1
HURST READINESS EXAM 2| UPDATE
COMPLETE FREQUENTLY TESTED
QUESTIONS WITH VERIFIED ANSWERS
|GET IT 100% ACCURATE!!
What medication should the nurse anticipate giving to a client in preterm labor
to stimulate maturation of the baby's lungs?
1. Magnesium sulfate 2. Terbutaline 3. Methotrexate 4. Betamethasone -
(ANSWER)Rationale
4. Correct: Betamethasone is used to stimulate maturation of the baby's lungs in
case preterm birth occurs. This medication is given to help prevent respiratory
distress syndrome (RDS) by improving storage and secretion of surfactant that
helps to keep the alveoli from collapsing. 1. Incorrect: Magnesium sulfate is given
to stop preterm labor, however, if delivery is imminent, then Betamethasone
should be given to stimulate maturation of the baby's lungs. 2. Incorrect:
Terbutaline is contraindicated in preterm labor, however, if delivery is imminent,
then Betamethasone should be given to stimulate maturation of the baby's lungs.
3. Incorrect: Methotrexate is used to stop the growth of the embryo in ectopic
pregnancy so that the fallopian tube can be saved. It is not an agent used in the
management of preterm labor.
An adult client has just returned to the nursing care unit following a gastroscopy.
Which intervention should the nurse include on the plan of care?
1. Vital sign checks every 15 min x 4 2. Supine position for 6 hours 3. NPO until
return of gag reflex 4. Irrigate NG tube every 2 hours 5. Raise four siderails -
(ANSWER)Rationale
,2
1., & 3. Correct: Vital signs post procedure are important to monitor for any post-
procedure complications such as bleeding or any signs of respiratory compromise.
VS are checked frequently for the first hour post procedure. Any client who has a
scope inserted down the throat and has received numbing medication in the back
of the throat to depress the gag reflex should be kept NPO until the gag reflex
returns. 2. Incorrect: Supine position for 6 hours is contraindicated. The HOB
should be elevated. In the event the client vomits, he/she is less likely to aspirate
with the HOB elevated. Supine position for 6 hours is used after a heart
catheterization. 4. Incorrect: A client who is going for a gastroscopy procedure
cannot have a nasal gastric tube. An NG tube would interfere with the procedure.
5. Incorrect: Raising all side rails is a form of restraint. Have the bed in low locked
position. Raise three side rails, and have call light within reach.
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?
1. Ask the UAP to put the client back in bed immediately. 2. Tell the UAP to take
the BP in the opposite arm in 15 minutes. 3. Have the LPN/LVN administer the
0900 furosemide and enalapril now. 4. Ask the LPN/LVN to assess the client for
pain. - (ANSWER)Rationale
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. 1. Incorrect: This is an
appropriate action, but does not address the problem of lowering the client's
blood pressure. 2. Incorrect: This is an appropriate action, but does not address
the problem of lowering the client's blood pressure. 4. Incorrect: This is an
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appropriate action, but does not address the problem of lowering the client's
blood pressure.
A client suffers from migraine headaches. What assessment finding would the
nurse expect to find during a migraine attack?
1. Unilateral, pulsating pain quality. 2. Bilateral, pressing/tightening pain quality.
3. Ipsilateral nasal congestion and rhinorrhea. 4. Headache occurs after
recovering from a headache treated with narcotics. - (ANSWER)Rationale
1. Correct: Migraine headaches have a pulsating pain quality, unilateral location,
moderate or severe pain intensity, aggravated by or causing avoidance of routine
physical activity (walking, climbing stairs). During headache at least one of the
following accompanies the headache: nausea and/or vomiting; photophobia and
phonophobia. 2. Incorrect: This is seen in tension headaches. Headaches last 30
minutes to 7 days. Pain is mild or moderate in intensity. It is not aggravated by
routine physical activity. Nausea/vomiting, photophobia and phonophobia are not
common manifestations with tension headaches. These usually start gradually,
often in the middle of the day. 3. Incorrect: This is associated with cluster
headaches, which are severe or very severe unilateral orbital, supraorbital and/or
temporal pain lasting 15-180 minutes. Symptoms include stabbing pain in one eye
with associated rhinorrhea (runny nose) and possible drooping eyelid on the
affected side. The headaches tend to occur in "clusters": typically one to three
headaches per day (but may be as many as eight) during a cluster period. 4.
Incorrect: Overuse of painkillers for headaches, can, ironically, lead to rebound
headaches. Culprits include over the counter medications such as aspirin,
acetaminophen or ibuprofen, as well as prescription medications. Too much
medication can cause the brain to shift into an excited state, triggering more
headaches. Also, rebound headaches are a symptom of withdrawal as the level of
medicine drops in the bloodstream. Rebound headaches may have associated
, 4
issues such as difficulty concentrating, irritability and restlessness but does not
typically include photophobia or visual disturbances as seen with migraines.
The nurse is caring for a client who was admitted to the hospital following a
severe motor vehicle crash (MVC) in which the client was trapped in the car for
several hours. The client is being closely monitored for the development of renal
failure. Which assessment finding would warrant immediate reporting?
1. Creatinine 1.1 mg/dl (97.24 mmol/L) 2. Urinary output of 150 mL per hour. 3.
Gradual increase of BUN levels. 4. Calcium levels of 9.0 mg/dL (2.25 mmol/L) -
(ANSWER)Rationale
3. Correct. Gradual accumulation of nitrogenous wastes results in elevated BUN
and serum creatinine. This is an indication of impaired renal function. 1. Incorrect.
This is a normal creatinine level. Gradual accumulation of nitrogenous wastes
from impaired renal function results in elevated BUN and serum creatinine. 2.
Incorrect. This is a normal output level. This level alone would not necessarily be
an indicator of acute renal failure and that value alone would not warrant
reporting it to the primary healthcare provider. 4. Incorrect. Calcium level of 9.0
mg/dL (2.25 mmol/L) is considered normal. When observing for renal functioning
you would assess the BUN and creatinine levels. In addition, the calcium level may
drop (hypocalcemia) in renal failure inverse relationship change due to the rising
serum phosphate levels. However, the calcium level presented is within normal
limits (WNL).
A client has been admitted for exacerbation of ulcerative colitis with severe
dehydration. What is the best indicator that this client has an actual fluid deficit?
HURST READINESS EXAM 2| UPDATE
COMPLETE FREQUENTLY TESTED
QUESTIONS WITH VERIFIED ANSWERS
|GET IT 100% ACCURATE!!
What medication should the nurse anticipate giving to a client in preterm labor
to stimulate maturation of the baby's lungs?
1. Magnesium sulfate 2. Terbutaline 3. Methotrexate 4. Betamethasone -
(ANSWER)Rationale
4. Correct: Betamethasone is used to stimulate maturation of the baby's lungs in
case preterm birth occurs. This medication is given to help prevent respiratory
distress syndrome (RDS) by improving storage and secretion of surfactant that
helps to keep the alveoli from collapsing. 1. Incorrect: Magnesium sulfate is given
to stop preterm labor, however, if delivery is imminent, then Betamethasone
should be given to stimulate maturation of the baby's lungs. 2. Incorrect:
Terbutaline is contraindicated in preterm labor, however, if delivery is imminent,
then Betamethasone should be given to stimulate maturation of the baby's lungs.
3. Incorrect: Methotrexate is used to stop the growth of the embryo in ectopic
pregnancy so that the fallopian tube can be saved. It is not an agent used in the
management of preterm labor.
An adult client has just returned to the nursing care unit following a gastroscopy.
Which intervention should the nurse include on the plan of care?
1. Vital sign checks every 15 min x 4 2. Supine position for 6 hours 3. NPO until
return of gag reflex 4. Irrigate NG tube every 2 hours 5. Raise four siderails -
(ANSWER)Rationale
,2
1., & 3. Correct: Vital signs post procedure are important to monitor for any post-
procedure complications such as bleeding or any signs of respiratory compromise.
VS are checked frequently for the first hour post procedure. Any client who has a
scope inserted down the throat and has received numbing medication in the back
of the throat to depress the gag reflex should be kept NPO until the gag reflex
returns. 2. Incorrect: Supine position for 6 hours is contraindicated. The HOB
should be elevated. In the event the client vomits, he/she is less likely to aspirate
with the HOB elevated. Supine position for 6 hours is used after a heart
catheterization. 4. Incorrect: A client who is going for a gastroscopy procedure
cannot have a nasal gastric tube. An NG tube would interfere with the procedure.
5. Incorrect: Raising all side rails is a form of restraint. Have the bed in low locked
position. Raise three side rails, and have call light within reach.
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?
1. Ask the UAP to put the client back in bed immediately. 2. Tell the UAP to take
the BP in the opposite arm in 15 minutes. 3. Have the LPN/LVN administer the
0900 furosemide and enalapril now. 4. Ask the LPN/LVN to assess the client for
pain. - (ANSWER)Rationale
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. 1. Incorrect: This is an
appropriate action, but does not address the problem of lowering the client's
blood pressure. 2. Incorrect: This is an appropriate action, but does not address
the problem of lowering the client's blood pressure. 4. Incorrect: This is an
,3
appropriate action, but does not address the problem of lowering the client's
blood pressure.
A client suffers from migraine headaches. What assessment finding would the
nurse expect to find during a migraine attack?
1. Unilateral, pulsating pain quality. 2. Bilateral, pressing/tightening pain quality.
3. Ipsilateral nasal congestion and rhinorrhea. 4. Headache occurs after
recovering from a headache treated with narcotics. - (ANSWER)Rationale
1. Correct: Migraine headaches have a pulsating pain quality, unilateral location,
moderate or severe pain intensity, aggravated by or causing avoidance of routine
physical activity (walking, climbing stairs). During headache at least one of the
following accompanies the headache: nausea and/or vomiting; photophobia and
phonophobia. 2. Incorrect: This is seen in tension headaches. Headaches last 30
minutes to 7 days. Pain is mild or moderate in intensity. It is not aggravated by
routine physical activity. Nausea/vomiting, photophobia and phonophobia are not
common manifestations with tension headaches. These usually start gradually,
often in the middle of the day. 3. Incorrect: This is associated with cluster
headaches, which are severe or very severe unilateral orbital, supraorbital and/or
temporal pain lasting 15-180 minutes. Symptoms include stabbing pain in one eye
with associated rhinorrhea (runny nose) and possible drooping eyelid on the
affected side. The headaches tend to occur in "clusters": typically one to three
headaches per day (but may be as many as eight) during a cluster period. 4.
Incorrect: Overuse of painkillers for headaches, can, ironically, lead to rebound
headaches. Culprits include over the counter medications such as aspirin,
acetaminophen or ibuprofen, as well as prescription medications. Too much
medication can cause the brain to shift into an excited state, triggering more
headaches. Also, rebound headaches are a symptom of withdrawal as the level of
medicine drops in the bloodstream. Rebound headaches may have associated
, 4
issues such as difficulty concentrating, irritability and restlessness but does not
typically include photophobia or visual disturbances as seen with migraines.
The nurse is caring for a client who was admitted to the hospital following a
severe motor vehicle crash (MVC) in which the client was trapped in the car for
several hours. The client is being closely monitored for the development of renal
failure. Which assessment finding would warrant immediate reporting?
1. Creatinine 1.1 mg/dl (97.24 mmol/L) 2. Urinary output of 150 mL per hour. 3.
Gradual increase of BUN levels. 4. Calcium levels of 9.0 mg/dL (2.25 mmol/L) -
(ANSWER)Rationale
3. Correct. Gradual accumulation of nitrogenous wastes results in elevated BUN
and serum creatinine. This is an indication of impaired renal function. 1. Incorrect.
This is a normal creatinine level. Gradual accumulation of nitrogenous wastes
from impaired renal function results in elevated BUN and serum creatinine. 2.
Incorrect. This is a normal output level. This level alone would not necessarily be
an indicator of acute renal failure and that value alone would not warrant
reporting it to the primary healthcare provider. 4. Incorrect. Calcium level of 9.0
mg/dL (2.25 mmol/L) is considered normal. When observing for renal functioning
you would assess the BUN and creatinine levels. In addition, the calcium level may
drop (hypocalcemia) in renal failure inverse relationship change due to the rising
serum phosphate levels. However, the calcium level presented is within normal
limits (WNL).
A client has been admitted for exacerbation of ulcerative colitis with severe
dehydration. What is the best indicator that this client has an actual fluid deficit?
