HURST Fundamentals

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A nurse working in a clinic is planning to assess a client for any sensory deficits. What assessments should the nurse include? 1. Ask the client about any recent changes in vision. 2. Observe the client's conversation with others. 3. Assess two-point discrimination. 4. Perform the Rinne test. 5. Test near vision with the Snellen chart.

2 3 5 4. Incorrect: Gloves are not needed when preparing antibiotics such as ceftriaxone by IV piggyback.

The nurse should wear gloves when administering which medication? 1. Lorazepam 1mg orally. 2. Nitroglycerin ointment 2% 0.5 inch to chest. 3. Ceftriaxone 250mg intramuscularly. 4. Metronidazole 500mg intravenous piggyback. 5. Humalog 8 units subcutaneously.

1 1. Correct: The gold standard for nasogastric feeding tube placement is radiographic confirmation with X-ray. This is the most reliable method!

What is the best method for the nurse to verify correct nasogastric (NG) tube placement after insertion? 1. X-ray of the upper GI 2. Gastric aspiration and pH testing 3. Auscultation of air instilled into the stomach 4. Visualization of the tube markings

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The client reports having trouble sleeping at night. "My mind is constantly working, and I can't fall asleep until 2:00 or 3:00 a.m."Which behaviors found in the assessment are likely to contribute to sleep difficulty? 1. Performs office work before going to bed. 2. Watches night-time drama shows on TV. 3. Drinks caffeine after dinner each evening. 4. Reads for pleasure before going to bed. 5. Exercises 45 minutes at 5 pm each evening.

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Where should a nurse place the stethoscope when auscultating heart sounds? 1. First intercostal space right of the sternum to hear sounds from the pulmonic valve area. 2. Fourth intercostal space to the left of the sternum to hear sounds from the tricuspid area. 3. Second intercostal space to the right of the sternum to hear sounds from the aortic valve area. 4. Third intercostal space in the midclavicular line to hear sounds from the mitral area. 5. Apex of the heart to hear the loudest 2nd heart sound (S2).

1 5 1. & 5. Correct: Yes, the most important and subtle changes are related to the client's level of consciousness, verbal ability, orientation, and ability to move to command. 2. Incorrect: No, only helps with the determination of brain death. 3. Incorrect: Identifies diseases of the brain and spinal cord. 4. Incorrect: This should be last resort.

Which assessments will provide the nurse with the most information regarding a client's neurologic function? 1. Level of consciousness 2. Doll's eyes reflex 3. Babinski reflex 4. Reaction to painful stimuli 5. Verbal ability

3 3. CORRECT: The true test of learning is for the client to be able to actually complete a self-care task independently. There is nothing wrong with the client referring to written instructions to complete the task.

A client with a new colostomy is learning to perform a colostomy irrigation. The nurse knows the teaching was successful when the client makes what statement? 1. "My spouse can verbalize all the steps in order." 2. "I have attended all the sessions on ostomy care." 3. "I can do the irrigation if I refer to the instructions." 4. "I don't need to irrigate if the ostomy is making stool."

3 Look at the pH of 7.5 (normal 7.35-7.45) which is high or alkalosis. So options 1 and 4 can be eliminated since these indicate acidosis. Next, look at the PaCO2 of 58 (normal 35-45) which is high or acidosis. Look at the HCO3 of 35 (normal 22-26) which is high or alkalosis. The HCO3 matches the pH as both indicate alkalosis. So the correct answer is Option 3: Partially compensated metabolic alkalosis.

A new nurse asks the charge nurse for assistance in interpreting arterial blood gases (ABGs) for a client. What acid/base imbalance should the charge nurse tell the new nurse these ABGs indicate in the client? pH - 7.5 PaO2 - 94% PaCO2 - 58 HCO3 - 35 1. Partially compensated metabolic acidosis 2. Partially compensated respiratory alkalosis 3. Partially compensated metabolic alkalosis 4. Partially compensated respiratory acidosis

1 2 1., & 2. Correct: The nurse needs to intervene in these situations. Both side rails should not be lowered because the client could fall out of the bed. The UAP should lower the side rail closest to themselves and keep the opposite rail up. Wash eyes with water only since soap is very irritating to the eyes. 3. Incorrect: This would be a correct action by the UAP. The nurse does not need to intervene. Temperatures less than 110°F (43°C) can chill the client, and a temperature greater than 115°F (46°C) may be too hot and burn the client. 4. Incorrect: This is a correct action and does not require intervention by the nurse. Firm strokes from distal to proximal areas promote circulation by increasing venous blood return.

A nurse is monitoring a newly hired unlicensed assistive personnel (UAP) perform a bed bath on a client needing total care. Which action by the UAP would require further teaching? 1. Lowers side rails on both sides of bed. 2. Washes eyes with mild soap and water from the inner to outer canthus. 3. Makes certain bath water temperature is between 110-115°F (43-46°C). 4. Uses long, firm strokes to wash from wrist to shoulder of each arm. 5. Performs a back massage after completing the bath.

1 1. Correct: Feeding tube clients tend to get dehydrated, especially clients on bed rest, because bed rest induces diuresis! If the client is already having neurological signs, a grand-mal seizure may be next! Better take seizure precautions while awaiting the serum sodium results.

An elderly, bed-bound client receiving G-tube feedings at home is transported to the emergency department after onset of behavioral changes and hallucinations. Which nursing action is priority while diagnostic testing is underway? 1. Initiate seizure precautions 2. Monitor for signs of increased intracranial pressure 3. Orient to time, place, and person 4. Obtain vital signs q 15 minutes

1 3 5 2. Incorrect: This question addressing client advocacy is not related to client compliance. Client compliance may improve if the nurse served as an appropriate client advocate. However, promotion of compliance is not a basic part of advocacy.

An intubated client admitted to the intensive care unit appears anxious and fearful of the equipment in the room. The nurse observes this and takes the time to explain each piece of equipment and its role in providing care to the client. How does this action demonstrate client advocacy? 1. Providing information to the client. 2. Promoting client compliance. 3. Providing emotional support. 4. Ensuring the client's wishes for treatment are followed. 5. Fostering a sense of security.

2 3 4 5 wearing sandals is a risk to the person who is visually impaired and elderly, as the shoe may come off unexpectedly.

The nurse is making a home assessment for the purpose of preventing injury for a visually impaired elderly client who also has diabetes. Which findings are important for the nurse to include in this assessment? 1. Episodes of mild anxiety 2. Rugs secured to the floor 3. Adequate lighting 4. Functional eye glasses 5. Client is wearing well-fitting closed toe shoes

2 4 5 2., 4., & 5. Correct: These interventions will decrease the risk of skin breakdown by eliminating sustained pressure to areas at greatest risk of breakdown. 1. Incorrect: Do not massage the damaged area because this may cause additional damage. 3. Incorrect: This is way too long. The client should only be on their paralyzed side for 30 minutes. 6. Incorrect: This is way too long. Skin breakdown can result within this period of time. The client's weight should be shifted within the wheelchair every 15-20 minutes.

The nurse is planning care for the prevention of skin breakdown in a client diagnosed with a stroke. What intervention is important for the nurse to include? 1. Massage reddened skin areas located over bony prominences. 2. Place pillows under lower extremities to raise heels off the bed. 3. Position client on paralyzed side for one hour. 4. Apply emollients to dry skin. 5. Place a gel seat cushion on the wheelchair seat. 6. Shift client weight every two hours while sitting in a wheelchair.

2 5 1. Incorrect: Informing the client that the curtain was open is an embarrassment to the client and may lead to a lack of trust in additional care that may be provided. It does not help solve the privacy issue, which the nurse has the responsibility to protect.

The nurse notices that a client's bedside privacy curtain has been left partially open during the client's bath. Which are appropriate actions for the nurse to take in order to ensure the client's right to privacy? 1. Inform the client that the curtain was left partially open. 2. Close the privacy curtain to protect the client's right to privacy. 3. Since the client did not notice the open privacy curtain no action is necessary. 4. Only a few visitors are on the unit at this time so no action is necessary. 5. Instruct the nurse giving the client's bath about the open curtain and need for privacy.

3 4 5. Incorrect: This intervention by the nurse is appropriate. In an emergency the side rails maybe raised when the safety of the client is at risk.

The nursing supervisor is preparing a staff development program concerning the legal parameters of torts. Which example would the supervisor include as an intentional tort? 1. Administering a 0900 medication at 1030. 2. Administering a medication to an incorrect client. 3. Performing an invasive procedure without an informed consent. 4. Telling a client that their medication will be withheld if client does not behave. 5. Raising the side rails without a prescription when a client is at risk to fall.

1 2 3 4 1., 2., 3., & 4. Correct: The Weber test uses a tuning fork to assess bone conduction by examining the lateralization of sounds. The Rinne test compares air to bone conduction. Audiometric testing determines the degree and type of hearing loss. The audiometer produces pure tones at varying intensities to which the client can respond. The ticking of a watch has a higher pitch than the normal voice. Have client occlude one ear. Out of the client's sight, place a ticking watch 1 inch (2-3 cm) from the unoccluded ear. Ask what the client can hear. Repeat with the other ear. With the whisper test, the examiner stands 12-24 inches (30-61 cm) to the side of the client and, after exhaling, speaks using a low whisper. The client is asked to repeat numbers or words or answer questions. Each ear is tested.

What test should the nurse use to test a client's gross hearing acuity? 1. Weber's 2. Rinne 3. Audiometry 4. Whisper 5. Monofiliment testing