HURST READINESS EXAM 1
QUESTIONS AND ANSWERS
The.nurse.is.teaching.a.group.of.pregnant.women.about.hormonal.changes.during.pregna
ncy..The.nurse.recognizes.that.teaching.was.successful.when.the.women.identify.which.h
ormone.as.causing.amenorrhea?.
1..Progesterone.2..Estrogen.3..Follicle-stimulating.hormone.
(FSH).4..Human.chorionic.gonadotropin.(hCG).-.ans✔Rationale
1..Correct:.Progesterone.causes.amenorrhea..2..Incorrect:.Estrogen.renders.the.female.g
enital.tract.suitable.for.fertilization..3..Incorrect:.This.stimulates.the.growth.of.the.graafian.f
ollicle.in.the.ovary..4..Incorrect:.This.is.the.hormone.present.in.urine.for.pregnancy.test
The.client.is.admitted.to.the.hospital.following.a.motor.vehicle.accident.and.has.sustained.
a.closed.chest.wound..The.nurse.notes.paradoxical.chest.wall.movement..Which.problem.
does.the.nurse.suspect?
1..Mediastinal.shift.2..Tension.pneumothorax.3..Flail.chest.4..Pulmonary.contusion.-.ans✔
Rationale
3..Correct:.Hallmark.of.flail.chest.is.paradoxical.chest.wall.movement..This.is.often.describ
ed.as.a.see-
saw.effect.when.observing.the.rise.and.fall.of.the.chest..1..Incorrect:.A.closed.or.open.tensi
on.pneumothorax.results.from.the.lung.collapsing.and.air.entering.into.the.pleural.cavity..T
his.results.in.pressure.shifting.toward.the.unaffected.pleural.cavity..2..Incorrect:.Tension.p
neumothorax.occurs.when.there.is.an.accumulation.of.air.in.the.pleural.cavity..The.client.m
ay.exhibit.dyspnea,.tachycardia,.or.hypotension..4..Incorrect:.A.pulmonary.contusion.usua
lly.results.from.blunt.trauma..Bruising.of.lung.would.be.demonstrated.by.pain.but.not.parad
oxical.chest.wall.movement.
Which.client.can.a.nurse.manager.safely.transfer.from.the.telemetry.unit.to.the.obstetrical.
unit.in.order.to.receive.a.new.admit?
,1..Client.admitted.with.possible.tuberculosis.
(TB).awaiting.skin.test.results..2..Client.diagnosed.with.seizure.disorder..3..Client.with.a.ne
w.pacemaker.scheduled.to.be.discharged.in.the.morning..4..Client.with.a.history.of.mild.he
art.failure.prescribed.one.unit.of.packed.red.blood.cells.for.anemia..-.ans✔Rationale
2..Correct:.OB.nurses.would.have.the.appropriate.knowledge.needed.to.care.for.a.client.wi
th.a.seizure.disorders,.because.they.care.for.clients.who.have.eclampsia.
(seizures)..1..Incorrect:.This.client.might.have.tuberculosis.
(TB).and.is.not.a.good.choice.to.move.to.the.OB.floor,.because.of.the.risk.for.transmission.
of.an.infectious.disease..3..Incorrect:.This.client.is.not.the.best.one.to.be.transferred.to.the.
OB.floor,.because.these.nurses.do.not.routinely.care.for.clients.with.a.new.pacemaker..Th
e.client.is.also.likely.to.remain.on.a.cardiac.monitor.until.discharge..4..Incorrect:.This.client.i
s.at.risk.for.fluid.volume.overload.since.there.is.a.history.of.heart.failure.and.would.require.c
lose.monitoring.while.receiving.a.blood.transfusion.
The.nurse.is.teaching.a.group.of.clients.who.have.reduced.peripheral.circulation.how.to.car
e.for.their.feet..What.points.should.the.nurse.include?
1..Check.shoes.for.rough.spots.in.the.lining..2..File.toenails.straight.across..3..Cover.feet.a
nd.between.toes.with.creams.to.moisten.the.skin..4..Break.in.new.shoes.gradually..5..Use.
pumice.stones.to.treat.calluses..-.ans✔Rationale
1.,.2.,.&.4..Correct:.Rubbing.from.rough.spots.in.the.shoe.can.lead.to.corns.or.calluses..File
.the.toenails.rather.than.cutting.to.avoid.skin.injury..File.nails.straight.across.the.ends.of.the
.toes..If.the.nails.are.too.thick.or.misshapen.to.file,.consult.podiatrist..Break.in.new.shoes.gr
adually.by.increasing.the.wearing.time.30-
60.minutes.each.day..3..Incorrect:.Cover.the.feet,.except.between.the.toes,.with.creams.or.
lotions.to.moisten.the.skin..Lotion.will.also.soften.calluses..A.lotion.that.reduces.dryness.eff
ectively.is.a.mixture.of.lanolin.and.mineral.oil..5..Incorrect:.Avoid.self-
treatment.of.corns.or.calluses..Pumice.stones.and.some.callus.and.corn.applications.are.in
jurious.to.the.skin..Do.not.cut.calluses.or.corns..Consult.a.podiatrist.or.primary.healthcare.p
rovider.first.
When.caring.for.young.adult.clients,.which.developmental.tasks.would.the.nurse.expect.to.
see?
1..Satisfying.and.supporting.the.next.generation..2..Reflecting.on.life.accomplishments..3..
Developing.meaningful.and.intimate.relationships..4..Giving.and.sharing.with.an.individual.
without.asking.what.will.be.given.or.shared.in.return..5..Developing.sense.of.fulfillment.by.v
olunteering.in.the.community..-.ans✔Rationale
3..&.4..Correct:.In.young.adulthood,.the.developmental.tasks.involve.intimacy.versus.isolat
ion..Intimacy.relates.more.to.sharing.than.to.sex..Intimacy.produces.feelings.of.safety,.clos
eness,.and.trust..1..Incorrect:.Parenting.is.a.primary.task.of.middle.adulthood..This.is.the.m
iddle.adulthood.stage.of.Generativity.versus.Stagnation,.where.each.adult.must.find.some.
way.to.satisfy.and.support.the.next.generation..2..Incorrect:.During.late.adulthood,.there.is.
refection.on.life.accomplishments..This.is.the.maturity.stage.of.Ego.Integrity.versus.Despai
r,.where.there.is.a.reflection.of.one's.life..5..Incorrect:.During.middle.age,.a.sense.of.fulfillm
,ent.can.be.found.by.volunteering.in.the.community..This.is.part.of.middle.age,.where.the.ad
ult.is.finding.ways.to.support.others.
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.inap
propriate.compensatory.behavior.to.prevent.weight.gain.5..Lack.of.exercise.-.ans✔Ration
ale
2.,.3..&.4..Correct:.Diagnostic.criteria.for.bulimia.nervosa.are.recurrent.episodes.of.binge.e
ating:.recurrent.inappropriate.compensatory.behavior.to.prevent.weight.gain.such.as.laxati
ve,.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..1..Incorrect:.
Amenorrhea.is.found.in.anorexia.nervosa..5..Incorrect:.Excessive.exercise.is.found.in.buli
mia.nervosa.as.a.means.to.compensate.for.the.binge.eating.
A.client.who.has.had.a.laparoscopic.cholecystectomy.develops.pain.in.the.left.shoulder..Vit
al.signs,.laboratory.studies,.and.an.electrocardiogram.are.within.normal.limits..What.does.t
he.nurse.recognize.as.a.contributing.cause.of.the.pain?
1..Surgical.cannulation.of.the.bile.duct.is.causing.spasm.and.pain..2..Carbon.dioxide.used.i
ntraperitoneally.is.irritating.the.phrenic.nerve..3..Large.abdominal.retractors.used.in.the.pr
ocedure.compressed.a.nerve..4..Side.lying.position.in.the.operating.room.generated.press
ure.damage..-.ans✔Rationale
2..Correct:.Phrenic.nerve.irritation.can.result.in.referred.pain.to.the.left.shoulder..Carbon.di
oxide.(CO2).is.used.to.inflate.the.abdominal/
chest.wall.during.the.procedure.for.better.visualization.of.the.internal.organs..If.the.CO2.irri
tates.the.phrenic.nerve,.it.radiates.to.the.shoulder..1..Incorrect:.Surgical.cannulation.of.the.
bile.duct.is.not.performed.during.a.laparoscopic.cholecystectomy..3..Incorrect:.Large.abdo
minal.retractors.are.not.used.during.this.procedure..This.is.done.via.a.small.incision.to.acc
ommodate.a.scope..4..Incorrect:.The.client.is.turned.in.several.directions.during.the.proced
ure.to.prevent.damage.to.the.abdominal.viscera.
A.client.is.admitted.to.the.medical.unit.with.an.acute.onset.of.fever,.chills.and.RUQ.pain..Vit
al.signs.are:.T.99.8°F.(37.7°C),.P.132,.RR.34,.B/P.142/82..ABG.results.are:.pH-
7.53,.PaCO2.30,.HCO3.22..The.nurse.determines.that.this.client.is.in.what.acid/
base.imbalance?
1..Respiratory.acidosis.2..Respiratory.alkalosis.3..Metabolic.acidosis.4..Metabolic.alkalosi
s.-.ans✔Rationale
2..Correct:.This.client.has.a.severe.infection..Hyperventilation.due.to.anxiety,.pain,.shock,.
severe.infection,.fever,.and.liver.failure.can.lead.to.respiratory.alkalosis..pH.>.7.45,.PCO2.
<.35,.HCO3.normal..1..Incorrect:.Not.acidosis.with.hyperventilation.and.pH.of.7.53..3..Incor
rect:.Not.a.metabolic.related.acid/
base.imbalance.since.the.HCO3.is.in.normal.range.and.is.not.acidosis..4..Incorrect:.Not.a.
metabolic.related.acid/base.imbalance.since.the.HCO3.is.in.normal.range.
, An.unlicensed.assistive.personnel.
(UAP).has.explained.how.to.prevent.the.spread.of.infection.to.the.charge.nurse..Which.stat
ement.by.the.UAP.indicates.that.further.teaching.is.needed?.
1.."Soap.and.water.should.be.used.for.hand.washing.when.our.hands.are.visibly.soiled.".2..
"Gloves.do.not.have.to.be.worn.when.taking.a.client's.vital.signs.or.passing.out.meal.trays."
.3.."Standard.precautions.should.be.used.on.all.clients.".4.."When.caring.for.a.client.who.ha
s.a.suppressed.immune.response,.a.N95.mask.should.be.worn.".-.ans✔Rationale
4..Correct:.Standard.precautions.are.needed..If.there.is.a.risk.for.coming.in.contact.with.cli
ent.secretions.or.excretions,.a.standard.mask.may.be.worn..Routine.nursing.care.does.not
.warrant.the.use.of.an.N95.mask..This.type.mask.is.needed.for.client's.who.are.placed.on.A
irborne.Precautions.such.as.for.tuberculosis.
(TB)..1..Incorrect:.This.is.a.correct.statement.regarding.the.prevention.of.infection..Hand.w
ashing.with.soap.and.water.is.part.of.standard.precautions..2..Incorrect:.This.is.a.correct.st
atement..Gloves.are.needed.when.coming.into.contact.with.body.fluids..3..Incorrect:.This.i
s.a.correct.statement..Standard.precautions.is.part.of.the.first.line.of.defense.against.the.sp
read.of.infection.
The.nurse.is.preparing.to.discharge.a.client.who.has.been.placed.on.tranylcypromine..The.
nurse.teaches.the.client.about.food.to.avoid.while.taking.this.medication..What.food.choice
.by.the.client.confirms.appropriate.understanding.of.the.teaching?
1..Cottage.cheese.2..Salami.3..Baked.chicken.4..Potatoes.-.ans✔Rationale
2..Correct:.The.client.taking.a.monoamine.oxidase.inhibitor.
(MAOI).such.as.tranylcypromine.should.avoid.foods.rich.in.tyramine.or.tryptophan..These.i
nclude:.cured.foods,.those.that.have.been.aged,.pickled,.fermented,.or.smoked..These.ca
n.precipitate.a.hypertensive.crisis..1..Incorrect:.Clients.taking.MAOIs.can.eat.cottage.chee
se.in.reasonable.amounts..3..Incorrect:.Clients.taking.MAOIs.can.eat.baked.chicken..4..Inc
orrect:.Clients.taking.MAOIs.can.eat.potatoes.
Which.nurse.is.providing.cost.effective.care.to.a.client?.
1..Providing.palliative.care.to.a.terminally.ill.client..2..Beginning.discharge.planning.on.adm
it..3..Counseling.clients.on.cigarette.smoking.cessation..4..Educating.a.group.of.parents.on
.the.importance.of.childhood.immunizations..5..Performing.a.postop.wound.dressing.chan
ge.using.clean.gloves..-.ans✔Rationale
1.,.2.,.3.,.&.4..Correct..Palliative.care.is.considered.cost.effective.when.caring.for.the.termin
ally.ill.client..There.was.a.60%.drop.reported.in.the.healthcare.costs.since.palliative.care.w
as.introduced..In.comparison.to.conventional.care,.palliative.care.is.considered.as.cost.eff
ective.in.reducing.unnecessary.utilization.of.resources..Palliative.care.has.focused.on.the.
efficient.and.the.effective.care.that.is.centered.on.the.clients..The.nurse.who.begins.discha
rge.planning.on.admit.is.providing.cost.effective.care..The.client.may.not.be.able.to.learn.all
.that.is.needed.if.waiting.until.the.day.of.discharge..Also,.supplies.and.equipment.may.be.n
eeded..If.waiting.until.the.day.of.discharge.to.determine.client.needs,.then.discharge.can.b
e.delayed..This.is.costly..Counseling.to.quit.cigarette.smoking,.colonoscopies,.giving.beta-
QUESTIONS AND ANSWERS
The.nurse.is.teaching.a.group.of.pregnant.women.about.hormonal.changes.during.pregna
ncy..The.nurse.recognizes.that.teaching.was.successful.when.the.women.identify.which.h
ormone.as.causing.amenorrhea?.
1..Progesterone.2..Estrogen.3..Follicle-stimulating.hormone.
(FSH).4..Human.chorionic.gonadotropin.(hCG).-.ans✔Rationale
1..Correct:.Progesterone.causes.amenorrhea..2..Incorrect:.Estrogen.renders.the.female.g
enital.tract.suitable.for.fertilization..3..Incorrect:.This.stimulates.the.growth.of.the.graafian.f
ollicle.in.the.ovary..4..Incorrect:.This.is.the.hormone.present.in.urine.for.pregnancy.test
The.client.is.admitted.to.the.hospital.following.a.motor.vehicle.accident.and.has.sustained.
a.closed.chest.wound..The.nurse.notes.paradoxical.chest.wall.movement..Which.problem.
does.the.nurse.suspect?
1..Mediastinal.shift.2..Tension.pneumothorax.3..Flail.chest.4..Pulmonary.contusion.-.ans✔
Rationale
3..Correct:.Hallmark.of.flail.chest.is.paradoxical.chest.wall.movement..This.is.often.describ
ed.as.a.see-
saw.effect.when.observing.the.rise.and.fall.of.the.chest..1..Incorrect:.A.closed.or.open.tensi
on.pneumothorax.results.from.the.lung.collapsing.and.air.entering.into.the.pleural.cavity..T
his.results.in.pressure.shifting.toward.the.unaffected.pleural.cavity..2..Incorrect:.Tension.p
neumothorax.occurs.when.there.is.an.accumulation.of.air.in.the.pleural.cavity..The.client.m
ay.exhibit.dyspnea,.tachycardia,.or.hypotension..4..Incorrect:.A.pulmonary.contusion.usua
lly.results.from.blunt.trauma..Bruising.of.lung.would.be.demonstrated.by.pain.but.not.parad
oxical.chest.wall.movement.
Which.client.can.a.nurse.manager.safely.transfer.from.the.telemetry.unit.to.the.obstetrical.
unit.in.order.to.receive.a.new.admit?
,1..Client.admitted.with.possible.tuberculosis.
(TB).awaiting.skin.test.results..2..Client.diagnosed.with.seizure.disorder..3..Client.with.a.ne
w.pacemaker.scheduled.to.be.discharged.in.the.morning..4..Client.with.a.history.of.mild.he
art.failure.prescribed.one.unit.of.packed.red.blood.cells.for.anemia..-.ans✔Rationale
2..Correct:.OB.nurses.would.have.the.appropriate.knowledge.needed.to.care.for.a.client.wi
th.a.seizure.disorders,.because.they.care.for.clients.who.have.eclampsia.
(seizures)..1..Incorrect:.This.client.might.have.tuberculosis.
(TB).and.is.not.a.good.choice.to.move.to.the.OB.floor,.because.of.the.risk.for.transmission.
of.an.infectious.disease..3..Incorrect:.This.client.is.not.the.best.one.to.be.transferred.to.the.
OB.floor,.because.these.nurses.do.not.routinely.care.for.clients.with.a.new.pacemaker..Th
e.client.is.also.likely.to.remain.on.a.cardiac.monitor.until.discharge..4..Incorrect:.This.client.i
s.at.risk.for.fluid.volume.overload.since.there.is.a.history.of.heart.failure.and.would.require.c
lose.monitoring.while.receiving.a.blood.transfusion.
The.nurse.is.teaching.a.group.of.clients.who.have.reduced.peripheral.circulation.how.to.car
e.for.their.feet..What.points.should.the.nurse.include?
1..Check.shoes.for.rough.spots.in.the.lining..2..File.toenails.straight.across..3..Cover.feet.a
nd.between.toes.with.creams.to.moisten.the.skin..4..Break.in.new.shoes.gradually..5..Use.
pumice.stones.to.treat.calluses..-.ans✔Rationale
1.,.2.,.&.4..Correct:.Rubbing.from.rough.spots.in.the.shoe.can.lead.to.corns.or.calluses..File
.the.toenails.rather.than.cutting.to.avoid.skin.injury..File.nails.straight.across.the.ends.of.the
.toes..If.the.nails.are.too.thick.or.misshapen.to.file,.consult.podiatrist..Break.in.new.shoes.gr
adually.by.increasing.the.wearing.time.30-
60.minutes.each.day..3..Incorrect:.Cover.the.feet,.except.between.the.toes,.with.creams.or.
lotions.to.moisten.the.skin..Lotion.will.also.soften.calluses..A.lotion.that.reduces.dryness.eff
ectively.is.a.mixture.of.lanolin.and.mineral.oil..5..Incorrect:.Avoid.self-
treatment.of.corns.or.calluses..Pumice.stones.and.some.callus.and.corn.applications.are.in
jurious.to.the.skin..Do.not.cut.calluses.or.corns..Consult.a.podiatrist.or.primary.healthcare.p
rovider.first.
When.caring.for.young.adult.clients,.which.developmental.tasks.would.the.nurse.expect.to.
see?
1..Satisfying.and.supporting.the.next.generation..2..Reflecting.on.life.accomplishments..3..
Developing.meaningful.and.intimate.relationships..4..Giving.and.sharing.with.an.individual.
without.asking.what.will.be.given.or.shared.in.return..5..Developing.sense.of.fulfillment.by.v
olunteering.in.the.community..-.ans✔Rationale
3..&.4..Correct:.In.young.adulthood,.the.developmental.tasks.involve.intimacy.versus.isolat
ion..Intimacy.relates.more.to.sharing.than.to.sex..Intimacy.produces.feelings.of.safety,.clos
eness,.and.trust..1..Incorrect:.Parenting.is.a.primary.task.of.middle.adulthood..This.is.the.m
iddle.adulthood.stage.of.Generativity.versus.Stagnation,.where.each.adult.must.find.some.
way.to.satisfy.and.support.the.next.generation..2..Incorrect:.During.late.adulthood,.there.is.
refection.on.life.accomplishments..This.is.the.maturity.stage.of.Ego.Integrity.versus.Despai
r,.where.there.is.a.reflection.of.one's.life..5..Incorrect:.During.middle.age,.a.sense.of.fulfillm
,ent.can.be.found.by.volunteering.in.the.community..This.is.part.of.middle.age,.where.the.ad
ult.is.finding.ways.to.support.others.
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.inap
propriate.compensatory.behavior.to.prevent.weight.gain.5..Lack.of.exercise.-.ans✔Ration
ale
2.,.3..&.4..Correct:.Diagnostic.criteria.for.bulimia.nervosa.are.recurrent.episodes.of.binge.e
ating:.recurrent.inappropriate.compensatory.behavior.to.prevent.weight.gain.such.as.laxati
ve,.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..1..Incorrect:.
Amenorrhea.is.found.in.anorexia.nervosa..5..Incorrect:.Excessive.exercise.is.found.in.buli
mia.nervosa.as.a.means.to.compensate.for.the.binge.eating.
A.client.who.has.had.a.laparoscopic.cholecystectomy.develops.pain.in.the.left.shoulder..Vit
al.signs,.laboratory.studies,.and.an.electrocardiogram.are.within.normal.limits..What.does.t
he.nurse.recognize.as.a.contributing.cause.of.the.pain?
1..Surgical.cannulation.of.the.bile.duct.is.causing.spasm.and.pain..2..Carbon.dioxide.used.i
ntraperitoneally.is.irritating.the.phrenic.nerve..3..Large.abdominal.retractors.used.in.the.pr
ocedure.compressed.a.nerve..4..Side.lying.position.in.the.operating.room.generated.press
ure.damage..-.ans✔Rationale
2..Correct:.Phrenic.nerve.irritation.can.result.in.referred.pain.to.the.left.shoulder..Carbon.di
oxide.(CO2).is.used.to.inflate.the.abdominal/
chest.wall.during.the.procedure.for.better.visualization.of.the.internal.organs..If.the.CO2.irri
tates.the.phrenic.nerve,.it.radiates.to.the.shoulder..1..Incorrect:.Surgical.cannulation.of.the.
bile.duct.is.not.performed.during.a.laparoscopic.cholecystectomy..3..Incorrect:.Large.abdo
minal.retractors.are.not.used.during.this.procedure..This.is.done.via.a.small.incision.to.acc
ommodate.a.scope..4..Incorrect:.The.client.is.turned.in.several.directions.during.the.proced
ure.to.prevent.damage.to.the.abdominal.viscera.
A.client.is.admitted.to.the.medical.unit.with.an.acute.onset.of.fever,.chills.and.RUQ.pain..Vit
al.signs.are:.T.99.8°F.(37.7°C),.P.132,.RR.34,.B/P.142/82..ABG.results.are:.pH-
7.53,.PaCO2.30,.HCO3.22..The.nurse.determines.that.this.client.is.in.what.acid/
base.imbalance?
1..Respiratory.acidosis.2..Respiratory.alkalosis.3..Metabolic.acidosis.4..Metabolic.alkalosi
s.-.ans✔Rationale
2..Correct:.This.client.has.a.severe.infection..Hyperventilation.due.to.anxiety,.pain,.shock,.
severe.infection,.fever,.and.liver.failure.can.lead.to.respiratory.alkalosis..pH.>.7.45,.PCO2.
<.35,.HCO3.normal..1..Incorrect:.Not.acidosis.with.hyperventilation.and.pH.of.7.53..3..Incor
rect:.Not.a.metabolic.related.acid/
base.imbalance.since.the.HCO3.is.in.normal.range.and.is.not.acidosis..4..Incorrect:.Not.a.
metabolic.related.acid/base.imbalance.since.the.HCO3.is.in.normal.range.
, An.unlicensed.assistive.personnel.
(UAP).has.explained.how.to.prevent.the.spread.of.infection.to.the.charge.nurse..Which.stat
ement.by.the.UAP.indicates.that.further.teaching.is.needed?.
1.."Soap.and.water.should.be.used.for.hand.washing.when.our.hands.are.visibly.soiled.".2..
"Gloves.do.not.have.to.be.worn.when.taking.a.client's.vital.signs.or.passing.out.meal.trays."
.3.."Standard.precautions.should.be.used.on.all.clients.".4.."When.caring.for.a.client.who.ha
s.a.suppressed.immune.response,.a.N95.mask.should.be.worn.".-.ans✔Rationale
4..Correct:.Standard.precautions.are.needed..If.there.is.a.risk.for.coming.in.contact.with.cli
ent.secretions.or.excretions,.a.standard.mask.may.be.worn..Routine.nursing.care.does.not
.warrant.the.use.of.an.N95.mask..This.type.mask.is.needed.for.client's.who.are.placed.on.A
irborne.Precautions.such.as.for.tuberculosis.
(TB)..1..Incorrect:.This.is.a.correct.statement.regarding.the.prevention.of.infection..Hand.w
ashing.with.soap.and.water.is.part.of.standard.precautions..2..Incorrect:.This.is.a.correct.st
atement..Gloves.are.needed.when.coming.into.contact.with.body.fluids..3..Incorrect:.This.i
s.a.correct.statement..Standard.precautions.is.part.of.the.first.line.of.defense.against.the.sp
read.of.infection.
The.nurse.is.preparing.to.discharge.a.client.who.has.been.placed.on.tranylcypromine..The.
nurse.teaches.the.client.about.food.to.avoid.while.taking.this.medication..What.food.choice
.by.the.client.confirms.appropriate.understanding.of.the.teaching?
1..Cottage.cheese.2..Salami.3..Baked.chicken.4..Potatoes.-.ans✔Rationale
2..Correct:.The.client.taking.a.monoamine.oxidase.inhibitor.
(MAOI).such.as.tranylcypromine.should.avoid.foods.rich.in.tyramine.or.tryptophan..These.i
nclude:.cured.foods,.those.that.have.been.aged,.pickled,.fermented,.or.smoked..These.ca
n.precipitate.a.hypertensive.crisis..1..Incorrect:.Clients.taking.MAOIs.can.eat.cottage.chee
se.in.reasonable.amounts..3..Incorrect:.Clients.taking.MAOIs.can.eat.baked.chicken..4..Inc
orrect:.Clients.taking.MAOIs.can.eat.potatoes.
Which.nurse.is.providing.cost.effective.care.to.a.client?.
1..Providing.palliative.care.to.a.terminally.ill.client..2..Beginning.discharge.planning.on.adm
it..3..Counseling.clients.on.cigarette.smoking.cessation..4..Educating.a.group.of.parents.on
.the.importance.of.childhood.immunizations..5..Performing.a.postop.wound.dressing.chan
ge.using.clean.gloves..-.ans✔Rationale
1.,.2.,.3.,.&.4..Correct..Palliative.care.is.considered.cost.effective.when.caring.for.the.termin
ally.ill.client..There.was.a.60%.drop.reported.in.the.healthcare.costs.since.palliative.care.w
as.introduced..In.comparison.to.conventional.care,.palliative.care.is.considered.as.cost.eff
ective.in.reducing.unnecessary.utilization.of.resources..Palliative.care.has.focused.on.the.
efficient.and.the.effective.care.that.is.centered.on.the.clients..The.nurse.who.begins.discha
rge.planning.on.admit.is.providing.cost.effective.care..The.client.may.not.be.able.to.learn.all
.that.is.needed.if.waiting.until.the.day.of.discharge..Also,.supplies.and.equipment.may.be.n
eeded..If.waiting.until.the.day.of.discharge.to.determine.client.needs,.then.discharge.can.b
e.delayed..This.is.costly..Counseling.to.quit.cigarette.smoking,.colonoscopies,.giving.beta-
