HURST READINESS EXAM 4 PRACTICE TEST
BANK EXAMPREP FULL SOLUTION SET
HIGHLY ACCURATE REVIEW
●● The nurse is assessing pain after surgery in a 3 year old client with a
known developmental delay. Which pain scale should the nurse use to
assess this client's pain level?
a. CRIES scale
b. numeric scale
c. FLACC scale
d. FACES scale.
Answer: c. FLACC scale
Rationale: The FLACC scale can be used for pediatric clients from age 2
months to 7 years and is appropriate when clients cannot communicate
their pain
●● A client recently diagnosed with diabetes is sent home with a
prescription for subcutaneous insulin. What statement made by the client
indicates that teaching has been effective regarding safe needle disposal?
a. "I should wrap the needle in a paper towel and place in the trash."
,b. "I should use a hospital issued biohazard container for all needles."
c. "I may use any hard plastic container with a screw-on cap."
d. "I should take my needles to the nearest hospital for disposal.".
Answer: c. "I may use any hard plastic container with a screw-on cap."
Rationale: At home, an FDA approved sharps container is not needed,
however, needles, syringes, and sharps may be disposed of in a hard
plastic container. Clients should follow their community guidelines for
sharps container disposal. This protects the sanitation engineers from
injury by the sharps.
●● 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?
a. don sterile gloves
b. place the client on reverse isolation
c. wear a particulate respirator
d. obtain a consent form
e. initiate airborne precautions.
Answer: c. wear a particulate respirator
e. initiate airborne precautions
,Rationale: A disposable particulate respirator that fits snugly around the
face is needed. The client needs to be on acid-fast bacilli (AFB) isolation
precautions, not reverse isolation. Airborne precautions include a private
room with negative pressure and a minimum of 6 air exchanges per hour.
Ultraviolet lamps and high efficiency particulate air filters are also
needed.
●● A hysterical college student arrives in the emergency department in
bloody soiled clothing. The nursing assessment reveals facial bruising
and multiple contusions consistent with the client's report of being
raped. Which initial nursing intervention takes priority at this time?
a. notify police of the alleged rape
b. allow the client privacy to wash self
c. remove clothing and bag for evidence
d. encourage client to express fears and anxiety.
Answer: d. encourage client to express fears and anxiety
Rationale: Although there are specific protocols that must be followed
when dealing with rape clients, it is important to remember that this
client had all control taken away during the attack. The emotional effects
of rape are as traumatizing as the physical injuries. Allowing the client to
first express emotions, such as fear or anxiety, returns a small amount of
control to a situation in which the client has little or none.
, ●● The nurse is caring for an adolescent client diagnosed with
depression. The client is prescribed fluoxetine. What is the best response
by the nurse when the client says, "What will this medicine do to me?"
a. it will increase the level of serotonin in the brain
b. it will decrease the production of noradrenaline
c. it will lower your level of the brain hormone norepinephrine
d. it will balance blood glucose and dopamine levels in your head.
Answer: a. it will increase the level of serotonin in the brain
Rationale: The action of fluoxetine is to increase the level of serotonin in
the central nervous system. There is a correlation between a low level of
serotonin and depression. The action of the drug should be explained to
the adolescent in a manner that will be understood.
●● A new mother brings her infant to the clinic for a well-baby checkup.
While at the clinic, the mother asks the nurse if there are any reasons
why her infant should not have the MMR vaccine. The nurse's response
is based on evidence that the MMR vaccine is contraindicated under
which condition?
a. a known allergy to gelatin
b. a family history of autism
c. in infants with diarrhea
BANK EXAMPREP FULL SOLUTION SET
HIGHLY ACCURATE REVIEW
●● The nurse is assessing pain after surgery in a 3 year old client with a
known developmental delay. Which pain scale should the nurse use to
assess this client's pain level?
a. CRIES scale
b. numeric scale
c. FLACC scale
d. FACES scale.
Answer: c. FLACC scale
Rationale: The FLACC scale can be used for pediatric clients from age 2
months to 7 years and is appropriate when clients cannot communicate
their pain
●● A client recently diagnosed with diabetes is sent home with a
prescription for subcutaneous insulin. What statement made by the client
indicates that teaching has been effective regarding safe needle disposal?
a. "I should wrap the needle in a paper towel and place in the trash."
,b. "I should use a hospital issued biohazard container for all needles."
c. "I may use any hard plastic container with a screw-on cap."
d. "I should take my needles to the nearest hospital for disposal.".
Answer: c. "I may use any hard plastic container with a screw-on cap."
Rationale: At home, an FDA approved sharps container is not needed,
however, needles, syringes, and sharps may be disposed of in a hard
plastic container. Clients should follow their community guidelines for
sharps container disposal. This protects the sanitation engineers from
injury by the sharps.
●● 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?
a. don sterile gloves
b. place the client on reverse isolation
c. wear a particulate respirator
d. obtain a consent form
e. initiate airborne precautions.
Answer: c. wear a particulate respirator
e. initiate airborne precautions
,Rationale: A disposable particulate respirator that fits snugly around the
face is needed. The client needs to be on acid-fast bacilli (AFB) isolation
precautions, not reverse isolation. Airborne precautions include a private
room with negative pressure and a minimum of 6 air exchanges per hour.
Ultraviolet lamps and high efficiency particulate air filters are also
needed.
●● A hysterical college student arrives in the emergency department in
bloody soiled clothing. The nursing assessment reveals facial bruising
and multiple contusions consistent with the client's report of being
raped. Which initial nursing intervention takes priority at this time?
a. notify police of the alleged rape
b. allow the client privacy to wash self
c. remove clothing and bag for evidence
d. encourage client to express fears and anxiety.
Answer: d. encourage client to express fears and anxiety
Rationale: Although there are specific protocols that must be followed
when dealing with rape clients, it is important to remember that this
client had all control taken away during the attack. The emotional effects
of rape are as traumatizing as the physical injuries. Allowing the client to
first express emotions, such as fear or anxiety, returns a small amount of
control to a situation in which the client has little or none.
, ●● The nurse is caring for an adolescent client diagnosed with
depression. The client is prescribed fluoxetine. What is the best response
by the nurse when the client says, "What will this medicine do to me?"
a. it will increase the level of serotonin in the brain
b. it will decrease the production of noradrenaline
c. it will lower your level of the brain hormone norepinephrine
d. it will balance blood glucose and dopamine levels in your head.
Answer: a. it will increase the level of serotonin in the brain
Rationale: The action of fluoxetine is to increase the level of serotonin in
the central nervous system. There is a correlation between a low level of
serotonin and depression. The action of the drug should be explained to
the adolescent in a manner that will be understood.
●● A new mother brings her infant to the clinic for a well-baby checkup.
While at the clinic, the mother asks the nurse if there are any reasons
why her infant should not have the MMR vaccine. The nurse's response
is based on evidence that the MMR vaccine is contraindicated under
which condition?
a. a known allergy to gelatin
b. a family history of autism
c. in infants with diarrhea
