Hurst Review Test 2 & Hurst Readiness Exam
2 [2026/2027] Updated Version | Verified
Questions & Detailed Rationales
What should the nurse document after a client has died? (SATA)
1. Time of death
2. Who pronounced the death
3. Disposition of personal articles
4. Destination of body
5. Primary healthcare provider's prescriptions
6. Time body left facility - ANSWER -1., 2., 3., 4., & 6. Correct: All of these are
correct options that should be documented. In addition to these things, the nurse
should also document consideration of and preparation for organ donation, family
notified and decisions made, and location of identification tags.
5. Incorrect: The primary healthcare provider's prescriptions do not need to be
documented after a client dies.
The client states, "I really do not want to have surgery. I have told my children
this, but they still want me to go through with the surgery. I do not know what to
do." What is the best response for the nurse as client advocate?
1. "Your children are concerned about you. The surgery is the best thing for your
health."
2. "You have some genuine concerns about the surgery, and you feel as if your
children are not addressing your concerns. You and your family will need to
resolve this before you go to surgery."
3. "I can contact your primary healthcare provider so that you can discuss your
concerns regarding surgery."
4. "You have some genuine concerns about the surgery, and you feel as if your
children are not addressing your concerns. Tell me more about your concerns." -
ANSWER -4. Correct: The nurse has a duty to advocate for the client if there is a
discrepancy between the care or proposed care and the client's wishes regarding
treatment. It is important to acknowledge the client's feelings and to demonstrate
compassion and a willingness to understand. This presents an opportunity for
,additional communication to help ANSWER some of the client's questions or set
up a client-family conference with the client, the client's family, and the primary
healthcare provider.
1. Incorrect: When the nurse agrees with the client's children, the nurse ignores the
client's feelings and does not address the issue of the client's treatment wishes.
2. Incorrect: When the nurse restates the client's comment without investigating the
client's concerns, the issue goes unresolved.
3. Incorrect: Offering only to contact the primary healthcare provider is an
incomplete solution and hints of the nurse not taking responsibility to investigate
the client's concerns. The client may be uncomfortable addressing concerns with
the primary healthcare provider before resolving the issue of treatment wishes with
family members.
The nurse makes selections from the hospital menu for a client who is confused
and suspicious of others. Which menu choice is best?
1. Ham and vegetable casserole
2. Cheese and crackers
3. Caffeine free tea
4. Packaged sugar free Jell-O - ANSWER -4. Correct: A client who is suspicious
of others needs foods that are packaged and can see them opened.
1. Incorrect: A client who is suspicious of others needs to be able to identify the
ingredients in the food that is being eaten. A casserole contains many ingredients,
and the client may fear that something has been added to the food.
2. Incorrect: Finger foods are best for clients that are manic.
3. Incorrect: Drinks and foods with no caffeine are okay for the confused and
suspicious client, but this menu choice is not the best choice from the list here.
A nurse has reinforced teaching to a client about home dressing changes using a
clean technique. Which statement made by a client indicates to the nurse that the
client understands this technique?
1. "The wound should be cleaned using a washcloth, soap, and water."
2. "Povidone-iodine should be applied to the wound with each dressing change."
,3. "It is important that I wash my hands using soap and water before removing my
dressing."
4. "I will use sterile gloves to clean my wound and change the dressings." -
ANSWER -3. Correct: Clean technique requires washing hands with soap and
water prior to removing the dressing.
1. Incorrect: The wound should be cleaned with 4x4's and sterile water. Soap can
be very drying to the wound. A washcloth may not be clean as it has been sitting in
a cabinet.
2. Incorrect: Povidone-iodine is harsh and damages healthy tissue, so should not be
applied to the wound.
4. Incorrect: Sterile gloves are not needed when using clean technique. Clean
gloves may be used.
When caring for a client on bedrest, which interventions should the nurse
implement to decrease the risk of deep vein thrombosis? (SATA)
1. Apply compression hose.
2. Place pillow under knees while supine.
3. Assist client to perform active foot and leg exercises.
4. Place client on intermittent pneumatic compression device.
5. Assess extremities for negative Homan's sign. - ANSWER -1., 3., & 4. Correct.
The client will need compression or compression hose and/or intermittent
pneumatic compression device. The client should perform leg and foot exercises to
decrease stagnation of blood. Compression hose, foot and leg exercises, as well as
pneumatic compression devices increase venous return and prevents stasis of
blood. Other interventions to decrease deep vein thrombosis (DVT) include early
ambulation, passive and active range of motion, isometric exercises, and
anticoagulant drugs such as heparin.
2. Incorrect: Do not compromise blood flow by placing pillows under the knees,
crossing legs, or sitting for long periods of time. When pillows are left under the
knees for an extended time, venous return could be compromised. A pillow under
the knees is not a recommended intervention for DVT prevention.
5. Incorrect: Do not assess Homan's sign, as it may dislodge a clot. Homan's sign is
not a preventative intervention. Assessing a Homan's sign is considered to be
controversial, and this test may contribute to the release or dislodgement of a clot.
, Which action, if done by a new LPN/VN, needs to be interrupted by the
precepting LPN/VN?
1. Mixes diazepam and hydromorphone in one syringe.
2. Administers diazepam before meals.
3. Raises side rails after administering hydromorphone.
4. Instructs client to call for assistance getting out of bed after administration of
diazepam. - ANSWER -1. Correct: In this question, you are looking for the
ANSWER that is unsafe and should not be done. Diazepam cannot be mixed with
any other medication. The charge nurse should intervene.
2. Incorrect: This is an appropriate action. Food in the stomach delays absorption
of diazepam, so it would need to be given before meals.
3. Incorrect: This would be an appropriate action. Hydromorphone is a narcotic
and can decrease level of consciousness (LOC) and increase the risk of falls, so the
nurse would be taking appropriate measures to ensure the client's safety.
4. Incorrect: This would be an appropriate action. Diazepam relaxes the muscles,
decreases LOC, and can increase the risk of falls.
A client with a history of congestive heart failure has an implantable cardioverter
defibrillator (ICD) surgically implanted. What teaching points should the nurse
reinforce with the client prior to discharge? (SATA)
1. Avoid hot baths and showers.
2. Increase intake of leafy green vegetable products.
3. Avoid magnets directly over the site.
4. Notify primary healthcare provider whenever a shock is delivered by the ICD.
5. Driving is not recommended for 1 year after placement of an ICD. - ANSWER
-3., & 4. Correct: Magnets can deactivate the defibrillator. Other transmitter
devices should also be avoided. Most arrhythmias need only one shock, but the
healthcare provider should be notified when a shock is delivered so that monitoring
can increase.
1. Incorrect: Hot baths or showers are not contraindicated with ICDs.
2. Incorrect: Increase of leafy green vegetable products would have no relation to
the ICD but should be avoided if the client is on warfarin.
2 [2026/2027] Updated Version | Verified
Questions & Detailed Rationales
What should the nurse document after a client has died? (SATA)
1. Time of death
2. Who pronounced the death
3. Disposition of personal articles
4. Destination of body
5. Primary healthcare provider's prescriptions
6. Time body left facility - ANSWER -1., 2., 3., 4., & 6. Correct: All of these are
correct options that should be documented. In addition to these things, the nurse
should also document consideration of and preparation for organ donation, family
notified and decisions made, and location of identification tags.
5. Incorrect: The primary healthcare provider's prescriptions do not need to be
documented after a client dies.
The client states, "I really do not want to have surgery. I have told my children
this, but they still want me to go through with the surgery. I do not know what to
do." What is the best response for the nurse as client advocate?
1. "Your children are concerned about you. The surgery is the best thing for your
health."
2. "You have some genuine concerns about the surgery, and you feel as if your
children are not addressing your concerns. You and your family will need to
resolve this before you go to surgery."
3. "I can contact your primary healthcare provider so that you can discuss your
concerns regarding surgery."
4. "You have some genuine concerns about the surgery, and you feel as if your
children are not addressing your concerns. Tell me more about your concerns." -
ANSWER -4. Correct: The nurse has a duty to advocate for the client if there is a
discrepancy between the care or proposed care and the client's wishes regarding
treatment. It is important to acknowledge the client's feelings and to demonstrate
compassion and a willingness to understand. This presents an opportunity for
,additional communication to help ANSWER some of the client's questions or set
up a client-family conference with the client, the client's family, and the primary
healthcare provider.
1. Incorrect: When the nurse agrees with the client's children, the nurse ignores the
client's feelings and does not address the issue of the client's treatment wishes.
2. Incorrect: When the nurse restates the client's comment without investigating the
client's concerns, the issue goes unresolved.
3. Incorrect: Offering only to contact the primary healthcare provider is an
incomplete solution and hints of the nurse not taking responsibility to investigate
the client's concerns. The client may be uncomfortable addressing concerns with
the primary healthcare provider before resolving the issue of treatment wishes with
family members.
The nurse makes selections from the hospital menu for a client who is confused
and suspicious of others. Which menu choice is best?
1. Ham and vegetable casserole
2. Cheese and crackers
3. Caffeine free tea
4. Packaged sugar free Jell-O - ANSWER -4. Correct: A client who is suspicious
of others needs foods that are packaged and can see them opened.
1. Incorrect: A client who is suspicious of others needs to be able to identify the
ingredients in the food that is being eaten. A casserole contains many ingredients,
and the client may fear that something has been added to the food.
2. Incorrect: Finger foods are best for clients that are manic.
3. Incorrect: Drinks and foods with no caffeine are okay for the confused and
suspicious client, but this menu choice is not the best choice from the list here.
A nurse has reinforced teaching to a client about home dressing changes using a
clean technique. Which statement made by a client indicates to the nurse that the
client understands this technique?
1. "The wound should be cleaned using a washcloth, soap, and water."
2. "Povidone-iodine should be applied to the wound with each dressing change."
,3. "It is important that I wash my hands using soap and water before removing my
dressing."
4. "I will use sterile gloves to clean my wound and change the dressings." -
ANSWER -3. Correct: Clean technique requires washing hands with soap and
water prior to removing the dressing.
1. Incorrect: The wound should be cleaned with 4x4's and sterile water. Soap can
be very drying to the wound. A washcloth may not be clean as it has been sitting in
a cabinet.
2. Incorrect: Povidone-iodine is harsh and damages healthy tissue, so should not be
applied to the wound.
4. Incorrect: Sterile gloves are not needed when using clean technique. Clean
gloves may be used.
When caring for a client on bedrest, which interventions should the nurse
implement to decrease the risk of deep vein thrombosis? (SATA)
1. Apply compression hose.
2. Place pillow under knees while supine.
3. Assist client to perform active foot and leg exercises.
4. Place client on intermittent pneumatic compression device.
5. Assess extremities for negative Homan's sign. - ANSWER -1., 3., & 4. Correct.
The client will need compression or compression hose and/or intermittent
pneumatic compression device. The client should perform leg and foot exercises to
decrease stagnation of blood. Compression hose, foot and leg exercises, as well as
pneumatic compression devices increase venous return and prevents stasis of
blood. Other interventions to decrease deep vein thrombosis (DVT) include early
ambulation, passive and active range of motion, isometric exercises, and
anticoagulant drugs such as heparin.
2. Incorrect: Do not compromise blood flow by placing pillows under the knees,
crossing legs, or sitting for long periods of time. When pillows are left under the
knees for an extended time, venous return could be compromised. A pillow under
the knees is not a recommended intervention for DVT prevention.
5. Incorrect: Do not assess Homan's sign, as it may dislodge a clot. Homan's sign is
not a preventative intervention. Assessing a Homan's sign is considered to be
controversial, and this test may contribute to the release or dislodgement of a clot.
, Which action, if done by a new LPN/VN, needs to be interrupted by the
precepting LPN/VN?
1. Mixes diazepam and hydromorphone in one syringe.
2. Administers diazepam before meals.
3. Raises side rails after administering hydromorphone.
4. Instructs client to call for assistance getting out of bed after administration of
diazepam. - ANSWER -1. Correct: In this question, you are looking for the
ANSWER that is unsafe and should not be done. Diazepam cannot be mixed with
any other medication. The charge nurse should intervene.
2. Incorrect: This is an appropriate action. Food in the stomach delays absorption
of diazepam, so it would need to be given before meals.
3. Incorrect: This would be an appropriate action. Hydromorphone is a narcotic
and can decrease level of consciousness (LOC) and increase the risk of falls, so the
nurse would be taking appropriate measures to ensure the client's safety.
4. Incorrect: This would be an appropriate action. Diazepam relaxes the muscles,
decreases LOC, and can increase the risk of falls.
A client with a history of congestive heart failure has an implantable cardioverter
defibrillator (ICD) surgically implanted. What teaching points should the nurse
reinforce with the client prior to discharge? (SATA)
1. Avoid hot baths and showers.
2. Increase intake of leafy green vegetable products.
3. Avoid magnets directly over the site.
4. Notify primary healthcare provider whenever a shock is delivered by the ICD.
5. Driving is not recommended for 1 year after placement of an ICD. - ANSWER
-3., & 4. Correct: Magnets can deactivate the defibrillator. Other transmitter
devices should also be avoided. Most arrhythmias need only one shock, but the
healthcare provider should be notified when a shock is delivered so that monitoring
can increase.
1. Incorrect: Hot baths or showers are not contraindicated with ICDs.
2. Incorrect: Increase of leafy green vegetable products would have no relation to
the ICD but should be avoided if the client is on warfarin.
