HURST REVIEW NCLEX -RN Readiness Exam 1:

HURST REVIEW NCLEX -RN Readiness Exam 1:

Questions & Answers

The primary healthcare provider has prescribed phenytoin 100 mg intravenous push (IVP) stat for an adult client. What is the least amount of time that the nurse can safely administer this medication?

• 1 minute
• 2 minutes
• 5 minutes
• 10 minutes

(Ans- 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 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. 1 / 4

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.

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?

• Relieve nausea
• Reduce pancreatic secretions
• Control fluid and electrolyte imbalance
• Remove the precipitating irritants

(Ans- 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 on keeping the stomach empty and dry. This allows the pancreas time to rest

and heal. Note: Autodigestion (pancreas digesting itself) is painful for 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, the food is not considered an irritant. Precipitating irritants are not a part of the pathophysiology occurring with pancreatitis.

• / 4

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?

• Identification of safe zones.
• Methods for accounting for all people present in the building.
• Warning system activation.
• Identification of the gymnasium as the routine safe place.
• Regular practice protocols.

(Ans- 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 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.

What should a nurse teach family members prior to them entering the room of a client who has agranulocytosis?

• Meticulous hand washing is needed.
• Do not visit if you have any infection.
• The client must wear a mask.
• Children under 12 may not visit.
• Flowers are not allowed in the room.

(Ans- 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

3. Incorrect: A mask must be worn by the visitor, not the client. The mask is

worn by visitors to prevent a possible spread of an airborne infection to the immunocompromised client.

A client diagnosed with major depression has been taking a selective serotonin reuptake inhibitor for the past 6 weeks. When visiting the mental health center, the nurse discusses the medication and response with the client. The nurse's assessment reveals that the client is confused about the date and about the prescribed dosage of the medication. Which question would be most important for the nurse to ask to further assess the situation?

• Are you having trouble sleeping at night?
• Do you have periods of muscle jerking?
• Are you having any sexual dysfunction?
• Is your mood improving?

(Ans- 2. Correct: Myoclonus, high body temperature, shaking, chills, and

mental confusion are some of the symptoms of serotonin syndrome. This client may be having symptoms of this adverse reaction which, if severe, can be fatal.

1. Incorrect: Sleep disturbances are common with depression. Selective

serotonin reuptake inhibitors (SSRIs) may cause insomnia; however, there is a more pertinent question needed for assessment of this client. You should be concerned with the more serious or life-threatening issue.

3. Incorrect: Sexual dysfunction may occur with the SSRIs; however, the

client is exhibiting significant symptoms of an adverse reaction which would take priority.

4. Incorrect: The response to the SSRI medications is important; however,

there is a more significant issue in this case. The possible serotonin syndrome is a serious situation that would be the priority for the nurse to address.

• / 4