HURST READINESS EXAM
(PRACTICE)
A.40.year.old.client.reports.a.diminished.ability.to.visually.focus.on.close.objects.and.has.al
so.noticed.a.need.for.a.well.lit.environment.to.enhance.vision..To.what.would.the.nurse.attri
bute.these.changes?
a..normal.changes.associated.with.aging
b..a.cataract.is.forming
c..symptoms.of.a.brain.tumor
d..precipitated.by.diabetic.retinopathy.-.ans✔a..normal.changes.associated.with.aging
Rationale:.aging.results.in.stiffening.of.the.lens,.thus.lessening.the.ability.to.focus..The.reti
na.is.less.sensitive.to.light,.making.accurate.vision.in.low-
light.situations.more.difficult..Pupillary.response.diminishes,.affecting.the.ability.to.adjust.t
o.changing.light.levels
The.nurse.is.assessing.pain.after.surgery.in.a.3.year.old.client.with.a.known.developmental
.delay..Which.pain.scale.should.the.nurse.use.to.assess.this.client's.pain.level?
a..CRIES.scale
b..numeric.scale
c..FLACC.scale
d..FACES.scale.-.ans✔c..FLACC.scale
Rationale:.The.FLACC.scale.can.be.used.for.pediatric.clients.from.age.2.months.to.7.years
.and.is.appropriate.when.clients.cannot.communicate.their.pain
A.client.recently.diagnosed.with.diabetes.is.sent.home.with.a.prescription.for.subcutaneou
s.insulin..What.statement.made.by.the.client.indicates.that.teaching.has.been.effective.reg
arding.safe.needle.disposal?
a.."I.should.wrap.the.needle.in.a.paper.towel.and.place.in.the.trash."
,b.."I.should.use.a.hospital.issued.biohazard.container.for.all.needles."
c.."I.may.use.any.hard.plastic.container.with.a.screw-on.cap."
d.."I.should.take.my.needles.to.the.nearest.hospital.for.disposal.".-.ans✔c.."I.may.use.any.h
ard.plastic.container.with.a.screw-on.cap."
Rationale:.At.home,.an.FDA.approved.sharps.container.is.not.needed,.however,.needles,.
syringes,.and.sharps.may.be.disposed.of.in.a.hard.plastic.container..Clients.should.follow.t
heir.community.guidelines.for.sharps.container.disposal..This.protects.the.sanitation.engin
eers.from.injury.by.the.sharps.
The.primary.healthcare.provider.suspects.the.client.has.tuberculosis.
(TB).and.prescribes.a.Mantoux.test..What.precautions.should.the.nurse.take.when.admini
stering.the.Mantoux.test?
a..don.sterile.gloves
b..place.the.client.on.reverse.isolation
c..wear.a.particulate.respirator
d..obtain.a.consent.form
e..initiate.airborne.precautions.-.ans✔c..wear.a.particulate.respirator
e..initiate.airborne.precautions
Rationale:.A.disposable.particulate.respirator.that.fits.snugly.around.the.face.is.needed..Th
e.client.needs.to.be.on.acid-fast.bacilli.
(AFB).isolation.precautions,.not.reverse.isolation..Airborne.precautions.include.a.private.r
oom.with.negative.pressure.and.a.minimum.of.6.air.exchanges.per.hour..Ultraviolet.lamps.
and.high.efficiency.particulate.air.filters.are.also.needed.
A.hysterical.college.student.arrives.in.the.emergency.department.in.bloody.soiled.clothing.
.The.nursing.assessment.reveals.facial.bruising.and.multiple.contusions.consistent.with.th
e.client's.report.of.being.raped..Which.initial.nursing.intervention.takes.priority.at.this.time?
a..notify.police.of.the.alleged.rape
b..allow.the.client.privacy.to.wash.self
c..remove.clothing.and.bag.for.evidence
d..encourage.client.to.express.fears.and.anxiety.-.ans✔d..encourage.client.to.express.fear
s.and.anxiety
Rationale:.Although.there.are.specific.protocols.that.must.be.followed.when.dealing.with.ra
pe.clients,.it.is.important.to.remember.that.this.client.had.all.control.taken.away.during.the.a
ttack..The.emotional.effects.of.rape.are.as.traumatizing.as.the.physical.injuries..Allowing.th
e.client.to.first.express.emotions,.such.as.fear.or.anxiety,.returns.a.small.amount.of.control.
to.a.situation.in.which.the.client.has.little.or.none.
The.nurse.is.caring.for.an.adolescent.client.diagnosed.with.depression..The.client.is.prescr
ibed.fluoxetine..What.is.the.best.response.by.the.nurse.when.the.client.says,."What.will.this
.medicine.do.to.me?"
,a..it.will.increase.the.level.of.serotonin.in.the.brain
b..it.will.decrease.the.production.of.noradrenaline
c..it.will.lower.your.level.of.the.brain.hormone.norepinephrine
d..it.will.balance.blood.glucose.and.dopamine.levels.in.your.head.-.ans✔a..it.will.increase.th
e.level.of.serotonin.in.the.brain
Rationale:.The.action.of.fluoxetine.is.to.increase.the.level.of.serotonin.in.the.central.nervou
s.system..There.is.a.correlation.between.a.low.level.of.serotonin.and.depression..The.actio
n.of.the.drug.should.be.explained.to.the.adolescent.in.a.manner.that.will.be.understood.
A.new.mother.brings.her.infant.to.the.clinic.for.a.well-
baby.checkup..While.at.the.clinic,.the.mother.asks.the.nurse.if.there.are.any.reasons.why.h
er.infant.should.not.have.the.MMR.vaccine..The.nurse's.response.is.based.on.evidence.th
at.the.MMR.vaccine.is.contraindicated.under.which.condition?
a..a.known.allergy.to.gelatin
b..a.family.history.of.autism
c..in.infants.with.diarrhea
d..a.known.allergy.to.sulfonamides.-.ans✔a..a.known.allergy.to.gelatin
Rationale:.The.MMR.vaccine.is.grown.using.chicken.embryos.and.manufactured.with.the.
use.of.gelatin..Known.allergies.to.gelatin.would.be.a.contraindication.for.administration.
A.client,.post.laparoscopic.cholecystectomy,.develops.pain.in.their.right.shoulder..Vital.sig
ns,.laboratory.studies,.and.an.electrocardiogram.are.within.normal.limits..What.does.the.n
urse.recognize.as.a.contributing.cause.of.the.pain?
a..surgical.cannulation.of.the.bile.duct.is.causing.spasm.and.pain
b..carbon.dioxide.used.intraperitoneally.is.irritating.the.phrenic.nerve
c..large.abdominal.retractors.used.in.the.procedure.compressed.a.nerve
d..side.lying.position.in.the.operating.room.generated.pressure.damage.-.ans✔b..carbon.di
oxide.used.intraperitoneally.is.irritating.the.phrenic.nerve
Rationale:.Phrenic.nerve.irritation.can.result.in.referred.pain.to.the.right.shoulder..Carbon.d
ioxide.is.used.to.inflate.the.abdominal/
chest.wall.during.the.procedure.for.better.visualization.of.the.internal.organs..If.the.CO2.irri
tates.the.phrenic.nerve,.it.radiates.to.the.shoulder.
Post.cataract.removal.a.client.reports.nausea.and.severe.pain.in.the.operative.eye..Which.
nursing.intervention.takes.priority?
a..administer.morphine.and.ondansetron
b..reposition.client.to.non-operative.side
c..massage.the.canthus.to.unblock.the.lacrimal.duct
d..notify.the.primary.healthcare.provider.-.ans✔d..notify.the.primary.healthcare.provider
, Rationale:.Severe.pain.with.nausea.indicates.an.increase.in.intraocular.pressure.and.need
s.to.be.reported.at.once..Eye.damage.can.result.if.not.resolved.quickly..The.primary.health
care.provider.may.prescribe.medications.or.take.the.client.back.to.surgery.
A.client.who.has.developed.hypovolemic.shock.is.receiving.albumin..What.assessment.fin
ding.by.the.nurse.indicates.that.the.albumin.has.been.effective?
a..swelling.in.the.legs
b..increase.in.urinary.output
c..proteinuria
d..increase.in.waist.measurement.-.ans✔b..increase.in.urinary.output
Rationale:.The.action.of.albumin.is.to.increase.the.serum.albumin.level..When.the.albumin.
level.increases,.there.is.a.shift.of.fluid.from.extracellular.to.intracellular..This.action.will.resu
lt.in.an.increase.in.urinary.output.
Which.tasks.would.be.appropriate.for.the.nurse.to.assign.to.an.LPN/VN?
a..changing.a.colostomy.bag
b..administer.antibiotic.via.IVPB
c..teach.insulin.self.administration.to.a.diabetic.client
d..administer.IV.pain.medication.to.a.2.day.post.op.client
e..check.for.urinary.retention
f..remove.wound.sutures.-.ans✔a..changing.a.colostomy.bag
b..administer.antibiotic.via.IVPB
e..check.for.urinary.retention
f..remove.wound.sutures
Rationale:.These.tasks.are.within.the.PNs.practice.scope.
The.nurse.is.teaching.a.group.of.pregnant.women.about.hormonal.changes.during.pregna
ncy..The.nurse.recognizes.that.teaching.was.successful.when.the.women.identify.which.h
ormone.as.causing.amenorrhea?
a..progesterone
b..estrogen
c..follicle-stimulating.hormone.(FSH)
d..human.chorionic.gonadotropin.(hCG).-.ans✔a..progesterone
What.client.will.the.charge.nurse.intervene.on.behalf.when.making.rounds?
a..the.client.turned.to.left.side.1.1/2.hour.ago
b..client.who.has.been.sitting.in.a.chair.for.2.1/2.hours
c..client.who.is.day.one.postop.from.hip.replacement.with.abduction.pillow.in.place
(PRACTICE)
A.40.year.old.client.reports.a.diminished.ability.to.visually.focus.on.close.objects.and.has.al
so.noticed.a.need.for.a.well.lit.environment.to.enhance.vision..To.what.would.the.nurse.attri
bute.these.changes?
a..normal.changes.associated.with.aging
b..a.cataract.is.forming
c..symptoms.of.a.brain.tumor
d..precipitated.by.diabetic.retinopathy.-.ans✔a..normal.changes.associated.with.aging
Rationale:.aging.results.in.stiffening.of.the.lens,.thus.lessening.the.ability.to.focus..The.reti
na.is.less.sensitive.to.light,.making.accurate.vision.in.low-
light.situations.more.difficult..Pupillary.response.diminishes,.affecting.the.ability.to.adjust.t
o.changing.light.levels
The.nurse.is.assessing.pain.after.surgery.in.a.3.year.old.client.with.a.known.developmental
.delay..Which.pain.scale.should.the.nurse.use.to.assess.this.client's.pain.level?
a..CRIES.scale
b..numeric.scale
c..FLACC.scale
d..FACES.scale.-.ans✔c..FLACC.scale
Rationale:.The.FLACC.scale.can.be.used.for.pediatric.clients.from.age.2.months.to.7.years
.and.is.appropriate.when.clients.cannot.communicate.their.pain
A.client.recently.diagnosed.with.diabetes.is.sent.home.with.a.prescription.for.subcutaneou
s.insulin..What.statement.made.by.the.client.indicates.that.teaching.has.been.effective.reg
arding.safe.needle.disposal?
a.."I.should.wrap.the.needle.in.a.paper.towel.and.place.in.the.trash."
,b.."I.should.use.a.hospital.issued.biohazard.container.for.all.needles."
c.."I.may.use.any.hard.plastic.container.with.a.screw-on.cap."
d.."I.should.take.my.needles.to.the.nearest.hospital.for.disposal.".-.ans✔c.."I.may.use.any.h
ard.plastic.container.with.a.screw-on.cap."
Rationale:.At.home,.an.FDA.approved.sharps.container.is.not.needed,.however,.needles,.
syringes,.and.sharps.may.be.disposed.of.in.a.hard.plastic.container..Clients.should.follow.t
heir.community.guidelines.for.sharps.container.disposal..This.protects.the.sanitation.engin
eers.from.injury.by.the.sharps.
The.primary.healthcare.provider.suspects.the.client.has.tuberculosis.
(TB).and.prescribes.a.Mantoux.test..What.precautions.should.the.nurse.take.when.admini
stering.the.Mantoux.test?
a..don.sterile.gloves
b..place.the.client.on.reverse.isolation
c..wear.a.particulate.respirator
d..obtain.a.consent.form
e..initiate.airborne.precautions.-.ans✔c..wear.a.particulate.respirator
e..initiate.airborne.precautions
Rationale:.A.disposable.particulate.respirator.that.fits.snugly.around.the.face.is.needed..Th
e.client.needs.to.be.on.acid-fast.bacilli.
(AFB).isolation.precautions,.not.reverse.isolation..Airborne.precautions.include.a.private.r
oom.with.negative.pressure.and.a.minimum.of.6.air.exchanges.per.hour..Ultraviolet.lamps.
and.high.efficiency.particulate.air.filters.are.also.needed.
A.hysterical.college.student.arrives.in.the.emergency.department.in.bloody.soiled.clothing.
.The.nursing.assessment.reveals.facial.bruising.and.multiple.contusions.consistent.with.th
e.client's.report.of.being.raped..Which.initial.nursing.intervention.takes.priority.at.this.time?
a..notify.police.of.the.alleged.rape
b..allow.the.client.privacy.to.wash.self
c..remove.clothing.and.bag.for.evidence
d..encourage.client.to.express.fears.and.anxiety.-.ans✔d..encourage.client.to.express.fear
s.and.anxiety
Rationale:.Although.there.are.specific.protocols.that.must.be.followed.when.dealing.with.ra
pe.clients,.it.is.important.to.remember.that.this.client.had.all.control.taken.away.during.the.a
ttack..The.emotional.effects.of.rape.are.as.traumatizing.as.the.physical.injuries..Allowing.th
e.client.to.first.express.emotions,.such.as.fear.or.anxiety,.returns.a.small.amount.of.control.
to.a.situation.in.which.the.client.has.little.or.none.
The.nurse.is.caring.for.an.adolescent.client.diagnosed.with.depression..The.client.is.prescr
ibed.fluoxetine..What.is.the.best.response.by.the.nurse.when.the.client.says,."What.will.this
.medicine.do.to.me?"
,a..it.will.increase.the.level.of.serotonin.in.the.brain
b..it.will.decrease.the.production.of.noradrenaline
c..it.will.lower.your.level.of.the.brain.hormone.norepinephrine
d..it.will.balance.blood.glucose.and.dopamine.levels.in.your.head.-.ans✔a..it.will.increase.th
e.level.of.serotonin.in.the.brain
Rationale:.The.action.of.fluoxetine.is.to.increase.the.level.of.serotonin.in.the.central.nervou
s.system..There.is.a.correlation.between.a.low.level.of.serotonin.and.depression..The.actio
n.of.the.drug.should.be.explained.to.the.adolescent.in.a.manner.that.will.be.understood.
A.new.mother.brings.her.infant.to.the.clinic.for.a.well-
baby.checkup..While.at.the.clinic,.the.mother.asks.the.nurse.if.there.are.any.reasons.why.h
er.infant.should.not.have.the.MMR.vaccine..The.nurse's.response.is.based.on.evidence.th
at.the.MMR.vaccine.is.contraindicated.under.which.condition?
a..a.known.allergy.to.gelatin
b..a.family.history.of.autism
c..in.infants.with.diarrhea
d..a.known.allergy.to.sulfonamides.-.ans✔a..a.known.allergy.to.gelatin
Rationale:.The.MMR.vaccine.is.grown.using.chicken.embryos.and.manufactured.with.the.
use.of.gelatin..Known.allergies.to.gelatin.would.be.a.contraindication.for.administration.
A.client,.post.laparoscopic.cholecystectomy,.develops.pain.in.their.right.shoulder..Vital.sig
ns,.laboratory.studies,.and.an.electrocardiogram.are.within.normal.limits..What.does.the.n
urse.recognize.as.a.contributing.cause.of.the.pain?
a..surgical.cannulation.of.the.bile.duct.is.causing.spasm.and.pain
b..carbon.dioxide.used.intraperitoneally.is.irritating.the.phrenic.nerve
c..large.abdominal.retractors.used.in.the.procedure.compressed.a.nerve
d..side.lying.position.in.the.operating.room.generated.pressure.damage.-.ans✔b..carbon.di
oxide.used.intraperitoneally.is.irritating.the.phrenic.nerve
Rationale:.Phrenic.nerve.irritation.can.result.in.referred.pain.to.the.right.shoulder..Carbon.d
ioxide.is.used.to.inflate.the.abdominal/
chest.wall.during.the.procedure.for.better.visualization.of.the.internal.organs..If.the.CO2.irri
tates.the.phrenic.nerve,.it.radiates.to.the.shoulder.
Post.cataract.removal.a.client.reports.nausea.and.severe.pain.in.the.operative.eye..Which.
nursing.intervention.takes.priority?
a..administer.morphine.and.ondansetron
b..reposition.client.to.non-operative.side
c..massage.the.canthus.to.unblock.the.lacrimal.duct
d..notify.the.primary.healthcare.provider.-.ans✔d..notify.the.primary.healthcare.provider
, Rationale:.Severe.pain.with.nausea.indicates.an.increase.in.intraocular.pressure.and.need
s.to.be.reported.at.once..Eye.damage.can.result.if.not.resolved.quickly..The.primary.health
care.provider.may.prescribe.medications.or.take.the.client.back.to.surgery.
A.client.who.has.developed.hypovolemic.shock.is.receiving.albumin..What.assessment.fin
ding.by.the.nurse.indicates.that.the.albumin.has.been.effective?
a..swelling.in.the.legs
b..increase.in.urinary.output
c..proteinuria
d..increase.in.waist.measurement.-.ans✔b..increase.in.urinary.output
Rationale:.The.action.of.albumin.is.to.increase.the.serum.albumin.level..When.the.albumin.
level.increases,.there.is.a.shift.of.fluid.from.extracellular.to.intracellular..This.action.will.resu
lt.in.an.increase.in.urinary.output.
Which.tasks.would.be.appropriate.for.the.nurse.to.assign.to.an.LPN/VN?
a..changing.a.colostomy.bag
b..administer.antibiotic.via.IVPB
c..teach.insulin.self.administration.to.a.diabetic.client
d..administer.IV.pain.medication.to.a.2.day.post.op.client
e..check.for.urinary.retention
f..remove.wound.sutures.-.ans✔a..changing.a.colostomy.bag
b..administer.antibiotic.via.IVPB
e..check.for.urinary.retention
f..remove.wound.sutures
Rationale:.These.tasks.are.within.the.PNs.practice.scope.
The.nurse.is.teaching.a.group.of.pregnant.women.about.hormonal.changes.during.pregna
ncy..The.nurse.recognizes.that.teaching.was.successful.when.the.women.identify.which.h
ormone.as.causing.amenorrhea?
a..progesterone
b..estrogen
c..follicle-stimulating.hormone.(FSH)
d..human.chorionic.gonadotropin.(hCG).-.ans✔a..progesterone
What.client.will.the.charge.nurse.intervene.on.behalf.when.making.rounds?
a..the.client.turned.to.left.side.1.1/2.hour.ago
b..client.who.has.been.sitting.in.a.chair.for.2.1/2.hours
c..client.who.is.day.one.postop.from.hip.replacement.with.abduction.pillow.in.place
