Hurst Readiness Exam 2 Practice

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• A newly admitted client with schizophrenia is unkempt and needs to attend to personal hygiene. Which statement by the nurse is most therapeutic?
• Which practice best ensures privacy and accuracy when using an interpreter for medical conversations?
• What is the primary objective of keeping the stomach empty in pancreatitis management?
• To protect staff when entering a room of a patient with shingles, which PPE is essential?
• A nurse supervisor notes an unlicensed assistive personnel (UAP) during care. Which observation will require the nurse to intervene?
• An RN on the general pediatric unit has been reassigned to the spinal/neurology unit. Which assignment would be most appropriate for this RN?
• A client at a mental health center has expressed suicidal thoughts and has access to firearms at home. Which action is priority?
• A client with signs of liver disease presents with jaundiced sclera, abdominal distension, leg swelling, and bruises in various stages of healing. Which nursing action is NOT appropriate?
• A client with glomerulonephritis is prescribed strict bedrest. Which explanation best supports this prescription?
• Which medication is anticipated to be given to a client in preterm labor to stimulate fetal lung maturation?
• A provider orders phenytoin 100 mg IV push through a non-tunneled central venous catheter. In what order should the nurse administer this prescription?
• Prolonged prednisone therapy commonly causes which fluid-related effect?
• Which assessment finding would indicate a chemotherapy patient may have difficulty maintaining proper nutrition?
• Which factor is NOT associated with increased cancer risk?
• Which meal demonstrates understanding of a low-tyramine option suitable with a monoamine oxidase inhibitor?
• Which behavior best supports a toddler’s autonomy?
• Which dietary change is accurate for constipation management to promote softer stools and easier passage?
• A nurse explains the role of benztropine when given with chlorpromazine. Which statement correctly describes its purpose?
• Before surgery, if the operative permit has not been signed and the client has received preoperative medication, what is the appropriate action?
• Why must a unit of packed red blood cells be completed within 4 hours of starting the transfusion?
• A child with respiratory syncytial virus (RSV) requires precautions. Which precautions are appropriate?
• Which practice best supports infection prevention for an immunocompromised patient?
• In suspected anthrax, which assessment question is most important to ask?
• A female patient taking captopril for hypertension says she plans to become pregnant. What should the nurse advise?
• A client asks what could have caused right-sided heart failure. Which explanation is best?
• Which safety intervention is NOT recommended for a home safety plan after a cerebrovascular accident with generalized weakness?
• Which is an expected side effect of nitroglycerin administration?
• A nurse from an adult unit was reassigned to the pediatric unit. Which client would be least appropriate to assign to this nurse?
• The nurse is caring for a client on the surgical unit. The primary healthcare provider prescribed morphine sulfate 20 mg IM as a one-time dose. The nurse has available morphine sulfate in a 20 mL vial labeled 15 mg per mL. How many mL should the nurse administer? Round to one decimal place.
• What is the role of surfactant in neonatal lungs?
• In a client with a T4 lesion experiencing autonomic dysreflexia, which action is incorrect to perform first?
• A newly hired nurse has to insert a feeding tube but has never performed the procedure. What is the best initial action?
• Which statement is NOT appropriate anticipatory guidance for children 18 months to 3 years?
• What should be documented in the chart regarding advance directives?
• When a nurse refuses to care for an HIV-positive client, what action should the charge nurse take first?
• In a psychiatric setting, which response to the statement 'Everyone here hates me' is best for the nurse to give?
• What is the primary cause of rheumatic fever?
• Which statement correctly describes the timing when taking sucralfate with lansoprazole?
• Which intervention best helps keep the airway clear of secretions in a client with pneumonia?
• During the insertion of a urinary catheter, the tip of the catheter touches the client's thigh. What action should the nurse take?
• A client with glaucoma is prescribed a prostaglandin agonist. Which client statement indicates a lack of understanding of the regimen?
• Which statement describes a NOT a side effect after two months of prednisone therapy?
• Which activity helps a 4-year-old learn what a newborn needs?
• Which patient would be most appropriate for assignment to the RN on a pediatric unit?
• Increased intracranial pressure: which sign is an early indicator?
• The nurse is caring for a client admitted to the unit with a chest tube. What monitoring frequency for respiratory status is appropriate?
• Which assessment finding would indicate potential increased intracranial pressure in a client with a ventriculoperitoneal shunt?
• Why should the closed drainage unit be kept below the level of the chest?
• In post-gastrectomy care, which action should be taken first if the NG tube drainage is not clear?
• In a triage scenario, which client requires emergent care due to possible airway compromise?
• Which statement indicates a need for further preoperative teaching for total laryngectomy?
• For a patient with liver disease and ascites, which meal pattern is recommended?
• Two hours after a gastrectomy, the NG tube is pink-tinged and occluded. What is the nurse's initial action?
• Which client should the nurse place in the room with a 6 year old with glomerulonephritis?
• Which symptom should prompt the nurse to notify the healthcare provider after balloon angioplasty?
• What is the best practice to obtain informed consent from a patient with limited English proficiency?
• An angry patient requests a copy of their medical records. Which statement best reflects the nurse\'s response?
• Which nurse assignment would be inappropriate for the charge nurse to give to a new admit with shingles?
• For the nurse's safety, what should be the initial action when an agitated patient enters the ED demanding to be seen?
• The nurse is at highest risk for blood-borne exposure during which situation?
• Which ABG pattern indicates metabolic alkalosis due to calcium carbonate ingestion?
• Evaluate discharge teaching for a client with type I diabetes mellitus. Which statement indicates teaching has been effective?
• Which statement is least typical of severe major depressive disorder?
• To reduce the risk of a complication after balloon angioplasty, which measure should the nurse implement as the most important?
• An employee sustains an eye injury after a chemical explosion. Which nursing action takes priority to prevent further damage?
• The Guthrie test for newborn screening is typically performed when?
• In pancreatitis, which statement best describes the effect of maintaining NG suction to keep the stomach empty?
• A nine-month-old patient is given a crushed tablet mixed in applesauce. Which action should the supervising nurse take?
• A client diagnosed with major depression is admitted for electroconvulsive therapy. The client asks how many treatments are typically required. What is the nurse's best answer?
• Which intervention should be included in the plan of care for a client after a gastroscopy?
• A client is monitored for potential renal failure after a severe trauma. Which assessment finding would warrant immediate reporting?
• Which acid-base disturbance is expected in a patient who is hyperventilating due to anxiety?
• In evaluating an elderly client at risk for suicide, which question should be asked first?
• If signs of a transfusion reaction occur during a transfusion, what is the immediate action?
• A school nurse is teaching preteens with acne how to care for the skin. Which practice should be avoided?
• Which practice best reduces the risk of needle-stick injuries during clinical procedures?
• Which statement describes a disadvantage of using ad hoc interpreters?
• Which action would be most appropriate to prevent respiratory complications in a patient who is 4 days post spinal fusion?
• Which statement best distinguishes clang association from neologisms?
• Which of the following is NOT a symptom of serotonin syndrome?
• Which item is high in tyramine and should be avoided with MAOI?
• In assessing dehydration due to gastrointestinal losses, which metric most accurately reflects fluid deficit?
• A client who speaks Spanish is admitted to the surgical unit. What is the best method for the nurse to inform the client about a pre-surgical procedure?
• Which statement about HIPAA privacy is NOT correct?
• A client in a psychiatric unit sings rhyming phrases; how should the nurse document this form of thought?
• Which statement best describes the thiamine deficiency condition that can accompany chronic alcohol use, presenting with ocular symptoms and ataxia?
• A case manager is assessing an unresponsive client diagnosed with terminal hepatic encephalopathy for equipment needs upon discharge home for hospice care. Which equipment should the case manager obtain for this client?
• A psychiatric unit patient with obsessive-compulsive disorder has frequent hand-washing rituals. Which nursing intervention would be advisable?
• Which post-procedure finding would warrant immediate reporting after a gastroscopy?
• On the third postoperative day, a client develops fever and shivering. The provider orders antibiotics after cultures are drawn. What should the nurse do first?
• During discharge instructions, a patient from an Asian cultural background avoids eye contact by looking at the floor. How should the nurse interpret this behavior?
• Which immunizations obtained by the age of two would indicate to the pediatric nurse that the child is up-to-date on immunizations?
• What is the minimum age for administering the meningococcal vaccine, and when is it routinely recommended?
• Which snack would indicate to the nurse that teaching about nutrition during chemotherapy has been successful?
• A patient with recurrent angina and hypertension has an admission order for spironolactone daily and a potassium supplement listed. Which prescription should be questioned immediately?
• Which test is most appropriate for screening lead exposure in a child at risk from living in an old, lead-painted home?
• What is the first action in the correct priority order when caring for a healthy newborn just delivered?
• Which technique is best to move an obese, dependent patient toward the top of the bed to protect skin from damage?
• A family member asks why a schizophrenic client is receiving chlorpromazine and benztropine. What is the best nurse response?
• Which action is essential to perform before initiating a blood transfusion?
• Following shift report, which ED patient should be assessed first?
• ECT treatments are generally administered in which setting?
• In a patient experiencing a sickle cell crisis, which prescription should be prioritized to address hydration?
• In suspected acute myocardial infarction, which medication should be administered immediately if hypoxia is present?
• Before entering the room of a client with agranulocytosis, which precaution is essential for family members?
• After total laryngectomy, which statement about breathing is true?
• What is the most important patient education to prevent rheumatic fever after streptococcal pharyngitis?
• A client had an abnormal MSAFP at 18 weeks; amniocentesis completed at 22 weeks. Which nursing action has priority?
• Before performing a renal biopsy with needle insertion, which preprocedure assessment is most important for the nurse to perform?
• A client with ulcerative colitis presents with severe dehydration. What is the best indicator that this client has an actual fluid deficit?
• A client admitted three months ago to a long-term care facility has lost 8 pounds with no changes in health status. Which strategy may help improve caloric intake?
• In pancreatitis management, what is the primary rationale for keeping the stomach empty with an NG tube on low suction?
• Which nurse response shows understanding of the violence cycle?
• Which of the following is NOT a recommended measure after admitting a client with a chest tube for a right pleural effusion?
• A client suffers from migraine headaches. Which assessment finding would the nurse expect during a migraine attack?
• Which question is most essential for safety assessment in command hallucinations?
• When taking a verbal or telephone prescription, which action is essential to ensure accuracy?
• Postpartum hemorrhage: which finding should be reported as a sign of concern?
• A psychiatric client is convinced the FBI is watching their house. What is the best nurse response to address the delusion?
• After amniocentesis, which statement about infection risk is most accurate?
• Which option is NOT considered an alternative pain control method?
• Rheumatic fever typically develops after a group A beta-hemolytic streptococcal infection within what timeframe?
• Which assessment finding would best indicate a positive Mantoux tuberculin skin test in a client?
• Which developmental task corresponds to the late life period (65 years and older) according to Erikson?
• What is the first step in administering a medication through a non-tunneled central venous catheter to ensure sterility?
• ECT treatments are typically administered how often?
• A group of women asks about preventing stress incontinence. Which statement should be avoided to help prevent bladder irritation?
• Which statement about magnesium sulfate in preterm labor is true?
• Which statement about celecoxib education is NOT correct?
• At 0830, a hypertensive client shows a blood pressure of 198/94. What is the best action to delegate to the LPN/LVN at this time?
• Which isolation precautions are appropriate for a client with shingles?
• In a client with fluid overload due to high CVP, which finding is most consistent?
• Which factor is NOT a risk factor for otitis media in children?
• Which prescription for a client diagnosed with acute heart failure should the nurse question?
• Which sign is a hallmark symptom of alcohol withdrawal delirium?
• Which client could the charge nurse assign to an LPN/VN?
• What is the typical severity of fever in rheumatic fever?
• Which statement about protective isolation is accurate?
• What is the third action in the correct priority order when assessing a healthy newborn after delivery?
• Which finding would most clearly indicate effective pain relief after a nonpharmacologic intervention such as guided imagery?
• A postoperative client’s intake and output for a shift lists several items. Calculate the client’s output in milliliters.
• Which ABG pattern is most consistent with fully compensated respiratory acidosis?
• What is a common trigger for autonomic dysreflexia in patients with spinal cord injury?
• A client with heavy recent alcohol use develops confusion and visual hallucinations on day 2 of hospitalization. What is the most likely diagnosis?
• The triage nurse in the emergency department assesses four clients. Which client would be the most appropriate to assign to the LPN/LVN?
• In a patient with abdominal aortic aneurysm, which prescription can be delegated to the LPN?
• In suspected rheumatic fever, which history data is most important to obtain?
• In a healthcare setting, which task is most appropriate to delegate to an unlicensed assistive personnel (UAP)?
• A nurse is caring for a client diagnosed with herpes varicella zoster. What pharmacologic agent should the nurse anticipate the primary healthcare provider will prescribe?
• Which action is most important to prevent shearing forces on the skin when moving an obese and dependent client toward the top of the bed?
• Which statement best demonstrates proper hygiene practice before donning sterile gloves in a hospital setting?
• A low-income family living near a salvage yard has a child. Which area of assessment is most important for the home health nurse?
• Which sign is a late indicator of increased intracranial pressure?
• The primary healthcare provider has prescribed phenytoin 100 mg intravenous push (IVP) stat for an adult client. What is the least amount of time that the nurse can safely administer this medication?
• Which statement about radiation therapy's effect on wound healing after neck surgery is accurate?
• A client’s two most recent CVP readings are 13 cm H2O. Which signs would you expect to see with fluid overload?
• What is the primary reason to draw blood cultures before starting antibiotics when a fever is suspected?
• For a pediatric patient experiencing a sickle cell crisis, which goal is appropriate?
• A client with cancer of the larynx undergoing radiation therapy asks about post-surgical recovery time. How should the nurse respond?
• Which statement made by a client after thyroidectomy would require further investigation by the nurse?
• In a patient with Delirium, which approach most effectively supports trust while addressing delusions?
• What is the purpose of flushing a central venous catheter with saline after medication administration?
• Which principle best reflects the obligation to care for all clients regardless of diagnosis?
• A patient is being discharged after total hip replacement. Which statement indicates understanding of hip dislocation prevention?
• A client on an SSRI for six weeks reports confusion and is worried about their symptoms. Which question would be most important to ask to assess a serious adverse reaction?
• Which approach best supports sibling adaptation when a newborn joins the family?
• Which statement about fluid management in acute heart failure is correct?
• Which activity BEST supports bonding between the 4-year-old and the newborn?
• Which action is NOT recommended to promote sibling adaptation for a 4-year-old when a newborn is expected?
• A nurse is caring for a client with suspected TB and airborne precautions. Which action demonstrates proper airborne precautions?
• When preparing a patient with hepatic encephalopathy for discharge home, which positioning action would best ease respirations?
• What is the priority concern when a tablet is crushed and mixed in 3 ounces of applesauce for a nine-month-old?
• A newly diagnosed diabetic learns about regular insulin. When is the greatest risk for hypoglycemia after the 8:00 a.m. dose?
• Which action BEST demonstrates to the preschooler that they are important in the family during the newborn's arrival?
• Which statement best describes why hyperventilation causes respiratory alkalosis?
• Which laboratory value is most indicative of acute renal impairment?
• A hospitalized client is to receive nadolol. Which finding should prompt the nurse to hold the medication and notify the provider?
• Which statement about herpes zoster vaccination is true?
• What flush technique is used to maintain patency and reduce catheter occlusion after administering a drug through a central venous catheter?
• A client with abdominal discomfort and constipation is admitted. Which finding would most concern the nurse for a potential obstruction?
• Which intervention best supports reducing ritualistic behavior in a client with obsessive-compulsive disorder?
• To prevent infection in an immunocompromised patient, which precaution is essential before entering the room?
• Which statement about borborygmi is correct?
• Which statement about advance directives is correct?
• Which is the appropriate handling method for transporting soiled linen after morning care?
• After a unit of packed red blood cells has been infusing for several hours and no reactions are present, what action is required?
• During rounds, which patient observation would require the charge nurse to intervene due to immobility-related risk?
• A client receiving glaucoma treatment with a prostaglandin agonist notes that the iris may darken in the treated eye. Which statement best reflects understanding of the regimen?
• How would you determine the correct size of an oropharyngeal airway for a client?
• During an infection in a client with type I diabetes mellitus, what happens to the blood glucose level?
• When a patient with a duodenal ulcer is prescribed lansoprazole and sucralfate, which sequence describes how to take these medications?
• The nurse explains that to monitor average blood glucose levels over time, which test should be returned to the clinic?