1. What medication Rationale
should the nurse 4. Correct:
anticipate giving to Betamethasone is used to stimulate maturation of the
a client in preterm baby's lungs in case preterm birth occurs. This med-
labor to stimulate ication is given to help prevent respiratory distress syn-
maturation of the drome (RDS) by improving storage and secretion of
baby's lungs? surfactant that helps to keep the alveoli from collaps-
ing.
1. Magnesium sul-
fate 1. Incorrect: Magnesium sulfate is given to stop preterm
2. Terbutaline labor, however, if delivery is imminent, then Betametha-
3. Methotrexate sone should be given to stimulate maturation of the
4. Betamethasone baby's lungs.
2. Incorrect: Terbutaline is contraindicated in preterm
labor, however, if delivery is imminent, then Betametha-
sone 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 Rationale
just returned to the 1., & 3. Correct:
nursing care unit Vital signs post procedure are important to monitor for
following a gas- any post-procedure complications such as bleeding or
troscopy. Which in- any signs of respiratory compromise. VS are checked
tervention should frequently for the first hour post procedure. Any client
the nurse include who has a scope inserted down the throat and has
on the plan of received numbing medication in the back of the throat
care? to depress the gag reflex should be kept NPO until the
gag reflex returns.
1. Vital sign checks
every 15 min x 4 2. Incorrect: Supine position for 6 hours is contraindi-
2. Supine position cated. The HOB should be elevated. In the event the
for 6 hours client vomits, he/she is less likely to aspirate with the
3. NPO until return HOB elevated. Supine position for 6 hours is used after
of gag reflex a heart catheterization.
4. Irrigate NG tube 4. Incorrect: A client who is going for a gastroscopy
, Hurst Readiness Exam 2
every 2 hours procedure cannot have a nasal gastric tube. An NG
5. Raise four side tube would interfere with the procedure.
rails 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 Rationale
client was admit- 3. Correct:
ted to the vascular The nurse should recognize the need for measures to
surgery unit during reduce the blood pressure. Administering the client's
the night shift with blood pressure medicine is aimed at correcting the
chronic hyperten- problem. It is appropriate to administer the medications
sion. At 0830, the at this time in relation to the time that the next dose is
unlicensed nurs- due.
ing assistant (UAP)
reports that the 1. Incorrect: This is an appropriate action, but does
client's BP is not address the problem of lowering the client's blood
198/94. What would pressure.
be the best ac- 2. Incorrect: This is an appropriate action, but does
tion for the charge not address the problem of lowering the client's blood
nurse to delegate pressure.
at this time? 4. Incorrect: This is an appropriate action, but does
not address the problem of lowering the client's blood
1. Ask the UAP to pressure.
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 admin-
ister the 0900
furosemide and
enalapril now.
4. Ask the LPN/LVN
to assess the client
for pain.
, Hurst Readiness Exam 2
4. A client suf- Rationale
fers from mi- 1. Correct:
graine headaches. Migraine headaches have a pulsating pain quality, uni-
What assessment lateral location, moderate or severe pain intensity, ag-
finding would the gravated by or causing avoidance of routine physical
nurse expect to activity (walking, climbing stairs). During headache at
find during a mi- least one of the following accompanies the headache:
graine attack? nausea and/or vomiting; photophobia and phonopho-
bia.
1. Unilateral, pul-
sating pain quality. 2. Incorrect: This is seen in tension headaches.
2. Bilateral, press- Headaches last 30 minutes to 7 days. Pain is mild or
ing/tightening pain moderate in intensity. It is not aggravated by routine
quality. physical activity. Nausea/vomiting, photophobia and
3. Ipsilateral nasal phonophobia are not common manifestations with ten-
congestion and rhi- sion headaches. These usually start gradually, often in
norrhea. the middle of the day.
4. Headache oc- 3. Incorrect: This is associated with cluster headaches,
curs after re- which are severe or very severe unilateral orbital,
covering from a supraorbital and/or temporal pain lasting 15-180 min-
headache treated utes. Symptoms include stabbing pain in one eye
with narcotics. 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, aceta-
minophen or ibuprofen, as well as prescription med-
ications. Too much medication can cause the brain to
shift into an excited state, triggering more headaches.
Also, rebound headaches are a symptom of withdraw-
al 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.
, Hurst Readiness Exam 2
5. The nurse is car- Rationale
ing for a client who 3. Correct.
was admitted to Gradual accumulation of nitrogenous wastes results in
the hospital follow- elevated BUN and serum creatinine. This is an indica-
ing a severe mo- tion of impaired renal function.
tor vehicle crash
(MVC) in which the 1. Incorrect. This is a normal creatinine level. Gradual
client was trapped accumulation of nitrogenous wastes from impaired re-
in the car for sever- nal function results in elevated BUN and serum creati-
al hours. The client nine.
is being closely 2. Incorrect. This is a normal output level. This level
monitored for the alone would not necessarily be an indicator of acute
development of re- renal failure and that value alone would not warrant
nal failure. Which reporting it to the primary healthcare provider.
assessment find- 4. Incorrect. Calcium level of 9.0 mg/dL (2.25 mmol/L) is
ing would warrant considered normal. When observing for renal function-
immediate report- ing you would assess the BUN and creatinine levels.
ing? In addition, the calcium level may drop (hypocalcemia)
in renal failure inverse relationship change due to the
1. Creatinine rising serum phosphate levels. However, the calcium
1.1 mg/dl (97.24 level presented is within normal limits (WNL).
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)
6. A client has been Rationale
admitted for exac- 3. Correct:
erbation of ulcera- Any acute weight gain or loss is fluid. Weight is the best
tive colitis with se- measurement for fluid loss or gain. Acute weight losses
vere dehydration. correspond to fluid volume deficits. This client has lost
What is the best 2.3 kg over a 2 day period, indicating a fluid volume
indicator that this deficit (FVD).
client has an actual
fluid deficit? 1. Incorrect: Although 10 loose stools would result in
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