Hurst (Readiness Exam #4) Questions and
answers
A charge nurse is planning care for several clients on the unit. Which
activities can the nurse safely delegate to an unlicensed assistive personnel
(UAP)?
1. Administer a nebulizer treatment to a client diagnosed with pneumonia.
2. Obtain vital signs on a postoperative client who required naloxone 5
minutes ago.
3. Report a urinary output (UOP) less than 50 ml/hr on a post-op client.
4. Assist a client with obtaining a clean catch urine sample.
5. Remove an indwelling urinary catheter from a client. - 3,4
What should the nurse teach a pregnant client who comes to the clinic
reporting hemorrhoids and constipation?
1. Increased rectal pressure from the gravid uterus may result in hemorrhoids.
2. Hormones decrease maternal GI motility, resulting in constipation.
3. The client needs more fiber in the diet.
4. A mild laxative is recommended to alleviate constipation.
5. The client needs to increase fluid
intake. Rationale - 1,2,3,5
What statements by a new nurse would indicate to the charge nurse an
understanding of how to maintain skin integrity for a client on bedrest?
1. "Clients on bedrest should be placed on therapeutic mattresses."
2. "I will assess for the skin every 4 hours."
3. "I will assess the skin using the Braden scale."
4. "A pillow will be placed between the knees when client is side lying."
5. "The incontinent client will be kept clean and dry." - 1,3,4,5
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?
1. Don sterile gloves.
2. Place the client on reverse isolation.
3. Wear a particulate respirator
4. Obtain a consent form.
,5. Initiate airborne precautions. - 3,5
Which finding should a nurse expect when assessing a healthy 65 year old
client?
1. Anomia
2. Presbyopia
3. BP 156/88
4. Apraxia - 2
The charge nurse is evaluating knowledge of tracheostomy suctioning of a
new nurse prior to that procedure being performed. Which statement by the
new nurse would indicate to the charge nurse that additional education is
needed?
1. "Prior to suctioning, I will hyper-oxygenate the client."
2. "I will instill normal saline bullets to liquefy secretions."
3. "I will allow at least 20 seconds between suctioning passes."
4. "Suctioning will be limited to a maximum of three catheter passes." - 2
The nurse observes a client at a follow-up appointment using correct cane
walking technique but losing balance each time the quad cane is lifted off of
the floor. The client reports a history of recent falls. What is the best action
for the nurse to take?
1. Inform the primary healthcare provider of the observations made
regarding quad cane use, and imbalance assessment.
2. Inform client that there are only a few assistive devices available
to help with ambulation.
3. Instruct the client on proper quad cane use.
4. Notify the primary healthcare provider after consulting with the neighbor. -
1
The nurse is caring for a newly diagnosed diabetic in diabetic hyperosmolar
hyperglycemic nonketotic (HHNK) state. What does the nurse anticipate the
immediate treatment plan for this client will include?
1. NPH insulin.
2. Potassium 40 mEq (40 mmol/L) slow intravenous push.
3. Intravenous administration of isotonic saline.
4. Intravenous sodium bicarbonate. - 3
What is most important for the nurse to do prior to initiating peritoneal
dialysis?
1. Aspirate for placement.
2. Have the client void.
3. Irrigate the catheter for patency.
4. Warm the dialysate fluid. - 4
, The nurse in the outpatient clinic performs an assessment on a client who
takes propranolol for management of palpitations associated with mitral valve
prolapse. Which statement by the client should be reported immediately to
the primary healthcare provider?
1. "My resting pulse was 60 this morning."
2. "I feel a little short of breath when walking."
3. "I have lost 5 pounds in the last 2 weeks."
4. "My blood pressure (BP) was lower this visit than last time." - 2
Blood and urine samples are sent to the laboratory for a client who has had
a spinal cord injury. After reviewing these results, the nurse would expect
which finding?
Exhibit
1. Gross hematuria
2. Septicemia
3. Urinary tract infection
4. Anemia - 3
The nurse is instructing a client on achieving relaxation using deep breathing
exercises. Which statement by the client indicates to the nurse that further
teaching is necessary?
1. "I can perform deep breathing exercises anywhere and at any time that I
feel tension and anxiety."
2. "I should sit or lie in a comfortable position, making sure my back is
straight."
3. "I will inhale slowly and deeply through my mouth focusing on my chest
expansion."
4. "When I have inhaled in as much as possible, I will hold my breath for a
few seconds before exhaling." - 3
A client diagnosed with pancreatitis becomes increasingly restless, confused
and has pulled out the NG tube and IV catheter. HR-128/min, BP 96/62.
Oxygen saturation = 90%. Skin is cool and clammy to touch. Prioritize the
actions that the nurse should take.
Initiate oxygen.
Insert another IV
line.
Obtain blood sugar level.
Insert NG tube.
Repeat vital sign checks - This is the correct order
A teenage client is placed on life-support as a result of a motor vehicle
accident (MVA). Following an electroencephalogram (EEG), the client has
been declared brain dead.
Which action by the nurse would take priority?
answers
A charge nurse is planning care for several clients on the unit. Which
activities can the nurse safely delegate to an unlicensed assistive personnel
(UAP)?
1. Administer a nebulizer treatment to a client diagnosed with pneumonia.
2. Obtain vital signs on a postoperative client who required naloxone 5
minutes ago.
3. Report a urinary output (UOP) less than 50 ml/hr on a post-op client.
4. Assist a client with obtaining a clean catch urine sample.
5. Remove an indwelling urinary catheter from a client. - 3,4
What should the nurse teach a pregnant client who comes to the clinic
reporting hemorrhoids and constipation?
1. Increased rectal pressure from the gravid uterus may result in hemorrhoids.
2. Hormones decrease maternal GI motility, resulting in constipation.
3. The client needs more fiber in the diet.
4. A mild laxative is recommended to alleviate constipation.
5. The client needs to increase fluid
intake. Rationale - 1,2,3,5
What statements by a new nurse would indicate to the charge nurse an
understanding of how to maintain skin integrity for a client on bedrest?
1. "Clients on bedrest should be placed on therapeutic mattresses."
2. "I will assess for the skin every 4 hours."
3. "I will assess the skin using the Braden scale."
4. "A pillow will be placed between the knees when client is side lying."
5. "The incontinent client will be kept clean and dry." - 1,3,4,5
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?
1. Don sterile gloves.
2. Place the client on reverse isolation.
3. Wear a particulate respirator
4. Obtain a consent form.
,5. Initiate airborne precautions. - 3,5
Which finding should a nurse expect when assessing a healthy 65 year old
client?
1. Anomia
2. Presbyopia
3. BP 156/88
4. Apraxia - 2
The charge nurse is evaluating knowledge of tracheostomy suctioning of a
new nurse prior to that procedure being performed. Which statement by the
new nurse would indicate to the charge nurse that additional education is
needed?
1. "Prior to suctioning, I will hyper-oxygenate the client."
2. "I will instill normal saline bullets to liquefy secretions."
3. "I will allow at least 20 seconds between suctioning passes."
4. "Suctioning will be limited to a maximum of three catheter passes." - 2
The nurse observes a client at a follow-up appointment using correct cane
walking technique but losing balance each time the quad cane is lifted off of
the floor. The client reports a history of recent falls. What is the best action
for the nurse to take?
1. Inform the primary healthcare provider of the observations made
regarding quad cane use, and imbalance assessment.
2. Inform client that there are only a few assistive devices available
to help with ambulation.
3. Instruct the client on proper quad cane use.
4. Notify the primary healthcare provider after consulting with the neighbor. -
1
The nurse is caring for a newly diagnosed diabetic in diabetic hyperosmolar
hyperglycemic nonketotic (HHNK) state. What does the nurse anticipate the
immediate treatment plan for this client will include?
1. NPH insulin.
2. Potassium 40 mEq (40 mmol/L) slow intravenous push.
3. Intravenous administration of isotonic saline.
4. Intravenous sodium bicarbonate. - 3
What is most important for the nurse to do prior to initiating peritoneal
dialysis?
1. Aspirate for placement.
2. Have the client void.
3. Irrigate the catheter for patency.
4. Warm the dialysate fluid. - 4
, The nurse in the outpatient clinic performs an assessment on a client who
takes propranolol for management of palpitations associated with mitral valve
prolapse. Which statement by the client should be reported immediately to
the primary healthcare provider?
1. "My resting pulse was 60 this morning."
2. "I feel a little short of breath when walking."
3. "I have lost 5 pounds in the last 2 weeks."
4. "My blood pressure (BP) was lower this visit than last time." - 2
Blood and urine samples are sent to the laboratory for a client who has had
a spinal cord injury. After reviewing these results, the nurse would expect
which finding?
Exhibit
1. Gross hematuria
2. Septicemia
3. Urinary tract infection
4. Anemia - 3
The nurse is instructing a client on achieving relaxation using deep breathing
exercises. Which statement by the client indicates to the nurse that further
teaching is necessary?
1. "I can perform deep breathing exercises anywhere and at any time that I
feel tension and anxiety."
2. "I should sit or lie in a comfortable position, making sure my back is
straight."
3. "I will inhale slowly and deeply through my mouth focusing on my chest
expansion."
4. "When I have inhaled in as much as possible, I will hold my breath for a
few seconds before exhaling." - 3
A client diagnosed with pancreatitis becomes increasingly restless, confused
and has pulled out the NG tube and IV catheter. HR-128/min, BP 96/62.
Oxygen saturation = 90%. Skin is cool and clammy to touch. Prioritize the
actions that the nurse should take.
Initiate oxygen.
Insert another IV
line.
Obtain blood sugar level.
Insert NG tube.
Repeat vital sign checks - This is the correct order
A teenage client is placed on life-support as a result of a motor vehicle
accident (MVA). Following an electroencephalogram (EEG), the client has
been declared brain dead.
Which action by the nurse would take priority?
