Hurst Readiness Exam 2 Complete
Questions and Answers with
Rationales.,
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 -
CORRECT ANSWER>>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. 1. Incorrect:
Magnesium sulfate is given to stop preterm labor, however, if delivery is
imminent, then Betamethasone should be given to stimulate maturation of
the baby's lungs. 2. Incorrect: Terbutaline is contraindicated in preterm labor,
however, if delivery is imminent, then Betamethasone should be given to
stimulate maturation of the baby's lungs. 3. Incorrect: Methotrexate is used
to stop the growth of the embryo in ectopic pregnancy so that the fallopian
tube can be saved. It is not an agent used in the management of preterm
labor.
An adult client has just returned to the nursing care unit following a
gastroscopy. Which intervention should the nurse include on 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
siderails - CORRECT ANSWER>>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. 2. Incorrect: Supine position
for 6 hours is contraindicated. The HOB should be elevated. In the event the
client vomits, he/she is less likely to aspirate with the HOB elevated. Supine
position for 6 hours is used after a heart catheterization. 4. Incorrect: A client
who is going for a gastroscopy procedure cannot have a nasal gastric tube.
An NG tube would interfere with the procedure. 5. Incorrect: Raising all side
rails is a form of restraint. Have the bed in low locked position. Raise three
side rails, and have call light within reach.
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. - CORRECT ANSWER>>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. 1. Incorrect: This is
an appropriate action, but does not address the problem of lowering the
,client's blood pressure. 2. Incorrect: This is an appropriate action, but does
not address the problem of lowering the client's blood pressure. 4. Incorrect:
This is an appropriate action, but does not address the problem of lowering
the client's blood pressure.
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. - CORRECT
ANSWER>>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. 2. Incorrect: This is seen in
tension headaches. Headaches last 30 minutes to 7 days. Pain is mild or
moderate in intensity. It is not aggravated by routine physical activity.
Nausea/vomiting, photophobia and phonophobia are not common
manifestations with tension headaches. These usually start gradually, often
in the middle of the day. 3. Incorrect: This is associated with cluster
headaches, which are severe or very severe unilateral orbital, supraorbital
and/or temporal pain lasting 15-180 minutes. Symptoms include stabbing
pain in one eye with associated rhinorrhea (runny nose) and possible
drooping eyelid on the affected side. The headaches tend to occur in
"clusters": typically one to three headaches per day (but may be as many as
eight) during a cluster period. 4. Incorrect: Overuse of painkillers for
, headaches, can, ironically, lead to rebound headaches. Culprits include over
the counter medications such as aspirin, acetaminophen or ibuprofen, as
well as prescription medications. Too much medication can cause the brain
to shift into an excited state, triggering more headaches. Also, rebound
headaches are a symptom of withdrawal as the level of medicine drops in the
bloodstream. Rebound headaches may have associated issues such as
difficulty concentrating, irritability and restlessness but does not typically
include photophobia or visual disturbances as seen with migraines.
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) - CORRECT ANSWER>>Rationale
3. Correct. Gradual accumulation of nitrogenous wastes results in elevated
BUN and serum creatinine. This is an indication of impaired renal function. 1.
Incorrect. This is a normal creatinine level. Gradual accumulation of
nitrogenous wastes from impaired renal function results in elevated BUN and
serum creatinine. 2. Incorrect. This is a normal output level. This level alone
would not necessarily be an indicator of acute renal failure and that value
alone would not warrant reporting it to the primary healthcare provider. 4.
Incorrect. Calcium level of 9.0 mg/dL (2.25 mmol/L) is considered normal.
When observing for renal functioning you would assess the BUN and
creatinine levels. In addition, the calcium level may drop (hypocalcemia) in
Questions and Answers with
Rationales.,
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 -
CORRECT ANSWER>>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. 1. Incorrect:
Magnesium sulfate is given to stop preterm labor, however, if delivery is
imminent, then Betamethasone should be given to stimulate maturation of
the baby's lungs. 2. Incorrect: Terbutaline is contraindicated in preterm labor,
however, if delivery is imminent, then Betamethasone should be given to
stimulate maturation of the baby's lungs. 3. Incorrect: Methotrexate is used
to stop the growth of the embryo in ectopic pregnancy so that the fallopian
tube can be saved. It is not an agent used in the management of preterm
labor.
An adult client has just returned to the nursing care unit following a
gastroscopy. Which intervention should the nurse include on 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
siderails - CORRECT ANSWER>>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. 2. Incorrect: Supine position
for 6 hours is contraindicated. The HOB should be elevated. In the event the
client vomits, he/she is less likely to aspirate with the HOB elevated. Supine
position for 6 hours is used after a heart catheterization. 4. Incorrect: A client
who is going for a gastroscopy procedure cannot have a nasal gastric tube.
An NG tube would interfere with the procedure. 5. Incorrect: Raising all side
rails is a form of restraint. Have the bed in low locked position. Raise three
side rails, and have call light within reach.
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. - CORRECT ANSWER>>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. 1. Incorrect: This is
an appropriate action, but does not address the problem of lowering the
,client's blood pressure. 2. Incorrect: This is an appropriate action, but does
not address the problem of lowering the client's blood pressure. 4. Incorrect:
This is an appropriate action, but does not address the problem of lowering
the client's blood pressure.
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. - CORRECT
ANSWER>>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. 2. Incorrect: This is seen in
tension headaches. Headaches last 30 minutes to 7 days. Pain is mild or
moderate in intensity. It is not aggravated by routine physical activity.
Nausea/vomiting, photophobia and phonophobia are not common
manifestations with tension headaches. These usually start gradually, often
in the middle of the day. 3. Incorrect: This is associated with cluster
headaches, which are severe or very severe unilateral orbital, supraorbital
and/or temporal pain lasting 15-180 minutes. Symptoms include stabbing
pain in one eye with associated rhinorrhea (runny nose) and possible
drooping eyelid on the affected side. The headaches tend to occur in
"clusters": typically one to three headaches per day (but may be as many as
eight) during a cluster period. 4. Incorrect: Overuse of painkillers for
, headaches, can, ironically, lead to rebound headaches. Culprits include over
the counter medications such as aspirin, acetaminophen or ibuprofen, as
well as prescription medications. Too much medication can cause the brain
to shift into an excited state, triggering more headaches. Also, rebound
headaches are a symptom of withdrawal as the level of medicine drops in the
bloodstream. Rebound headaches may have associated issues such as
difficulty concentrating, irritability and restlessness but does not typically
include photophobia or visual disturbances as seen with migraines.
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) - CORRECT ANSWER>>Rationale
3. Correct. Gradual accumulation of nitrogenous wastes results in elevated
BUN and serum creatinine. This is an indication of impaired renal function. 1.
Incorrect. This is a normal creatinine level. Gradual accumulation of
nitrogenous wastes from impaired renal function results in elevated BUN and
serum creatinine. 2. Incorrect. This is a normal output level. This level alone
would not necessarily be an indicator of acute renal failure and that value
alone would not warrant reporting it to the primary healthcare provider. 4.
Incorrect. Calcium level of 9.0 mg/dL (2.25 mmol/L) is considered normal.
When observing for renal functioning you would assess the BUN and
creatinine levels. In addition, the calcium level may drop (hypocalcemia) in
