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Hurst Readiness Exam 2
What medication should the nurse anticipate giving to a client in preterm labor to stimulate maturation of the baby's lungs?
- Magnesium sulfate
- Terbutaline
- Methotrexate
- Betamethasone
Rationale
- Correct: Betamethasone is used to stimulate maturation of the baby's lungs in case preterm birth occurs. This medication is given to help prevent respiratory distress syndrome (RDS) by improving storage and secretion of surfactant that helps to keep the alveoli from collapsing.
An adult client has just returned to the nursing care unit following a gastroscopy. Which intervention should the nurse include in the plan of care?
- Vital sign checks every 15 min x 4
- Supine position for 6 hours
- NPO until return of gag reflex
- Irrigate NG tube every 2 hours
- Raise four side rails
Rationale
1., & 3. Correct: Vital signs post-procedure are important to monitor for any post-procedure complications such as bleeding or any signs of respiratory compromise. VS are checked frequently for the first-hour post-procedure. Any client who has a scope inserted down the throat and has received numbing medication in the back of the throat to depress the gag reflex should be kept NPO until the gag reflex returns.
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?
- 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.
- Ask the LPN/LVN to assess the client for pain.
Rationale
- 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.
A client suffers from migraine headaches. What assessment finding would the nurse expect to find during a migraine attack?
- Unilateral, pulsating pain quality.
- Bilateral, pressing/tightening pain quality.
- Ipsilateral nasal congestion and rhinorrhea.
- Headache occurs after recovering from a headache treated with narcotics.
Rationale
- Correct: Migraine headaches have a pulsating pain quality, unilateral location, moderate or severe pain intensity, aggravated by or causing avoidance of routine physical activity (walking, climbing stairs). During headache at least one of the following accompanies the headache: nausea and/or vomiting; photophobia and phonophobia..
The nurse is caring for a client who was admitted to the hospital following a severe motor vehicle crash (MVC) in which the client was trapped in the car for several hours. The client is being closely monitored for the development of renal failure. Which assessment finding would warrant immediate reporting?
Rationale
1., 2., & 3. Correct These clients are stable and require predictable care that can be done appropriately by the LPN/VN
The triage nurse in the emergency department (ED) assesses 4 clients. Which client is in need of emergent care?
- A 52 year old who has a partially amputated finger.
- A 9 month old with temperature of 103°F (39.4°C).
- A two year old with excessive drooling and a weak cough.
- A 28 year old experiencing a migraine headache for three days.
Rationale
- Correct: The two year old is exhibiting signs of respiratory difficulty with excessive drooling and a weak cough. Partial airway obstruction is likely and maybe the result of acute epiglottitis in which rapid progression to severe respiratory distress can occur. Airway takes priority over the other clients.
A new nurse has a prescription to insert a feeding tube. The new nurse has never performed the procedure, but learned how to do it while in nursing school. What would be the best action by this nurse?
- Ask to observe another nurse perform the procedure.
- Look up how to perform the procedure in the policy and procedure manual.
- Tell the charge nurse that someone else will have to place the feeding tube down the client.
- Insert the feeding tube as learned in nursing school.
Rationale
- Correct. The best action for the nurse to take is to look up how the procedure is done in the agency by looking it up in the policy and procedure manual. The nurse could then discuss the procedure with an experienced nurse and ask the nurse to observe the new nurse while inserting the feeding tube.
How would the nurse determine the correct size oropharyngeal airway for a client?
- Select the same size as the little finger of the victim.
- Measure from the tip of the lips to the epiglottis.
- Determine the length from the earlobe to the xiphoid process.
- Measure from the earlobe to the corner of the mouth.
Rationale
- Correct: An airway of proper size will extend from the corner of the client's mouth to the tip of the earlobe on the same side of the client's face
A client, who only speaks Spanish, is admitted to the surgical unit. What is the best method for the nurse to inform the client about a pre-surgical procedure?
- Use an audiotape made in Spanish to inform the client of the pre-surgical procedure.
- Draw pictures of what the client can expect prior to surgery.
- Facial expressions and gestures can be used to let the client know what to expect.
- Enlist the help of a Spanish speaking family friend to tell the client what to expect prior to surgery.
Rationale
- Correct: Audiotapes made in the language of high volume clients who speak a language other than English is helpful to inform clients about admission procedures, room and unit orientation, and pre-surgical procedures. The tapes are received from sources where reliability of information is provided. This is the most reliable option for providing accurate information.
To reduce the risk of developing a complication following balloon angioplasty, the nurse should implement which measure?
- Monitor cardiac rhythm
- Assess the puncture site every 8 hours
- Measure urinary output hourly
- Prevent flexion of the affected leg
Rationale
1., 2. & 5. Correct: Initially meet the client's dependency needs as required to keep anxiety from escalating. Anything that increases the client's anxiety tends to increase the ritualistic behavior. Positive reinforcement for nonritualistic behavior takes the focus off of the ritual. A lack of attention to ritualistic behaviors can help to decrease the ritual. By creating a regular schedule when the client goes to the bathroom, (where the handwashing ritual occurs most frequently) allows the client a structured but limited time for the ritual. This can help give the client a sense of control of the maladaptive behavior until the client can start setting own limits on the behavior and develop more adaptive coping mechanisms
An angry client visits the primary healthcare provider's office and requests a copy of their medical records. The client is angry after being placed on hold several times for over 10 minutes when requesting an appointment. What should the nurse tell this client?
- All client appointment calls are transferred to the scheduling clerk.
- The client will have to speak to the primary healthcare provider.
- A copy of the record may be obtained within 24 hours of the request.
- Medical records must stay within the facility unless requested by another primary healthcare provider.
Rationale
- Correct: The client has the right to the personal medical record. Generally, a period of time is required to get the record copied. The client may be charged for the copy. This assures the client that the request will receive attention
Question: A client is preparing to be discharged after a total hip replacement. Which statements, if made by the client, would indicate to the nurse that teaching has been successful regarding prevention of hip prosthesis dislocation?
- I should not cross my affected leg over my other leg.
- I should not bend at the waist more than 90 degrees.
- While lying in bed, I should not turn my affected leg inward.
- It is necessary to keep my knees together at all times.
- When I sleep, I should keep a pillow between my legs.
Rationale
1., 2., 3. & 5. Correct: One of the most common problems after hip surgery is dislocation. Until the hip prosthesis stabilizes, it is necessary to follow these instructions for proper positioning to avoid dislocation. Flexion and movement of the leg on the affected side past midline should be avoided. 4. Incorrect: The knees should be kept apart at all times. This is called abduction and is needed to keep the new head of the femur (prosthetic device) in the acetabulum and therefore prevent hip dislocation until healing occurs and tissues are strong enough to hold the joint in place. pa-
Question: A female client taking captopril for hypertension tells the clinic nurse that she is planning to get pregnant. What recommendation should the nurse make?
- "Captopril can be taken safely during pregnancy, but we will need to decrease your dose so you do not become hypotensive."
- "We will need to increase your dose of captopril once you become pregnant."
- "In order to prevent neural tube defects, start taking folic acid."
- "Captopril can cause serious harm to an unborn baby, so you must prevent pregnancy while taking this medication. "
Rationale
- Correct: Captopril should not be taken during pregnancy because serious harm (possibly fatal) to the unborn baby can result when taken during pregnancy
Question: The RN is caring for a client diagnosed with an abdominal aortic aneurysm. Which prescription can the RN delegate to the LPN?
- Obtain vital signs every 15 minutes.
- Insert a urinary catheter for hourly urinary outputs.
- Place a PICC line for fluid management.
- Provide morphine 1 mg per PCA pump at a 10 minute lockout.
Rationale
- Correct. Inserting a urinary catheter is within the scope of practice for the LPN. This task does
Which interventions should be included in the plan of care for an adult client with constipation?
- Allow adequate time for defecation.
- Provide privacy for bowel elimination.
- Suggest increasing fluid intake (unless contraindicated).
- Encourage client to increase fiber in the diet.
- Encourage the client to delay the urge to defecate until after a meal.
Rationale
1., 2., 3. & 4. Correct: Clients should have ample time for defecation. Rushing the client may lead to a client ignoring the urge. Since clients may be hesitant to have a bowel movement in the presence of others, privacy should be provided. (The nurse may need to stay with weak or disabled clients.) Increasing fluid intake will lead to softer stools. This makes defecation easier. Fiber deficiencies may contribute to constipation. Fiber in the diet adds bulk to the stools which help them pass more readily through the intestines.
The occupational health nurse is caring for an employee after a chemical explosion at the local tire factory. The client reports a foreign body in the right eye. The right eye is watery, and the client reports photophobia. Which nursing action takes priority?
- Evert eyelid and examine for foreign body.
- Measure visual acuity.
- Notify the receiving hospital immediately for the transfer of the client.
- Place an eye shield over the eye.
Rationale
- Correct: If a foreign body is the result of the explosion or blunt or sharp trauma, the eye should be protected from further damage by placing an eye shield over the eye (or if a shield is not available, a paper cup to prevent rubbing of the eye). Then make arrangements to transport the client for emergency care by an ophthalmologist. If the movement of the unaffected eye creates movement in the affected eye, it may be necessary to cover the unaffected eye also to prevent further injury to the eye from movement
The nurse in the emergency department suspects that a client's lesion is caused by anthrax. What assessment question is most important?
- Have you traveled out of the United States recently?
- Have you recently worked with any farm animals or any animal-skin products?
- Have you experienced any gastrointestinal upset recently?
- Have you eaten any home-canned foods recently?
Rationale
- Correct: Cutaneous anthrax may be contracted by working with contaminated animal-skin products. Anthrax is found in nature and commonly infects wild and domestic hoofed animals. 1. Incorrect: Cutaneous anthrax is also found in the United States, so asking about travel abroad would not be necessary
A client was admitted to the medical unit with pneumonia 2 days ago. There is a history of drinking 5-6 martinis every night for the past 2 years. Today, the nurse notes that the client is disoriented to time and place and is seeing imaginary spiders on the ceiling. The nurse cannot understand what the client is saying. What is this client most likely experiencing?
- Wernicke's Encephalopathy
- Korsakoff's Psychosis
- Alcohol Withdrawal
- Alcohol Withdrawal Delirium
Rationale
- Correct: Alcohol Withdrawal Delirium usually occurs on the second or third day following cessation of or reduction in prolonged, heavy alcohol use. Symptoms are the same as for delirium: Difficulty sustaining and shifting attention. Extremely distractible; disorganized thinking; rambling, irrelevant, pressured, and incoherent speech; impaired reasoning ability; disoriented to time and place; impairment of recent memory; delusions and hallucinations
A low income family with children lives in an old, run-down apartment building situated close to a salvage yard in a poor neighborhood. Which area of assessment would be most important for the home health nurse?
- Immunization status
- School-related problems
- Tell me more about your thoughts.
Rationale
- Correct: The client's delusions can be very distressing. The nurse should empathize with the feelings of the client, but should not validate the belief itself. Empathy displays that the nurse is concerned, interested, and accepts the client but does not support the delusion
An elderly male, diagnosed with chronic renal failure and depression, lives alone. Which question should the home health nurse ask first when assessing this client?
- Have you had suicidal thoughts in the past?
- How are you feeling today?
- Have you had thoughts of harming yourself?
- Do you have guns in your home?
Rationale
- Correct: Suicide assessment should begin with direct questions about the presence of suicidal thinking. The nurse should recognize that elderly men are at higher risk for committing suicide, especially those with a history of depression, chronic illness and isolation
The nurse is caring for a client who is receiving a prostaglandin agonist for the treatment of glaucoma. Which comment by the client indicates a lack of understanding of the treatment regimen?
- I must only use the drops in the eye with the increased pressure.
- My eyes may be different colors, so I will use the drops in both eyes.
- I must be careful not to overmedicate even if it is just an eye drop.
- The eyelashes in the eye with the higher pressure may get longer.
Rationale
- Correct: The color of the iris may darken in the eye being treated; however, it is important that the client understand that drops should not be placed in the unaffected eye. Prostaglandins cause increased permeability in the sclera to aqueous fluid. So, as the prostaglandin agonist increases this activity, the outflow of aqueous fluid increases and the ocular pressure decreases. Administering the drops in the unaffected eye may result in a subnormal intraocular pressure
The nurse is planning care for a pediatric client reporting acute pain with sickle cell crisis? What should the nurse identify as an appropriate goal for this client?
- Client will report a pain level of less than
2 on a Faces scale. 2. The nurse will administer prescribed pain meds around the clock.
- Client will only take breakthrough pain medication.
- Client will use distraction instead of pain medication.
Rationale
- Correct: Yes, having a pain level of less than
What measures should the unit nurse initiate after admitting a client who had a chest tube inserted for pleural effusion of the right lung?
- Place in semi-Fowler's position.
- Connect to oxygen saturation monitor.
- Assess respiratory status every 2 hours.
- Prevent dependent loops in closed drainage unit tubing.
- Maintain closed drainage unit at the level of the client's chest.
Rationale
1., 2., 3., & 4. Correct: A pleural effusion is a collection of fluid in the pleural space that moves to the bottom of the chest cavity when upright. The semi-Fowler's position allows the client to be in an upright position to promote drainage and facilitate ease of respirations by promoting lung expansion. Since lung expansion is compromised with a pleural effusion, the oxygen level should be assessed using an oxygen saturation monitor. The client's respiratory status should be assessed at least every 2 hours: respiratory rate, work of breathing, breath sounds, pulse oximetry. The development of kinks, loops, or pressure on the drainage tubing can produce back pressure, which may force fluid back into the pleural space or interfere with the drainage
A home health nurse inspects the home of a client scheduled to be discharged home after receiving care for a cerebrovascular accident with generalized weakness. What safety interventions should the nurse recommend based on findings within the home?
an understanding of an acceptable food to eat?
- Smoked turkey and dressing, sweet peas and carrots and milk.
- Baked chicken over pasta with parmesan sauce, baked potato and tea.
- Fried catfish, French fries, coleslaw and apple juice.
- Liver smothered in gravy and onions, rice, squash and water.
Rationale
- Correct: These foods are not high in tyramine. Tyramine is an amino acid that helps in the regulation of blood pressure. MAOIs block the enzyme monoamine oxidase which is responsible for breaking down excess tyramine in the body. Eating foods high in tyramine while on MAOIs can result in dangerously high levels of tyramine in the body. This can lead to a serious rise in blood pressure, creating an emergency situation. Tyramine is found in protein-containing foods and the levels increase as these foods age. Food such as strong or aged cheese, cured meats, smoked or process meats, liver (especially aged liver), pickled or fermented foods, sauces, soybeans, dried or overripe fruits, meat tenderizers, brewer's yeast, alcoholic beverages and caffeine- such as in tea, cokes and coffee are considered to be high in tyramine and should be avoided in clients taking MAOIs.
A client diagnosed with serotonin syndrome is admitted to the unit. The nurse is familiar with this adverse reaction to the serotonin reuptake inhibitors. Which symptoms can the nurse expect on assessment?
- Fever and shivering
- Agitation
- Decreased body temperature
- Constipation
- Increased heart rate
Rationale
1., 2. & 5. Correct: Serotonin syndrome is a group of symptoms that can result from the use of certain serotonin reuptake inhibitors. These symptoms can range from mild to severe and include high body temperature, agitation, increased reflexes, diaphoresis, tremors, dilated pupils and diarrhea. The client is likely to experience shivering with fever. Increased heart rate and blood pressure are also commonly experienced. More severe symptoms, including muscle rigidity and seizures, can occur. If not treated, serotonin syndrome can be fatal
The nurse on a neuro-rehabilitation unit is caring for a client with a T4 lesion. The client suddenly reports a severe, pounding headache. Profuse diaphoresis is noted on the forehead. The blood pressure is 180/112 and the heart rate is 56. What interventions should the nurse initiate?
- Place client supine with legs elevated.
- Assess bladder and bowel for distention.
- Examine skin for pressure areas.
- Eliminate drafts.
- Remove triggering stimulus.
- Administer hydralazine if BP does not return to normal.
Rationale
2., 3., 4., 5. & 6. Correct: The client is experiencing autonomic dysreflexia, which is a potentially dangerous syndrome that can develop in clients with spinal cord injuries. The cause of autonomic dysreflexia with these associated symptoms is a strong sensory or noxious stimulus. The most common stimulus is bowel, bladder distention, or irritation. Any painful, irritating or strong stimulus including environmental temperature changes, drafts, etc. can trigger autonomic dysreflexia. It is considered a medical emergency and must be promptly treated.
A healthy newborn has just been delivered and placed in the care of the nurse. What nursing actions should the nurse initiate? Place in the correct priority order.
Bulb suction excessive mucus.
Assess newborn's airway and breathing.
Assess newborn's heart rate.
Administer sterile ophthalmic ointment containing 0.5% erythromycin.
Place identification bands on newborn and mom.
Rationale
Remember Maslow's hierarchy of needs will guide your assessment. First, Assess newborn's airway and breathing. The most critical change that a newborn must make physiologically is the initiation of breathing. The nurse should assess the newborn's crying. If the cry is weak, it may indicate a respiratory disturbance. Other signs of respiratory compromise may include: stridor,
clients would be most appropriate for the charge nurse to assign to the RN?
- 2 - year-old with asthma receiving IV medication.
- 6 - year-old with new onset seizures.
- 12 - year-old with colitis receiving TPN.
- 2-month-old with urinary tract infection.
- 10-year-old paraplegic needing assistance with bowel training.
Rationale
1., 2., 3. Correct: These clients should be assigned to the RN as they will require more frequent assessment due to the nature of each diagnosis and have a potential for more rapid change in condition. Also, these clients may require skills by the RN that the LPN/VN could not do; for example, giving IV medications that asthma clients take; teaching the family about seizures, meds, and management; and administering TPN intravenously
The nurse is caring for a client admitted to the psychiatric unit with a diagnosis of major depression. What behaviors could the nurse expect upon assessment of this client?
- Withdrawn behavior
- Sitting in room, lights out, drapes closed
- Unkempt appearance
- Overeating
- Severe insomnia
Rationale
1., 2., 3., & 5. Correct: The client with severe depression has extremely low self-esteem and low energy levels and may just sit for hours. Depressed clients prefer to be alone and avoid social interactions. The room environment mimics the mood of the client (dark and gloomy). The client may not have the energy to bathe, change clothes, or even comb hair. The severely depressed person may have severe insomnia. However, sleeping too much is also a symptom of mild depression
A child is being admitted with possible rheumatic fever. What assessment data would be most important for the nurse to obtain from the parent?
- 102° F (38.89° C) temperature that started 2 days previously.
- History of pharyngitis approximately 4 weeks ago.
- Vomiting for 3 days.
- A cough that started about 1 week earlier.
Rationale
- 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.
A nurse is planning to provide information regarding suicide to a high school assembly. What information should the nurse include?
- Do not keep secrets for the suicidal person.
- Express concern for a person expressing thoughts of suicide.
- Teens often don't mean what they say, so only take suicide seriously if grades are dropping as well.
- Inform group of suicide intervention sources.
- Do not leave a suicidal person alone.
Rationale
1., 2., 4. & 5. Correct: If a person reveals that suicide is being considered, this should never be kept secret. Help should be sought for the person immediately. It is also important to be direct and non-secretive with suicidal clients. It is appropriate to express concern for their thoughts. The use of empathy, warmth and concern indicates to the client that their feelings are being understood and viewed as real, which helps to build trust with the client. Resources for assistance are important to include in all health teaching programs. The teens need to know what resources are readily available if someone is considering suicide. The client contemplating suicide should not be left alone. This is for the client's safety until further assistance can be
