Hurst Readiness Exam 2 – 1 Questions With Complete
Solutions
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 Answers 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 case manager is assessing an unresponsive client diagnosed
with terminal hepatic encephalopathy for equipment needs upon
discharge home for hospice care. Which equipment should the
case manager obtain for this client?
,1. Alternating pressure mattress 2. Hospital bed 3. Walker 4.
Suction equipment 5. Oxygen Correct Answers Rationale
1., 2., 4., & 5. Correct: An alternating pressure mattress will help
to prevent pressure ulcers. The risk of respiratory compromise
increases as the neurologic status deteriorates. A hospital bed is
needed so that the head of the client's bed can be elevated to 30
degrees to ease respirations and decrease the work of breathing.
The client with hepatic encephalopathy is unresponsive due to
accumulation of toxins and may need suctioning if unable to
clear secretions from the oropharynx. Hepatic encephalopathy
frequently has associated bleeding varices. The increasing
ascites leads to hypovolemia. Both of these conditions can result
in hypoxemia for the client at the end stages of liver disease;
therefore, oxygen therapy is provided. 3. Incorrect: As hepatic
encephalopathy progresses and toxins accumulate, the client
lapses into a coma. Therefore, the unresponsive client will not
be ambulatory and would not need a walker.
A child is being admitted with possible rheumatic fever. What
assessment data would be most important for the nurse to obtain
from the parent?
1. 102° F (38.89° C) temperature that started 2 days previously.
2. History of pharyngitis approximately 4 weeks ago. 3.
Vomiting for 3 days. 4. A cough that started about 1 week
earlier. Correct Answers Rationale
2. Correct: Rheumatic fever is often the result of untreated or
improperly treated group A β-hemolytic streptococcal infections
(GABHS), such as pharyngitis. Therefore, the history of
pharyngitis or upper respiratory infection is a key assessment
finding for establishing a diagnosis of rheumatic fever.
,Subsequent development of rheumatic fever usually occurs 2 to
6 weeks following the GABHS, so the assessment should
include a remote history of pharyngitis. 1. Incorrect: The fever
with rheumatic fever is usually low grade and is considered a
minor manifestation of rheumatic fever. 3. Incorrect: Vomiting
is not a commonly associated symptom with rheumatic fever
and is not considered a major manifestation of rheumatic fever.
Although the child may have a history of vomiting, this finding
would not be specific to rheumatic fever. 4. Incorrect: A cough
is not an associated symptom of rheumatic fever. The time
frame for the development of rheumatic fever is not appropriate
if the cough started 1 week earlier, even if it had been associated
with an upper respiratory streptococcal infection.
A client arrives in the emergency department after severely
lacerating the left hand with a knife. HR 96, BP 150/88, R 36.
The client is extremely anxious and crying uncontrollably.
Based on this assessment, the nurse should anticipate that this
client is likely in which acid base imbalance?
1. Respiratory acidosis 2. Respiratory alkalosis 3. Metabolic
acidosis 4. Metabolic alkalosis Correct Answers Rationale
2. Correct: Hyperventilation due to anxiety, pain, shock, severe
infection, fever, liver failure can lead to respiratory alkalosis.
With each of these, the client loses too much CO2. The
reduction of CO2 creates an excessive loss of acid, resulting in
an alkalotic state. Since the problem is respiratory, it is
respiratory alkalosis. 1. Incorrect: This problem is respiratory,
but there is excessive CO2 loss. CO2 combines with water to
form an acid. If too much of the CO2 is lost, the result of the
acid forming substance loss would be alkalosis-Not acidosis. 3.
, Incorrect: The problem in this situation is respiratory in origin
and has acid loss. Therefore, it is not metabolic nor acidotic in
nature. 4. Incorrect: The problem in this situation is the
excessive loss of CO2 from the respiratory system secondary to
hyperventilation. Although the CO2 loss creates an alkalotic
state, it is respiratory, not metabolic in origin.
A client asked the nurse what could have caused them to
develop right sided heart failure? What would be the best
response by the nurse?
1. High blood pressure in the lungs. 2. Long term hypertension.
3. The inability of the mitral valve to close properly. 4.
Narrowing of the aorta. Correct Answers Rationale
1. Correct: Yes, the right side of the heart pumps to the lungs.
When the client has higher pressure in the pulmonary circuit
from such things as emphysema, the pulmonary pressure can
exceed the systemic pressure. The result is back flow to the right
side of the heart and resulting right sided heart failure. 2.
Incorrect: No, that's left-sided heart failure. Hypertension
increases afterload which can ultimately result in back flow to
the left side of the heart and resulting left sided heart failure. 3.
Incorrect: Not related to pulmonary hypertension. The mitral
valve is located between the left atrium and left ventricle. If
mild, there may be little or no obvious symptoms. However, if
severe, left sided heart failure may occur. 4. Incorrect: Not
related to pulmonary hypertension. Narrowing of the aorta
makes it harder to get blood out of the left ventricle (high
afterload). The resulting back flow of blood would result in left
sided heart failure.
Solutions
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 Answers 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 case manager is assessing an unresponsive client diagnosed
with terminal hepatic encephalopathy for equipment needs upon
discharge home for hospice care. Which equipment should the
case manager obtain for this client?
,1. Alternating pressure mattress 2. Hospital bed 3. Walker 4.
Suction equipment 5. Oxygen Correct Answers Rationale
1., 2., 4., & 5. Correct: An alternating pressure mattress will help
to prevent pressure ulcers. The risk of respiratory compromise
increases as the neurologic status deteriorates. A hospital bed is
needed so that the head of the client's bed can be elevated to 30
degrees to ease respirations and decrease the work of breathing.
The client with hepatic encephalopathy is unresponsive due to
accumulation of toxins and may need suctioning if unable to
clear secretions from the oropharynx. Hepatic encephalopathy
frequently has associated bleeding varices. The increasing
ascites leads to hypovolemia. Both of these conditions can result
in hypoxemia for the client at the end stages of liver disease;
therefore, oxygen therapy is provided. 3. Incorrect: As hepatic
encephalopathy progresses and toxins accumulate, the client
lapses into a coma. Therefore, the unresponsive client will not
be ambulatory and would not need a walker.
A child is being admitted with possible rheumatic fever. What
assessment data would be most important for the nurse to obtain
from the parent?
1. 102° F (38.89° C) temperature that started 2 days previously.
2. History of pharyngitis approximately 4 weeks ago. 3.
Vomiting for 3 days. 4. A cough that started about 1 week
earlier. Correct Answers Rationale
2. Correct: Rheumatic fever is often the result of untreated or
improperly treated group A β-hemolytic streptococcal infections
(GABHS), such as pharyngitis. Therefore, the history of
pharyngitis or upper respiratory infection is a key assessment
finding for establishing a diagnosis of rheumatic fever.
,Subsequent development of rheumatic fever usually occurs 2 to
6 weeks following the GABHS, so the assessment should
include a remote history of pharyngitis. 1. Incorrect: The fever
with rheumatic fever is usually low grade and is considered a
minor manifestation of rheumatic fever. 3. Incorrect: Vomiting
is not a commonly associated symptom with rheumatic fever
and is not considered a major manifestation of rheumatic fever.
Although the child may have a history of vomiting, this finding
would not be specific to rheumatic fever. 4. Incorrect: A cough
is not an associated symptom of rheumatic fever. The time
frame for the development of rheumatic fever is not appropriate
if the cough started 1 week earlier, even if it had been associated
with an upper respiratory streptococcal infection.
A client arrives in the emergency department after severely
lacerating the left hand with a knife. HR 96, BP 150/88, R 36.
The client is extremely anxious and crying uncontrollably.
Based on this assessment, the nurse should anticipate that this
client is likely in which acid base imbalance?
1. Respiratory acidosis 2. Respiratory alkalosis 3. Metabolic
acidosis 4. Metabolic alkalosis Correct Answers Rationale
2. Correct: Hyperventilation due to anxiety, pain, shock, severe
infection, fever, liver failure can lead to respiratory alkalosis.
With each of these, the client loses too much CO2. The
reduction of CO2 creates an excessive loss of acid, resulting in
an alkalotic state. Since the problem is respiratory, it is
respiratory alkalosis. 1. Incorrect: This problem is respiratory,
but there is excessive CO2 loss. CO2 combines with water to
form an acid. If too much of the CO2 is lost, the result of the
acid forming substance loss would be alkalosis-Not acidosis. 3.
, Incorrect: The problem in this situation is respiratory in origin
and has acid loss. Therefore, it is not metabolic nor acidotic in
nature. 4. Incorrect: The problem in this situation is the
excessive loss of CO2 from the respiratory system secondary to
hyperventilation. Although the CO2 loss creates an alkalotic
state, it is respiratory, not metabolic in origin.
A client asked the nurse what could have caused them to
develop right sided heart failure? What would be the best
response by the nurse?
1. High blood pressure in the lungs. 2. Long term hypertension.
3. The inability of the mitral valve to close properly. 4.
Narrowing of the aorta. Correct Answers Rationale
1. Correct: Yes, the right side of the heart pumps to the lungs.
When the client has higher pressure in the pulmonary circuit
from such things as emphysema, the pulmonary pressure can
exceed the systemic pressure. The result is back flow to the right
side of the heart and resulting right sided heart failure. 2.
Incorrect: No, that's left-sided heart failure. Hypertension
increases afterload which can ultimately result in back flow to
the left side of the heart and resulting left sided heart failure. 3.
Incorrect: Not related to pulmonary hypertension. The mitral
valve is located between the left atrium and left ventricle. If
mild, there may be little or no obvious symptoms. However, if
severe, left sided heart failure may occur. 4. Incorrect: Not
related to pulmonary hypertension. Narrowing of the aorta
makes it harder to get blood out of the left ventricle (high
afterload). The resulting back flow of blood would result in left
sided heart failure.
