Hurst Readiness Exam 2 Questions With
Correct Answers
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 |- |CORRECT |
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 |- |CORRECT |ANSWER✔✔-
Rationale
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. |- |CORRECT |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 |
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. |- |CORRECT |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 |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) |- |CORRECT |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? |
1. |Stool |count |of |10 |episodes |of |diarrhea |in |24 |hours. |2. |Weight |increase |of |2 |kg |and |a |24 |
hour |output |of |1000 |mL. |3. |Admission |weight |of |74.3 |kg |and |2 |days |later |a |weight |of |72 |kg. |4.
|Daily |intake |of |2400 |mL |and |an |output |of |1600 |mL, |plus |diarrheal |stools. |- |CORRECT |
ANSWER✔✔-Rationale
3. |Correct: |Any |acute |weight |gain |or |loss |is |fluid. |Weight |is |the |best |measurement |for |fluid |
loss |or |gain. |Acute |weight |losses |correspond |to |fluid |volume |deficits. |This |client |has |lost |2.3 |kg
|over |a |2 |day |period, |indicating |a |fluid |volume |deficit |(FVD). |1. |Incorrect: |Although |10 |loose |
stools |would |result |in |fluid |loss, |the |stool |count |of |10 |episodes |of |diarrhea |is |an |inaccurate |
measurement. |The |amount |of |fluid |loss |can |vary |depending |on |the |amount |of |diarrhea, |10
|"episodes" |does |not |indicate |how |much |fluid |is |lost. |2. |Incorrect: |Weight |gains |indicate |fluid |
volume |retention |and |excess. |This |question |asks |about |fluid |volume |deficit. |Also, |it |does |not |
take |into |account |the |client's |intake. |Only |the |output |is |considered, |so |output |has |less |
meaning |without |being |compared |to |the |intake. |4. |Incorrect: |Daily |I&O |is |good |information |to |
have |when |assessing |fluid |status, |but |the |diarrhea |stools |are |an |inaccurate |measurement. |The
|weight |remains |the |best |measurement |for |indicating |a |fluid |deficit.
The |nurse |is |working |with |a |LPN/VN |and |an |unlicensed |assistive |personnel |(UAP). |Which |
clients |would |be |appropriate |for |the |nurse |to |assign |to |the |LPN/VN? |
1. |In |Bucks |traction |requiring |frequent |pain |medication. |2. |24 |hours |post |appendectomy. |3. |
Diagnosed |with |cholelithiasis |and |scheduled |for |surgery |in |the |AM. |4. |Admitted |6 |hours |ago |in
|adrenal |insufficiency. |5. |Client |newly |diagnosed |with |Type |2 |diabetes. |- |CORRECT |
ANSWER✔✔-Rationale
1., |2., |& |3. |Correct |These |clients |are |stable |and |require |predictable |care |that |can |be |done |
appropriately |by |the |LPN/VN. |4. |Incorrect: |This |client |has |adrenal |insufficiency. |Primary |
adrenal |insufficiency |occurs |when |at |least |90 |percent |of |the |adrenal |cortex |has |been |
destroyed |generally |from |autoimmune |disorders. |Secondary |adrenal |insufficiency |can |be |
caused |by |such |things |as |abrupt |stoppage |of |corticosteroid |medications |and |surgical |removal |
of |pituitary |tumors. |As |a |result, |often |both |glucocorticoid |(cortisol) |and |mineralocorticoid |
(aldosterone) |hormones |may |be |lacking. |This |puts |the |client |at |risk |for |fluid |volume |deficit |
(FVD) |and |shock. |This |requires |the |higher |level |assessment |skills |of |the |RN. |5. |Incorrect: |A |
Correct Answers
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 |- |CORRECT |
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 |- |CORRECT |ANSWER✔✔-
Rationale
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. |- |CORRECT |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 |
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. |- |CORRECT |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 |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) |- |CORRECT |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? |
1. |Stool |count |of |10 |episodes |of |diarrhea |in |24 |hours. |2. |Weight |increase |of |2 |kg |and |a |24 |
hour |output |of |1000 |mL. |3. |Admission |weight |of |74.3 |kg |and |2 |days |later |a |weight |of |72 |kg. |4.
|Daily |intake |of |2400 |mL |and |an |output |of |1600 |mL, |plus |diarrheal |stools. |- |CORRECT |
ANSWER✔✔-Rationale
3. |Correct: |Any |acute |weight |gain |or |loss |is |fluid. |Weight |is |the |best |measurement |for |fluid |
loss |or |gain. |Acute |weight |losses |correspond |to |fluid |volume |deficits. |This |client |has |lost |2.3 |kg
|over |a |2 |day |period, |indicating |a |fluid |volume |deficit |(FVD). |1. |Incorrect: |Although |10 |loose |
stools |would |result |in |fluid |loss, |the |stool |count |of |10 |episodes |of |diarrhea |is |an |inaccurate |
measurement. |The |amount |of |fluid |loss |can |vary |depending |on |the |amount |of |diarrhea, |10
|"episodes" |does |not |indicate |how |much |fluid |is |lost. |2. |Incorrect: |Weight |gains |indicate |fluid |
volume |retention |and |excess. |This |question |asks |about |fluid |volume |deficit. |Also, |it |does |not |
take |into |account |the |client's |intake. |Only |the |output |is |considered, |so |output |has |less |
meaning |without |being |compared |to |the |intake. |4. |Incorrect: |Daily |I&O |is |good |information |to |
have |when |assessing |fluid |status, |but |the |diarrhea |stools |are |an |inaccurate |measurement. |The
|weight |remains |the |best |measurement |for |indicating |a |fluid |deficit.
The |nurse |is |working |with |a |LPN/VN |and |an |unlicensed |assistive |personnel |(UAP). |Which |
clients |would |be |appropriate |for |the |nurse |to |assign |to |the |LPN/VN? |
1. |In |Bucks |traction |requiring |frequent |pain |medication. |2. |24 |hours |post |appendectomy. |3. |
Diagnosed |with |cholelithiasis |and |scheduled |for |surgery |in |the |AM. |4. |Admitted |6 |hours |ago |in
|adrenal |insufficiency. |5. |Client |newly |diagnosed |with |Type |2 |diabetes. |- |CORRECT |
ANSWER✔✔-Rationale
1., |2., |& |3. |Correct |These |clients |are |stable |and |require |predictable |care |that |can |be |done |
appropriately |by |the |LPN/VN. |4. |Incorrect: |This |client |has |adrenal |insufficiency. |Primary |
adrenal |insufficiency |occurs |when |at |least |90 |percent |of |the |adrenal |cortex |has |been |
destroyed |generally |from |autoimmune |disorders. |Secondary |adrenal |insufficiency |can |be |
caused |by |such |things |as |abrupt |stoppage |of |corticosteroid |medications |and |surgical |removal |
of |pituitary |tumors. |As |a |result, |often |both |glucocorticoid |(cortisol) |and |mineralocorticoid |
(aldosterone) |hormones |may |be |lacking. |This |puts |the |client |at |risk |for |fluid |volume |deficit |
(FVD) |and |shock. |This |requires |the |higher |level |assessment |skills |of |the |RN. |5. |Incorrect: |A |
