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, teacorrect answerRationale
2. Correct: Client needs low sodium and increased proteins. 1. Incorrect: This selection is too high in sodium and fats. 3. Incorrect: This selection has no protein. Remember, nephrotic syndrome is the exception to the rule of limiting protein. These clients need increased protein to compensate for the large loss of protein in the urine. 4. Incorrect: This selection has no protein. Remember, nephrotic syndrome is the exception to the rule of limiting protein. These clients need increased protein to compensate for the large loss of protein in the urine.
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? You answered this question Correctly 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 shoescorrect answerRationaleStrategies 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. 2. Incorrect: Crossing the leg can pop the hip out of place and prevent total healing and success with the replacement. 5. Incorrect: To tie shoes, the client has to bend over which can pop the hip out of place. The client would need to have shoes that do not require tying or have someone do it for them.
What risk factors should the nurse include when conducting a class about type 2 diabetes mellitus? You answered this question Correctly 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.correct answerRationaleStrategies 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. 2. Incorrect: Being overweight is a primary risk factor for type 2 diabetes. The more fatty tissue, the more resistant cells become to insulin. 3. Incorrect: A type
1 diabetic will remain a type 1 diabetic. 4. Incorrect: African Americans, Hispanics, American Indians, and
Asian Americans are more likely to develop type 2 diabetes than Caucasians are.
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? You answered this question Correctly 1. Pantoprazole 2. Phenytoin 3. Imipramine HCI 4. Aminocaproic acidcorrect answerRationaleStrategies 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. 2. Incorrect: Phenytoin is an anticonvulsant. Seizures are not a side effect of methylprednisolone. 3. Incorrect: Imipramine HCI is an antidepressant which is not routinely given with methylprednisolone (Although mood changes can occur with steroid administration, anti-depressants are not routinely given). 4. Incorrect: Aminocaproic acid is given when clients are bleeding. Bleeding is not a side effect of methylprednisolone.
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. You answered this question CorrectlyThe Correct Order Apply clean gloves. Remove soiled dressings. Discard soiled dressings and clean gloves in red bag. Don sterile gloves. Clean surgical wound with moistened sterile 4x4's. 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. Your Selected Order Apply clean gloves. Remove soiled dressings. Discard soiled dressings and clean gloves in red bag. Don sterile gloves. Clean surgical wound with moistened sterile 4x4's. 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.correct answerRationaleStrategies 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.
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? You answered this question Incorrectly 1. Lorazepam 2. Atropine 3. Benztropine 4. Chlorpromazinecorrect answerRationaleStrategies 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. 1. Incorrect: This is a sedative/hypnotic or antianxiety agent. It is not used for treatment of extrapyramidal side effects. 2. Incorrect: This is an anticholinergic agent, but not one commonly used to treat pseudoparkinsonism, a form of extrapyramidal side effects. It is commonly used to treat arrhythmias and preoperatively to decrease secretions. 4. Incorrect: This is another antipsychotic medication.
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? You answered this question Correctly 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.correct answerRationaleStrategies 1., 3. & 4. Correct: The nurse should suspect that the client is suffering from tuberculosis. Early pulmonary TB is asymptomatic. When the bacterial load increases, nonspecific symptoms of fatigue, weight loss, afternoon fevers, and night sweats may set in. As disease advances, cough, sputum production, and hemoptysis may appear. This client has the classic symptoms of TB and should be placed on airborne precautions. N95 respirator ensures that the nurse does not inhale the TB organism. Placing in a semi-Fowler's position reduces the work of breathing. 2. Incorrect: Unless contraindicated, 3-4 liters of fluid is needed per day to liquefy secretions. 5. Incorrect: Visitors are allowed if standard and airborne precautions are followed.
Which task should the nurse perform first? You answered this question Correctly 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.correct answerRationaleStrategies 1. Correct: The tracheostomy tube must be suctioned to keep the client's airway open. Suctioning the tracheostomy should take priority. Remember, airway first. 2. Incorrect: The client may be uncomfortable from the colostomy bag leaking. This task can be delegated. The suctioning of the client does not have priority over airway. 3. Incorrect: Important, but not priority over airway. There is no indication from the question that the new client is in distress. The priority intervention is to maintain the
airway. 4. Incorrect: Important, but it does not take priority over airway.
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? You answered this question Correctly 1. Observation and support of ventilation 2. Insertion of indwelling urinary catheter 3. Nasogastric suctioning 4. Frequent assessments of level of consciousnesscorrect answerRationaleStrategies 1. Correct: Guillain-Barre syndrome is an acquired inflammatory disease that results in demyelinization of the peripheral nerves. It is usually ascending in nature and can lead to respiratory paresis or paralysis. 2. Incorrect: Insertion of an indwelling urinary catheter may in fact be necessary but does not prioritize higher than support of ventilation. 3. Incorrect: Nasogastric suctioning is not a need identified with Guillain-Barre syndrome. Guillain-Barre does not affect the LOC. 4. Incorrect: The client's cognitive function remains intact, and there is no data in the stem of the question that indicates otherwise; therefore, ventilation is the priority.
The nurse recognizes that treatment has been successful in resolving fluid volume excess based on which assessment findings? You answered this question Correctly 1. Continued lethargy 2. Heart rate 112/min 3. Decreasing shortness of breath 4. BP 114/78 5. Increased thirstcorrect answerRationaleStrategies 3. & 4. Correct: Urinary output should increase with decreasing shortness of breath as hydration is corrected, and BP should be normal. 1. Incorrect: Level of consciousness (LOC) should improve with perfusion to the brain. 2. Incorrect: Heart rate should decrease if hydration is corrected. 5. Incorrect: Thirst level should be decreased if hydration is corrected.
The oncoming nurse has just received report and is preparing to make initial rounds. Which postpartum client should the nurse see first? You answered this question Correctly 1. A primipara 6 hours postpartum saturating one peripad every two hours 2. A multigravida 1 hour postpartum and reporting intense perineal pain 3. A primigravida 12 hours postpartum with the uterine fundus at the umbilicus 4. A multigravida 72 hours postpartum with a brownish pink lochia discharge.correct answerRationaleStrategies 2. Correct: Intense perineal pain is a symptom of a perineal hematoma which
is a medical emergency. 1. Incorrect: Expected findings for the postpartum period are described here. This is a normal peripad saturation and does not indicate a problem. 3. Incorrect: Expected findings for the postpartum period are described here. This is the proper position of the fundus 12 hours postpartum. 4. Incorrect: Expected findings for the postpartum period are described here also. A client postpartal 72 hours should have a brownish pink lochia discharge.
The primary healthcare provider prescribes glycopyrrolate 0.2 mg IM thirty minutes prior to electroconvulsive therapy (ECT). What should be the nurse's response when the client asks why this drug is being given? You answered this question Incorrectly 1. "The action of the medication is complex." 2. "This drug will prevent you from having a seizure." 3. "This medication will relax your muscles so that you do not break a bone." 4. "Glycopyrrolate will decrease stomach secretions."correct answerRationaleStrategies 4. Correct: Glycopyrrolate is an anticholinergic. Glycopyrrolate blocks the activity of acetylcholine which reduces secretions in the mouth, throat, airway, and stomach. It is used prior to procedures to decrease the risk of aspiration. 1. Incorrect: The client has a right to be told the reason the drug is given. This is a nontherapeutic communication response. The nurse should not refuse the client's desire to understand their medications. 2. Incorrect: Glycopyrrolate blocks the secretions in the mouth, throat, airway and stomach. The medication does not prevent the client having a seizure. The ECT will induce a seizure, which is the desire. 3. Incorrect: This is not the drug's purpose so this would be incorrect information to give to the client.
The nurse is searching for information about the nursing care of a client receiving an experimental drug for the treatment of obesity. Which database is most likely to address this issue? You answered this question Correctly 1. Cumulative Index for Nursing and Allied Health Literature (CINAHL) 2. Cochrane Library 3. Health and Wellness Resource Center 4. MEDLINEcorrect answerRationaleStrategies 1. Correct: The Cumulative Index for Nursing and Allied Health Literature (CINAHL) is a source for reviewing
nursing and allied health information. It is also located in other healthcare data bases. 2. Incorrect: Cochrane Library includes evidence based medicine databases. 3. Incorrect: The Health and Wellness Resource Center provides access to a variety of journal articles, magazines, and pamphlets. 4. Incorrect: MEDLINE is one of the major sources for biomedical information.
A client comes to the clinic reporting palpitations, as well as nausea and vomiting while taking metronidazole. The nurse notes that the client is flushed and has a heart rate of 118 bpm. Based on this information, what is the most important question for the nurse to ask the client? You answered this question Correctly 1. "Do you take metronidazole on an empty stomach?" 2. "Are you using any products that contain alcohol?" 3. "How long have you had these symptoms?" 4. "What other medications are you currently taking?"correct answerRationaleStrategies 2. Correct: Flushing, nausea and vomiting, palpitations, tachycardia, psychosis are signs of disulfiram-type reaction seen when using products containing alcohol (cologne, after shave lotion, or path splashes) or ingesting alcohol products while taking metronidazole. 1. Incorrect: Although it is preferable to take metronidazole on an empty
