nurs 600 hurst readiness exam 3 liberty university
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Hurst Readiness Exam 3 questions and
answers graded A+ 100%
Which menu selection by the client diagnosed with nephrotic syndrome indicates that
teaching of proper diet was understood? You answered this question Correctly 1.
Pancakes with whipped butter, syrup, bacon, apple juice 2. Scrambled eggs, sliced
turkey, biscuit, whole milk 3. Grits, fresh fruit, toast, coffee 4. Bagel with jelly, hash
browns, tea - Rationale
2. Correct: Client needs low sodium and increased proteins. 1. Incorrect: This selection
is too high in sodium and fats. 3. Incorrect: This selection has no protein. Remember,
nephrotic syndrome is the exception to the rule of limiting protein. These clients need
increased protein to compensate for the large loss of protein in the urine. 4. Incorrect:
This selection has no protein. Remember, nephrotic syndrome is the exception to the
rule of limiting protein. These clients need increased protein to compensate for the large
loss of protein in the urine.
Following a total hip replacement, the nurse provides discharge teaching to the client.
The nurse knows that teaching was effective when the client states which activities are
safe to perform? You answered this question Correctly 1. Using an abduction pillow
while sleeping 2. Crossing the legs 3. Using a toilet extender 4. Showering rather than
taking a bath 5. Tying shoes - RationaleStrategies 1., 3., & 4. Correct: The client
should use an abduction pillow to keep hip in proper alignment and prevent hip
dislocation. A toilet extender keeps the hip in proper alignment and prevents hip
dislocation. Showering rather than sitting in a tub will prevent flexion of the hip. 2.
Incorrect: Crossing the leg can pop the hip out of place and prevent total healing and
success with the replacement. 5. Incorrect: To tie shoes, the client has to bend over
which can pop the hip out of place. The client would need to have shoes that do not
require tying or have someone do it for them.
What risk factors should the nurse include when conducting a class about type 2
diabetes mellitus? You answered this question Correctly 1. Fat distribution greater in
abdomen than in hips. 2. Being underweight. 3. Having type 1 diabetes as a child
increases risk for type 2 diabetes. 4. Caucasians are more likely to develop type 2
diabetes than Hispanics. 5. Polycystic ovary syndrome. - RationaleStrategies 1., & 5.
Correct: If the body stores fat primarily in the abdomen, risk of type 2 diabetes is greater
than if body stores fat elsewhere, such as hips and thighs. Women with polycystic ovary
syndrome have increased risk of diabetes. 2. Incorrect: Being overweight is a primary
risk factor for type 2 diabetes. The more fatty tissue, the more resistant cells become to
insulin. 3. Incorrect: A type 1 diabetic will remain a type 1 diabetic. 4. Incorrect: African
Americans, Hispanics, American Indians, and Asian Americans are more likely to
develop type 2 diabetes than Caucasians are.
,The nurse is caring for a client following spinal surgery. The client is placed on
methylprednisolone. What additional drug therapy would the nurse expect to be
prescribed with methylprednisolone? You answered this question Correctly 1.
Pantoprazole 2. Phenytoin 3. Imipramine HCI 4. Aminocaproic acid -
RationaleStrategies 1. Correct: A potential side effect of methylprednisolone is a peptic
ulcer. The primary healthcare provider will prescribe a proton pump inhibitor or H2
blocker to prevent this side effect. 2. Incorrect: Phenytoin is an anticonvulsant. Seizures
are not a side effect of methylprednisolone. 3. Incorrect: Imipramine HCI is an
antidepressant which is not routinely given with methylprednisolone (Although mood
changes can occur with steroid administration, anti-depressants are not routinely given).
4. Incorrect: Aminocaproic acid is given when clients are bleeding. Bleeding is not a side
effect of methylprednisolone.
In what order, after initially washing hands, should the nurse change a dressing on an
infected abdominal surgical wound that has a Penrose drain and a large amount of
purulent drainage? Place in priority order from first to last. You answered this question
CorrectlyThe Correct Order Apply clean gloves. Remove soiled dressings. Discard
soiled dressings and clean gloves in red bag. Don sterile gloves. Clean surgical wound
with moistened sterile 4x4's. Clean around Penrose drain using a circular pattern inside
to outside. Place dry, sterile 4x4's over surgical wound and Penrose drain. Apply
abdominal dressing pad. Your Selected Order Apply clean gloves. Remove soiled
dressings. Discard soiled dressings and clean gloves in red bag. Don sterile gloves.
Clean surgical wound with moistened sterile 4x4's. Clean around Penrose drain using a
circular pattern inside to outside. Place dry, sterile 4x4's over surgical wound and
Penrose drain. Apply abdominal dressing pad. - RationaleStrategies First, apply clean
gloves. Second, remove soiled dressings. Third, discard soiled dressings and clean
gloves in red bag. Fourth, don sterile gloves. Fifth, clean surgical wound with moistened
sterile 4x4's. Sixth, clean around Penrose drain using circular pattern inside to outside.
Seventh, place dry, sterile 4x4's over surgical wound and Penrose drain. Eighth, apply
abdominal dressing pad.
A client diagnosed with schizophrenia who is taking monthly haloperidol injections
develops slurred speech, shuffling gait and drooling. Which prescribed PRN medication
would the nurse administer? You answered this question Incorrectly 1. Lorazepam 2.
Atropine 3. Benztropine 4. Chlorpromazine - RationaleStrategies 3. Correct: These
signs and symptoms are reflective of pseudoparkinsonism, a form of extrapyramidal
side effects which are side effects of the haloperidol. An anticholinergic agent maybe
used for treatment. This is an anticholinergic agent that may be used for extrapyramidal
side effects. 1. Incorrect: This is a sedative/hypnotic or antianxiety agent. It is not used
for treatment of extrapyramidal side effects. 2. Incorrect: This is an anticholinergic
agent, but not one commonly used to treat pseudoparkinsonism, a form of
extrapyramidal side effects. It is commonly used to treat arrhythmias and preoperatively
to decrease secretions. 4. Incorrect: This is another antipsychotic medication.
,A nurse is caring for a client who reports fatigue, weight loss, afternoon fevers, night
sweats, cough, and hemoptysis. What interventions should the nurse initiate? You
answered this question Correctly 1. Wear an N95 respirator when caring for client. 2.
Restrict fluid intake to 500 mL per day. 3. Position client in semi-Fowler's position. 4.
Place client in a negative pressure airflow room. 5. Do not allow visitors for 48 hours. -
RationaleStrategies 1., 3. & 4. Correct: The nurse should suspect that the client is
suffering from tuberculosis. Early pulmonary TB is asymptomatic. When the bacterial
load increases, nonspecific symptoms of fatigue, weight loss, afternoon fevers, and
night sweats may set in. As disease advances, cough, sputum production, and
hemoptysis may appear. This client has the classic symptoms of TB and should be
placed on airborne precautions. N95 respirator ensures that the nurse does not inhale
the TB organism. Placing in a semi-Fowler's position reduces the work of breathing. 2.
Incorrect: Unless contraindicated, 3-4 liters of fluid is needed per day to liquefy
secretions. 5. Incorrect: Visitors are allowed if standard and airborne precautions are
followed.
Which task should the nurse perform first? You answered this question Correctly 1.
Suctioning the tracheostomy. 2. Changing a colostomy bag that is leaking. 3.
Performing an admission assessment on a client. 4. Administering pain medication to a
postoperative client. - RationaleStrategies 1. Correct: The tracheostomy tube must be
suctioned to keep the client's airway open. Suctioning the tracheostomy should take
priority. Remember, airway first. 2. Incorrect: The client may be uncomfortable from the
colostomy bag leaking. This task can be delegated. The suctioning of the client does not
have priority over airway. 3. Incorrect: Important, but not priority over airway. There is no
indication from the question that the new client is in distress. The priority intervention is
to maintain the airway. 4. Incorrect: Important, but it does not take priority over airway.
A nurse is caring for a client hospitalized with Guillain-Barre syndrome. Which is the
most important nursing measure to include in the nursing care plan for this client? You
answered this question Correctly 1. Observation and support of ventilation 2. Insertion
of indwelling urinary catheter 3. Nasogastric suctioning 4. Frequent assessments of
level of consciousness - RationaleStrategies 1. Correct: Guillain-Barre syndrome is an
acquired inflammatory disease that results in demyelinization of the peripheral nerves. It
is usually ascending in nature and can lead to respiratory paresis or paralysis. 2.
Incorrect: Insertion of an indwelling urinary catheter may in fact be necessary but does
not prioritize higher than support of ventilation. 3. Incorrect: Nasogastric suctioning is
not a need identified with Guillain-Barre syndrome. Guillain-Barre does not affect the
LOC. 4. Incorrect: The client's cognitive function remains intact, and there is no data in
the stem of the question that indicates otherwise; therefore, ventilation is the priority.
The nurse recognizes that treatment has been successful in resolving fluid volume
excess based on which assessment findings? You answered this question Correctly 1.
Continued lethargy 2. Heart rate 112/min 3. Decreasing shortness of breath 4. BP
114/78 5. Increased thirst - RationaleStrategies 3. & 4. Correct: Urinary output should
increase with decreasing shortness of breath as hydration is corrected, and BP should
be normal. 1. Incorrect: Level of consciousness (LOC) should improve with perfusion to
, the brain. 2. Incorrect: Heart rate should decrease if hydration is corrected. 5. Incorrect:
Thirst level should be decreased if hydration is corrected.
The oncoming nurse has just received report and is preparing to make initial rounds.
Which postpartum client should the nurse see first? You answered this question
Correctly 1. A primipara 6 hours postpartum saturating one peripad every two hours 2. A
multigravida 1 hour postpartum and reporting intense perineal pain 3. A primigravida 12
hours postpartum with the uterine fundus at the umbilicus 4. A multigravida 72 hours
postpartum with a brownish pink lochia discharge. - RationaleStrategies 2. Correct:
Intense perineal pain is a symptom of a perineal hematoma which is a medical
emergency. 1. Incorrect: Expected findings for the postpartum period are described
here. This is a normal peripad saturation and does not indicate a problem. 3. Incorrect:
Expected findings for the postpartum period are described here. This is the proper
position of the fundus 12 hours postpartum. 4. Incorrect: Expected findings for the
postpartum period are described here also. A client postpartal 72 hours should have a
brownish pink lochia discharge.
The primary healthcare provider prescribes glycopyrrolate 0.2 mg IM thirty minutes prior
to electroconvulsive therapy (ECT). What should be the nurse's response when the
client asks why this drug is being given? You answered this question Incorrectly 1. "The
action of the medication is complex." 2. "This drug will prevent you from having a
seizure." 3. "This medication will relax your muscles so that you do not break a bone." 4.
"Glycopyrrolate will decrease stomach secretions." - RationaleStrategies 4. Correct:
Glycopyrrolate is an anticholinergic. Glycopyrrolate blocks the activity of acetylcholine
which reduces secretions in the mouth, throat, airway, and stomach. It is used prior to
procedures to decrease the risk of aspiration. 1. Incorrect: The client has a right to be
told the reason the drug is given. This is a nontherapeutic communication response.
The nurse should not refuse the client's desire to understand their medications. 2.
Incorrect: Glycopyrrolate blocks the secretions in the mouth, throat, airway and
stomach. The medication does not prevent the client having a seizure. The ECT will
induce a seizure, which is the desire. 3. Incorrect: This is not the drug's purpose so this
would be incorrect information to give to the client.
The nurse is searching for information about the nursing care of a client receiving an
experimental drug for the treatment of obesity. Which database is most likely to address
this issue? You answered this question Correctly 1. Cumulative Index for Nursing and
Allied Health Literature (CINAHL) 2. Cochrane Library 3. Health and Wellness Resource
Center 4. MEDLINE - RationaleStrategies 1. Correct: The Cumulative Index for
Nursing and Allied Health Literature (CINAHL) is a source for reviewing nursing and
allied health information. It is also located in other healthcare data bases. 2. Incorrect:
Cochrane Library includes evidence based medicine databases. 3. Incorrect: The
Health and Wellness Resource Center provides access to a variety of journal articles,
magazines, and pamphlets. 4. Incorrect: MEDLINE is one of the major sources for
biomedical information.
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