Nursing Clinical Hurst Examination: Serotonin Syndrome Recognition, Myoclonus
Assessment, Schizophrenia Management, Chlorpromazine Therapy, Benztropine
Intervention, Extrapyramidal Symptoms, Infection Control, Protective Isolation,
Agranulocytosis Precautions, Postoperative Laryngectomy Care, Airway
Management, Central Venous Pressure Monitoring, Fluid Volume Excess,
Metabolic Alkalosis Interpretation, Respiratory Alkalosis Analysis,
Glomerulonephritis Pathophysiology, Diuresis Promotion, Pancreatitis
Management, Nasogastric Suction Therapy, Intracranial Pressure Assessment,
Neurological Status Monitoring, Postpartum Hemorrhage Identification, Perineal
Pad Saturation Evaluation, Pediatric Developmental Guidance, Sibling
Adaptation Strategies, Guthrie Test Screening, Phenylketonuria Detection,
Pneumonia Secretion Clearance, Incentive Spirometry Education, Suicide Risk
Assessment, Violence Cycle Awareness, Ethical Nursing Practice, and Advance
Directive Documentation Exam Questions Verified and Provided with Complete
A+ Graded Rationales Latest Updated 2026
What medication should the nurse anticipate giving to a client in preterm labor to stimulate
maturation of the baby's lungs?
1. Magnesium sulfate 2. Terbutaline 3. Methotrexate 4. Betamethasone
Rationale
4. 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. 1.
Incorrect: Magnesium sulfate is given to stop preterm labor, however, if delivery is imminent,
then Betamethasone should be given to stimulate maturation of the baby's lungs. 2. Incorrect:
Terbutaline is contraindicated in preterm labor, however, if delivery is imminent, then
Betamethasone should be given to stimulate maturation of the baby's lungs. 3. Incorrect:
Methotrexate is used to stop the growth of the embryo in ectopic pregnancy so that the
fallopian tube can be saved. It is not an agent used in the management of preterm labor.
,An adult client has just returned to the nursing care unit following a gastroscopy. Which
intervention should the nurse include on the plan of care?
1. Vital sign checks every 15 min x 4 2. Supine position for 6 hours 3. NPO until return of gag
reflex 4. Irrigate NG tube every 2 hours 5. Raise four siderails
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. 2. Incorrect: Supine position for 6 hours is
contraindicated. The HOB should be elevated. In the event the client vomits, he/she is less likely
to aspirate with the HOB elevated. Supine position for 6 hours is used after a heart
catheterization. 4. Incorrect: A client who is going for a gastroscopy procedure cannot have a
nasal gastric tube. An NG tube would interfere with the procedure. 5. Incorrect: Raising all side
rails is a form of restraint. Have the bed in low locked position. Raise three side rails, and have
call light within reach.
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?
1. 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. 4. Ask the LPN/LVN to assess the client for pain.
Rationale
3. 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. 1. Incorrect: This is an appropriate action, but does not address the problem of lowering
,the client's blood pressure. 2. Incorrect: This is an appropriate action, but does not address the
problem of lowering the client's blood pressure. 4. Incorrect: This is an appropriate action, but
does not address the problem of lowering the client's blood pressure.
A client suffers from migraine headaches. What assessment finding would the nurse expect to
find during a migraine attack?
1. Unilateral, pulsating pain quality. 2. Bilateral, pressing/tightening pain quality. 3. Ipsilateral
nasal congestion and rhinorrhea. 4. Headache occurs after recovering from a headache treated
with narcotics.
Rationale
1. 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. 2. Incorrect: This is seen in tension
headaches. Headaches last 30 minutes to 7 days. Pain is mild or moderate in intensity. It is not
aggravated by routine physical activity. Nausea/vomiting, photophobia and phonophobia are
not common manifestations with tension headaches. These usually start gradually, often in the
middle of the day. 3. Incorrect: This is associated with cluster headaches, which are severe or
very severe unilateral orbital, supraorbital and/or temporal pain lasting 15-180 minutes.
Symptoms include stabbing pain in one eye with associated rhinorrhea (runny nose) and
possible drooping eyelid on the affected side. The headaches tend to occur in "clusters":
typically one to three headaches per day (but may be as many as eight) during a cluster period.
4. Incorrect: Overuse of painkillers for headaches, can, ironically, lead to rebound headaches.
Culprits include over the counter medications such as aspirin, acetaminophen or ibuprofen, as
well as prescription medications. Too much medication can cause the brain to shift into an
excited state, triggering more headaches. Also, rebound headaches are a symptom of
withdrawal as the level of medicine drops in the bloodstream. Rebound headaches may have
associated issues such as difficulty concentrating, irritability and restlessness but does not
typically include photophobia or visual disturbances as seen with migraines.
, 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?
1. Creatinine 1.1 mg/dl (97.24 mmol/L) 2. Urinary output of 150 mL per hour. 3. Gradual
increase of BUN levels. 4. Calcium levels of 9.0 mg/dL (2.25 mmol/L)
Rationale
3. Correct. Gradual accumulation of nitrogenous wastes results in elevated BUN and serum
creatinine. This is an indication of impaired renal function. 1. Incorrect. This is a normal
creatinine level. Gradual accumulation of nitrogenous wastes from impaired renal function
results in elevated BUN and serum creatinine. 2. Incorrect. This is a normal output level. This
level alone would not necessarily be an indicator of acute renal failure and that value alone
would not warrant reporting it to the primary healthcare provider. 4. Incorrect. Calcium level of
9.0 mg/dL (2.25 mmol/L) is considered normal. When observing for renal functioning you would
assess the BUN and creatinine levels. In addition, the calcium level may drop (hypocalcemia) in
renal failure inverse relationship change due to the rising serum phosphate levels. However, the
calcium level presented is within normal limits (WNL).
A client has been admitted for exacerbation of ulcerative colitis with severe dehydration. What
is the best indicator that this client has an actual fluid deficit?
1. Stool count of 10 episodes of diarrhea in 24 hours. 2. Weight increase of 2 kg and a 24 hour
output of 1000 mL. 3. Admission weight of 74.3 kg and 2 days later a weight of 72 kg. 4. Daily
intake of 2400 mL and an output of 1600 mL, plus diarrheal stools.
Rationale
3. Correct: Any acute weight gain or loss is fluid. Weight is the best measurement for fluid loss
or gain. Acute weight losses correspond to fluid volume deficits. This client has lost 2.3 kg over a
2 day period, indicating a fluid volume deficit (FVD). 1. Incorrect: Although 10 loose stools
would result in fluid loss, the stool count of 10 episodes of diarrhea is an inaccurate
measurement. The amount of fluid loss can vary depending on the amount of diarrhea, 10
"episodes" does not indicate how much fluid is lost. 2. Incorrect: Weight gains indicate fluid
Assessment, Schizophrenia Management, Chlorpromazine Therapy, Benztropine
Intervention, Extrapyramidal Symptoms, Infection Control, Protective Isolation,
Agranulocytosis Precautions, Postoperative Laryngectomy Care, Airway
Management, Central Venous Pressure Monitoring, Fluid Volume Excess,
Metabolic Alkalosis Interpretation, Respiratory Alkalosis Analysis,
Glomerulonephritis Pathophysiology, Diuresis Promotion, Pancreatitis
Management, Nasogastric Suction Therapy, Intracranial Pressure Assessment,
Neurological Status Monitoring, Postpartum Hemorrhage Identification, Perineal
Pad Saturation Evaluation, Pediatric Developmental Guidance, Sibling
Adaptation Strategies, Guthrie Test Screening, Phenylketonuria Detection,
Pneumonia Secretion Clearance, Incentive Spirometry Education, Suicide Risk
Assessment, Violence Cycle Awareness, Ethical Nursing Practice, and Advance
Directive Documentation Exam Questions Verified and Provided with Complete
A+ Graded Rationales Latest Updated 2026
What medication should the nurse anticipate giving to a client in preterm labor to stimulate
maturation of the baby's lungs?
1. Magnesium sulfate 2. Terbutaline 3. Methotrexate 4. Betamethasone
Rationale
4. 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. 1.
Incorrect: Magnesium sulfate is given to stop preterm labor, however, if delivery is imminent,
then Betamethasone should be given to stimulate maturation of the baby's lungs. 2. Incorrect:
Terbutaline is contraindicated in preterm labor, however, if delivery is imminent, then
Betamethasone should be given to stimulate maturation of the baby's lungs. 3. Incorrect:
Methotrexate is used to stop the growth of the embryo in ectopic pregnancy so that the
fallopian tube can be saved. It is not an agent used in the management of preterm labor.
,An adult client has just returned to the nursing care unit following a gastroscopy. Which
intervention should the nurse include on the plan of care?
1. Vital sign checks every 15 min x 4 2. Supine position for 6 hours 3. NPO until return of gag
reflex 4. Irrigate NG tube every 2 hours 5. Raise four siderails
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. 2. Incorrect: Supine position for 6 hours is
contraindicated. The HOB should be elevated. In the event the client vomits, he/she is less likely
to aspirate with the HOB elevated. Supine position for 6 hours is used after a heart
catheterization. 4. Incorrect: A client who is going for a gastroscopy procedure cannot have a
nasal gastric tube. An NG tube would interfere with the procedure. 5. Incorrect: Raising all side
rails is a form of restraint. Have the bed in low locked position. Raise three side rails, and have
call light within reach.
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?
1. 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. 4. Ask the LPN/LVN to assess the client for pain.
Rationale
3. 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. 1. Incorrect: This is an appropriate action, but does not address the problem of lowering
,the client's blood pressure. 2. Incorrect: This is an appropriate action, but does not address the
problem of lowering the client's blood pressure. 4. Incorrect: This is an appropriate action, but
does not address the problem of lowering the client's blood pressure.
A client suffers from migraine headaches. What assessment finding would the nurse expect to
find during a migraine attack?
1. Unilateral, pulsating pain quality. 2. Bilateral, pressing/tightening pain quality. 3. Ipsilateral
nasal congestion and rhinorrhea. 4. Headache occurs after recovering from a headache treated
with narcotics.
Rationale
1. 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. 2. Incorrect: This is seen in tension
headaches. Headaches last 30 minutes to 7 days. Pain is mild or moderate in intensity. It is not
aggravated by routine physical activity. Nausea/vomiting, photophobia and phonophobia are
not common manifestations with tension headaches. These usually start gradually, often in the
middle of the day. 3. Incorrect: This is associated with cluster headaches, which are severe or
very severe unilateral orbital, supraorbital and/or temporal pain lasting 15-180 minutes.
Symptoms include stabbing pain in one eye with associated rhinorrhea (runny nose) and
possible drooping eyelid on the affected side. The headaches tend to occur in "clusters":
typically one to three headaches per day (but may be as many as eight) during a cluster period.
4. Incorrect: Overuse of painkillers for headaches, can, ironically, lead to rebound headaches.
Culprits include over the counter medications such as aspirin, acetaminophen or ibuprofen, as
well as prescription medications. Too much medication can cause the brain to shift into an
excited state, triggering more headaches. Also, rebound headaches are a symptom of
withdrawal as the level of medicine drops in the bloodstream. Rebound headaches may have
associated issues such as difficulty concentrating, irritability and restlessness but does not
typically include photophobia or visual disturbances as seen with migraines.
, 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?
1. Creatinine 1.1 mg/dl (97.24 mmol/L) 2. Urinary output of 150 mL per hour. 3. Gradual
increase of BUN levels. 4. Calcium levels of 9.0 mg/dL (2.25 mmol/L)
Rationale
3. Correct. Gradual accumulation of nitrogenous wastes results in elevated BUN and serum
creatinine. This is an indication of impaired renal function. 1. Incorrect. This is a normal
creatinine level. Gradual accumulation of nitrogenous wastes from impaired renal function
results in elevated BUN and serum creatinine. 2. Incorrect. This is a normal output level. This
level alone would not necessarily be an indicator of acute renal failure and that value alone
would not warrant reporting it to the primary healthcare provider. 4. Incorrect. Calcium level of
9.0 mg/dL (2.25 mmol/L) is considered normal. When observing for renal functioning you would
assess the BUN and creatinine levels. In addition, the calcium level may drop (hypocalcemia) in
renal failure inverse relationship change due to the rising serum phosphate levels. However, the
calcium level presented is within normal limits (WNL).
A client has been admitted for exacerbation of ulcerative colitis with severe dehydration. What
is the best indicator that this client has an actual fluid deficit?
1. Stool count of 10 episodes of diarrhea in 24 hours. 2. Weight increase of 2 kg and a 24 hour
output of 1000 mL. 3. Admission weight of 74.3 kg and 2 days later a weight of 72 kg. 4. Daily
intake of 2400 mL and an output of 1600 mL, plus diarrheal stools.
Rationale
3. Correct: Any acute weight gain or loss is fluid. Weight is the best measurement for fluid loss
or gain. Acute weight losses correspond to fluid volume deficits. This client has lost 2.3 kg over a
2 day period, indicating a fluid volume deficit (FVD). 1. Incorrect: Although 10 loose stools
would result in fluid loss, the stool count of 10 episodes of diarrhea is an inaccurate
measurement. The amount of fluid loss can vary depending on the amount of diarrhea, 10
"episodes" does not indicate how much fluid is lost. 2. Incorrect: Weight gains indicate fluid
