Hurst Readiness Exam 2 Study Guide with Complete Solution
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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 - ANSWER Rationale
4. Correct: Betamethasone is used to stimulate maturation of the baby's lungs in ...
hurst readiness exam 2 study guide with complete solution
what medication should the nurse anticipate giving to a client in preterm labor to stimulate maturation of the babys lungs
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Hurst Readiness Exam 2 Study Guide
with Complete Solution
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 - 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 - 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. -
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. - 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) - 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 renal failure inverse
relationship change due to the rising serum phosphate levels. However, the calcium
level presented is within normal limits (WNL).
A client has been admitted for exacerbation of ulcerative colitis with severe dehydration.
What is the best indicator that this client has an actual fluid deficit?
1. Stool count of 10 episodes of diarrhea in 24 hours. 2. Weight increase of 2 kg and a
24 hour output of 1000 mL. 3. Admission weight of 74.3 kg and 2 days later a weight of
72 kg. 4. Daily intake of 2400 mL and an output of 1600 mL, plus diarrheal stools. -
ANSWER Rationale
3. Correct: Any acute weight gain or loss is fluid. Weight is the best measurement for
fluid loss or gain. Acute weight losses correspond to fluid volume deficits. This client has
lost 2.3 kg over a 2 day period, indicating a fluid volume deficit (FVD). 1. Incorrect:
Although 10 loose stools would result in fluid loss, the stool count of 10 episodes of
diarrhea is an inaccurate measurement. The amount of fluid loss can vary depending on
the amount of diarrhea, 10 "episodes" does not indicate how much fluid is lost. 2.
Incorrect: Weight gains indicate fluid volume retention and excess. This question asks
about fluid volume deficit. Also, it does not take into account the client's intake. Only the
output is considered, so output has less meaning without being compared to the intake.
4. Incorrect: Daily I&O is good information to have when assessing fluid status, but the
diarrhea stools are an inaccurate measurement. The weight remains the best
measurement for indicating a fluid deficit.
The nurse is working with a LPN/VN and an unlicensed assistive personnel (UAP).
Which clients would be appropriate for the nurse to assign to the LPN/VN?
1. In Bucks traction requiring frequent pain medication. 2. 24 hours post appendectomy.
3. Diagnosed with cholelithiasis and scheduled for surgery in the AM. 4. Admitted 6
hours ago in adrenal insufficiency. 5. Client newly diagnosed with Type 2 diabetes. -
ANSWER Rationale
1., 2., & 3. Correct These clients are stable and require predictable care that can be
done appropriately by the LPN/VN. 4. Incorrect: This client has adrenal insufficiency.
Primary adrenal insufficiency occurs when at least 90 percent of the adrenal cortex has
been destroyed generally from autoimmune disorders. Secondary adrenal insufficiency
, can be caused by such things as abrupt stoppage of corticosteroid medications and
surgical removal of pituitary tumors. As a result, often both glucocorticoid (cortisol) and
mineralocorticoid (aldosterone) hormones may be lacking. This puts the client at risk for
fluid volume deficit (FVD) and shock. This requires the higher level assessment skills of
the RN. 5. Incorrect: A newly diagnosed client may be unstable and would require
assessment, care plan development and teaching for the newly diagnosed diabetic
which cannot be performed by the PN.
The triage nurse in the emergency department (ED) assesses 4 clients. Which client is
in need of emergent care?
1. A 52 year old who has a partially amputated finger. 2. A 9 month old with temperature
of 103°F (39.4°C). 3. A two year old with excessive drooling and a weak cough. 4. A 28
year old experiencing a migraine headache for three days. - ANSWER Rationale
3. Correct: The two year old is exhibiting signs of respiratory difficulty with excessive
drooling and a weak cough. Partial airway obstruction is likely and maybe the result of
acute epiglottitis in which rapid progression to severe respiratory distress can occur .
Airway takes priority over the other clients. 1. Incorrect: The partial amputation would
have associated bleeding could be seen next, but airway takes priority. 2. Incorrect:
Most fevers in children do not last for long periods and do not have much consequence.
Elevated temperature would not take priority over airway. Antipyretics can be given in
triage. 4. Incorrect: The migraine is not emergent. Take care of life-threatening
illnesses/injuries first. Remember, pain never killed anyone.
A new nurse has a prescription to insert a feeding tube. The new nurse has never
performed the procedure, but learned how to do it while in nursing school. What would
be the best action by this nurse?
1. Ask to observe another nurse perform the procedure. 2. Look up how to perform the
procedure in the policy and procedure manual. 3. Tell the charge nurse that someone
else will have to place the feeding tube down the client. 4. Insert the feeding tube as
learned in nursing school. - ANSWER Rationale
2. Correct. The best action for the nurse to take is to look up how the procedure is done
in the agency by looking it up in the policy and procedure manual. The nurse could then
discuss the procedure with an experienced nurse and ask the nurse to observe the new
nurse while inserting the feeding tube. 1. Incorrect. This is passive and would not
benefit the new nurse to strengthen the skills. The best action would be to look up how
to do the procedure, discuss with another nurse, and ask that nurse to observe the
insertion of the feeding tube. 3. Incorrect. This is not the best option. The new nurse
needs to insert the feeding tube in order to become more proficient with this skill. This
option will not help the new nurse gain confidence in nursing skills. 4. Incorrect.
Although the new nurse should have the basic knowledge of feeding tube insertion, the
nurse should follow agency policy and procedure. It is then best to discuss the
procedure with another nurse and ask the nurse to observe the feeding tube insertion
since this nurse has never performed the skill.
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