Hurst Readiness Exam 4 Exam Test with Latest Updated
(Questions and Answers)
Terms in this set (125) EXAM Q&A
Which client must the nurse assign to a private room? Rationale
1. Primiparous client who delivered twins at 28 weeks
gestation two days ago
2. Postpartum client on IV Ampicillin and Gentamicin
for chorioamnionitis
3. Postpartum client whose 2 hour old infant is being
worked up for sepsis
4. Postpartum client 32 hours after delivery with a
temperature of 101º F (38.05 ° C)
4. Correct: A temperature of 100.5° F (38.05° C)
or greater in a client more than 24
hours postpartum is likely an
indication of infection. This client
should be kept separate from other
mothers and babies.
,1. InCorrect: The preterm twins are in the NICU and 2. InCorrect: Chorioamnionitis is not
not in their mother's room (a client with term twins contagious. 3. InCorrect: The infant
would need a private room because of space may have an infection and will remain
considerations). in the NICU. The mother is not
infected.
Post thyroidectomy, the nurse assesses the client for Rationale
complications by performing which assessment?
1. Perform blood glucose monitoring every 6 hours
2. Check for a positive Chvostek's
3. Assess swallowing reflex
4. Monitor neck dressings for change in fit and
comfort
5. Administer desmopressin per nasal spray for urinary
output (UOP) greater than 200 mL/hr
2., 3., & 4. Correct: A positive Chvostek's and
Trousseau's is indicative of tetany
(low calcium). This can occur when
one or more of the parathyroids are
accidently removed when the thyroid
is removed. A weak, raspy voice,
swallowing difficulty, and impaired
respiratory status can be caused by
, nerve injury. Change in fit and
comfort of the dressing can indicate
possible neck swelling, which can
affect the airway.
1. InCorrect: A possible complication of a 5. InCorrect: The action of
thyroidectomy is to remove one or more parathyroid desmopressin is to increase the
glands. The parathyroids' action is to regulate the reabsorption of water in the kidney. A
serum calcium levels. The parathyroid does not decrease in vasopressin, (antidiuretic
regulate the blood glucose levels. hormone) is not a complication of a
thyroidectomy.
A client diagnosed with pancreatitis becomes Rationale:
increasingly restless, confused and has pulled out the
NG tube and IV catheter. HR-128/min, BP 96/62.
Oxygen saturation = 90%. Skin is cool and clammy to
touch. Prioritize the actions that the nurse should take.
The Correct Order:
Initiate oxygen.
Insert another IV line.
Obtain blood sugar level.
Insert NG tube.
Repeat vital sign checks
First, initiate oxygen. The client is anxious and has Third, check the client's blood sugar.
tachycardia, signs of hypoxia. The BP is also low, so Since the pancreas is sick, insulin
, the client might be bleeding internally. If there is a production can be decreased so glucose
decreased circulating blood volume then there is less can go up. This is next in the priority
hemoglobin to carry oxygen, so increasing the line of the available options. You have
available oxygen will help the client until the problem addressed air and circulation, so blood
is corrected. Second, get the IV started so fluid glucose would be next.
resuscitation can continue.This increased volume will
improve the blood pressure. More volume, more
pressure. The IV will also provide a port for needed
medications.
Fourth, insert the NG tube so that the client can be What is the best instruction the nurse
kept empty and dry and you can prevent aspiration if should provide when administering
the client starts vomiting. Last, recheck vital signs to acetylsalicylic acid 81 mg to a client
assess effectiveness of your nursing actions. experiencing severe, crushing chest
pain radiating up the left jaw?
1. Chew the acetylsalicylic acid prior to
swallowing.
2. Place the acetylsalicylic acid under
the tongue so that it can dissolve.
3. Swallow the acetylsalicylic acid
tablet.
4. Insert the acetylsalicylic acid
between the cheek and gum for greater
(Questions and Answers)
Terms in this set (125) EXAM Q&A
Which client must the nurse assign to a private room? Rationale
1. Primiparous client who delivered twins at 28 weeks
gestation two days ago
2. Postpartum client on IV Ampicillin and Gentamicin
for chorioamnionitis
3. Postpartum client whose 2 hour old infant is being
worked up for sepsis
4. Postpartum client 32 hours after delivery with a
temperature of 101º F (38.05 ° C)
4. Correct: A temperature of 100.5° F (38.05° C)
or greater in a client more than 24
hours postpartum is likely an
indication of infection. This client
should be kept separate from other
mothers and babies.
,1. InCorrect: The preterm twins are in the NICU and 2. InCorrect: Chorioamnionitis is not
not in their mother's room (a client with term twins contagious. 3. InCorrect: The infant
would need a private room because of space may have an infection and will remain
considerations). in the NICU. The mother is not
infected.
Post thyroidectomy, the nurse assesses the client for Rationale
complications by performing which assessment?
1. Perform blood glucose monitoring every 6 hours
2. Check for a positive Chvostek's
3. Assess swallowing reflex
4. Monitor neck dressings for change in fit and
comfort
5. Administer desmopressin per nasal spray for urinary
output (UOP) greater than 200 mL/hr
2., 3., & 4. Correct: A positive Chvostek's and
Trousseau's is indicative of tetany
(low calcium). This can occur when
one or more of the parathyroids are
accidently removed when the thyroid
is removed. A weak, raspy voice,
swallowing difficulty, and impaired
respiratory status can be caused by
, nerve injury. Change in fit and
comfort of the dressing can indicate
possible neck swelling, which can
affect the airway.
1. InCorrect: A possible complication of a 5. InCorrect: The action of
thyroidectomy is to remove one or more parathyroid desmopressin is to increase the
glands. The parathyroids' action is to regulate the reabsorption of water in the kidney. A
serum calcium levels. The parathyroid does not decrease in vasopressin, (antidiuretic
regulate the blood glucose levels. hormone) is not a complication of a
thyroidectomy.
A client diagnosed with pancreatitis becomes Rationale:
increasingly restless, confused and has pulled out the
NG tube and IV catheter. HR-128/min, BP 96/62.
Oxygen saturation = 90%. Skin is cool and clammy to
touch. Prioritize the actions that the nurse should take.
The Correct Order:
Initiate oxygen.
Insert another IV line.
Obtain blood sugar level.
Insert NG tube.
Repeat vital sign checks
First, initiate oxygen. The client is anxious and has Third, check the client's blood sugar.
tachycardia, signs of hypoxia. The BP is also low, so Since the pancreas is sick, insulin
, the client might be bleeding internally. If there is a production can be decreased so glucose
decreased circulating blood volume then there is less can go up. This is next in the priority
hemoglobin to carry oxygen, so increasing the line of the available options. You have
available oxygen will help the client until the problem addressed air and circulation, so blood
is corrected. Second, get the IV started so fluid glucose would be next.
resuscitation can continue.This increased volume will
improve the blood pressure. More volume, more
pressure. The IV will also provide a port for needed
medications.
Fourth, insert the NG tube so that the client can be What is the best instruction the nurse
kept empty and dry and you can prevent aspiration if should provide when administering
the client starts vomiting. Last, recheck vital signs to acetylsalicylic acid 81 mg to a client
assess effectiveness of your nursing actions. experiencing severe, crushing chest
pain radiating up the left jaw?
1. Chew the acetylsalicylic acid prior to
swallowing.
2. Place the acetylsalicylic acid under
the tongue so that it can dissolve.
3. Swallow the acetylsalicylic acid
tablet.
4. Insert the acetylsalicylic acid
between the cheek and gum for greater
