HURST ACTUAL TEST PAPER QUESTIONS AND
ANSWERS SET A+
✔✔how does one use a walker? - ✔✔- walk into the walker
✔✔crutches should be ___________ below the __________ to decrease risk of
brachial nerve damage - ✔✔1-2 in
- axilla
✔✔when on crutches how should one rest body weight on hands or axilla? - ✔✔- hands
✔✔when walking up and down stairs with crutches, its up with the good leg and down
with the ___________ leg - ✔✔bad
✔✔when using a cane you should use which side of the body to walk? - ✔✔- strong
✔✔the nurse is caring for a client that has metabolic acidosis secondary to acute renal
failure. what is the inital client repsonse to this problem?
1. resp. rate increases to blow off acid
2. resp. rate decreases to conserve acid and buffer the kidneys response
3. kidneys will excrete hydrogen and retain bicarb
4. sodium will shift to cells and buffer the hydrogens - ✔✔1. resp. rate increases to blow
off acid
✔✔pH- 7.30
paO2-91
paCO2- 50
HCO3- 24
1. resp. alkalosis
2. resp. acidosis
3. metabolic alkalosis
4. metabolic acidosis - ✔✔2. resp acidosis
,✔✔a client is hospitalized hundreds of miles from home for a bone marrow transplant.
the client is in a protective environment while undergoing intense chemotherapy. the
clients sibilings come to visit and has obv manifestations of an URI. which nursing
action would be most app. at this time?
1. do not allow the sibiling to visit, and do not upset the client by mentioning the sibilings
visit
2. allow the sibiling to wave at the client through the window or door, then offer the use
of the unit phone so they can talk
3. allow the sibiling to visit after donning a sterile gown, mask, and gloves, but prohinit
physical contact - ✔✔2. allow the sibiling to wave at the client through thr window or
door, then offer to use the unit phone so they can talk
✔✔a client is admitted to the medical unit with a diagnosis of addisons disease? what
nursing interventions should the nurse implement for this client? select all that apply
1. monitor for decreased K levels
2. assist the client to select food low in NA
3. administer fludrocortisone as prescribed
4. monitor I & O
5. record daily weight - ✔✔3. administer fludrocortisone as prescribed
4. monitor i & O
5. record daily weights
✔✔which statements made by a client after receiving education regarding bleeding
precautions would indicate to the nurse that teaching was successful? select all that
apply
1. i cannot shave while i am at risk for bleeding
2. it is important to gargle with a commercial mouthwash three times a day
3. stool softeners will help prevent rectal bleeding
4. prior to sexual intercourse, i will use water based lubricant
5. i will use a soft toothbrush - ✔✔3. stool softeners will help prevent rectal bleeding
4. prior to sexual intercourse, i will use water base lube
4. i will use a soft toothbrush
✔✔a client is reporting shortness of breath and neck pressure following a
thyroidectomy. what is the priority nursing intervention?
1. elevate the head of bed, and remove the dressing, and stay with the client
2. call a code, open the trach set, and position the client supine
3. have the client say " EEE" to check for laryngeal integrity and assess Chvosteks sign
4. call the primary healthcare provider and assess vital signs - ✔✔1. elevate the head of
the bed, remove the dressing, and stay with the client
✔✔the nurse observes a client in the manic phase of bipolar disorder in group therapy.
the client has interrupted the counselors group session multiple times and states " i
already know this information dealing with others when you are down. " which nursing
action is app.?
,1. ask the client to walk with the nurse to get a snack
2. ask the group to reflect on the clients behavior to determine if it is app.
3. ask the group to tell the client how they feel about the disruptions
4. instruct the client to perform jumping jacks to get rid of some energy - ✔✔1. ask the
client to walk with the nurse to get a snack
✔✔which client should the nurse identify as being HIGHEST risk for suicide ?
1. seventy six year old widower with chronic renal failure
2. nineteen year old taking antidepressants
3. twenty eight year old, post partum, crying weekly
4. fifty year old with OCD - ✔✔1. seventy six year old widower with chronic renal failure
✔✔the client is transferred to the rehabilitation facility following an iscemic stroke
affecting the right side and aphasia. which nursing action would promote communication
with the client?
1. encourage client to shake head in response to questions
2. speak in a loud voice during interactions
3. speak using phrases and short sentences
4. encourage the use of a radio to stimulate the client - ✔✔- 3. speak using phrases an
short sentences
✔✔the nurse is caring for a client with pneumonia. which nursing observation would
indicate a therapeutic response to the treatment for the infection?
1. oral temp. of 101 ( 38.3) ; increased chest pain with non-productive cough
2. productive cough with thick green sputum; states feels tired
3. resp. 20, with no reports of dyspnea; moderate amt of thick , white sputum
4. white cell count of 10,000 mm3, urine output at 40 mL/hr. and no sputum - ✔✔3. resp
20, with no reports of dyspnea; moderate amt of thick, white sputum
✔✔a client had surgery for cancer of the colon and a colostomy was performed. prior to
discharge, the client asks, will i still be able to swim? the nurses response would be
based on which understanding?
1. swimming is not recommended. the client should begin looking for others areas of
interest
2. swimming is not restricted if the client wears a dressing over the stoma at all times
3. the client cannot go into the water that is over the stoma area, but can go into water
up to the stoma area
4. there are no restrictions on the activity of the client with a colostomy; all previous
activities may be resumed - ✔✔4. there are no restrictions on the activity of a client with
a colostomy; all previous activities may be resumed
✔✔the nurse is evaluating whether a client understands the procedure for collecting a
24 hours urine sample. the nurse recognizes that teaching was successful when the
client makes which statements? select all that apply
1. i should start the 24 hour urine collection at the time of my first saved urine specimen
, 2. if i forget to collect any urine, i will need to start over
3. it is important to ensure that no feces or toilet tissue mixes with the urine
4. when the 24 hours is up, i need to void and collect that specimen
5. the urine specimen should be stored in the refrigerator during collection - ✔✔2. if i
forget to collect any urine, i will need to start over
3. it is important to ensure that no feces or toilet tissue mixes with the urine
4. when the 24 hours is up, i meed to void and collect that specimen
✔✔an elderly client is prescribed to begin ambulation with a walker following hip
replacement surgery. which intervention by the nurse will best help this client?
1. sit in a low chair for ease in getting up with a walker
2. make sure rubber caps are present on all 4 legs of the walker
3. begin weight-bearing on the affected hip immediately
4. practice tying your shoes before using the walker - ✔✔- 2. make sure rubber caps are
present on all 4 legs of the walker
✔✔a client is diagnosed with a concussion has an abrupt increase in urinary output.
which nursing action takes priority ?
1. monitoring urine output
2. checking pulse
3. checking blood pressure
4. monitoring level of consciousness - ✔✔3. checking blood pressure
✔✔which client outcomes should the nurse expect to see in a client who has received
successful treatment for fluid volume deficient ?
1. resolution of orthostatic hypotension
2. maintenance of weight loss
3. compliance with sodium restricted diet
4. maintenance of serum Na about 148 mEq - ✔✔1. resolution of orthostatic
hypoytension
✔✔which medications should the nurse identify as contributing to CO2 retention in a
client? select all that apply
1. hydromorphone
2. furosemide
3. prednisolone
4. promethazine
5. temazepam - ✔✔1. hydromorphone
4. promethazine
5. temazepam
✔✔the unlicensed assistive personnel reports to the nurse that a client with dementia
has been walking into other clients rooms insisting " this room is mine" what is the
BEST suggestion the nurse can give to the UAP?
1. calmly sit with the client and engage in a memory activity
ANSWERS SET A+
✔✔how does one use a walker? - ✔✔- walk into the walker
✔✔crutches should be ___________ below the __________ to decrease risk of
brachial nerve damage - ✔✔1-2 in
- axilla
✔✔when on crutches how should one rest body weight on hands or axilla? - ✔✔- hands
✔✔when walking up and down stairs with crutches, its up with the good leg and down
with the ___________ leg - ✔✔bad
✔✔when using a cane you should use which side of the body to walk? - ✔✔- strong
✔✔the nurse is caring for a client that has metabolic acidosis secondary to acute renal
failure. what is the inital client repsonse to this problem?
1. resp. rate increases to blow off acid
2. resp. rate decreases to conserve acid and buffer the kidneys response
3. kidneys will excrete hydrogen and retain bicarb
4. sodium will shift to cells and buffer the hydrogens - ✔✔1. resp. rate increases to blow
off acid
✔✔pH- 7.30
paO2-91
paCO2- 50
HCO3- 24
1. resp. alkalosis
2. resp. acidosis
3. metabolic alkalosis
4. metabolic acidosis - ✔✔2. resp acidosis
,✔✔a client is hospitalized hundreds of miles from home for a bone marrow transplant.
the client is in a protective environment while undergoing intense chemotherapy. the
clients sibilings come to visit and has obv manifestations of an URI. which nursing
action would be most app. at this time?
1. do not allow the sibiling to visit, and do not upset the client by mentioning the sibilings
visit
2. allow the sibiling to wave at the client through the window or door, then offer the use
of the unit phone so they can talk
3. allow the sibiling to visit after donning a sterile gown, mask, and gloves, but prohinit
physical contact - ✔✔2. allow the sibiling to wave at the client through thr window or
door, then offer to use the unit phone so they can talk
✔✔a client is admitted to the medical unit with a diagnosis of addisons disease? what
nursing interventions should the nurse implement for this client? select all that apply
1. monitor for decreased K levels
2. assist the client to select food low in NA
3. administer fludrocortisone as prescribed
4. monitor I & O
5. record daily weight - ✔✔3. administer fludrocortisone as prescribed
4. monitor i & O
5. record daily weights
✔✔which statements made by a client after receiving education regarding bleeding
precautions would indicate to the nurse that teaching was successful? select all that
apply
1. i cannot shave while i am at risk for bleeding
2. it is important to gargle with a commercial mouthwash three times a day
3. stool softeners will help prevent rectal bleeding
4. prior to sexual intercourse, i will use water based lubricant
5. i will use a soft toothbrush - ✔✔3. stool softeners will help prevent rectal bleeding
4. prior to sexual intercourse, i will use water base lube
4. i will use a soft toothbrush
✔✔a client is reporting shortness of breath and neck pressure following a
thyroidectomy. what is the priority nursing intervention?
1. elevate the head of bed, and remove the dressing, and stay with the client
2. call a code, open the trach set, and position the client supine
3. have the client say " EEE" to check for laryngeal integrity and assess Chvosteks sign
4. call the primary healthcare provider and assess vital signs - ✔✔1. elevate the head of
the bed, remove the dressing, and stay with the client
✔✔the nurse observes a client in the manic phase of bipolar disorder in group therapy.
the client has interrupted the counselors group session multiple times and states " i
already know this information dealing with others when you are down. " which nursing
action is app.?
,1. ask the client to walk with the nurse to get a snack
2. ask the group to reflect on the clients behavior to determine if it is app.
3. ask the group to tell the client how they feel about the disruptions
4. instruct the client to perform jumping jacks to get rid of some energy - ✔✔1. ask the
client to walk with the nurse to get a snack
✔✔which client should the nurse identify as being HIGHEST risk for suicide ?
1. seventy six year old widower with chronic renal failure
2. nineteen year old taking antidepressants
3. twenty eight year old, post partum, crying weekly
4. fifty year old with OCD - ✔✔1. seventy six year old widower with chronic renal failure
✔✔the client is transferred to the rehabilitation facility following an iscemic stroke
affecting the right side and aphasia. which nursing action would promote communication
with the client?
1. encourage client to shake head in response to questions
2. speak in a loud voice during interactions
3. speak using phrases and short sentences
4. encourage the use of a radio to stimulate the client - ✔✔- 3. speak using phrases an
short sentences
✔✔the nurse is caring for a client with pneumonia. which nursing observation would
indicate a therapeutic response to the treatment for the infection?
1. oral temp. of 101 ( 38.3) ; increased chest pain with non-productive cough
2. productive cough with thick green sputum; states feels tired
3. resp. 20, with no reports of dyspnea; moderate amt of thick , white sputum
4. white cell count of 10,000 mm3, urine output at 40 mL/hr. and no sputum - ✔✔3. resp
20, with no reports of dyspnea; moderate amt of thick, white sputum
✔✔a client had surgery for cancer of the colon and a colostomy was performed. prior to
discharge, the client asks, will i still be able to swim? the nurses response would be
based on which understanding?
1. swimming is not recommended. the client should begin looking for others areas of
interest
2. swimming is not restricted if the client wears a dressing over the stoma at all times
3. the client cannot go into the water that is over the stoma area, but can go into water
up to the stoma area
4. there are no restrictions on the activity of the client with a colostomy; all previous
activities may be resumed - ✔✔4. there are no restrictions on the activity of a client with
a colostomy; all previous activities may be resumed
✔✔the nurse is evaluating whether a client understands the procedure for collecting a
24 hours urine sample. the nurse recognizes that teaching was successful when the
client makes which statements? select all that apply
1. i should start the 24 hour urine collection at the time of my first saved urine specimen
, 2. if i forget to collect any urine, i will need to start over
3. it is important to ensure that no feces or toilet tissue mixes with the urine
4. when the 24 hours is up, i need to void and collect that specimen
5. the urine specimen should be stored in the refrigerator during collection - ✔✔2. if i
forget to collect any urine, i will need to start over
3. it is important to ensure that no feces or toilet tissue mixes with the urine
4. when the 24 hours is up, i meed to void and collect that specimen
✔✔an elderly client is prescribed to begin ambulation with a walker following hip
replacement surgery. which intervention by the nurse will best help this client?
1. sit in a low chair for ease in getting up with a walker
2. make sure rubber caps are present on all 4 legs of the walker
3. begin weight-bearing on the affected hip immediately
4. practice tying your shoes before using the walker - ✔✔- 2. make sure rubber caps are
present on all 4 legs of the walker
✔✔a client is diagnosed with a concussion has an abrupt increase in urinary output.
which nursing action takes priority ?
1. monitoring urine output
2. checking pulse
3. checking blood pressure
4. monitoring level of consciousness - ✔✔3. checking blood pressure
✔✔which client outcomes should the nurse expect to see in a client who has received
successful treatment for fluid volume deficient ?
1. resolution of orthostatic hypotension
2. maintenance of weight loss
3. compliance with sodium restricted diet
4. maintenance of serum Na about 148 mEq - ✔✔1. resolution of orthostatic
hypoytension
✔✔which medications should the nurse identify as contributing to CO2 retention in a
client? select all that apply
1. hydromorphone
2. furosemide
3. prednisolone
4. promethazine
5. temazepam - ✔✔1. hydromorphone
4. promethazine
5. temazepam
✔✔the unlicensed assistive personnel reports to the nurse that a client with dementia
has been walking into other clients rooms insisting " this room is mine" what is the
BEST suggestion the nurse can give to the UAP?
1. calmly sit with the client and engage in a memory activity
