Hurst
Readiness
Exam
1
A
child
is
admitted
to
the
hospital
with
a
temp
of
102.2°F
(
39.0°C),
lethargic,
and
no
urinary
output
in
6
hours.
Which
prescription
would
be
priority
for
the
nurse
to
initiate
for
this
child?
-
Blood
cultures
times
two
A
client
arrives
at
the
emergency
department
with
a
pneumothorax.
A
chest
tube
is
inserted
and
placed
to
20
cm
of
suction.
Two
hours
later,
the
nurse
notes
tidaling
in
the
water-seal
chamber.
Based
on
this
data,
what
intervention
should
the
nurse
initiate?
-
Document
the
finding.
A
client
at
32
weeks
gestation
is
admitted
to
the
obstetric
unit
with
a
BP
of
142/90
and
1+
proteinurea.
Since
no
private
rooms
are
available,
the
charge
nurse
must
assign
the
client
to
a
semi-private
room.
Which
client
should
the
charge
nurse
assign
this
client
to
room
with?
-
Pre-term
labor
client
with
twins
at
28
weeks
gestation.
A
client
comes
into
the
clinic
for
a
routine
check-up
during
the
second
trimester
of
pregnancy .
The
client
reports
gastrointestinal
(GI)
upset
and
constipation.
The
nurse
reviews
the
client's
medications.
Which
client
medication
is
most
commonly
associated
with
GI
upset
and
constipation?
-
Ferrous
sulfate
A
client
diagnosed
with
depression
asks
the
nurse,
"What
is
causing
me
to
be
depressed
so
often?"
What
is
the
best
response
by
the
nurse?
-
"There
are
a
number
of
reasons
that
may
contribute
to
depression,
such
as
a
decreased
level
of
chemicals
in
your
brain."
A
client
diagnosed
with
schizophrenia
tells
the
nurse,
"God
is
going
to
heal
me.
I
do
not
need
medication."
Which
response
by
the
nurse
would
best
promote
compliance
with
the
prescribed
medication
regimen?
-
Many
people
of
faith
believe
that
one
way
God
works
to
heal
is
through
medication
A
client
has
a
prescription
for
digoxin
0.125
mg
IV
push
every
morning.
Prior
to
administering
digoxin,
the
nurse
notes
that
the
digoxin
level
drawn
this
morning
was
0.9
ng/mL.
Which
action
would
be
most
important
for
the
nurse
to
take?
-
Administer
the
digoxin
A
client
has
been
taking
enoxaparin
40
mg
subcutaneous
once
a
day
for
1
week.
Which
action
should
the
nurse
take?
exhibit:
Hgb
-
15
g/dl
(2.3
mmol/l)
Hct
-
42%
Platelets
-
110,000/
mm3
aPTT
-
110
seconds
INR
-
1.2
-
Administer
protamine
sulfate
50
mg
over
10
minutes.
A
client
has
just
delivered
a
newborn.
Based
on
the
primary
healthcare
provider's
notation,
what
prescriptions
does
the
nurse
anticipate
administering
to
the
mother?
exhibit:
Healthy
male
(21
inches
long,
7
pounds)
delivered
to
22
y/o
female
Para
1
Gravida
Client
is
Rh
negative
and
the
newborn
is
Rh
positive.
Rubella
titer
less
than
1:8.
Hepatitis
B
status
negative.
Tetanus
toxoid
2
years
ago
-
1.
Measles,
mumps
and
rubella
(MMR)
vaccine
4.
RH0(D)
immune
globulin
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?
-
Notify
the
primary
healthcare
provider.
A
client
is
admitted
to
the
hospital
with
a
platelet
count
of
132,000
mm3
and
a
white
cell
count
of
8,495
cells/mcL.
What
interventions
should
the
nurse
implement?
-
1.
Monitor
stools
for
occult
blood.
2.
Place
on
fall
prevention.
4.
Restrict
venipunctures.
A
client
is
admitted
to
the
intensive
care
unit
after
overdosing
on
meperidine.
What
is
the
nurse's
first
priority?
-
Administer
naloxone
hydrochloride
0.4
mg
IV
every
2-3
minutes
prn.
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?
-
Respiratory
alkalosis
A
client
is
admitted
with
a
diagnosis
of
myasthenia
gravis.
What
interventions
should
the
nurse
include
to
manage
this
client's
swallowing
and
chewing
impairment?
-
1.
Provide
foods
that
are
soft
and
tender.
2.
Allow
client
to
rest
between
bites.
3.
Encourage
client
to
drink
thickened
liquids.
A
client
is
being
admitted
with
a
diagnosis
of
cirrhosis
of
the
liver.
What
assessment
findings
should
the
nurse
anticipate
in
this
client?
-
1.
Firm,
nodular
liver
2.
Ascites
4.
Increased
ALT
and
AST
levels
6.
Bleeding
from
the
GI
tract
A
client
is
being
treated
in
the
emergency
department
for
dehydration.
Which
central
venous
pressure
(CVP)
reading
would
the
nurse
identify
as
the
desired
response
to
treatment?
-
4
mm
Hg
A
client
is
taking
a
nonsteroidal
anti-inflammatory
drug
(NSAID)
for
the
relief
of
joint
pain.
A
gastrointestinal
bleed
is
suspected.
Which
laboratory
value
alerts
the
nurse
to
the
possibility
that
the
client
is
chronically
losing
small
amounts
of
blood?
-
Elevated
reticulocyte
count
indicates
increased
production
of
RBCs.
A
client
of
Jewish
faith
has
requested
a
Kosher
diet.
Which
food
tray
would
the
nurse
provide
to
the
client?
-
Broiled
white
fish,
baked
potato,
mixed
salad
and
tea
A
client
presents
to
the
emergency
department
(ED)
reporting
fever,
cough,
and
malaise.
The
nurse
notes
that
the
client
has
a
rash
appearing
as
vesicles,
most
prominently
on
the
face,
palms
of
the
hands,
and
soles
of
the
feet.
In
addition
to
triaging
the
client
as
emergent,
what
should
the
nurse
do?
-
Place
the
client
in
a
negative
pressure
room.
A
client
returned
to
the
unit
following
a
total
hip
replacement.
What
statement
by
the
client
would
indicate
to
the
nurse
that
teaching
has
been
successful?
-
"I
will
not
elevate
the
head
of
the
bed."
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
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