect: The nurse cannot answer the questions. The informed consent comes from discussion between the primary healthcare provider and the client.

Question:

The nurse is planning care for a pediatric client reporting acute pain with sickle cell crisis? What should the nurse identify as an appropriate goal for this client?

You answered this question Correctly

1. Client will report a pain level of less than 2 on a Faces scale.

2. The nurse will administer prescribed pain meds around the clock.

3. Client will only take breakthrough pain medication.

4. Client will use distraction instead of pain medication.

Rationale:

1. Correct: Yes, this is the best goal for pain and it is age appropriate.
2. Incorrect: The goal should be client centered.
3. Incorrect: We are focusing on client response, not limiting pain med
4. Incorrect: Sickle cell crisis is very painful and pain medication is needed.

Question: 35

As a member of the emergency preparedness planning team at the hospital, which actions should the nurse encourage the team to implement?

You answered this question Correctly

1. Developing a response plan for each potential disaster.

2. Providing education to employees on the response plan.

3. Practicing the response plan on a regular basis.

4. Evaluating the hospital's level of preparedness.

5. Assigment of all client care duties to the Nursing Supervisor.

Rationale:

2., 3. & 4. Correct: Developing a single response plan, educating individuals to the specifics of the response plan, and practicing the plan and evaluating the facility’s level of preparedness are effective means of implementing emergency preparedness. The basic principles of

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4. Incorrect: Butter sauce and bread pudding are high fat items.

Question: 38

The nurse has been teaching the client about warfarin for prevention of pulmonary emboli. Which comments by the client indicate understanding of the medication?

You answered this question Incorrectly

1. “I must get my blood levels checked regularly.”

2. “I shouldn’t change my diet to include a lot of foods containing vitamin K

without supervision.”

3. “I should eat lots of foods containing vitamin K.”

4. “I should report this medication to any primary healthcare provider that I see.”

5. “I should not change the dosage without talking with my primary

healthcare provider.”

Rationale:

1., 2., 4. & 5. Correct: The client should comply with regular checks of INR levels. Vitamin K reverses the therapeutic action of warfarin. The client should report using warfarin to any primary healthcare provider, as treatment may be changed due to this medication. The client should not manipulate the dosage unless instructed by the primary healthcare provider. The anticoagulant effect must be closely monitored.

3. Incorrect: Vitamin K reverses the anticoagulant effects of warfarin.

Question:

A primipara at 36 weeks gestation is seen in the OB/GYN clinic. Which sign/symptom should the nurse immediately report to the primary healthcare provider?

You answered this question Correctly

1. Puffy hands and face

2. Reports dyspnea

3. Pedal edema

4. Trace proteinurea

Rationale:

1. Correct: Facial and upper extremity edema can be a sign of preeclampsia, which can endanger both the mother and fetus.
2. Incorrect: Dyspnea should be assessed for severity, but is a common symptom in 3 rd^ trimester of pregnancy.
3. Incorrect: Pedal edema should be assessed, but is common in 3 rd^ trimester of pregnancy.
4. Incorrect: Trace proteinurea is a benign sign in 3 rd^ trimester of pregnancy.

Question: 40

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Case managers use clinical pathways in the process of evaluating and coordinating client care with the multidisciplinary team. What is a clinical pathway?

You answered this question Correctly

1. A decision-making flowchart that uses the if/then method to address

client responses to treatment.

2. A set of practice guidelines developed by a professional medical organization

such as the American Nurses Association or the American College of Surgeons.

3. A standardized set of preprinted primary healthcare provider orders for client

care, which expedite the order process and can be customized to individual clients.

4. A set of practice guidelines based on a specific client diagnosis, which provides

an overview of the multidisciplinary plan of care.

Rationale:

4. Correct: A clinical pathway is a set of multi-disciplinary client care guidelines for a specific diagnosis or condition. It can be used to guide the plan of care and to identify deviations from the plan of care.
5. Incorrect: A decision-making flowchart that uses the if/then method is the definition of an algorithm.
6. Incorrect: A set of practice guidelines developed by professional medical organizations is the definition of a practice guideline.
7. Incorrect: A standardized set of preprinted primary healthcare provider orders is the definition of a primary healthcare provider preprinted order set.

Question: 41

The home care nurse is caring for a group of clients. Which client is at highest risk for suicide?

You answered this question Correctly

1. 76 year old widower with chronic renal failure

2. 19 year old with new SSRI therapy

3. 28 year old post-partum crying weekly

4. 50 year old client with obsessive-compulsive disorder (OCD) and depression

Rationale:

1. Correct: Yes, elderly with chronic disease, especially men are very high risk.
2. Incorrect: There is an increased incidence and risk in this population, but look for the highest risk.
3. Incorrect: Many post-partum clients cry weekly. This is not the red flag for suicide.
4. Incorrect: Another male, and chronic disease, but the widower is the higher risk.

Question: