CC4 HURST QUESTIONS WITH
SOLUTIONS 100% GRADED A+ 2024
UPDATED (ACTUAL EXAM).
What nursing interventions should the nurse include when planning care for
a client admitted with Guillain-Barre' Syndrome?
Select all that apply
1. Monitor for contractures.
2. Place prone for 30 minutes, 4 times per day.
3. Provide therapeutic massage for pain relief.
4. Teach range of motion exercises.
5. Provide high protein meals 3 times a day.
6. Refer to physical therapist. - Solution 1. Monitor for contractures.
3. Provide therapeutic massage for pain relief.
4. Teach range of motion exercises.
6. Refer to physical therapist.
A nurse is teaching a client who has frequent urinary tract infections how to
prevent future infections. What statement by the client would indicate to the
nurse that treatment has been successful?
Select all that apply
1. "I will go to the bathroom as soon as the urge to void hits me."
2. "It is important for me to drink five to six 8 ounce glasses of water every
day."
3. "I should eat foods such as plums and prunes to increase the acidity of
my urine."
4. "Nylon underwear should be worn when I am free from infection."
5. "When I clean after voiding, I will discard toilet paper after each swipe." -
Solution 1. "I will go to the bathroom as soon as the urge to void hits me."
3. "I should eat foods such as plums and prunes to increase the acidity of
my urine."
5. "When I clean after voiding, I will discard toilet paper after each swipe."
An elderly client is admitted to the outpatient unit with anemia and is
receiving a blood transfusion. What is the nurse's priority assessment?
1. Monitor for peripheral edema.
,2. Assess breath sounds.
3. Keep bedrails up at all times.
4. Monitor hemoglobin every 6 hours. - Solution 2. Assess breath sounds
What lab values should the nurse monitor when caring for a client
diagnosed with acute leukemia?
Select all that apply
1. Hemoglobin
2. Hematocrit
3. Lactate dehydrogenase (LDH)
4. Platelets
5. White blood cells
6. Metanephrine - Solution 1. Hemoglobin
2. Hematocrit
4. Platelets
5. White blood cells
A client with a terminal illness, asks the nurse about palliative care. What
would be the nurse's best response?
1. Palliative care is a holistic way of finding a cure for a serious illness.
2. Palliative care begins when the client has 3 months or less to live.
3. Palliative care will require you to change to a palliative care healthcare
provider.
4. Palliative care prevents and treats symptoms and side effects of disease
and treatments. - Solution 4. Palliative care prevents and treats symptoms
and side effects of disease and treatments.
Which food items, if chosen by a client diagnosed with diverticulosis, would
indicate to the nurse that the client understands the prescribed diet?
Select all that apply
1. Avocados
2. Acorn squash
3. Applesauce
4. Lima beans
5. Raspberries
6. Cottage cheese - Solution 1. Avocados
2. Acorn squash
4. Lima beans
5. Raspberries
,High fiber foods include raw fruits, legumes, vegetables, whole bread, and
cereals.
Which signs/symptoms should the nurse monitor for in a client admitted
with a diagnosis of pheochromocytoma?
Select all that apply
1. Headache
2. Hypotension
3. Hyperglycemia
4. Bradycardia
5. Polycythemia
6. Leukopenia - Solution 1. Headache
3. Hyperglycemia
What assessment findings would the nurse expect when evaluating
whether treatment has been effective for a client hospitalized with systolic
heart failure?
Select all that apply
1. 3+ pedal edema
2. CVP of 6 mm Hg
3. One day weight loss of 2 pounds (0.9 kg)
4. Purse-lip breathing
5. Pale nail beds
6. Urine output at 50 mL/hr - Solution 2. CVP of 6 mm Hg
3. One day weight loss of 2 pounds (0.9 kg)
6. Urine output at 50 mL/hr
A client arrives at the Emergency Department after receiving 3rd degree
burns to the upper chest, neck, and face area. What would be the priority
nursing intervention?
1. Prepare for endotracheal intubation.
2. Monitor hourly urinary output.
3. Treatment of the open burn wounds.
4. Assessment and management of pain. - Solution 1. Prepare for
endotracheal intubation
A client is to be discharged following cataract removal with lens
implantation. What statement by the client indicates to the nurse that
teaching has been successful?
1. "I must keep both eyes covered till my check-up."
, 2. "I should only have pain for about two days."
3. "I will no longer have to wear reading glasses."
4. "My vision will be blurry for a couple weeks." - Solution 4. "My vision
will be blurry for a couple weeks."
Which nursing action takes priority once a term infant has delivered
vaginally?
1. Apply identification bands
2. Apply eye ointment
3. Dry the baby
4. Obtain footprints - Solution 3. Dry the baby
A mother of a newborn is crying and tells the nurse, "I am worried about my
baby. His Apgar score was 6 and the nurses had to help him breath for a
while." What response should the nurse make to this mother?
1. "Don't worry about what score your baby received on the Apgar. The
nurses know how to take care of him."
2. "Stop crying. Your baby is fine now and will continue to get stronger as
the day progresses."
3. "Your baby's Apgar score was normal. The score was 6 at 1 minute
which is typical."
4. "It is normal for you to feel this way. Let me explain what the Apgar
score is used for." - Solution 4. "It is normal for you to feel this way. Let me
explain what the Apgar score is used for."
The nurse is assessing a newborn to determine gestational age. What
findings by the nurse would indicate the infant is premature?
Select all that apply
1. Folded ear pinna springs back slowly.
2. Peripheral cyanosis on feet and hands.
3. Shoulders and chest have moderate lanugo.
4. Vernix covering axilla, back and buttocks.
5. Feet soles entirely covered with creases. - Solution 1. Folded ear pinna
springs back slowly.
3. Shoulders and chest have moderate lanugo.
4. Vernix covering axilla, back and buttocks.
What room assignment would be best for the nurse to make for a
primigravida with gestational diabetes who was admitted for glycemic
control?
SOLUTIONS 100% GRADED A+ 2024
UPDATED (ACTUAL EXAM).
What nursing interventions should the nurse include when planning care for
a client admitted with Guillain-Barre' Syndrome?
Select all that apply
1. Monitor for contractures.
2. Place prone for 30 minutes, 4 times per day.
3. Provide therapeutic massage for pain relief.
4. Teach range of motion exercises.
5. Provide high protein meals 3 times a day.
6. Refer to physical therapist. - Solution 1. Monitor for contractures.
3. Provide therapeutic massage for pain relief.
4. Teach range of motion exercises.
6. Refer to physical therapist.
A nurse is teaching a client who has frequent urinary tract infections how to
prevent future infections. What statement by the client would indicate to the
nurse that treatment has been successful?
Select all that apply
1. "I will go to the bathroom as soon as the urge to void hits me."
2. "It is important for me to drink five to six 8 ounce glasses of water every
day."
3. "I should eat foods such as plums and prunes to increase the acidity of
my urine."
4. "Nylon underwear should be worn when I am free from infection."
5. "When I clean after voiding, I will discard toilet paper after each swipe." -
Solution 1. "I will go to the bathroom as soon as the urge to void hits me."
3. "I should eat foods such as plums and prunes to increase the acidity of
my urine."
5. "When I clean after voiding, I will discard toilet paper after each swipe."
An elderly client is admitted to the outpatient unit with anemia and is
receiving a blood transfusion. What is the nurse's priority assessment?
1. Monitor for peripheral edema.
,2. Assess breath sounds.
3. Keep bedrails up at all times.
4. Monitor hemoglobin every 6 hours. - Solution 2. Assess breath sounds
What lab values should the nurse monitor when caring for a client
diagnosed with acute leukemia?
Select all that apply
1. Hemoglobin
2. Hematocrit
3. Lactate dehydrogenase (LDH)
4. Platelets
5. White blood cells
6. Metanephrine - Solution 1. Hemoglobin
2. Hematocrit
4. Platelets
5. White blood cells
A client with a terminal illness, asks the nurse about palliative care. What
would be the nurse's best response?
1. Palliative care is a holistic way of finding a cure for a serious illness.
2. Palliative care begins when the client has 3 months or less to live.
3. Palliative care will require you to change to a palliative care healthcare
provider.
4. Palliative care prevents and treats symptoms and side effects of disease
and treatments. - Solution 4. Palliative care prevents and treats symptoms
and side effects of disease and treatments.
Which food items, if chosen by a client diagnosed with diverticulosis, would
indicate to the nurse that the client understands the prescribed diet?
Select all that apply
1. Avocados
2. Acorn squash
3. Applesauce
4. Lima beans
5. Raspberries
6. Cottage cheese - Solution 1. Avocados
2. Acorn squash
4. Lima beans
5. Raspberries
,High fiber foods include raw fruits, legumes, vegetables, whole bread, and
cereals.
Which signs/symptoms should the nurse monitor for in a client admitted
with a diagnosis of pheochromocytoma?
Select all that apply
1. Headache
2. Hypotension
3. Hyperglycemia
4. Bradycardia
5. Polycythemia
6. Leukopenia - Solution 1. Headache
3. Hyperglycemia
What assessment findings would the nurse expect when evaluating
whether treatment has been effective for a client hospitalized with systolic
heart failure?
Select all that apply
1. 3+ pedal edema
2. CVP of 6 mm Hg
3. One day weight loss of 2 pounds (0.9 kg)
4. Purse-lip breathing
5. Pale nail beds
6. Urine output at 50 mL/hr - Solution 2. CVP of 6 mm Hg
3. One day weight loss of 2 pounds (0.9 kg)
6. Urine output at 50 mL/hr
A client arrives at the Emergency Department after receiving 3rd degree
burns to the upper chest, neck, and face area. What would be the priority
nursing intervention?
1. Prepare for endotracheal intubation.
2. Monitor hourly urinary output.
3. Treatment of the open burn wounds.
4. Assessment and management of pain. - Solution 1. Prepare for
endotracheal intubation
A client is to be discharged following cataract removal with lens
implantation. What statement by the client indicates to the nurse that
teaching has been successful?
1. "I must keep both eyes covered till my check-up."
, 2. "I should only have pain for about two days."
3. "I will no longer have to wear reading glasses."
4. "My vision will be blurry for a couple weeks." - Solution 4. "My vision
will be blurry for a couple weeks."
Which nursing action takes priority once a term infant has delivered
vaginally?
1. Apply identification bands
2. Apply eye ointment
3. Dry the baby
4. Obtain footprints - Solution 3. Dry the baby
A mother of a newborn is crying and tells the nurse, "I am worried about my
baby. His Apgar score was 6 and the nurses had to help him breath for a
while." What response should the nurse make to this mother?
1. "Don't worry about what score your baby received on the Apgar. The
nurses know how to take care of him."
2. "Stop crying. Your baby is fine now and will continue to get stronger as
the day progresses."
3. "Your baby's Apgar score was normal. The score was 6 at 1 minute
which is typical."
4. "It is normal for you to feel this way. Let me explain what the Apgar
score is used for." - Solution 4. "It is normal for you to feel this way. Let me
explain what the Apgar score is used for."
The nurse is assessing a newborn to determine gestational age. What
findings by the nurse would indicate the infant is premature?
Select all that apply
1. Folded ear pinna springs back slowly.
2. Peripheral cyanosis on feet and hands.
3. Shoulders and chest have moderate lanugo.
4. Vernix covering axilla, back and buttocks.
5. Feet soles entirely covered with creases. - Solution 1. Folded ear pinna
springs back slowly.
3. Shoulders and chest have moderate lanugo.
4. Vernix covering axilla, back and buttocks.
What room assignment would be best for the nurse to make for a
primigravida with gestational diabetes who was admitted for glycemic
control?
