HURST REVIEW NCLEX -RN Readiness Exam 1

HURST REVIEW NCLEX -RN Readiness Exam 1 Latest Update 125 Questions and Verified Correct Answers Guaranteed Success 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?

• Ask the UAP to put the client back in bed immediately.
• Tell the UAP to take the BP in the opposite arm in 15 minutes.
• Have the LPN/LVN administer the 0900 furosemide and enalapril now.
• Ask the LPN/LVN to assess the client for pain. - Correct 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.

• Incorrect: This is an appropriate action, but does not address the problem of lowering

the client's blood pressure.

• Incorrect: This is an appropriate action, but does not address the problem of lowering

the client's blood pressure.

• Incorrect: This is an appropriate action, but does not address the problem of lowering

the client's blood pressure.

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?

• Alternating pressure mattress
• Hospital bed
• Walker
• Suction equipment
• Oxygen - Correct 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.

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• 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.

A child is being admitted with possible rheumatic fever. What assessment data would be most important for the nurse to obtain from the parent?

• 102° F (38.89° C) temperature that started 2 days previously.
• History of pharyngitis approximately 4 weeks ago.
• Vomiting for 3 days.
• A cough that started about 1 week earlier. - Correct 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.

• Incorrect: The fever with rheumatic fever is usually low grade and is considered a

minor manifestation of rheumatic fever.

• 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.

• 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.

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?

• Respiratory acidosis
• Respiratory alkalosis
• Metabolic acidosis
• Metabolic alkalosis - Correct 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.

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• Incorrect: The problem in this situation is respiratory in origin and has acid loss.

Therefore, it is not metabolic nor acidotic in nature.

• Incorrect: The problem in this situation is the excessive loss of CO2 from the

respiratory system secondary to hyperventilation. Although the CO2 loss creates an alkalotic state, it is respiratory, not metabolic in origin.

A client asked the nurse what could have caused them to develop right sided heart failure? What would be the best response by the nurse?

• High blood pressure in the lungs.
• Long term hypertension.
• The inability of the mitral valve to close properly.
• Narrowing of the aorta. - Correct Answer:1. Correct: Yes, the right side of the heart

pumps to the lungs. When the client has higher pressure in the pulmonary circuit from such things as emphysema, the pulmonary pressure can exceed the systemic pressure.The result is back flow to the right side of the heart and resulting right sided heart failure.

• Incorrect: No, that's left-sided heart failure. Hypertension increases afterload which

can ultimately result in back flow to the left side of the heart and resulting left sided heart failure.

• Incorrect: Not related to pulmonary hypertension. The mitral valve is located between

the left atrium and left ventricle. If mild, there may be little or no obvious symptoms.However, if severe, left sided heart failure may occur.

• Incorrect: Not related to pulmonary hypertension. Narrowing of the aorta makes it

harder to get blood out of the left ventricle (high afterload). The resulting backflow of blood would result in left sided heart failure.

A client comes into the emergency department (ED) and demands to be seen immediately, but refuses to tell the triage nurse the problem. During the assessment, the client starts yelling and shaking their fist. For the nurse's safety, what should be the nurse's initial action?

• Tell the client to stay calm, and that treatment will be provided soon.
• Explain that unless the client behaves, they will be sent away from the ED.
• Notify the client that security will be called if they do not go to the waiting room

immediately.

• Find a safe place away from the client and then notify security. - Correct Answer:4.

Correct: Self-protection is a priority. There is no advantage to protecting others if medical caregivers are injured. Security officers and police must gain control of the situation first, and then care is provided.

• Incorrect: This does not provide safety for the nurse and might increase the client's

anger.

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• Incorrect: This is not a true statement and does not provide immediate safety for the

nurse. Clients seeking treatment are not refused care in the ED.

• Incorrect: This is not the initial action. Finding a safe place is the first action for the

nurse's safety. Also, the angry client does not need to be sent to the waiting room around other clients at this time.

A client diagnosed with a duodenal ulcer is prescribed lansoprazole and sucralfate.What should the nurse teach the client about how to take these medications?

• Take together immediately before meals.
• Take together immediately after meals.
• Take the sucralfate first, wait at least 30 minutes, then take the lansoprazole.
• Take the lansoprazole first, wait at least 30 minutes, then take the sucralfate. -

Correct Answer:4. Correct: When prescribed any medication along with sucralfate, the client should avoid taking the medication at the same time with sucralfate. Sucralfate can make it harder for the body to absorb lansoprazole because it forms a "coating" or "barrier" on the stomach lining. Therefore, the client should wait at least 30 minutes after taking the lansoprazole before taking sucralfate.

• Incorrect: Taking sucralfate and lansoprazole at the same time will decrease the

effects of lansoprazole because the sucralfate coats the stomach lining and reduces the absorption of the lansoprazole.

• Incorrect: Taking sucralfate and lansoprazole at the same time will decrease the

effects of lansoprazole because the sucralfate coats the stomach lining and reduces the absorption of the lansoprazole..

• Incorrect: Sucralfate can make it harder for your body to absorb lansoprazole

because of the barrier created on the stomach lining.

A client diagnosed with glomerulonephritis presents with generalized malaise, weight gain, generalized edema, and flank pain. The primary healthcare provider prescribes antibiotics and strict bedrest. What is the best explanation to give the client regarding the strict bedrest prescription?

• Promotes diuresis
• Prevents injury
• Promotes rest
• Stimulates RBC production - Correct Answer:1. Correct: Bedrest and the supine

position promote diuresis. When the client is supine, there is a gradual shift of fluids away from the legs toward the thorax, abdomen and head. This increased volume causes the right atrium of the heart to stretch and release ANP, which leads to diuresis: renal blood flow increases due to vasodilation, and aldosterone and ADH secretion are inhibited.

• Incorrect: Bedrest can keep the client from falling and injuring self; however, that is

not why it has been prescribed.

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