Hurst Readiness Exam 4: Questions

Hurst Readiness Exam 4: Questions &

Answers

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)?

• Administer a nebulizer treatment to a client diagnosed with pneumonia.
• Obtain vital signs on a postoperative client who required naloxone 5

minutes ago.

• Report a urinary output (UOP) less than 50 ml/hr on a post-op client.
• Assist a client with obtaining a clean catch urine sample.
• Remove an indwelling urinary catheter from a client.

(Ans- 3,4

What should the nurse teach a pregnant client who comes to the clinic reporting hemorrhoids and constipation?

• Increased rectal pressure from the gravid uterus may result in

hemorrhoids.

• Hormones decrease maternal GI motility, resulting in constipation.
• The client needs more fiber in the diet.
• A mild laxative is recommended to alleviate constipation.
• The client needs to increase fluid intake.

(Ans- 1,2,3,5

What statements by a new nurse would indicate to the charge nurse an understanding of how to maintain skin integrity for a client on bedrest?

• "Clients on bedrest should be placed on therapeutic mattresses."
• "I will assess for the skin every 4 hours."
• "I will assess the skin using the Braden scale." 1 / 4

• "A pillow will be placed between the knees when client is side lying."
• "The incontinent client will be kept clean and dry."

(Ans- 1,3,4,5

The primary healthcare provider suspects the client has tuberculosis (TB) and prescribes a Mantoux test. What precautions should the nurse take when administering the Mantoux test?

• Don sterile gloves.
• Place the client on reverse isolation.
• Wear a particulate respirator
• Obtain a consent form.
• Initiate airborne precautions.

(Ans- 3,5

Which finding should a nurse expect when assessing a healthy 65 year old client?

• Anomia
• Presbyopia

3. BP 156/88

• Apraxia

(Ans- 2

The charge nurse is evaluating knowledge of tracheostomy suctioning of a new nurse prior to that procedure being performed. Which statement by the new nurse would indicate to the charge nurse that additional education is needed?

• "Prior to suctioning, I will hyper-oxygenate the client."
• "I will instill normal saline bullets to liquefy secretions."
• "I will allow at least 20 seconds between suctioning passes."
• "Suctioning will be limited to a maximum of three catheter passes."

(Ans- 2

• / 4

The nurse observes a client at a follow-up appointment using correct cane walking technique but losing balance each time the quad cane is lifted off of the floor. The client reports a history of recent falls. What is the best action for the nurse to take?

• Inform the primary healthcare provider of the observations made

regarding quad cane use, and imbalance assessment.

• Inform client that there are only a few assistive devices available to help

with ambulation.

• Instruct the client on proper quad cane use.
• Notify the primary healthcare provider after consulting with the neighbor.

(Ans- 1

The nurse is caring for a newly diagnosed diabetic in diabetic hyperosmolar hyperglycemic nonketotic (HHNK) state. What does the nurse anticipate the immediate treatment plan for this client will include?

• NPH insulin.
• Potassium 40 mEq (40 mmol/L) slow intravenous push.
• Intravenous administration of isotonic saline.
• Intravenous sodium bicarbonate.

(Ans- 3

What is most important for the nurse to do prior to initiating peritoneal dialysis?

• Aspirate for placement.
• Have the client void.
• Irrigate the catheter for patency.
• Warm the dialysate fluid.

(Ans- 4

The nurse in the outpatient clinic performs an assessment on a client who takes propranolol for management of palpitations associated with mitral 3 / 4

valve prolapse. Which statement by the client should be reported immediately to the primary healthcare provider?

• "My resting pulse was 60 this morning."
• "I feel a little short of breath when walking."
• "I have lost 5 pounds in the last 2 weeks."
• "My blood pressure (BP) was lower this visit than last time."

(Ans- 2

Blood and urine samples are sent to the laboratory for a client who has had a spinal cord injury. After reviewing these results, the nurse would expect which finding?

Exhibit

• Gross hematuria
• Septicemia
• Urinary tract infection
• Anemia

(Ans- 3

The nurse is instructing a client on achieving relaxation using deep breathing exercises. Which statement by the client indicates to the nurse that further teaching is necessary?

• "I can perform deep breathing exercises anywhere and at any time that I

feel tension and anxiety."

• "I should sit or lie in a comfortable position, making sure my back is

straight."

• "I will inhale slowly and deeply through my mouth focusing on my chest

expansion."

• "When I have inhaled in as much as possible, I will hold my breath for a

few seconds before exhaling." (Ans- 3

• / 4