Hurst Readiness Exam 2
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.
An adult client has just returned to the nursing care unit following a gastroscopy. Which
intervention should the nurse include in 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 side rails
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.
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.
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. .
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.
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).
The nurse is working with a LPN/VN and an unlicensed assistive personnel (UAP). Which clients
would be appropriate for the nurse to assign to the LPN/VN?
1. In Bucks traction requiring frequent pain medication.
2. 24 hours post appendectomy.
3. Diagnosed with cholelithiasis and scheduled for surgery in the AM.
4. Admitted 6 hours ago in adrenal insufficiency.
5. Client newly diagnosed with Type 2 diabetes.
, Rationale
1., 2., & 3. Correct These clients are stable and require predictable care that can be done
appropriately by the LPN/VN
The triage nurse in the emergency department (ED) assesses 4 clients. Which client is in need of
emergent care?
1. A 52 year old who has a partially amputated finger.
2. A 9 month old with temperature of 103°F (39.4°C).
3. A two year old with excessive drooling and a weak cough.
4. A 28 year old experiencing a migraine headache for three days.
Rationale
3. Correct: The two year old is exhibiting signs of respiratory difficulty with excessive drooling
and a weak cough. Partial airway obstruction is likely and maybe the result of acute epiglottitis in
which rapid progression to severe respiratory distress can occur . Airway takes priority over the
other clients.
A new nurse has a prescription to insert a feeding tube. The new nurse has never performed the
procedure, but learned how to do it while in nursing school. What would be the best action by
this nurse?
1. Ask to observe another nurse perform the procedure.
2. Look up how to perform the procedure in the policy and procedure manual.
3. Tell the charge nurse that someone else will have to place the feeding tube down the client.
4. Insert the feeding tube as learned in nursing school.
Rationale
2. Correct. The best action for the nurse to take is to look up how the procedure is done in the
agency by looking it up in the policy and procedure manual. The nurse could then discuss the
procedure with an experienced nurse and ask the nurse to observe the new nurse while
inserting the feeding tube.
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.
An adult client has just returned to the nursing care unit following a gastroscopy. Which
intervention should the nurse include in 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 side rails
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.
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.
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. .
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.
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).
The nurse is working with a LPN/VN and an unlicensed assistive personnel (UAP). Which clients
would be appropriate for the nurse to assign to the LPN/VN?
1. In Bucks traction requiring frequent pain medication.
2. 24 hours post appendectomy.
3. Diagnosed with cholelithiasis and scheduled for surgery in the AM.
4. Admitted 6 hours ago in adrenal insufficiency.
5. Client newly diagnosed with Type 2 diabetes.
, Rationale
1., 2., & 3. Correct These clients are stable and require predictable care that can be done
appropriately by the LPN/VN
The triage nurse in the emergency department (ED) assesses 4 clients. Which client is in need of
emergent care?
1. A 52 year old who has a partially amputated finger.
2. A 9 month old with temperature of 103°F (39.4°C).
3. A two year old with excessive drooling and a weak cough.
4. A 28 year old experiencing a migraine headache for three days.
Rationale
3. Correct: The two year old is exhibiting signs of respiratory difficulty with excessive drooling
and a weak cough. Partial airway obstruction is likely and maybe the result of acute epiglottitis in
which rapid progression to severe respiratory distress can occur . Airway takes priority over the
other clients.
A new nurse has a prescription to insert a feeding tube. The new nurse has never performed the
procedure, but learned how to do it while in nursing school. What would be the best action by
this nurse?
1. Ask to observe another nurse perform the procedure.
2. Look up how to perform the procedure in the policy and procedure manual.
3. Tell the charge nurse that someone else will have to place the feeding tube down the client.
4. Insert the feeding tube as learned in nursing school.
Rationale
2. Correct. The best action for the nurse to take is to look up how the procedure is done in the
agency by looking it up in the policy and procedure manual. The nurse could then discuss the
procedure with an experienced nurse and ask the nurse to observe the new nurse while
inserting the feeding tube.
