Hurst Readiness Exam 1 || All Correct.
The nurse is teaching a group of pregnant women about hormonal changes during pregnancy.
The nurse recognizes that teaching was successful when the women identify which hormone
as causing amenorrhea?
1. Progesterone 2. Estrogen 3. Follicle-stimulating hormone (FSH) 4. Human chorionic
gonadotropin (hCG) correct answers Rationale
1. Correct: Progesterone causes amenorrhea. 2. Incorrect: Estrogen renders the female genital
tract suitable for fertilization. 3. Incorrect: This stimulates the growth of the graafian follicle
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 correct
answers Rationale
3. Correct: Hallmark of flail chest is paradoxical chest wall movement. This is often
described as a see-saw effect when observing the rise and fall of the chest. 1. Incorrect: A
closed or open tension pneumothorax results from the lung collapsing and air entering into
the pleural cavity. This results in pressure shifting toward the unaffected pleural cavity. 2.
Incorrect: Tension pneumothorax occurs when there is an accumulation of air in the pleural
cavity. The client may exhibit dyspnea, tachycardia, or hypotension. 4. Incorrect: A
pulmonary contusion usually results from blunt trauma. Bruising of lung would be
demonstrated by pain but not paradoxical 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 new pacemaker scheduled to be discharged
in the morning. 4. Client with a history of mild heart failure prescribed one unit of packed red
blood cells for anemia. correct answers Rationale
2. Correct: OB nurses would have the appropriate knowledge needed to care for a client with
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. The client is also likely to remain on a cardiac monitor until
discharge. 4. Incorrect: This client is at risk for fluid volume overload since there is a history
of heart failure and would require close monitoring while receiving a blood transfusion.
The nurse is teaching a group of clients who have reduced peripheral circulation how to care
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 and
between toes with creams to moisten the skin. 4. Break in new shoes gradually. 5. Use
pumice stones to treat calluses. correct answers 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
gradually 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 effectively 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 injurious to the skin. Do not cut calluses or corns. Consult a podiatrist or
primary healthcare provider 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
volunteering in the community. correct answers Rationale
3. & 4. Correct: In young adulthood, the developmental tasks involve intimacy versus
isolation. Intimacy relates more to sharing than to sex. Intimacy produces feelings of safety,
closeness, and trust. 1. Incorrect: Parenting is a primary task of middle adulthood. This is the
middle 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 Despair,
where there is a reflection of one's life. 5. Incorrect: During middle age, a sense of fulfillment
can be found by volunteering in the community. This is part of middle age, where the adult 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 inappropriate compensatory behavior to prevent weight gain 5.
Lack of exercise correct answers Rationale
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.
1. Incorrect: Amenorrhea is found in anorexia nervosa. 5. Incorrect: Excessive exercise is
found in bulimia nervosa as a means to compensate for the binge eating.
A client who has had a laparoscopic cholecystectomy develops pain in the left shoulder. Vital
signs, laboratory studies, and an electrocardiogram are within normal limits. What does the
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
intraperitoneally is irritating the phrenic nerve. 3. Large abdominal retractors used in the
procedure compressed a nerve. 4. Side lying position in the operating room generated
pressure damage. correct answers Rationale
2. Correct: Phrenic nerve irritation can result in referred pain to the left shoulder. Carbon
dioxide (CO2) is used to inflate the abdominal/chest wall during the procedure for better
visualization of the internal organs. If the CO2 irritates 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 abdominal retractors are not used during
this procedure. This is done via a small incision to accommodate a scope. 4. Incorrect: The
client is turned in several directions during the procedure 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.
Vital 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 alkalosis
correct answers 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.
Incorrect: 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 statement 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 has
a suppressed immune response, a N95 mask should be worn." correct answers Rationale
4. Correct: Standard precautions are needed. If there is a risk for coming in contact with client
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 Airborne
Precautions such as for tuberculosis (TB). 1. Incorrect: This is a correct statement regarding
the prevention of infection. Hand washing with soap and water is part of standard
precautions. 2. Incorrect: This is a correct statement. Gloves are needed when coming into
contact with body fluids. 3. Incorrect: This is a correct statement. Standard precautions is part
of the first line of defense against the spread 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 correct answers Rationale
2. Correct: The client taking a monoamine oxidase inhibitor (MAOI) such as tranylcypromine
should avoid foods rich in tyramine or tryptophan. These include: cured foods, those that
have been aged, pickled, fermented, or smoked. These can precipitate a hypertensive crisis. 1.
Incorrect: Clients taking MAOIs can eat cottage cheese in reasonable amounts. 3. Incorrect:
Clients taking MAOIs can eat baked chicken. 4. Incorrect: 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
admit. 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
change using clean gloves. correct answers Rationale
1., 2., 3., & 4. Correct. Palliative care is considered cost effective when caring for the
terminally ill client. There was a 60% drop reported in the healthcare costs since palliative
care was introduced. In comparison to conventional care, palliative care is considered as cost
effective 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 discharge
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 needed.
If waiting until the day of discharge to determine client needs, then discharge can be delayed.
This is costly. Counseling to quit cigarette smoking, colonoscopies, giving beta-blockers to
clients after heart attacks are well-established interventions that are effective and also are
cost-effective. Two additional preventive interventions were found to be cost-saving:
childhood immunization and counseling adults on the use of low dose aspirin. 5. Incorrect. A
postop surgical wound dressing change is a sterile procedure: Sterile gloves are necessary and
failure to use them could lead to infection, which would then increase the cost of care to a
client.
A client is admitted for observation following an unrestrained motor vehicle accident. A
bystander stated that the client lost consciousness for 1-2 minutes. On admission, the client
reports a headache and had a Glasgow coma scale (GCS) of 14. The GCS is now 12. What is
the priority nursing intervention for this client?
1. Continue to assess every 15 minutes. 2. Stimulate the client with a sternal rub. 3.
Administer acetaminophen with codeine for headache. 4. Notify the primary healthcare
provider. correct answers Rationale
4. Correct: On the Glasgow coma scale, we like a number between 13 to 15. This assessment
score has dropped to 12, so the client is getting worse and the headache could mean
increasing intracranial pressure (ICP). This is the only intervention that can fix the problem.
1. Incorrect: Reassessing in 15 minutes is delaying treatment. When neuro changes start
happening, they happen rapidly. 2. Incorrect: Stimulating the client will increase the client's
ICP. 3. Incorrect: A sedative should NOT be administered. The client's level of conscious has
decreased.
The nurse is assessing a client who is being treated with a non-steroidal anti-inflammatory
medication (NSAID) for an acute flare-up of gout. Which finding is expected in the
assessment?
1. Dramatic decrease in pain after beginning medications. 2. Severe abdominal pain
following medication administration. 3. Decreased plasma uric acid levels. 4. Low-grade
fever and rash. correct answers Rationale
1. Correct. The client usually experiences dramatic improvement within 24 hours after
beginning NSAIDs. 2. Incorrect. Most clients can tolerate NSAIDs fairly well. If severe pain
in experienced, the primary healthcare provider should be notified immediately. 3. Incorrect.
NSAIDs do not reduce plasma uric acid levels. 4. Incorrect. This is not an adverse effect of
NSAIDs, in fact, most NSAIDs are also antipyretics and would prevent fever.
The nurse is teaching a group of pregnant women about hormonal changes during pregnancy.
The nurse recognizes that teaching was successful when the women identify which hormone
as causing amenorrhea?
1. Progesterone 2. Estrogen 3. Follicle-stimulating hormone (FSH) 4. Human chorionic
gonadotropin (hCG) correct answers Rationale
1. Correct: Progesterone causes amenorrhea. 2. Incorrect: Estrogen renders the female genital
tract suitable for fertilization. 3. Incorrect: This stimulates the growth of the graafian follicle
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 correct
answers Rationale
3. Correct: Hallmark of flail chest is paradoxical chest wall movement. This is often
described as a see-saw effect when observing the rise and fall of the chest. 1. Incorrect: A
closed or open tension pneumothorax results from the lung collapsing and air entering into
the pleural cavity. This results in pressure shifting toward the unaffected pleural cavity. 2.
Incorrect: Tension pneumothorax occurs when there is an accumulation of air in the pleural
cavity. The client may exhibit dyspnea, tachycardia, or hypotension. 4. Incorrect: A
pulmonary contusion usually results from blunt trauma. Bruising of lung would be
demonstrated by pain but not paradoxical 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 new pacemaker scheduled to be discharged
in the morning. 4. Client with a history of mild heart failure prescribed one unit of packed red
blood cells for anemia. correct answers Rationale
2. Correct: OB nurses would have the appropriate knowledge needed to care for a client with
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. The client is also likely to remain on a cardiac monitor until
discharge. 4. Incorrect: This client is at risk for fluid volume overload since there is a history
of heart failure and would require close monitoring while receiving a blood transfusion.
The nurse is teaching a group of clients who have reduced peripheral circulation how to care
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 and
between toes with creams to moisten the skin. 4. Break in new shoes gradually. 5. Use
pumice stones to treat calluses. correct answers 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
gradually 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 effectively 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 injurious to the skin. Do not cut calluses or corns. Consult a podiatrist or
primary healthcare provider 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
volunteering in the community. correct answers Rationale
3. & 4. Correct: In young adulthood, the developmental tasks involve intimacy versus
isolation. Intimacy relates more to sharing than to sex. Intimacy produces feelings of safety,
closeness, and trust. 1. Incorrect: Parenting is a primary task of middle adulthood. This is the
middle 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 Despair,
where there is a reflection of one's life. 5. Incorrect: During middle age, a sense of fulfillment
can be found by volunteering in the community. This is part of middle age, where the adult 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 inappropriate compensatory behavior to prevent weight gain 5.
Lack of exercise correct answers Rationale
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.
1. Incorrect: Amenorrhea is found in anorexia nervosa. 5. Incorrect: Excessive exercise is
found in bulimia nervosa as a means to compensate for the binge eating.
A client who has had a laparoscopic cholecystectomy develops pain in the left shoulder. Vital
signs, laboratory studies, and an electrocardiogram are within normal limits. What does the
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
intraperitoneally is irritating the phrenic nerve. 3. Large abdominal retractors used in the
procedure compressed a nerve. 4. Side lying position in the operating room generated
pressure damage. correct answers Rationale
2. Correct: Phrenic nerve irritation can result in referred pain to the left shoulder. Carbon
dioxide (CO2) is used to inflate the abdominal/chest wall during the procedure for better
visualization of the internal organs. If the CO2 irritates 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 abdominal retractors are not used during
this procedure. This is done via a small incision to accommodate a scope. 4. Incorrect: The
client is turned in several directions during the procedure 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.
Vital 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 alkalosis
correct answers 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.
Incorrect: 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 statement 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 has
a suppressed immune response, a N95 mask should be worn." correct answers Rationale
4. Correct: Standard precautions are needed. If there is a risk for coming in contact with client
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 Airborne
Precautions such as for tuberculosis (TB). 1. Incorrect: This is a correct statement regarding
the prevention of infection. Hand washing with soap and water is part of standard
precautions. 2. Incorrect: This is a correct statement. Gloves are needed when coming into
contact with body fluids. 3. Incorrect: This is a correct statement. Standard precautions is part
of the first line of defense against the spread 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 correct answers Rationale
2. Correct: The client taking a monoamine oxidase inhibitor (MAOI) such as tranylcypromine
should avoid foods rich in tyramine or tryptophan. These include: cured foods, those that
have been aged, pickled, fermented, or smoked. These can precipitate a hypertensive crisis. 1.
Incorrect: Clients taking MAOIs can eat cottage cheese in reasonable amounts. 3. Incorrect:
Clients taking MAOIs can eat baked chicken. 4. Incorrect: 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
admit. 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
change using clean gloves. correct answers Rationale
1., 2., 3., & 4. Correct. Palliative care is considered cost effective when caring for the
terminally ill client. There was a 60% drop reported in the healthcare costs since palliative
care was introduced. In comparison to conventional care, palliative care is considered as cost
effective 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 discharge
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 needed.
If waiting until the day of discharge to determine client needs, then discharge can be delayed.
This is costly. Counseling to quit cigarette smoking, colonoscopies, giving beta-blockers to
clients after heart attacks are well-established interventions that are effective and also are
cost-effective. Two additional preventive interventions were found to be cost-saving:
childhood immunization and counseling adults on the use of low dose aspirin. 5. Incorrect. A
postop surgical wound dressing change is a sterile procedure: Sterile gloves are necessary and
failure to use them could lead to infection, which would then increase the cost of care to a
client.
A client is admitted for observation following an unrestrained motor vehicle accident. A
bystander stated that the client lost consciousness for 1-2 minutes. On admission, the client
reports a headache and had a Glasgow coma scale (GCS) of 14. The GCS is now 12. What is
the priority nursing intervention for this client?
1. Continue to assess every 15 minutes. 2. Stimulate the client with a sternal rub. 3.
Administer acetaminophen with codeine for headache. 4. Notify the primary healthcare
provider. correct answers Rationale
4. Correct: On the Glasgow coma scale, we like a number between 13 to 15. This assessment
score has dropped to 12, so the client is getting worse and the headache could mean
increasing intracranial pressure (ICP). This is the only intervention that can fix the problem.
1. Incorrect: Reassessing in 15 minutes is delaying treatment. When neuro changes start
happening, they happen rapidly. 2. Incorrect: Stimulating the client will increase the client's
ICP. 3. Incorrect: A sedative should NOT be administered. The client's level of conscious has
decreased.
The nurse is assessing a client who is being treated with a non-steroidal anti-inflammatory
medication (NSAID) for an acute flare-up of gout. Which finding is expected in the
assessment?
1. Dramatic decrease in pain after beginning medications. 2. Severe abdominal pain
following medication administration. 3. Decreased plasma uric acid levels. 4. Low-grade
fever and rash. correct answers Rationale
1. Correct. The client usually experiences dramatic improvement within 24 hours after
beginning NSAIDs. 2. Incorrect. Most clients can tolerate NSAIDs fairly well. If severe pain
in experienced, the primary healthcare provider should be notified immediately. 3. Incorrect.
NSAIDs do not reduce plasma uric acid levels. 4. Incorrect. This is not an adverse effect of
NSAIDs, in fact, most NSAIDs are also antipyretics and would prevent fever.
