Hurst Readiness exam 2(missed questions) || with Error-free
Answers.
1., 2., 4. & 5. Correct: The client must be turned every two hours. You may not be able to
turn the client totally on the side of the fracture, but you must relieve pressure points. Place
pillow between legs to keep affected leg in abducted position. Encourage fluid intake and
ankle and foot exercises to prevent deep vein thrombosis (DVT).
3. Incorrect: The client has a fractured hip that has not been surgically fixed. Sitting up in a
chair could do more injury and cause more pain. correct answers The nurse is planning care
for a client who has a fractured hip. Which nursing interventions should the nurse plan to use
for impaired physical mobility?
1. Turn every two hours
2. Place a pillow between legs when turning
3. Sit in a chair three times per day
4. Encourage fluid intake
5. Encourage ankle and foot exercises
3. Correct: Anxiety, restlessness, or a sense of apprehension is often the first sign/symptoms
of acute pulmonary edema.1. Incorrect: Blood pressure is normal. The number one concern
right now is the anxiety: an early sign of pulmonary edema.
2. Incorrect: Although we would want to help the client having nausea, the anxiety is of
upmost importance, as it might indicate acute pulmonary edema.
4. Incorrect: The client is dehydrated. A urinary output of 50 mL/hr, although low, is not at a
critical level. Signs of pulmonary edema will take priority. correct answers A nurse is caring
for a 65 year-old client diagnosed with dehydration. The client has been receiving
intravenous normal saline at 150 mL/hour for the past 4 hours. Which finding would the
nurse need to notify the primary healthcare provider?
1. Blood pressure 136/842.
Report of nausea
3. Anxiety
4. Urinary output at 50 mL/hour
4. Correct: Insulin syringes and needles should be stored at room temperature. The potential
benefits or risks of refrigerating the syringe are unknown.1. Incorrect: Insulin injection sites
are rotated, but within a chosen site e.g., the abdomen. Once all the sites in that area are used,
then another area of the body is selected e.g., the arm.
2. Incorrect: As a rule, remember clear before cloudy; that is, draw up the regular (clear)
insulin first, and then draw up the long acting insulin, isophane suspension (cloudy).
3. Incorrect: Gently blot any blood with a gauze pad. Do not massage the site. Massaging or
rubbing the site will alter the rate of absorption of the medication. correct answers What
instruction is most important to include when teaching a child how to self administer a
combined dose of isophane suspension and regular insulin subcutaneously?
1. Alternate the injection sites from one body area to another with each dose.
2. Draw up the isophane suspension insulin first and then regular insulin into the same insulin
syringe.
3. Massage the injection site after the medication is injected.
4. Insulin syringes should be stored at room temperature.
, 2. & 4. Correct: Not removing the hair at all is preferred, but if this is not an option the use of
clippers or a depilatory cream may be used to prevent trauma to the skin before surgery.1.
Incorrect: Using a razor for hair removal is not recommended because it causes micro-
abrasions of the skin. Bacteria multiply in the micro-abrasions, increasing the risk of
infection. This is not appropriate for a client going to surgery. correct answers The nurse is
preparing a client for surgery. Which methods are appropriate for the nurse to use in
removing excessive body hair?
1. Shaving the hair with a razor.
2. Removing the hair with clippers.
3. Lathering the skin with soap and water prior to shaving with a razor.
4. Using a depilatory cream.
5. Always use a new, sharp razor.
3., & 4. Correct: The frontal lobe is responsible for motor control, ability to speak words,
concentration, memory, and judgment. correct answers What impaired functions does the
nurse expect to observe in the client admitted with an injury to the frontal lobe of the brain?1.
Decreased sensation to touch.2. Impaired vision.3. Impaired speech.4. Decreased
concentration.5. Decreased hearing.
1, & 2. Correct: AV shunts should have the presence of a bruit and a thrill which indicates
patency. correct answers The nurse is caring for a client with chronic renal failure who
receives dialysis treatment. Which findings would indicate to the nurse that the client's AV
shunt is patent? SATA.
1. A bruit is heard with a stethoscope.
2. A thrill is felt on palpation.
3. There is a blood return on the venous side of the shunt.
4. Urine output greater than 30 mL/hr.
5. There is a strong radial pulse in the arm with the AV shunt.
2., 3. & 4. Correct: Diagnostic criteria for bulimia nervosa are recurrent episodes of binge
eating: recurrent inappropriate compensatory behavior to prevent weight gain such as
laxative, diuretic, or enema use, induced vomiting, fasting, and excessive exercise; and
feeling of self-worth unduly influenced by weight. Amenorrhea is found in anorexia nervosa.
correct answers What symptoms does the nurse expect to see in a client with bulimia
nervosa?
1. Amenorrhea
2. Feelings of self-worth unduly influenced by weight
3. Recurrent episodes of binge eating
4. Recurrent inappropriate compensatory behavior to prevent weight gain
5. Lack of exercise
2. ferrous sulfate correct answers A client comes into the clinic for a routine check-up during
the second trimester of pregnancy. The client reports gastrointestinal (GI) upset and
constipation. The nurse reviews the client's medications. Which client medication is most
commonly associated with GI upset and constipation?
1. Calcium supplement
2. Ferrous sulfate
3. Folic acid
4. Cetirizine
Answers.
1., 2., 4. & 5. Correct: The client must be turned every two hours. You may not be able to
turn the client totally on the side of the fracture, but you must relieve pressure points. Place
pillow between legs to keep affected leg in abducted position. Encourage fluid intake and
ankle and foot exercises to prevent deep vein thrombosis (DVT).
3. Incorrect: The client has a fractured hip that has not been surgically fixed. Sitting up in a
chair could do more injury and cause more pain. correct answers The nurse is planning care
for a client who has a fractured hip. Which nursing interventions should the nurse plan to use
for impaired physical mobility?
1. Turn every two hours
2. Place a pillow between legs when turning
3. Sit in a chair three times per day
4. Encourage fluid intake
5. Encourage ankle and foot exercises
3. Correct: Anxiety, restlessness, or a sense of apprehension is often the first sign/symptoms
of acute pulmonary edema.1. Incorrect: Blood pressure is normal. The number one concern
right now is the anxiety: an early sign of pulmonary edema.
2. Incorrect: Although we would want to help the client having nausea, the anxiety is of
upmost importance, as it might indicate acute pulmonary edema.
4. Incorrect: The client is dehydrated. A urinary output of 50 mL/hr, although low, is not at a
critical level. Signs of pulmonary edema will take priority. correct answers A nurse is caring
for a 65 year-old client diagnosed with dehydration. The client has been receiving
intravenous normal saline at 150 mL/hour for the past 4 hours. Which finding would the
nurse need to notify the primary healthcare provider?
1. Blood pressure 136/842.
Report of nausea
3. Anxiety
4. Urinary output at 50 mL/hour
4. Correct: Insulin syringes and needles should be stored at room temperature. The potential
benefits or risks of refrigerating the syringe are unknown.1. Incorrect: Insulin injection sites
are rotated, but within a chosen site e.g., the abdomen. Once all the sites in that area are used,
then another area of the body is selected e.g., the arm.
2. Incorrect: As a rule, remember clear before cloudy; that is, draw up the regular (clear)
insulin first, and then draw up the long acting insulin, isophane suspension (cloudy).
3. Incorrect: Gently blot any blood with a gauze pad. Do not massage the site. Massaging or
rubbing the site will alter the rate of absorption of the medication. correct answers What
instruction is most important to include when teaching a child how to self administer a
combined dose of isophane suspension and regular insulin subcutaneously?
1. Alternate the injection sites from one body area to another with each dose.
2. Draw up the isophane suspension insulin first and then regular insulin into the same insulin
syringe.
3. Massage the injection site after the medication is injected.
4. Insulin syringes should be stored at room temperature.
, 2. & 4. Correct: Not removing the hair at all is preferred, but if this is not an option the use of
clippers or a depilatory cream may be used to prevent trauma to the skin before surgery.1.
Incorrect: Using a razor for hair removal is not recommended because it causes micro-
abrasions of the skin. Bacteria multiply in the micro-abrasions, increasing the risk of
infection. This is not appropriate for a client going to surgery. correct answers The nurse is
preparing a client for surgery. Which methods are appropriate for the nurse to use in
removing excessive body hair?
1. Shaving the hair with a razor.
2. Removing the hair with clippers.
3. Lathering the skin with soap and water prior to shaving with a razor.
4. Using a depilatory cream.
5. Always use a new, sharp razor.
3., & 4. Correct: The frontal lobe is responsible for motor control, ability to speak words,
concentration, memory, and judgment. correct answers What impaired functions does the
nurse expect to observe in the client admitted with an injury to the frontal lobe of the brain?1.
Decreased sensation to touch.2. Impaired vision.3. Impaired speech.4. Decreased
concentration.5. Decreased hearing.
1, & 2. Correct: AV shunts should have the presence of a bruit and a thrill which indicates
patency. correct answers The nurse is caring for a client with chronic renal failure who
receives dialysis treatment. Which findings would indicate to the nurse that the client's AV
shunt is patent? SATA.
1. A bruit is heard with a stethoscope.
2. A thrill is felt on palpation.
3. There is a blood return on the venous side of the shunt.
4. Urine output greater than 30 mL/hr.
5. There is a strong radial pulse in the arm with the AV shunt.
2., 3. & 4. Correct: Diagnostic criteria for bulimia nervosa are recurrent episodes of binge
eating: recurrent inappropriate compensatory behavior to prevent weight gain such as
laxative, diuretic, or enema use, induced vomiting, fasting, and excessive exercise; and
feeling of self-worth unduly influenced by weight. Amenorrhea is found in anorexia nervosa.
correct answers What symptoms does the nurse expect to see in a client with bulimia
nervosa?
1. Amenorrhea
2. Feelings of self-worth unduly influenced by weight
3. Recurrent episodes of binge eating
4. Recurrent inappropriate compensatory behavior to prevent weight gain
5. Lack of exercise
2. ferrous sulfate correct answers A client comes into the clinic for a routine check-up during
the second trimester of pregnancy. The client reports gastrointestinal (GI) upset and
constipation. The nurse reviews the client's medications. Which client medication is most
commonly associated with GI upset and constipation?
1. Calcium supplement
2. Ferrous sulfate
3. Folic acid
4. Cetirizine
