Hurst Readiness Exam #4 Questions & Answers, Graded 100%

Hurst Readiness Exam #4 Questions & Answers, Graded 100% -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