Hurst Readiness Exam 1 Latest Update 2023 2024 125 Questions and Verified Correct Answers Guaranteed Success 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 2. Ceftriaxone 250 mg IV every 12 hours 3. Start IV &
monitor site. 4. 1/2 normal saline at 40 mL/hr - Correct Answer:Rationale
- Correct: Immediate blood cultures should be obtained on this child, as sepsis is
suspected with any temperature this high. The nurse would also need to get diagnostics before treatment is initiated so that correct interventions are prescribed. 2. Incorrect: The ceftriaxone is administered after the appropriate IV has been initiated. This would be the last intervention to be initiated. 3. Incorrect: The IV can be started at any point, but should be done after the cultures so the blood sample would not be affected in anyway. 4. Incorrect: Fluids will be started after the cultures are obtained and after the IV is started so as not to alter the results of the blood work and ensure correct treatment.
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?
- Ausculate the lung sounds. 2. Document the finding. 3. Notify the primary healthcare
provider. 4. Place the client on oxygen. - Correct Answer:Rationale
- Correct: Tidaling (fluctuations in the water-seal chamber) with respiratory effort is
normal. 1. Incorrect: The lung sounds should be assessed with a pneumothorax.
However, look at the hint: The question is talking about tidaling. 3. Incorrect: The primary healthcare provider does not need to be notified. Tidaling in the water-seal chamber is not an abnormal finding. 4. Incorrect: The question gives no indication of the client having active symptoms of respiratory distress. It is not an appropriate intervention.
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?
- Postpartum woman who delivered at term. 2. Woman in preterm labor at 35 weeks
gestation. 3. Woman with placenta previa at 37 weeks gestation. 4. Pre-term labor client
with twins at 28 weeks gestation. - Correct Answer:Rationale
- Correct: Both clients are presenting with the possibility of preterm deliveries. The
room should be kept quiet to decrease stimulation of the clients. Also, the client with preeclampsia should not be stimulated which could increase her blood pressure. 1. 1 / 4
Incorrect: The client will require frequent postpartum assessments and nursing care.The client will likely have a great deal of activity in her room and this would be potentially harmful to the newly admitted client. 2. Incorrect: This client will have a increase of activities in her room as the preterm labor progresses. There is also the potential of an emergency delivery. 3. Incorrect: The client is admitted with placenta previa. Emergency deliveries may occur if the client becomes hypovolemic or there are signs of fetal compromise.
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?
- Calcium supplement 2. Ferrous sulfate 3. Folic acid 4. Cetirizine - Correct
Answer:Rationale
- Correct: Ferrous sulfate commonly causes constipation and GI upset. These side
effects can be diminished with proper teaching regarding diet and taking medication
with food. 1. Incorrect: Calcium may cause constipation but generally relieves
symptoms associated with gastric acid indigestion. Calcium is often used for the treatment of transient acid indigestion and heartburn. 3. Incorrect: Constipation and GI upset are not generally associated with folic acid administration. 4. Incorrect: Constipation is an adverse effect associated with cetirizine administration, since it is an antihistamine.
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. " 2. "You experience depression because of your elevated levels of thyroid hormones." 3. "The primary healthcare provider will have to explain to you what is causing your depression." 4. "Tell me what you think causes
you to be depressed." - Correct Answer:Rationale
1. Correct: Decreased levels of norepinephrine, dopamine, and serotonin are
neurotransmitter implications for depression. By giving this type of information to the client, it helps with their understanding of the depression and empowers them with knowledge. 2. Incorrect: Elevated levels of thyroid hormones are thought to contribute to panic disorder or manic-type behaviors. Decreased levels of thyroid hormones are affiliated with depression, but not increased levels, so this would be wrong. 3. Incorrect: The nurse can discuss this with the client. This would be ignoring the client's desire to have information and post-pone providing much-needed help to the client. 4. Incorrect: This statement may allow for dialogue, but does not answer the client's question.
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?
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- Yes, I believe that God will heal you. 2. Many people of faith believe that one way
God works to heal is through medication. 3. We are talking about taking your medications right now. 4. What if God does not heal you and you should have taken the
medication? - Correct Answer:Rationale
- Correct: This allows the client to keep the belief that God will heal but will do it
through the medication. This promotes compliance with the prescribed medication regimen. 1. Incorrect: The nurse does not know if God will heal the client and does not
promote compliance with the prescribed medication regimen. 3. Incorrect: This
approach may make the client angry, which will close the communication between the client and the nurse. It also does not promote compliance with the prescribed medication regimen. 4. Incorrect: This approach is argumentative and puts the client on the defense, which will close the communication between the client and the nurse.
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. 2. Hold the digoxin. 3. Notify the primary healthcare provider.
4. Repeat the digoxin level. - Correct Answer:Rationale
- Correct: This is a normal digoxin level. The nurse would administer the prescribed
digoxin. The therapeutic serum levels of digoxin range from 0.5 to 2 ng/mL. 2. Incorrect: This is a normal digoxin level. The nurse would administer the prescribed digoxin. 3.Incorrect: There is no need to notify the primary healthcare provider of a normal digoxin
level. 4. Incorrect: There is no need to repeat a normal laboratory value.
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. 2. Type and cross match for 2
units PRBCs 3. Increase enoxaparin dose to increase INR 4. Give the scheduled dose
of enoxaparin - Correct Answer:Rationale
- Correct: Protamine sulfate is given for heparin overdose. It is a heparin antagonist.
Overdose is seen with a aPTT of 110 seconds. Depending on therapeutic intent, a client's aPTT levels should be between 60-80 seconds. (Normal aPTT for a client not on an anticoagulant is 25-35 seconds). 2. Incorrect: RBC, Hgb, Hct are normal. Blood transfusion is not indicated. 3. Incorrect: PT is not used to measure the therapeutic effect of enoxaparin, but rather aPTT. PT and INR are used for warfarin. 4. Incorrect: aPTT is too long at 110 seconds. Therapeutic level is 60-80 seconds.
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?
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exhibit: Healthy male (21 inches long, 7 pounds) delivered to 22 y/o female Para 1 Gravida 1. 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
- Measles, mumps and rubella (MMR) vaccine 2. Hepatitis A vaccine 3. Hepatitis B
immune globulin 4. RH0(D) immune globulin 5. Tetanus toxoid - Correct
Answer:Rationale
1., & 4. Correct: A client who has a titer of less than 1:8 is administered a subcutaneous injection of rubella vaccine, or measles, mumps and rubella vaccine (MMR) during the postpartum period to protect a subsequent fetus from malformations. Clients should not get pregnant for 4 weeks following the vaccination. All Rh negative moms who have Rh positive newborns must be given RH0(D) immune globulin IM within 72 hours of newborn being born to suppress antibody formation in the mother. 2. Incorrect: The mother is negative for hepatitis but current guidelines recommend that the newborn be given the hepatitis B vaccine. Hepatitis A vaccine is not given. 3. Incorrect: The mother is negative for hepatitis. If the newborn had been born to a mom who has hepatitis B, the newborn would receive the hepatitis B vaccine and the Hepatitis B immune globulin within 12 hours of birth. 5. Incorrect: Mom is up to date on tetanus toxoid vaccine.
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
- What is the priority nursing intervention for this client?
- Continue to assess every 15 minutes. 2. Stimulate the client with a sternal rub. 3.
Administer acetaminophen with codeine for headache. 4. Notify the primary healthcare
provider. - Correct Answer:Rationale
4. Correct: On the Glasgow coma scale, we like a number between 13 to 15. This
assessment score has dropped to 12, so the client is getting worse and the headache could mean increasing intracranial pressure (ICP). This is the only intervention that can fix the problem. 1. Incorrect: Reassessing in 15 minutes is delaying treatment. When neuro changes start happening, they happen rapidly. 2. Incorrect: Stimulating the client will increase the client's ICP. 3. Incorrect: A sedative should NOT be administered. The client's level of conscious has decreased.
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?
- Monitor stools for occult blood. 2. Place on fall prevention. 3. Place client in protective
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isolation. 4. Restrict venipunctures. 5. Limit visitors. - Correct Answer:RationaleStrategies 1., 2., & 4. Correct: A normal platelet count ranges from 150,000-400,000 mm3. This is a low platelet count, so interventions should focus on bleeding precautions. The white cell count (WBC) is normal (5,000-10,000 cells/mcL).Bleeding precautions would include monitoring for bleeding, such as monitoring stools for occult blood. The client is at risk for injury, so fall prevention is needed. Since the client will bleed more easily, restrict venipunctures. 3. Incorrect: The client has a normal