Hurst Readiness Exam 3
Which menu selection by the client diagnosed with nephrotic syndrome indicates that teaching
of proper diet was understood? You answered this question Correctly
1. Pancakes with whipped butter, syrup, bacon, apple juice
2. Scrambled eggs, sliced turkey, biscuit, whole milk
3. Grits, fresh fruit, toast, coffee
4. Bagel with jelly, hash browns, tea
Rationale
2. Correct: Client needs low sodium and increased proteins
2. Following a total hip replacement, the nurse provides discharge teaching to the client. The
nurse knows that teaching was effective when the client states which activities are safe to
perform.
1. Using an abduction pillow while sleeping
2. Crossing the legs
3. Using a toilet extender
4. Showering rather than taking a bath
5. Tying shoes
RationaleStrategies 1., 3., & 4. Correct: The client should use an abduction pillow to keep hip in
proper alignment and prevent hip dislocation. A toilet extender keeps the hip in proper
alignment and prevents hip dislocation. Showering rather than sitting in a tub will prevent flexion
of the hip.
3. What risk factors should the nurse include when conducting a class about type 2 diabetes
mellitus?
1. Fat distribution greater in abdomen than in hips.
,2. Being underweight.
3. Having type 1 diabetes as a child increases risk for type 2 diabetes.
4. Caucasians are more likely to develop type 2 diabetes than Hispanics.
5. Polycystic ovary syndrome.
RationaleStrategies 1., & 5. Correct: If the body stores fat primarily in the abdomen, risk of type
2 diabetes is greater than if body stores fat elsewhere, such as hips and thighs. Women with
polycystic ovary syndrome have increased risk of diabetes.
4. The nurse is caring for a client following spinal surgery. The client is placed on
methylprednisolone. What additional drug therapy would the nurse expect to be prescribed with
methylprednisolone?
1. Pantoprazole
2. Phenytoin
3. Imipramine HCI
4. Aminocaproic acid
RationaleStrategies 1. Correct: A potential side effect of methylprednisolone is a peptic ulcer. The
primary healthcare provider will prescribe a proton pump inhibitor or H2 blocker to prevent this
side effect
5. In what order, after initially washing hands, should the nurse change a dressing on an infected
abdominal surgical wound that has a Penrose drain and a large amount of purulent drainage?
Place in priority order from first to last.
Apply clean gloves.
Remove soiled dressings.
Discard soiled dressings and clean gloves in red bag.
Don sterile gloves.
Clean surgical wound with moistened sterile 4x4s.
Clean around Penrose drain using a circular pattern inside to outside.
Place dry, sterile 4x4's over surgical wound and Penrose drain.
,Apply abdominal dressing pad.
RationaleStrategies First, apply clean gloves. Second, remove soiled dressings. Third,
discard soiled dressings and clean gloves in red bag. Fourth, don sterile gloves. Fifth, clean
surgical wound with moistened sterile 4x4's. Sixth, clean around Penrose drain using circular
pattern inside to outside. Seventh, place dry, sterile 4x4's over surgical wound and Penrose drain.
Eighth, apply abdominal dressing pad.
6. A client diagnosed with schizophrenia who is taking monthly haloperidol injections develops
slurred speech, shuffling gait and drooling. Which prescribed PRN medication would the nurse
administer?
1. Lorazepam
2. Atropine
3. Benztropine
4. Chlorpromazine
RationaleStrategies 3. Correct: These signs and symptoms are reflective of pseudoparkinsonism,
a form of extrapyramidal side effects which are side effects of the haloperidol. An anticholinergic
agent maybe used for treatment. This is an anticholinergic agent that may be used for
extrapyramidal side effects.
A nurse is caring for a client who reports fatigue, weight loss, afternoon fevers, night sweats,
cough, and hemoptysis. What interventions should the nurse initiate?
1. Wear an N95 respirator when caring for client.
2. Restrict fluid intake to 500 mL per day.
3. Position client in semi-Fowler's position.
4. Place client in a negative pressure airflow room.
5. Do not allow visitors for 48 hours.
RationaleStrategies 1., 3. & 4. Correct:
, Which task should the nurse perform first?
1. Suctioning the tracheostomy.
2. Changing a colostomy bag that is leaking.
3. Performing an admission assessment on a client.
4. Administering pain medication to a postoperative client.
RationaleStrategies 1. Correct:
A nurse is caring for a client hospitalized with Guillain-Barre syndrome. Which is the most
important nursing measure to include in the nursing care plan for this client?
1. Observation and support of ventilation
2. Insertion of indwelling urinary catheter
3. Nasogastric suctioning
4. Frequent assessments of level of consciousness
RationaleStrategies 1. Correct:
The nurse recognizes that treatment has been successful in resolving fluid volume excess based
on which assessment findings?
1. Continued lethargy
2. Heart rate 112/min
3. Decreasing shortness of breath
4. BP 114/78
5. Increased thirst
RationaleStrategies 3. & 4. Correct
The oncoming nurse has just received report and is preparing to make initial rounds. Which
postpartum client should the nurse see first?
1. A primipara 6 hours postpartum saturating one peripad every two hours
Which menu selection by the client diagnosed with nephrotic syndrome indicates that teaching
of proper diet was understood? You answered this question Correctly
1. Pancakes with whipped butter, syrup, bacon, apple juice
2. Scrambled eggs, sliced turkey, biscuit, whole milk
3. Grits, fresh fruit, toast, coffee
4. Bagel with jelly, hash browns, tea
Rationale
2. Correct: Client needs low sodium and increased proteins
2. Following a total hip replacement, the nurse provides discharge teaching to the client. The
nurse knows that teaching was effective when the client states which activities are safe to
perform.
1. Using an abduction pillow while sleeping
2. Crossing the legs
3. Using a toilet extender
4. Showering rather than taking a bath
5. Tying shoes
RationaleStrategies 1., 3., & 4. Correct: The client should use an abduction pillow to keep hip in
proper alignment and prevent hip dislocation. A toilet extender keeps the hip in proper
alignment and prevents hip dislocation. Showering rather than sitting in a tub will prevent flexion
of the hip.
3. What risk factors should the nurse include when conducting a class about type 2 diabetes
mellitus?
1. Fat distribution greater in abdomen than in hips.
,2. Being underweight.
3. Having type 1 diabetes as a child increases risk for type 2 diabetes.
4. Caucasians are more likely to develop type 2 diabetes than Hispanics.
5. Polycystic ovary syndrome.
RationaleStrategies 1., & 5. Correct: If the body stores fat primarily in the abdomen, risk of type
2 diabetes is greater than if body stores fat elsewhere, such as hips and thighs. Women with
polycystic ovary syndrome have increased risk of diabetes.
4. The nurse is caring for a client following spinal surgery. The client is placed on
methylprednisolone. What additional drug therapy would the nurse expect to be prescribed with
methylprednisolone?
1. Pantoprazole
2. Phenytoin
3. Imipramine HCI
4. Aminocaproic acid
RationaleStrategies 1. Correct: A potential side effect of methylprednisolone is a peptic ulcer. The
primary healthcare provider will prescribe a proton pump inhibitor or H2 blocker to prevent this
side effect
5. In what order, after initially washing hands, should the nurse change a dressing on an infected
abdominal surgical wound that has a Penrose drain and a large amount of purulent drainage?
Place in priority order from first to last.
Apply clean gloves.
Remove soiled dressings.
Discard soiled dressings and clean gloves in red bag.
Don sterile gloves.
Clean surgical wound with moistened sterile 4x4s.
Clean around Penrose drain using a circular pattern inside to outside.
Place dry, sterile 4x4's over surgical wound and Penrose drain.
,Apply abdominal dressing pad.
RationaleStrategies First, apply clean gloves. Second, remove soiled dressings. Third,
discard soiled dressings and clean gloves in red bag. Fourth, don sterile gloves. Fifth, clean
surgical wound with moistened sterile 4x4's. Sixth, clean around Penrose drain using circular
pattern inside to outside. Seventh, place dry, sterile 4x4's over surgical wound and Penrose drain.
Eighth, apply abdominal dressing pad.
6. A client diagnosed with schizophrenia who is taking monthly haloperidol injections develops
slurred speech, shuffling gait and drooling. Which prescribed PRN medication would the nurse
administer?
1. Lorazepam
2. Atropine
3. Benztropine
4. Chlorpromazine
RationaleStrategies 3. Correct: These signs and symptoms are reflective of pseudoparkinsonism,
a form of extrapyramidal side effects which are side effects of the haloperidol. An anticholinergic
agent maybe used for treatment. This is an anticholinergic agent that may be used for
extrapyramidal side effects.
A nurse is caring for a client who reports fatigue, weight loss, afternoon fevers, night sweats,
cough, and hemoptysis. What interventions should the nurse initiate?
1. Wear an N95 respirator when caring for client.
2. Restrict fluid intake to 500 mL per day.
3. Position client in semi-Fowler's position.
4. Place client in a negative pressure airflow room.
5. Do not allow visitors for 48 hours.
RationaleStrategies 1., 3. & 4. Correct:
, Which task should the nurse perform first?
1. Suctioning the tracheostomy.
2. Changing a colostomy bag that is leaking.
3. Performing an admission assessment on a client.
4. Administering pain medication to a postoperative client.
RationaleStrategies 1. Correct:
A nurse is caring for a client hospitalized with Guillain-Barre syndrome. Which is the most
important nursing measure to include in the nursing care plan for this client?
1. Observation and support of ventilation
2. Insertion of indwelling urinary catheter
3. Nasogastric suctioning
4. Frequent assessments of level of consciousness
RationaleStrategies 1. Correct:
The nurse recognizes that treatment has been successful in resolving fluid volume excess based
on which assessment findings?
1. Continued lethargy
2. Heart rate 112/min
3. Decreasing shortness of breath
4. BP 114/78
5. Increased thirst
RationaleStrategies 3. & 4. Correct
The oncoming nurse has just received report and is preparing to make initial rounds. Which
postpartum client should the nurse see first?
1. A primipara 6 hours postpartum saturating one peripad every two hours
