HURST READINESS EXAM 2
COMPREHENSIVE CERTIFICATION TEST
PAPER QUESTIONS AND SOLUTIONS
GRADED A PLUS VERIFIED
●● 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
Answer: 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.
Answer: 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.
Answer: 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)
Answer: 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).
COMPREHENSIVE CERTIFICATION TEST
PAPER QUESTIONS AND SOLUTIONS
GRADED A PLUS VERIFIED
●● 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
Answer: 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.
Answer: 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.
Answer: 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)
Answer: 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).
