HURST READINESS EXAM 4 ASSESSMENT
REVIEW SHEET CERTIFICATION
QUESTIONS AND SOLUTIONS COMPLETE
PREPARATION VERIFIED
●● Post cataract removal a client reports nausea and severe pain in the
operative eye. Which nursing intervention takes priority?.
Answer: 1. Administer morphine and ondansetron.
2. Reposition client to non-operative side.
3. Massage the canthus to unblock the lacrimal duct.
4. Notify the primary healthcare provider.
Correct: notify the primary healthcare provider. This indicates increased
intraocular pressure
●● The nurse is caring for a client who has taken an acetaminophen
overdose. Which symptom is the client most likely to exhibit?.
Answer: 1. Expectorating pink frothy sputum- This is a symptom of
pulmonary edema, not liver damage.
2. Sudden onset of mid-sternal chest pain- This is a symptom of
myocardial ischemia, not liver damage.
3. Jaundiced conjunctiva
,4. Diaphoresis and fever- Acetaminophen would decrease fever, and
fever could cause diaphoresis so neither of these are expected with
acetaminophen overdose.
correct: 3- this is a sign of liver damage which is caused by Tylenol
overdose
●● The home health nurse is assessing the home environment for
possible irritants that could increase/precipitate symptoms of respiratory
problems. Which assessment questions would be important to determine
level of risk?.
Answer: SATA
1. What type of heat do you use in the home?
2. Does anyone in the home have hobbies that involve sanding of wood
or use of chemicals?
3. Is there anyone in the home who smokes?
4. Do you routinely use aerosol sprays for personal care or cleaning?
5. Is your water supply treated by a municipal agency?- water supply
would not affect respiratory status
Correct: 1,2,3,4 Presence of wood smoke could increase respiratory
problems. Poorly vented gas heaters could increase carbon monoxide in
the environment. Use of solvents or other agents that produce irritating
fumes could increase risk. The particles from the sanding could irritate
the respiratory tract as well. Second-hand smoke is irritating to the
respiratory tract. Aerosols could trigger respiratory problems.
,●● A client diagnosed with schizophrenia tells the nurse, "God is going
to heal me. I do not need medication." Which response by the nurse
would best promote compliance with the prescribed medication
regimen?.
Answer: 1. Yes, I believe that God will heal you.
2. Many people of faith believe that one way God works to heal is
through medication.
3. We are talking about taking your medications right now.
4. What if God does not heal you and you should have taken the
medication?
correct: 2 This allows the client to keep the belief that God will heal but
will do it through the medication. This promotes compliance with the
prescribed medication regimen.
●● The nurse is assisting an unlicensed assistive personnel (UAP) move
an obese and dependent client toward the top of the bed. Which action is
most important to prevent shearing forces on the skin?.
Answer: 1. Each person puts hands under the client and slides client
toward the top of the bed.
2. Apply powder to the sheet before pulling client toward the top of the
bed.
3. Place turn sheet under the client and use it to slide the client toward
the top of bed.
, 4. Seek assistance of another person before pulling up in bed.
Correct: 3
●● A client consumes a lacto-ovo vegetarian diet at home. During
hospitalization, the primary healthcare provider prescribes an increased
calorie diet. Which foods are appropriate for the nurse to serve as
between meal snacks to boost caloric intake?.
Answer: 1. Cheese sandwich and milk
2. Boiled eggs but no dairy products
3. Fish sticks and cocktail sausages
4. Fresh vegetables but no milk or eggs
correct: 1- this is because a lacto-ovo diet allows for dairy and eggs to be
eaten but does not include meat
●● The postanesthesia care unit has received several postoperative
clients. While encouraging the clients to cough and deep breathe, the
nurse realizes that coughing poses thegreatest risk to which client?.
Answer: 1. A female with an abdominal hysterectomy- we want client to
cough and deep breathe to prevent atelactisis
2. A male who had a right upper lobectomy- want client to cough and
deep breathe
REVIEW SHEET CERTIFICATION
QUESTIONS AND SOLUTIONS COMPLETE
PREPARATION VERIFIED
●● Post cataract removal a client reports nausea and severe pain in the
operative eye. Which nursing intervention takes priority?.
Answer: 1. Administer morphine and ondansetron.
2. Reposition client to non-operative side.
3. Massage the canthus to unblock the lacrimal duct.
4. Notify the primary healthcare provider.
Correct: notify the primary healthcare provider. This indicates increased
intraocular pressure
●● The nurse is caring for a client who has taken an acetaminophen
overdose. Which symptom is the client most likely to exhibit?.
Answer: 1. Expectorating pink frothy sputum- This is a symptom of
pulmonary edema, not liver damage.
2. Sudden onset of mid-sternal chest pain- This is a symptom of
myocardial ischemia, not liver damage.
3. Jaundiced conjunctiva
,4. Diaphoresis and fever- Acetaminophen would decrease fever, and
fever could cause diaphoresis so neither of these are expected with
acetaminophen overdose.
correct: 3- this is a sign of liver damage which is caused by Tylenol
overdose
●● The home health nurse is assessing the home environment for
possible irritants that could increase/precipitate symptoms of respiratory
problems. Which assessment questions would be important to determine
level of risk?.
Answer: SATA
1. What type of heat do you use in the home?
2. Does anyone in the home have hobbies that involve sanding of wood
or use of chemicals?
3. Is there anyone in the home who smokes?
4. Do you routinely use aerosol sprays for personal care or cleaning?
5. Is your water supply treated by a municipal agency?- water supply
would not affect respiratory status
Correct: 1,2,3,4 Presence of wood smoke could increase respiratory
problems. Poorly vented gas heaters could increase carbon monoxide in
the environment. Use of solvents or other agents that produce irritating
fumes could increase risk. The particles from the sanding could irritate
the respiratory tract as well. Second-hand smoke is irritating to the
respiratory tract. Aerosols could trigger respiratory problems.
,●● A client diagnosed with schizophrenia tells the nurse, "God is going
to heal me. I do not need medication." Which response by the nurse
would best promote compliance with the prescribed medication
regimen?.
Answer: 1. Yes, I believe that God will heal you.
2. Many people of faith believe that one way God works to heal is
through medication.
3. We are talking about taking your medications right now.
4. What if God does not heal you and you should have taken the
medication?
correct: 2 This allows the client to keep the belief that God will heal but
will do it through the medication. This promotes compliance with the
prescribed medication regimen.
●● The nurse is assisting an unlicensed assistive personnel (UAP) move
an obese and dependent client toward the top of the bed. Which action is
most important to prevent shearing forces on the skin?.
Answer: 1. Each person puts hands under the client and slides client
toward the top of the bed.
2. Apply powder to the sheet before pulling client toward the top of the
bed.
3. Place turn sheet under the client and use it to slide the client toward
the top of bed.
, 4. Seek assistance of another person before pulling up in bed.
Correct: 3
●● A client consumes a lacto-ovo vegetarian diet at home. During
hospitalization, the primary healthcare provider prescribes an increased
calorie diet. Which foods are appropriate for the nurse to serve as
between meal snacks to boost caloric intake?.
Answer: 1. Cheese sandwich and milk
2. Boiled eggs but no dairy products
3. Fish sticks and cocktail sausages
4. Fresh vegetables but no milk or eggs
correct: 1- this is because a lacto-ovo diet allows for dairy and eggs to be
eaten but does not include meat
●● The postanesthesia care unit has received several postoperative
clients. While encouraging the clients to cough and deep breathe, the
nurse realizes that coughing poses thegreatest risk to which client?.
Answer: 1. A female with an abdominal hysterectomy- we want client to
cough and deep breathe to prevent atelactisis
2. A male who had a right upper lobectomy- want client to cough and
deep breathe
