Hurst Readiness Exam 1
The nurse is teaching a group of pregnant women about hormonal changes during pregnancy. The nurse
recognizes that teaching was successful when the women identify which hormone as causing amenorrhea?
1. Progesterone
2. Estrogen
3. Follicle-stimulating hormone (FSH)
4. Human chorionic gonadotropin (hCG)
Rationale 1. Correct: Progesterone causes amenorrhea. 2. Incorrect: Estrogen renders the female genital tract suitable for
fertilization. 3. Incorrect: This stimulates the growth of the graafian follicle in the ovary. 4. Incorrect: This is the hormone
present in urine for pregnancy test
The client is admitted to the hospital following a motor vehicle accident and has sustained a closed chest
wound. The nurse notes paradoxical chest wall movement. Which problem does the nurse suspect?
1. Mediastinal shift
2. Tension pneumothorax
3. Flail chest
4. Pulmonary contusion
Rationale 3. Correct: Hallmark of flail chest is paradoxical chest wall movement. This is often described as a
see-saw effect when observing the rise and fall of the chest. 1. Incorrect: A closed or open tension pneumothorax
results from the lung collapsing and air entering into the pleural cavity. This results in pressure shifting toward
the unaffected pleural cavity. 2. Incorrect: Tension pneumothorax occurs when there is an accumulation of air in the
pleural cavity. The client may exhibit dyspnea, tachycardia, or hypotension. 4. Incorrect: A pulmonary contusion usually
results from blunt trauma. Bruising of lung would be demonstrated by pain but not paradoxical chest wall movement.
Which client can a nurse manager safely transfer from the telemetry unit to the obstetrical unit in order to
receive a new admit?
1. Client admitted with possible tuberculosis (TB) awaiting skin test results. 2. Client diagnosed with seizure
disorder. 3. Client with a new pacemaker scheduled to be discharged in the morning. 4. Client with a history
of mild heart failure prescribed one unit of packed red blood cells for anemia.
Rationale
2. Correct: OB nurses would have the appropriate knowledge needed to care for a client with a seizure
disorder, because they care for clients who have eclampsia (seizures). 1. Incorrect: This client might have
tuberculosis (TB) and is not a good choice to move to the OB floor, because of the risk for transmission of an
infectious disease. 3. Incorrect: This client is not the best one to be transferred to the OB floor, because these
nurses do not routinely care for clients with a new pacemaker. The client is also likely to remain on a cardiac
monitor until discharge. 4. Incorrect: This client is at risk for fluid volume overload since there is a history of
heart failure and would require close monitoring while receiving a blood transfusion.
The nurse is teaching a group of clients who have reduced peripheral circulation how to care for their feet.
What points should the nurse include?
1. Check shoes for rough spots in the lining. 2. File toenails straight across. 3. Cover feet and between toes
with creams to moisten the skin. 4. Break in new shoes gradually. 5. Use pumice stones to treat calluses.
Rationale
1., 2., & 4. Correct: Rubbing from rough spots in the shoe can lead to corns or calluses. File the toenails
rather than cutting to avoid skin injury. File nails straight across the ends of the toes. If the nails are too
thick or misshapen to file, consult podiatrist. Break in new shoes gradually by increasing the wearing time
30-60 minutes each day. 3. Incorrect: Cover the feet, except between the toes, with creams or lotions to
moisten the skin. Lotion will also soften calluses. A lotion that reduces dryness effectively is a mixture of
lanolin and mineral oil. 5. Incorrect: Avoid self-treatment of corns or calluses. Pumice stones and some callus
and corn applications are injurious to the skin. Do not cut calluses or corns. Consult a podiatrist or primary
healthcare provider first.
When caring for young adult clients, which developmental tasks would the nurse expect to see?
1. Satisfying and supporting the next generation. 2. Reflecting on life accomplishments. 3. Developing
meaningful and intimate relationships. 4. Giving and sharing with an individual without asking what will be
given or shared in return. 5. Developing sense of fulfillment by volunteering in the community.
Rationale
,3. & 4. Correct: In young adulthood, the developmental tasks involve intimacy versus isolation. Intimacy
relates more to sharing than to sex. Intimacy produces feelings of safety, closeness, and trust. 1. Incorrect:
Parenting is a primary task of middle adulthood. This is the middle adulthood stage of Generativity versus
Stagnation, where each adult must find some way to satisfy and support the next generation. 2. Incorrect:
During late adulthood, there is refection on life accomplishments. This is the maturity stage of Ego Integrity
versus Despair, where there is a reflection of one's life. 5. Incorrect: During middle age, a sense of fulfillment
can be found by volunteering in the community. This is part of middle age, where the adult is finding ways to
support others.
What symptoms does the nurse expect to see in a client with bulimia nervosa?
1. Amenorrhea 2. Feelings of self-worth unduly influenced by weight 3. Recurrent episodes of binge eating 4.
Recurrent inappropriate compensatory behavior to prevent weight gain 5. Lack of exercise
Rationale
2., 3. & 4. Correct: Diagnostic criteria for bulimia nervosa are recurrent episodes of binge eating: recurrent
inappropriate compensatory behavior to prevent weight gain such as laxative, diuretic, or enema use, induced
vomiting, fasting, and excessive exercise; and feeling of self-worth unduly influenced by weight. Amenorrhea is
found in anorexia nervosa. 1. Incorrect: Amenorrhea is found in anorexia nervosa. 5. Incorrect: Excessive
exercise is found in bulimia nervosa as a means to compensate for the binge eating.
A client who has had a laparoscopic cholecystectomy develops pain in the left shoulder. Vital signs, laboratory
studies, and an electrocardiogram are within normal limits. What does the nurse recognize as a contributing
cause of the pain?
1. Surgical cannulation of the bile duct is causing spasm and pain. 2. Carbon dioxide used intraperitoneally
is irritating the phrenic nerve. 3. Large abdominal retractors used in the procedure compressed a nerve. 4.
Side lying position in the operating room generated pressure damage.
Rationale
2. Correct: Phrenic nerve irritation can result in referred pain to the left shoulder. Carbon dioxide (CO2) is
used to inflate the abdominal/chest wall during the procedure for better visualization of the internal organs. If
the CO2 irritates the phrenic nerve, it radiates to the shoulder. 1. Incorrect: Surgical cannulation of the bile
duct is not performed during a laparoscopic cholecystectomy. 3. Incorrect: Large abdominal retractors are not
used during this procedure. This is done via a small incision to accommodate a scope. 4. Incorrect: The client
is turned in several directions during the procedure to prevent damage to the abdominal viscera.
A client is admitted to the medical unit with an acute onset of fever, chills and RUQ pain. Vital signs are: T
99.8°F (37.7°C), P 132, RR 34, B/P 142/82. ABG results are: pH-7.53, PaCO2 30, HCO3 22. The nurse
determines that this client is in what acid/base imbalance?
1. Respiratory acidosis 2. Respiratory alkalosis 3. Metabolic acidosis 4. Metabolic alkalosis
Rationale
2. Correct: This client has a severe infection. Hyperventilation due to anxiety, pain, shock, severe infection,
fever, and liver failure can lead to respiratory alkalosis. pH > 7.45, PCO2 < 35, HCO3 normal. 1. Incorrect: Not
acidosis with hyperventilation and pH of 7.53. 3. Incorrect: Not a metabolic related acid/base imbalance since
the HCO3 is in normal range and is not acidosis. 4. Incorrect: Not a metabolic related acid/base imbalance
since the HCO3 is in normal range.
An unlicensed assistive personnel (UAP) has explained how to prevent the spread of infection to the charge
nurse. Which statement by the UAP indicates that further teaching is needed?
1. "Soap and water should be used for hand washing when our hands are visibly soiled." 2. "Gloves do not
have to be worn when taking a client's vital signs or passing out meal trays." 3. "Standard precautions should
be used on all clients." 4. "When caring for a client who has a suppressed immune response, a N95 mask
should be worn."
Rationale
4. Correct: Standard precautions are needed. If there is a risk for coming in contact with client secretions or
excretions, a standard mask may be worn. Routine nursing care does not warrant the use of an N95 mask.
This type mask is needed for client's who are placed on Airborne Precautions such as for tuberculosis (TB). 1.
Incorrect: This is a correct statement regarding the prevention of infection. Hand washing with soap and water
is part of standard precautions. 2. Incorrect: This is a correct statement. Gloves are needed when coming into
,contact with body fluids. 3. Incorrect: This is a correct statement. Standard precautions is part of the first line
of defense against the spread of infection.
The nurse is preparing to discharge a client who has been placed on tranylcypromine. The nurse teaches the
client about food to avoid while taking this medication. What food choice by the client confirms appropriate
understanding of the teaching?
1. Cottage cheese 2. Salami 3. Baked chicken 4. Potatoes
Rationale
2. Correct: The client taking a monoamine oxidase inhibitor (MAOI) such as tranylcypromine should avoid
foods rich in tyramine or tryptophan. These include: cured foods, those that have been aged, pickled,
fermented, or smoked. These can precipitate a hypertensive crisis. 1. Incorrect: Clients taking MAOIs can eat
cottage cheese in reasonable amounts. 3. Incorrect: Clients taking MAOIs can eat baked chicken. 4. Incorrect:
Clients taking MAOIs can eat potatoes.
Which nurse is providing cost effective care to a client?
1. Providing palliative care to a terminally ill client. 2. Beginning discharge planning on admit. 3. Counseling
clients on cigarette smoking cessation. 4. Educating a group of parents on the importance of childhood
immunizations. 5. Performing a postop wound dressing change using clean gloves.
Rationale
1., 2., 3., & 4. Correct. Palliative care is considered cost effective when caring for the terminally ill client.
There was a 60% drop reported in the healthcare costs since palliative care was introduced. In comparison to
conventional care, palliative care is considered as cost effective in reducing unnecessary utilization of
resources. Palliative care has focused on the efficient and the effective care that is centered on the clients. The
nurse who begins discharge planning on admit is providing cost effective care. The client may not be able to
learn all that is needed if waiting until the day of discharge. Also, supplies and equipment may be needed. If
waiting until the day of discharge to determine client needs, then discharge can be delayed. This is costly.
Counseling to quit cigarette smoking, colonoscopies, giving beta-blockers to clients after heart attacks are
well-established interventions that are effective and also are cost-effective. Two additional preventive
interventions were found to be cost-saving: childhood immunization and counseling adults on the use of low
dose aspirin. 5. Incorrect. A postop surgical wound dressing change is a sterile procedure: Sterile gloves are
necessary and failure to use them could lead to infection, which would then increase the cost of care to a
client.
A client is admitted for observation following an unrestrained motor vehicle accident. A bystander stated that
the client lost consciousness for 1-2 minutes. On admission, the client reports a headache and had a Glasgow
coma scale (GCS) of 14. The GCS is now 12. What is the priority nursing intervention for this client?
1. Continue to assess every 15 minutes. 2. Stimulate the client with a sternal rub. 3. Administer
acetaminophen with codeine for headache. 4. Notify the primary healthcare provider.
Rationale
4. Correct: On the Glasgow coma scale, we like a number between 13 to 15. This assessment score has
dropped to 12, so the client is getting worse and the headache could mean increasing intracranial pressure
(ICP). This is the only intervention that can fix the problem. 1. Incorrect: Reassessing in 15 minutes is
delaying treatment. When neuro changes start happening, they happen rapidly. 2. Incorrect: Stimulating the
client will increase the client's ICP. 3. Incorrect: A sedative should NOT be administered. The client's level of
conscious has decreased.
The nurse is assessing a client who is being treated with a non-steroidal anti-inflammatory medication
(NSAID) for an acute flare-up of gout. Which finding is expected in the assessment?
1. Dramatic decrease in pain after beginning medications. 2. Severe abdominal pain following medication
administration. 3. Decreased plasma uric acid levels. 4. Low-grade fever and rash.
Rationale
1. Correct. The client usually experiences dramatic improvement within 24 hours after beginning NSAIDs. 2.
Incorrect. Most clients can tolerate NSAIDs fairly well. If severe pain in experienced, the primary healthcare
provider should be notified immediately. 3. Incorrect. NSAIDs do not reduce plasma uric acid levels. 4.
Incorrect. This is not an adverse effect of NSAIDs, in fact, most NSAIDs are also antipyretics and would
prevent fever.
, A home care nurse is preparing to perform venipuncture on a client to draw blood. As the nurse gathers
supplies, the client begins to experience palpitations, trembling, nausea, shortness of breath and a feeling of
losing control. How should the nurse communicate with this client?
1. Use simple words. 2. Speak loudly to the client. 3. Do not speak to the client at this time. 4. Use open-
ended questions to ask what is wrong.
Rationale
1. Correct: Use simple words, because the client cannot comprehend anything but the most elemental
communications during a panic attack. 2. Incorrect: A calm, low level of intensity to reduce anxiety is needed.
Speaking loudly will increase the client's anxiety. 3. Incorrect: Calm, simple words are needed instead of
silence which could be interpreted as ignoring the client. 4. Incorrect: Simple communication of reassurance
needed. This is not the time for open ended questions and would increase the client's anxiety.
The nurse is preparing a client for surgery. Which methods are appropriate for the nurse to use in removing
excessive body hair?
1. Shaving the hair with a razor. 2. Removing the hair with clippers. 3. Lathering the skin with soap and
water prior to shaving with a razor. 4. Using a depilatory cream. 5. Always use a new, sharp razor.
Rationale
2. & 4. Correct: Not removing the hair at all is preferred, but if this is not an option the use of clippers or a
depilatory cream may be used to prevent trauma to the skin before surgery. 1. Incorrect: Using a razor for hair
removal is not recommended because it causes micro-abrasions of the skin. Bacteria multiply in the micro-
abrasions, increasing the risk of infection. This is not appropriate for a client going to surgery. 3. Incorrect:
Using a razor for hair removal is not recommended because it causes micro-abrasions of the skin. Bacteria
multiply in the micro-abrasions, increasing the risk of infection. This is not appropriate for a client going to
surgery. 5. Incorrect: Using a razor for hair removal is not recommended because it causes micro-abrasions of
the skin. Bacteria multiply in the micro-abrasions, increasing the risk of infection. This is not appropriate for
a client going to surgery.
A new mother calls the clinic and tells the nurse, "I don't have any help taking care of my 3 week old baby. I
don't know what to do. I just feel like I can't take care of him anymore. I wish I never had him sometimes.
Maybe then my husband would spend more time at home." What would be the nurse's best response?
1. "You are experiencing maternity blues, which will go away on its own." 2. "You are just tired. Tell your
husband that you need his help." 3. "Come to the clinic now so that we can help you." 4. "Have you thought
about getting a family member to help with the baby?"
Rationale
3. Correct: This client is exhibiting signs of postpartum psychosis. Post partum psychosis is characterized by
depressed mood, agitation, indecision, lack of concentration, guilt, and an abnormal attitude toward bodily
functions. There is a lack of interest in or rejection of the baby, or a morbid fear that the baby may be harmed.
Risks of suicide and infanticide should not be overlooked. 1. Incorrect: Maternity blues includes tearfulness,
despondency, anxiety and subjectivity with impaired concentration. 2. Incorrect: This ignores a potentially
life-threatening problem. The client is not just tired. 4. Incorrect: This ignores a potentially life-threatening
problem. Assume the worse. Think about the safety of mom and baby.
The primary healthcare provider instructs the nurse to place body tissue obtained from a biopsy into a
container with formalin prior to sending it to pathology. The nurse has not handled formalin before. What
would be the nurse's best action?
1. Call the pathology department for directions on formalin's use and precautions. 2. Look formalin up in the
drug handbook 3. Read about formalin on the Material Safety Data Sheet (MSDS). 4. Explain to the primary
healthcare provider that nurses are not allowed to use formalin.
Rationale
3. Correct: All hazardous materials must have a MSDS, which includes the identity of the chemical, the
physical and chemical characteristics, the physical and health hazards, primary routes of entry, exposure
limits, precautions for safe handling, controls to limit exposure, emergency and first-aid procedures, and the
name of the manufacturer or distributor. 1. Incorrect: The nurse should look at the MSDS, the best source of
information. Calling another department does not ensure that the nurse will get as comprehensive
information as the MSDS provides. 2. Incorrect: The drug handbook is for medication, not handling of
The nurse is teaching a group of pregnant women about hormonal changes during pregnancy. The nurse
recognizes that teaching was successful when the women identify which hormone as causing amenorrhea?
1. Progesterone
2. Estrogen
3. Follicle-stimulating hormone (FSH)
4. Human chorionic gonadotropin (hCG)
Rationale 1. Correct: Progesterone causes amenorrhea. 2. Incorrect: Estrogen renders the female genital tract suitable for
fertilization. 3. Incorrect: This stimulates the growth of the graafian follicle in the ovary. 4. Incorrect: This is the hormone
present in urine for pregnancy test
The client is admitted to the hospital following a motor vehicle accident and has sustained a closed chest
wound. The nurse notes paradoxical chest wall movement. Which problem does the nurse suspect?
1. Mediastinal shift
2. Tension pneumothorax
3. Flail chest
4. Pulmonary contusion
Rationale 3. Correct: Hallmark of flail chest is paradoxical chest wall movement. This is often described as a
see-saw effect when observing the rise and fall of the chest. 1. Incorrect: A closed or open tension pneumothorax
results from the lung collapsing and air entering into the pleural cavity. This results in pressure shifting toward
the unaffected pleural cavity. 2. Incorrect: Tension pneumothorax occurs when there is an accumulation of air in the
pleural cavity. The client may exhibit dyspnea, tachycardia, or hypotension. 4. Incorrect: A pulmonary contusion usually
results from blunt trauma. Bruising of lung would be demonstrated by pain but not paradoxical chest wall movement.
Which client can a nurse manager safely transfer from the telemetry unit to the obstetrical unit in order to
receive a new admit?
1. Client admitted with possible tuberculosis (TB) awaiting skin test results. 2. Client diagnosed with seizure
disorder. 3. Client with a new pacemaker scheduled to be discharged in the morning. 4. Client with a history
of mild heart failure prescribed one unit of packed red blood cells for anemia.
Rationale
2. Correct: OB nurses would have the appropriate knowledge needed to care for a client with a seizure
disorder, because they care for clients who have eclampsia (seizures). 1. Incorrect: This client might have
tuberculosis (TB) and is not a good choice to move to the OB floor, because of the risk for transmission of an
infectious disease. 3. Incorrect: This client is not the best one to be transferred to the OB floor, because these
nurses do not routinely care for clients with a new pacemaker. The client is also likely to remain on a cardiac
monitor until discharge. 4. Incorrect: This client is at risk for fluid volume overload since there is a history of
heart failure and would require close monitoring while receiving a blood transfusion.
The nurse is teaching a group of clients who have reduced peripheral circulation how to care for their feet.
What points should the nurse include?
1. Check shoes for rough spots in the lining. 2. File toenails straight across. 3. Cover feet and between toes
with creams to moisten the skin. 4. Break in new shoes gradually. 5. Use pumice stones to treat calluses.
Rationale
1., 2., & 4. Correct: Rubbing from rough spots in the shoe can lead to corns or calluses. File the toenails
rather than cutting to avoid skin injury. File nails straight across the ends of the toes. If the nails are too
thick or misshapen to file, consult podiatrist. Break in new shoes gradually by increasing the wearing time
30-60 minutes each day. 3. Incorrect: Cover the feet, except between the toes, with creams or lotions to
moisten the skin. Lotion will also soften calluses. A lotion that reduces dryness effectively is a mixture of
lanolin and mineral oil. 5. Incorrect: Avoid self-treatment of corns or calluses. Pumice stones and some callus
and corn applications are injurious to the skin. Do not cut calluses or corns. Consult a podiatrist or primary
healthcare provider first.
When caring for young adult clients, which developmental tasks would the nurse expect to see?
1. Satisfying and supporting the next generation. 2. Reflecting on life accomplishments. 3. Developing
meaningful and intimate relationships. 4. Giving and sharing with an individual without asking what will be
given or shared in return. 5. Developing sense of fulfillment by volunteering in the community.
Rationale
,3. & 4. Correct: In young adulthood, the developmental tasks involve intimacy versus isolation. Intimacy
relates more to sharing than to sex. Intimacy produces feelings of safety, closeness, and trust. 1. Incorrect:
Parenting is a primary task of middle adulthood. This is the middle adulthood stage of Generativity versus
Stagnation, where each adult must find some way to satisfy and support the next generation. 2. Incorrect:
During late adulthood, there is refection on life accomplishments. This is the maturity stage of Ego Integrity
versus Despair, where there is a reflection of one's life. 5. Incorrect: During middle age, a sense of fulfillment
can be found by volunteering in the community. This is part of middle age, where the adult is finding ways to
support others.
What symptoms does the nurse expect to see in a client with bulimia nervosa?
1. Amenorrhea 2. Feelings of self-worth unduly influenced by weight 3. Recurrent episodes of binge eating 4.
Recurrent inappropriate compensatory behavior to prevent weight gain 5. Lack of exercise
Rationale
2., 3. & 4. Correct: Diagnostic criteria for bulimia nervosa are recurrent episodes of binge eating: recurrent
inappropriate compensatory behavior to prevent weight gain such as laxative, diuretic, or enema use, induced
vomiting, fasting, and excessive exercise; and feeling of self-worth unduly influenced by weight. Amenorrhea is
found in anorexia nervosa. 1. Incorrect: Amenorrhea is found in anorexia nervosa. 5. Incorrect: Excessive
exercise is found in bulimia nervosa as a means to compensate for the binge eating.
A client who has had a laparoscopic cholecystectomy develops pain in the left shoulder. Vital signs, laboratory
studies, and an electrocardiogram are within normal limits. What does the nurse recognize as a contributing
cause of the pain?
1. Surgical cannulation of the bile duct is causing spasm and pain. 2. Carbon dioxide used intraperitoneally
is irritating the phrenic nerve. 3. Large abdominal retractors used in the procedure compressed a nerve. 4.
Side lying position in the operating room generated pressure damage.
Rationale
2. Correct: Phrenic nerve irritation can result in referred pain to the left shoulder. Carbon dioxide (CO2) is
used to inflate the abdominal/chest wall during the procedure for better visualization of the internal organs. If
the CO2 irritates the phrenic nerve, it radiates to the shoulder. 1. Incorrect: Surgical cannulation of the bile
duct is not performed during a laparoscopic cholecystectomy. 3. Incorrect: Large abdominal retractors are not
used during this procedure. This is done via a small incision to accommodate a scope. 4. Incorrect: The client
is turned in several directions during the procedure to prevent damage to the abdominal viscera.
A client is admitted to the medical unit with an acute onset of fever, chills and RUQ pain. Vital signs are: T
99.8°F (37.7°C), P 132, RR 34, B/P 142/82. ABG results are: pH-7.53, PaCO2 30, HCO3 22. The nurse
determines that this client is in what acid/base imbalance?
1. Respiratory acidosis 2. Respiratory alkalosis 3. Metabolic acidosis 4. Metabolic alkalosis
Rationale
2. Correct: This client has a severe infection. Hyperventilation due to anxiety, pain, shock, severe infection,
fever, and liver failure can lead to respiratory alkalosis. pH > 7.45, PCO2 < 35, HCO3 normal. 1. Incorrect: Not
acidosis with hyperventilation and pH of 7.53. 3. Incorrect: Not a metabolic related acid/base imbalance since
the HCO3 is in normal range and is not acidosis. 4. Incorrect: Not a metabolic related acid/base imbalance
since the HCO3 is in normal range.
An unlicensed assistive personnel (UAP) has explained how to prevent the spread of infection to the charge
nurse. Which statement by the UAP indicates that further teaching is needed?
1. "Soap and water should be used for hand washing when our hands are visibly soiled." 2. "Gloves do not
have to be worn when taking a client's vital signs or passing out meal trays." 3. "Standard precautions should
be used on all clients." 4. "When caring for a client who has a suppressed immune response, a N95 mask
should be worn."
Rationale
4. Correct: Standard precautions are needed. If there is a risk for coming in contact with client secretions or
excretions, a standard mask may be worn. Routine nursing care does not warrant the use of an N95 mask.
This type mask is needed for client's who are placed on Airborne Precautions such as for tuberculosis (TB). 1.
Incorrect: This is a correct statement regarding the prevention of infection. Hand washing with soap and water
is part of standard precautions. 2. Incorrect: This is a correct statement. Gloves are needed when coming into
,contact with body fluids. 3. Incorrect: This is a correct statement. Standard precautions is part of the first line
of defense against the spread of infection.
The nurse is preparing to discharge a client who has been placed on tranylcypromine. The nurse teaches the
client about food to avoid while taking this medication. What food choice by the client confirms appropriate
understanding of the teaching?
1. Cottage cheese 2. Salami 3. Baked chicken 4. Potatoes
Rationale
2. Correct: The client taking a monoamine oxidase inhibitor (MAOI) such as tranylcypromine should avoid
foods rich in tyramine or tryptophan. These include: cured foods, those that have been aged, pickled,
fermented, or smoked. These can precipitate a hypertensive crisis. 1. Incorrect: Clients taking MAOIs can eat
cottage cheese in reasonable amounts. 3. Incorrect: Clients taking MAOIs can eat baked chicken. 4. Incorrect:
Clients taking MAOIs can eat potatoes.
Which nurse is providing cost effective care to a client?
1. Providing palliative care to a terminally ill client. 2. Beginning discharge planning on admit. 3. Counseling
clients on cigarette smoking cessation. 4. Educating a group of parents on the importance of childhood
immunizations. 5. Performing a postop wound dressing change using clean gloves.
Rationale
1., 2., 3., & 4. Correct. Palliative care is considered cost effective when caring for the terminally ill client.
There was a 60% drop reported in the healthcare costs since palliative care was introduced. In comparison to
conventional care, palliative care is considered as cost effective in reducing unnecessary utilization of
resources. Palliative care has focused on the efficient and the effective care that is centered on the clients. The
nurse who begins discharge planning on admit is providing cost effective care. The client may not be able to
learn all that is needed if waiting until the day of discharge. Also, supplies and equipment may be needed. If
waiting until the day of discharge to determine client needs, then discharge can be delayed. This is costly.
Counseling to quit cigarette smoking, colonoscopies, giving beta-blockers to clients after heart attacks are
well-established interventions that are effective and also are cost-effective. Two additional preventive
interventions were found to be cost-saving: childhood immunization and counseling adults on the use of low
dose aspirin. 5. Incorrect. A postop surgical wound dressing change is a sterile procedure: Sterile gloves are
necessary and failure to use them could lead to infection, which would then increase the cost of care to a
client.
A client is admitted for observation following an unrestrained motor vehicle accident. A bystander stated that
the client lost consciousness for 1-2 minutes. On admission, the client reports a headache and had a Glasgow
coma scale (GCS) of 14. The GCS is now 12. What is the priority nursing intervention for this client?
1. Continue to assess every 15 minutes. 2. Stimulate the client with a sternal rub. 3. Administer
acetaminophen with codeine for headache. 4. Notify the primary healthcare provider.
Rationale
4. Correct: On the Glasgow coma scale, we like a number between 13 to 15. This assessment score has
dropped to 12, so the client is getting worse and the headache could mean increasing intracranial pressure
(ICP). This is the only intervention that can fix the problem. 1. Incorrect: Reassessing in 15 minutes is
delaying treatment. When neuro changes start happening, they happen rapidly. 2. Incorrect: Stimulating the
client will increase the client's ICP. 3. Incorrect: A sedative should NOT be administered. The client's level of
conscious has decreased.
The nurse is assessing a client who is being treated with a non-steroidal anti-inflammatory medication
(NSAID) for an acute flare-up of gout. Which finding is expected in the assessment?
1. Dramatic decrease in pain after beginning medications. 2. Severe abdominal pain following medication
administration. 3. Decreased plasma uric acid levels. 4. Low-grade fever and rash.
Rationale
1. Correct. The client usually experiences dramatic improvement within 24 hours after beginning NSAIDs. 2.
Incorrect. Most clients can tolerate NSAIDs fairly well. If severe pain in experienced, the primary healthcare
provider should be notified immediately. 3. Incorrect. NSAIDs do not reduce plasma uric acid levels. 4.
Incorrect. This is not an adverse effect of NSAIDs, in fact, most NSAIDs are also antipyretics and would
prevent fever.
, A home care nurse is preparing to perform venipuncture on a client to draw blood. As the nurse gathers
supplies, the client begins to experience palpitations, trembling, nausea, shortness of breath and a feeling of
losing control. How should the nurse communicate with this client?
1. Use simple words. 2. Speak loudly to the client. 3. Do not speak to the client at this time. 4. Use open-
ended questions to ask what is wrong.
Rationale
1. Correct: Use simple words, because the client cannot comprehend anything but the most elemental
communications during a panic attack. 2. Incorrect: A calm, low level of intensity to reduce anxiety is needed.
Speaking loudly will increase the client's anxiety. 3. Incorrect: Calm, simple words are needed instead of
silence which could be interpreted as ignoring the client. 4. Incorrect: Simple communication of reassurance
needed. This is not the time for open ended questions and would increase the client's anxiety.
The nurse is preparing a client for surgery. Which methods are appropriate for the nurse to use in removing
excessive body hair?
1. Shaving the hair with a razor. 2. Removing the hair with clippers. 3. Lathering the skin with soap and
water prior to shaving with a razor. 4. Using a depilatory cream. 5. Always use a new, sharp razor.
Rationale
2. & 4. Correct: Not removing the hair at all is preferred, but if this is not an option the use of clippers or a
depilatory cream may be used to prevent trauma to the skin before surgery. 1. Incorrect: Using a razor for hair
removal is not recommended because it causes micro-abrasions of the skin. Bacteria multiply in the micro-
abrasions, increasing the risk of infection. This is not appropriate for a client going to surgery. 3. Incorrect:
Using a razor for hair removal is not recommended because it causes micro-abrasions of the skin. Bacteria
multiply in the micro-abrasions, increasing the risk of infection. This is not appropriate for a client going to
surgery. 5. Incorrect: Using a razor for hair removal is not recommended because it causes micro-abrasions of
the skin. Bacteria multiply in the micro-abrasions, increasing the risk of infection. This is not appropriate for
a client going to surgery.
A new mother calls the clinic and tells the nurse, "I don't have any help taking care of my 3 week old baby. I
don't know what to do. I just feel like I can't take care of him anymore. I wish I never had him sometimes.
Maybe then my husband would spend more time at home." What would be the nurse's best response?
1. "You are experiencing maternity blues, which will go away on its own." 2. "You are just tired. Tell your
husband that you need his help." 3. "Come to the clinic now so that we can help you." 4. "Have you thought
about getting a family member to help with the baby?"
Rationale
3. Correct: This client is exhibiting signs of postpartum psychosis. Post partum psychosis is characterized by
depressed mood, agitation, indecision, lack of concentration, guilt, and an abnormal attitude toward bodily
functions. There is a lack of interest in or rejection of the baby, or a morbid fear that the baby may be harmed.
Risks of suicide and infanticide should not be overlooked. 1. Incorrect: Maternity blues includes tearfulness,
despondency, anxiety and subjectivity with impaired concentration. 2. Incorrect: This ignores a potentially
life-threatening problem. The client is not just tired. 4. Incorrect: This ignores a potentially life-threatening
problem. Assume the worse. Think about the safety of mom and baby.
The primary healthcare provider instructs the nurse to place body tissue obtained from a biopsy into a
container with formalin prior to sending it to pathology. The nurse has not handled formalin before. What
would be the nurse's best action?
1. Call the pathology department for directions on formalin's use and precautions. 2. Look formalin up in the
drug handbook 3. Read about formalin on the Material Safety Data Sheet (MSDS). 4. Explain to the primary
healthcare provider that nurses are not allowed to use formalin.
Rationale
3. Correct: All hazardous materials must have a MSDS, which includes the identity of the chemical, the
physical and chemical characteristics, the physical and health hazards, primary routes of entry, exposure
limits, precautions for safe handling, controls to limit exposure, emergency and first-aid procedures, and the
name of the manufacturer or distributor. 1. Incorrect: The nurse should look at the MSDS, the best source of
information. Calling another department does not ensure that the nurse will get as comprehensive
information as the MSDS provides. 2. Incorrect: The drug handbook is for medication, not handling of
