Hurst Readiness Exam 2 Questions with Correct Answers and Complete
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1. What medication should the nurse anticipate giving to a client in preterm
labor to stimulate maturation of the baby's lungs?
1. M
...
Hurst Readiness Exam 2 Questions with Correct Answers and Complete
Solution
1 / 78
1. 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: 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.
2. 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 side rails: 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 beHurst Readiness Exam 2 Questions with Correct Answers and Complete
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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.
3. 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.: 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.
4. 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.-
: 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 followingHurst Readiness Exam 2 Questions with Correct Answers and Complete
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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.
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