Hurst Readiness Exam 4 || All Answers Are Verified.
Which client must the nurse assign to a private room? You answered this question Correctly
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) correct answers RationaleStrategies 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 not in their mother's room (a
client with term twins would need a private room because of space considerations). 2.
Incorrect: Chorioamnionitis is not contagious. 3. Incorrect: The infant may have an infection
and will remain in the NICU. The mother is not infected.
Post thyroidectomy, the nurse assesses the client for complications by performing which
assessment? You answered this question Correctly 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 correct answers RationaleStrategies 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
thyroidectomy is to remove one or more parathyroid glands. The parathyroids' action is to
regulate the serum calcium levels. The parathyroid does not regulate the blood glucose levels.
5. Incorrect: The action of desmopressin is to increase the reabsorption of water in the
kidney. A decrease in vasopressin, (antidiuretic hormone) is not a complication of a
thyroidectomy.
A client diagnosed with pancreatitis becomes 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. You answered this
question IncorrectlyThe Correct Order Initiate oxygen. Insert another IV line. Obtain blood
sugar level. Insert NG tube. Repeat vital sign checks Your Selected Order Repeat vital sign
checks Initiate oxygen. Obtain blood sugar level. Insert NG tube. Insert another IV line.
correct answers RationaleStrategies First, initiate oxygen. The client is anxious and has
tachycardia, signs of hypoxia. The BP is also low, so the client might be bleeding internally.
If there is a decreased circulating blood volume then there is less hemoglobin to carry
oxygen, so increasing the available oxygen will help the client until the problem is corrected.
Second, get the IV started so fluid 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. Third, check the client's blood sugar. Since the pancreas is sick, insulin
production can be decreased so glucose can go up. This is next in the priority line of the
available options. You have addressed air and circulation, so blood glucose would be next.
Fourth, insert the NG tube so that the client can be kept empty and dry and you can prevent
aspiration if the client starts vomiting. Last, recheck vital signs to assess effectiveness of your
nursing actions.
,What is the best instruction the nurse should provide when administering acetylsalicylic acid
81 mg to a client experiencing severe, crushing chest pain radiating up the left jaw? You
answered this question Correctly 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 absorption. correct answers RationaleStrategies 1. Correct: Acetylsalicylic acid has
been shown to decrease mortality and re-infarction rates after MI. The fastest way to get the
aspirin into the circulatory system is to have the client chew the acetylsalicylic acid prior to
swallowing. 2. Incorrect: Nitroglycerin is administered sublingual (SL) or buccal. Initially
acetylsalicylic acid is administered by chewing the tablet or swallowing the tablet. 3.
Incorrect: If a solid dose pill is prescribed, the pill should be chewed. Faster absorption is
obtained from chewing, rather than swallowing acetylsalicylic acid. 4. Incorrect:
Nitroglycerin is administered SL or buccal. Initially acetylsalicylic acid would be chewed to
increase the absorption rate.
A client who has developed hypovolemic shock is receiving albumin. What assessment
finding by the nurse indicates that the albumin has been effective? You answered this
question Correctly 1. Swelling in the legs 2. Increase in uninary output 3. Proteinuria 4.
Increase in waist measurement correct answers RationaleStrategies 2. Correct: The action of
albumin is to increase the serum albumin level. When the albumin level increases there is a
shift of fluid from extracellular to intracellular. This action will result in an increase in
urinary output. 1. Incorrect: This is a symptom of hypoalbuminemia. There is a shift in the
fluid from intracellular to extracellular. This results in the swelling of the legs. 3. Incorrect:
Hypoalbuminemia may cause damage to the kidneys. Proteinuria is indicative of renal
disease or damage. 4. Incorrect: There may be a increased accumulation of fluid in the
abdomen. The ascites is due to the decreased albumin level in the vascular space, which also
causes damage to the liver.
A nurse is attempting to develop trust with a psychiatric client exhibiting concrete thinking.
Which nursing intervention would promote trust in this individual? You answered this
question Incorrectly 1. Attend an activity with the client who is reluctant to go alone. 2.
Allow the client to break an insignificant rule. 3. Consider client preferences when possible in
decisions concerning care. 4. Provide a blanket when the client is cold. 5. Provide food when
the client is hungry. correct answers RationaleStrategies 1., 3., 4. & 5. Correct: Trust is
demonstrated through nursing interventions that convey a sense of warmth and care to the
client. These interventions are initiated simply, concretely, and directed toward activities that
address the client's basic needs for physiological and psychological safety and security.
Concrete thinking focuses thought processes on specifics, rather than generalities, and
immediate issues, rather than eventual outcomes. Examples of nursing interventions that
would promote trust in an individual who is thinking concretely include such things as:
providing a blanket when the client is cold, providing food when the client is hungry, keeping
promises, being honest, providing a written, structured schedule of activities, attending
activities with the client if he is reluctant to go alone, being consistent in adhering to unit
guidelines, and taking the client's preferences, requests, and opinions into consideration when
possible in decisions concerning care. 2. Incorrect: The client should be informed of all rules,
simply and clearly, with reasons for certain policies and rules. Be consistent and provide
written, structured, scheduled activities. Allowing a client to break a rule would not
encourage them to think about the outcomes of their actions.
,A charge nurse is planning care for several clients on the unit. Which activities can the nurse
safely delegate to an unlicensed assistive personnel (UAP)? You answered this question
Incorrectly 1. Administer a nebulizer treatment to a client diagnosed with pneumonia. 2.
Obtain vital signs on a postoperative client who required naloxone 5 minutes ago. 3. Report a
urinary output (UOP) less than 50 ml/hr on a post-op client. 4. Assist a client with obtaining a
clean catch urine sample. 5. Remove an indwelling urinary catheter from a client. correct
answers RationaleStrategies 3., & 4. Correct: A UAP can report the amount of UOP but
cannot interpret it. A clean catch urine sample is a noninvasive procedure. The UAP can
assist the client to obtain the clean catch urinary sample. Both activities are the right person
and right task of delegation. 1. Incorrect: A UAP cannot administer medications. This is the
wrong task for an UAP. 2. Incorrect: The client received naloxone to reverse the action of an
opioid medication. A UAP should not be assigned to obtain vital signs on an unstable client.
This is the wrong person to perform removal of an indwelling urinary catheter. 5. Incorrect:
A UAP cannot remove an indwelling urinary catheter.
Which interventions should the nurse initiate to lessen acid reflux in a client diagnosed with
gastroesophagel reflux disease (GERD)? You answered this question Correctly 1. Provide
small, frequent meals. 2. Avoid carbonated beverages. 3. Administer omeprazole as
prescribed. 4. Assist with smoking cessation. 5. Place in left lateral position for 2 hours after
eating. correct answers RationaleStrategies 1., 2., 3., & 4. Correct: All of these actions are
correct to help alleviate dyspepsia. When a client has GERD, the stomach's contents reflux
into the esophagus. Small frequent meals will decrease possible reflux by decreasing the
stomach content. Smoking can relax the lower muscle of the esophagus. Drinking a
carbonated drink may cause the stomach to expand. Both smoking and drinking a carbonated
drink increase the potential of reflux. The action of omeprazole is to reduce the acid that is
produced in the stomach. 5. Incorrect: The client should be positioned with the head of the
bed (HOB) elevated for 2-3 hours after eating. This position will decrease the potential for
esophageal reflux.
A nurse from the neonatal unit is transferred to the adult medical-surgical unit. Which client
should the charge nurse assign to the neonatal nurse? You answered this question Incorrectly
1. Undergoing surgery for placement of a central venous catheter. 2. Diagnosed with
leukemia, hospitalized for induction of high-dose chemotherapy. 3. Receiving IV heparin for
left leg thrombosis. 4. Admitted with a cerebrovascular accident. correct answers
RationaleStrategies 1. Correct: This is the most stable client to give to the nurse who was
transferred from the neonatal unit. A neonatal nurse cares for central lines daily in this
specialty area and can transfer this knowledge to the adult client. 2. Incorrect: This is not a
good client for a neonatal nurse because knowledge of lab values, chemotherapy precautions,
protective isolation and chemotherapy drugs is required for the nurse in order to care for this
client. 3. Incorrect: This is not the best client for a neonatal nurse because thrombosis
problems are not commonly seen in the nursery. Monitoring clotting factors and being aware
of signs and symptoms of pulmonary emboli are essential for safe care of this client. 4.
Incorrect: This client is very unstable and requires skilled observation and assessment using
the Glasgow Scale. This level of assessment is not utilized in a neonatal unit.
A client with a history of increasing dyspnea over the past week comes to the emergency
department. After arterial blood gases (ABGs) are drawn, which information would be
important for the nurse to document? You answered this question Correctly 1. The client had
not been NPO prior to the test. 2. The client was on 2 L of oxygen by nasal canula. 3. Lung
sounds are wet. 4. Client is sitting in upright position. correct answers RationaleStrategies 2.
, Correct: The fact that the client is on 2 L/min of oxygen will affect the analysis of the ABG
results. If the client is on oxygen, the partial pressure of oxygen (PO2) will be elevated due to
the increased inhaled oxygen. 1. Incorrect: Whether the client has eaten or been NPO will not
affect the evaluation of the ABG results. 3. Incorrect: An assessment of the client's lung
sounds must be performed for a client with a history of dyspnea. This assessment will not
directly affect the ABGs result. 4. Incorrect: The client's position will not directly affect the
evaluation of the ABG results.
The nurse is providing care to a client who has a large abdominal dressing. Which
intervention is most likely to reduce the risk of skin irritation due to frequent dressing
changes? You answered this question Correctly 1. Use a paper tape for adhering the dressing.
2. Use tape sparingly. 3. Secure the dressing with Montgomery straps. 4. Change the dressing
only if it becomes saturated with drainage. correct answers RationaleStrategies 3. Correct:
Montgomery straps will allow the dressing to be held in place without the use of tape. The
adhesive on the ends of the straps is the only adhesive used. 1. Incorrect: Paper tape may be
less irritating; however, with repeated changes, skin irritation is more likely. Montgomery
straps will decrease the repeated tape changes. 2. Incorrect: Use of the tape should be
sufficient to secure the dressing and applied in a way to allow mobility if placed over a joint.
There still is an increase of skin irritation from applying the tape. 4. Incorrect: The soiled
dressing is a medium for bacteria growth. The dressing should be changed as ordered or
required.
A newborn in a neonatal unit is to receive penicillin G benzathine 50,000 units/kg
intramuscularly (IM). The newborn weighs 6 lbs (2.7 kg). The dispensed dose is 25,000 units
per 1 mL. What should the nurse do? You answered this question Incorrectly 1. Administer
the drug intravenously (IV) since a large volume is required. 2. Choose three injection sites
and give the medication as prescribed. 3. Consult with the pharmacy for a different
medication concentration. 4. Read the available drug information to determine how to
administer the medication. correct answers RationaleStrategies 3. Correct: The nurse must
consult with the pharmacy to receive further instructions. The dose is greater than the allowed
volume to be given IM, which warrants clarification by the pharmacy. 1. Incorrect: Since the
drug is prescribed IM, the route should not be changed to IV administration because this
violates the prescription as written. 2. Incorrect: The dose is greater than the allowed volume
to be given IM, which warrants clarification by the pharmacy. You want to avoid having to
give three injections. 4. Incorrect: The concern is not drug information or administration; it is
the concentration, which can only be provided by the pharmacy.
A nurse is preparing to conduct a presentation on barriers to therapeutic communication with
clients from a culture other than the nurse's culture. Which points should the nurse include in
the presentation? You answered this question Incorrectly 1. Lack of knowledge about a
client's culture is a major barrier to therapeutic communication. 2. Follow cultural beliefs
when caring for all clients of that particular culture. 3. Ethnocentrism facilitates therapeutic
communication. 4. Do not touch the client until you know what the cultural belief is about
touching. 5. Adapt care to client's cultural needs and preferences. correct answers
RationaleStrategies 1., 4. & 5. Correct: Nurses must understand and take into consideration
the cultural differences of their clients. Some cultures do not approve of touching or shaking
hands. By assessing the client's culture preference, the nurse is able to provide individualized
care. 2. Incorrect: Do not stereotype all clients of a certain culture. Ask questions. Allow for
individuality. To provide culturally competent care, the nurse must recognize individual
preferences within the client's culture. 3. Incorrect: Ethnocentrism is the belief that one's own
Which client must the nurse assign to a private room? You answered this question Correctly
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) correct answers RationaleStrategies 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 not in their mother's room (a
client with term twins would need a private room because of space considerations). 2.
Incorrect: Chorioamnionitis is not contagious. 3. Incorrect: The infant may have an infection
and will remain in the NICU. The mother is not infected.
Post thyroidectomy, the nurse assesses the client for complications by performing which
assessment? You answered this question Correctly 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 correct answers RationaleStrategies 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
thyroidectomy is to remove one or more parathyroid glands. The parathyroids' action is to
regulate the serum calcium levels. The parathyroid does not regulate the blood glucose levels.
5. Incorrect: The action of desmopressin is to increase the reabsorption of water in the
kidney. A decrease in vasopressin, (antidiuretic hormone) is not a complication of a
thyroidectomy.
A client diagnosed with pancreatitis becomes 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. You answered this
question IncorrectlyThe Correct Order Initiate oxygen. Insert another IV line. Obtain blood
sugar level. Insert NG tube. Repeat vital sign checks Your Selected Order Repeat vital sign
checks Initiate oxygen. Obtain blood sugar level. Insert NG tube. Insert another IV line.
correct answers RationaleStrategies First, initiate oxygen. The client is anxious and has
tachycardia, signs of hypoxia. The BP is also low, so the client might be bleeding internally.
If there is a decreased circulating blood volume then there is less hemoglobin to carry
oxygen, so increasing the available oxygen will help the client until the problem is corrected.
Second, get the IV started so fluid 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. Third, check the client's blood sugar. Since the pancreas is sick, insulin
production can be decreased so glucose can go up. This is next in the priority line of the
available options. You have addressed air and circulation, so blood glucose would be next.
Fourth, insert the NG tube so that the client can be kept empty and dry and you can prevent
aspiration if the client starts vomiting. Last, recheck vital signs to assess effectiveness of your
nursing actions.
,What is the best instruction the nurse should provide when administering acetylsalicylic acid
81 mg to a client experiencing severe, crushing chest pain radiating up the left jaw? You
answered this question Correctly 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 absorption. correct answers RationaleStrategies 1. Correct: Acetylsalicylic acid has
been shown to decrease mortality and re-infarction rates after MI. The fastest way to get the
aspirin into the circulatory system is to have the client chew the acetylsalicylic acid prior to
swallowing. 2. Incorrect: Nitroglycerin is administered sublingual (SL) or buccal. Initially
acetylsalicylic acid is administered by chewing the tablet or swallowing the tablet. 3.
Incorrect: If a solid dose pill is prescribed, the pill should be chewed. Faster absorption is
obtained from chewing, rather than swallowing acetylsalicylic acid. 4. Incorrect:
Nitroglycerin is administered SL or buccal. Initially acetylsalicylic acid would be chewed to
increase the absorption rate.
A client who has developed hypovolemic shock is receiving albumin. What assessment
finding by the nurse indicates that the albumin has been effective? You answered this
question Correctly 1. Swelling in the legs 2. Increase in uninary output 3. Proteinuria 4.
Increase in waist measurement correct answers RationaleStrategies 2. Correct: The action of
albumin is to increase the serum albumin level. When the albumin level increases there is a
shift of fluid from extracellular to intracellular. This action will result in an increase in
urinary output. 1. Incorrect: This is a symptom of hypoalbuminemia. There is a shift in the
fluid from intracellular to extracellular. This results in the swelling of the legs. 3. Incorrect:
Hypoalbuminemia may cause damage to the kidneys. Proteinuria is indicative of renal
disease or damage. 4. Incorrect: There may be a increased accumulation of fluid in the
abdomen. The ascites is due to the decreased albumin level in the vascular space, which also
causes damage to the liver.
A nurse is attempting to develop trust with a psychiatric client exhibiting concrete thinking.
Which nursing intervention would promote trust in this individual? You answered this
question Incorrectly 1. Attend an activity with the client who is reluctant to go alone. 2.
Allow the client to break an insignificant rule. 3. Consider client preferences when possible in
decisions concerning care. 4. Provide a blanket when the client is cold. 5. Provide food when
the client is hungry. correct answers RationaleStrategies 1., 3., 4. & 5. Correct: Trust is
demonstrated through nursing interventions that convey a sense of warmth and care to the
client. These interventions are initiated simply, concretely, and directed toward activities that
address the client's basic needs for physiological and psychological safety and security.
Concrete thinking focuses thought processes on specifics, rather than generalities, and
immediate issues, rather than eventual outcomes. Examples of nursing interventions that
would promote trust in an individual who is thinking concretely include such things as:
providing a blanket when the client is cold, providing food when the client is hungry, keeping
promises, being honest, providing a written, structured schedule of activities, attending
activities with the client if he is reluctant to go alone, being consistent in adhering to unit
guidelines, and taking the client's preferences, requests, and opinions into consideration when
possible in decisions concerning care. 2. Incorrect: The client should be informed of all rules,
simply and clearly, with reasons for certain policies and rules. Be consistent and provide
written, structured, scheduled activities. Allowing a client to break a rule would not
encourage them to think about the outcomes of their actions.
,A charge nurse is planning care for several clients on the unit. Which activities can the nurse
safely delegate to an unlicensed assistive personnel (UAP)? You answered this question
Incorrectly 1. Administer a nebulizer treatment to a client diagnosed with pneumonia. 2.
Obtain vital signs on a postoperative client who required naloxone 5 minutes ago. 3. Report a
urinary output (UOP) less than 50 ml/hr on a post-op client. 4. Assist a client with obtaining a
clean catch urine sample. 5. Remove an indwelling urinary catheter from a client. correct
answers RationaleStrategies 3., & 4. Correct: A UAP can report the amount of UOP but
cannot interpret it. A clean catch urine sample is a noninvasive procedure. The UAP can
assist the client to obtain the clean catch urinary sample. Both activities are the right person
and right task of delegation. 1. Incorrect: A UAP cannot administer medications. This is the
wrong task for an UAP. 2. Incorrect: The client received naloxone to reverse the action of an
opioid medication. A UAP should not be assigned to obtain vital signs on an unstable client.
This is the wrong person to perform removal of an indwelling urinary catheter. 5. Incorrect:
A UAP cannot remove an indwelling urinary catheter.
Which interventions should the nurse initiate to lessen acid reflux in a client diagnosed with
gastroesophagel reflux disease (GERD)? You answered this question Correctly 1. Provide
small, frequent meals. 2. Avoid carbonated beverages. 3. Administer omeprazole as
prescribed. 4. Assist with smoking cessation. 5. Place in left lateral position for 2 hours after
eating. correct answers RationaleStrategies 1., 2., 3., & 4. Correct: All of these actions are
correct to help alleviate dyspepsia. When a client has GERD, the stomach's contents reflux
into the esophagus. Small frequent meals will decrease possible reflux by decreasing the
stomach content. Smoking can relax the lower muscle of the esophagus. Drinking a
carbonated drink may cause the stomach to expand. Both smoking and drinking a carbonated
drink increase the potential of reflux. The action of omeprazole is to reduce the acid that is
produced in the stomach. 5. Incorrect: The client should be positioned with the head of the
bed (HOB) elevated for 2-3 hours after eating. This position will decrease the potential for
esophageal reflux.
A nurse from the neonatal unit is transferred to the adult medical-surgical unit. Which client
should the charge nurse assign to the neonatal nurse? You answered this question Incorrectly
1. Undergoing surgery for placement of a central venous catheter. 2. Diagnosed with
leukemia, hospitalized for induction of high-dose chemotherapy. 3. Receiving IV heparin for
left leg thrombosis. 4. Admitted with a cerebrovascular accident. correct answers
RationaleStrategies 1. Correct: This is the most stable client to give to the nurse who was
transferred from the neonatal unit. A neonatal nurse cares for central lines daily in this
specialty area and can transfer this knowledge to the adult client. 2. Incorrect: This is not a
good client for a neonatal nurse because knowledge of lab values, chemotherapy precautions,
protective isolation and chemotherapy drugs is required for the nurse in order to care for this
client. 3. Incorrect: This is not the best client for a neonatal nurse because thrombosis
problems are not commonly seen in the nursery. Monitoring clotting factors and being aware
of signs and symptoms of pulmonary emboli are essential for safe care of this client. 4.
Incorrect: This client is very unstable and requires skilled observation and assessment using
the Glasgow Scale. This level of assessment is not utilized in a neonatal unit.
A client with a history of increasing dyspnea over the past week comes to the emergency
department. After arterial blood gases (ABGs) are drawn, which information would be
important for the nurse to document? You answered this question Correctly 1. The client had
not been NPO prior to the test. 2. The client was on 2 L of oxygen by nasal canula. 3. Lung
sounds are wet. 4. Client is sitting in upright position. correct answers RationaleStrategies 2.
, Correct: The fact that the client is on 2 L/min of oxygen will affect the analysis of the ABG
results. If the client is on oxygen, the partial pressure of oxygen (PO2) will be elevated due to
the increased inhaled oxygen. 1. Incorrect: Whether the client has eaten or been NPO will not
affect the evaluation of the ABG results. 3. Incorrect: An assessment of the client's lung
sounds must be performed for a client with a history of dyspnea. This assessment will not
directly affect the ABGs result. 4. Incorrect: The client's position will not directly affect the
evaluation of the ABG results.
The nurse is providing care to a client who has a large abdominal dressing. Which
intervention is most likely to reduce the risk of skin irritation due to frequent dressing
changes? You answered this question Correctly 1. Use a paper tape for adhering the dressing.
2. Use tape sparingly. 3. Secure the dressing with Montgomery straps. 4. Change the dressing
only if it becomes saturated with drainage. correct answers RationaleStrategies 3. Correct:
Montgomery straps will allow the dressing to be held in place without the use of tape. The
adhesive on the ends of the straps is the only adhesive used. 1. Incorrect: Paper tape may be
less irritating; however, with repeated changes, skin irritation is more likely. Montgomery
straps will decrease the repeated tape changes. 2. Incorrect: Use of the tape should be
sufficient to secure the dressing and applied in a way to allow mobility if placed over a joint.
There still is an increase of skin irritation from applying the tape. 4. Incorrect: The soiled
dressing is a medium for bacteria growth. The dressing should be changed as ordered or
required.
A newborn in a neonatal unit is to receive penicillin G benzathine 50,000 units/kg
intramuscularly (IM). The newborn weighs 6 lbs (2.7 kg). The dispensed dose is 25,000 units
per 1 mL. What should the nurse do? You answered this question Incorrectly 1. Administer
the drug intravenously (IV) since a large volume is required. 2. Choose three injection sites
and give the medication as prescribed. 3. Consult with the pharmacy for a different
medication concentration. 4. Read the available drug information to determine how to
administer the medication. correct answers RationaleStrategies 3. Correct: The nurse must
consult with the pharmacy to receive further instructions. The dose is greater than the allowed
volume to be given IM, which warrants clarification by the pharmacy. 1. Incorrect: Since the
drug is prescribed IM, the route should not be changed to IV administration because this
violates the prescription as written. 2. Incorrect: The dose is greater than the allowed volume
to be given IM, which warrants clarification by the pharmacy. You want to avoid having to
give three injections. 4. Incorrect: The concern is not drug information or administration; it is
the concentration, which can only be provided by the pharmacy.
A nurse is preparing to conduct a presentation on barriers to therapeutic communication with
clients from a culture other than the nurse's culture. Which points should the nurse include in
the presentation? You answered this question Incorrectly 1. Lack of knowledge about a
client's culture is a major barrier to therapeutic communication. 2. Follow cultural beliefs
when caring for all clients of that particular culture. 3. Ethnocentrism facilitates therapeutic
communication. 4. Do not touch the client until you know what the cultural belief is about
touching. 5. Adapt care to client's cultural needs and preferences. correct answers
RationaleStrategies 1., 4. & 5. Correct: Nurses must understand and take into consideration
the cultural differences of their clients. Some cultures do not approve of touching or shaking
hands. By assessing the client's culture preference, the nurse is able to provide individualized
care. 2. Incorrect: Do not stereotype all clients of a certain culture. Ask questions. Allow for
individuality. To provide culturally competent care, the nurse must recognize individual
preferences within the client's culture. 3. Incorrect: Ethnocentrism is the belief that one's own
