HURST REVIEW NCLEX – RN NEWEST 2024 REAL ACTUAL EXAM 1 QUESTIONS AND CORRECT DETAILED ANSWERS VERIFIED BY EXPERTS ALREADY GRADED A+

HURST REVIEW NCLEX
– RN NEWEST 2024
REAL ACTUAL EXAM 1
QUESTIONS AND
CORRECT DETAILED
ANSWERS VERIFIED
BY EXPERTS ALREADY
GRADED A+
A nurse is planning to provide information
regarding suicide to a high school assembly.
What information should the nurse include?
1. Do not keep secrets for the suicidal person.
2. Express concern for a person expressing
thoughts of suicide.
3. Teens often don't mean what they say, so
only take suicide seriously if grades are
dropping as well.
4. Inform group of suicide intervention sources.
5. Do not leave a suicidal person alone. -
ANSWER-1., 2., 4. & 5. Correct: If a person
reveals that suicide is being considered, this
should never be kept secret. Help should be
sought for the person immediately. It is also
important to be direct and non-secretive with
suicidal clients. It is appropriate to express
concern for their thoughts. The use of empathy,
warmth and concern indicates to the client that
their feelings are being understood and viewed
as real, which helps to build trust with the
client. Resources for assistance are important
to include in all health teaching programs. The
teens need to know what resources are readily
available if someone is considering suicide. The
client contemplating suicide should not be left
alone. This is for the client's safety until further
assistance can be obtained
3. Incorrect: Most clients who commit suicide
have told at least one person that they were
contemplating suicide before thy actually
committed the act. Therefore, suicidal
comments should be considered important risk
factors that require evaluation, and all
comments should be taken seriously. Anyone
expressing suicidal feelings needs immediate
attention.
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?
1. Identification of safe zones.
2. Methods for accounting for all people
present in the building.
3. Warning system activation.
4. Identification of the gymnasium as the
routine safe place.
5. Regular practice protocols. - ANSWER-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.
A client in a psychiatric unit sings over and
over, "It is hot, I am a hot tot in a lot, I sit all day
on a cot drinking a pop." How should the nurse
document this form of thought?
1. Neologisms
2. Dissociation
3. Fugue
4. Clang Association - ANSWER-4. Correct: Clang
association involves the choice of words
governed by sounds, often taking the form of
rhyming even though the words themselves
don't have any logical reason to be grouped
together.
1. Incorrect: The psychotic person invents new
words, or neologisms, that are meaningless to
others but have symbolic meaning to the
psychotic person.
2. Incorrect: Dissociation is the splitting off of
clusters of mental contents from conscious
awareness. It is a mental process that leads to a
lack of connection in the client's thoughts,
memory and sense of identity. In its mild form,
it is similar to daydreaming. In a more severe
form, it can be manifested as multiple
personalities.
3. Incorrect: Fugue is sudden, unexpected
travel away from home or customary place of
daily activities, with inability to recall some or
all of one's past. The person is unaware that
anything has been forgotten. Following
recovery, there is no memory of the time
during the fugue.
The nurse on a neuro rehabilitation unit is
caring for a client with a T4 lesion. The client
suddenly reports a severe, pounding headache.
Profuse diaphoresis is noted on the forehead.
The blood pressure is 180/112 and the heart
rate is 56. What interventions should the nurse
initiate?
1. Place client supine with legs elevated.
2. Assess bladder and bowel for distention.
3. Examine skin for pressure areas.
4. Eliminate drafts.
5. Remove triggering stimulus.
6. Administer hydralazine if BP does not return
to normal. - ANSWER-2., 3., 4., 5. & 6. Correct:
The client is experiencing autonomic
dysreflexia, which is a potentially dangerous
syndrome that can develop in clients with
spinal cord injuries. The cause of autonomic
dysreflexia with these associated symptoms is a
strong sensory or noxious stimulus. The most
common stimulus is bowel, bladder distention,
or irritation. Any painful, irritating or strong
stimulus including environmental temperature
changes, drafts, etc. can trigger autonomic
dysreflexia. It is considered a medical
emergency and must be promptly treated.
1. Incorrect: The client should be placed
immediately in a sitting position to lower blood
pressure. The supine position with the legs
elevated could increase the BP to higher and
more dangerous levels.
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. 1 minute
2. 2 minutes
3. 5 minutes
4. 10 minutes - ANSWER-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.
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?
1. Relieve nausea
2. Reduce pancreatic secretions
3. Control fluid and electrolyte imbalance
4. Remove the precipitating irritants - ANSWER2. 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.
What should a nurse teach family members
prior to them entering the room of a client who
has agranulocytosis?
1. Meticulous hand washing is needed.
2. Do not visit if you have any infection.
3. The client must wear a mask.
4. Children under 12 may not visit.
5. Flowers are not allowed in the room. -
ANSWER-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.
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?
1. Are you having trouble sleeping at night?
2. Do you have periods of muscle jerking?
3. Are you having any sexual dysfunction?
4. Is your mood improving? - ANSWER-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.
A client diagnosed with serotonin syndrome is
admitted to the unit. The nurse is familiar with
this adverse reaction to the serotonin reuptake
inhibitors. Which symptoms can the nurse
expect on assessment?
1. Fever and shivering
2. Agitation
3. Decreased body temperature
4. Constipation
5. Increased heart rate - ANSWER-1., 2. & 5.
Correct: Serotonin syndrome is a group of
symptoms that can result from the use of
certain serotonin reuptake inhibitors. These
symptoms can range from mild to severe and
include high body temperature, agitation,
increased reflexes, diaphoresis, tremors,
dilated pupils and diarrhea. The client is likely
to experience shivering with fever. Increased
heart rate and blood pressure are also
commonly experienced. More severe
symptoms, including muscle rigidity and
seizures, can occur. If not treated, serotonin
syndrome can be fatal.
3. Incorrect: Increased body temperature is
expected as is increased diaphoresis.
4. Incorrect: Diarrhea, not constipation, is a
symptom of serotonin syndrome.
The emergency department nurse is assessing a
client who presents with severe epigastric pain.
The client reports that three rolls of calcium
carbonate were consumed in the past eight
hours to treat the indigestion. Which blood gas
report does the nurse associate with this
situation?
1. pH - 7.49, pCO2 - 40, HCO3 - 30
2. pH - 7.32, pCO2 - 48, HCO3 - 20
3. pH - 7.38, pCO2 - 52, HCO3 - 32
4. pH - 7.29, pCO2 - 54, HCO3 - 26 - ANSWER-1.
Correct: These ABGs are indicative of metabolic
alkalosis. The pH is high, the pCO2 is within
normal limits and the bicarb is high (alkalosis).
So, the excess Tums (calcium carbonate) could
have caused metabolic alkalosis.
2. Incorrect: The client is not hypoventilating
and would not be in metabolic acidosis because
he ate 3 rolls of Tums which is a base. These
ABGs are indicative of acidosis. The pH is low
(acidosis), the pCO2 is high (acidosis) and the
bicarb is low (acidosis).
3. Incorrect: The client is not a long-term COPD
client as these ABGs might suggest. These ABGs
are indicative of fully compensated respiratory
acidosis. The pH is normal. The pCO2 is high (as
with chronic retention) and the bicarb is high to
help compensate.
4. Incorrect: These ABGs are the result of an
acute ventilation problem. They are indicative
of respiratory acidosis. The pH is low, the pCO2
is high, and the bicarb is normal. No
compensation has begun at this point