Hurst Readiness Exam 2: Questions &
Answers
What medication should the nurse anticipate giving to a client in preterm
labor to stimulate maturation of the baby’s lungs?
- Magnesium sulfate
- Terbutaline
- Methotrexate
- Betamethasone
(Ans- Rationale - 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. - 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. - 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. - 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? - Vital sign checks every 15 min x 4
- Supine position for 6 hours
- NPO until return of gag reflex
- Irrigate NG tube every 2 hours
- Raise four side rails
(Ans- 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. - 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. - Incorrect: A client who is going for a gastroscopy procedure cannot have
a nasal gastric tube. An NG tube would interfere with the procedure. - 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? - 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. - Have the LPN/LVN administer the 0900 furosemide and enalapril now.
- Ask the LPN/LVN to assess the client for pain.
(Ans- Rationale - 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.
- Incorrect: This is an appropriate action, but does not address the
problem of lowering the client’s blood pressure. - Incorrect: This is an appropriate action, but does not address the
problem of lowering the client’s blood pressure. - 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? - Unilateral, pulsating pain quality.
- Bilateral, pressing/tightening pain quality.
- Ipsilateral nasal congestion and rhinorrhea.
- Headache occurs after recovering from a headache treated with
narcotics.
(Ans- Rationale - 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. - 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. - 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.
- 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? - Creatinine 1.1 mg/dl (97.24 mmol/L)
- Urinary output of 150 mL per hour.
- Gradual increase of BUN levels.
- Calcium levels of 9.0 mg/dL (2.25 mmol/L)
(Ans- Rationale - Correct.
Gradual accumulation of nitrogenous wastes results in elevated BUN and
serum creatinine. This is an indication of impaired renal function. - Incorrect. This is a normal creatinine level. Gradual accumulation of
nitrogenous wastes from impaired renal function results in elevated BUN
and serum creatinine. - 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. - 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