Western Governors University

NURSING BS C471

Quiz 1

1)A client who has a head injury is transported to the emergency department. Which assessment does the emergency department nurse perform immediately?

1. Pupil response
2. Motor function
3. Respiratory status
4. Short-term memory

2. The nurse is assessing a client with a history of heart failure who is receiving a unit of packed red blood cells. The client’s respiratory rate is 33 breaths/min and blood pressure is 140/90 mm Hg. Which action does the nurse take first?

1. Administer prescribed diphenhydramine (Benadryl).
2. Continue to monitor the client’s vital signs.
3. Stop the infusion of packed red blood cells.
4. Slow the infusion rate of the transfusion.

3. The nurse is a assessing a client with hypertension. Which client outcome is indicative of effective hypertension management?

1. Pedal edema is not present in the lower legs.
2. No complaints of sexual dysfunction occur.
3. No indication of renal impairment is present.
4. The blood pressure reading is 148/94 mm Hg.

4. A client who had a stroke combs her hair only on the right side of her head and washes only the right side of her face. How does the nurse interpret these actions?

1. Poor left-sided motor control
2. Paralysis or contractures on the right side
3. Limited visual perception of the left fields
4. Unawareness of the existence of her left side

5. The nurse is providing health education to a client with chronic venous stasis ulcers. What priority instruction does the nurse include?

1. “Apply antiembolism stockings before getting out of bed in the morning.”

2. “Clean venous ulcers with Betadine before applying a dressing.”
3. “Take 1 low-dose aspirin (81 mg) daily to prevent inflammation.”
4. “Remove and reapply a new DuoDerm dressing to your ulcers each day.”

6. When obtaining a client’s vital signs, the nurse assesses a blood pressure of 134/88 mm Hg. What is the nurse’s best intervention?

1. Call the health care provider and report the finding.
2. Reassess the client’s blood pressure at the next yearly physical.
3. Administer an additional antihypertensive medication to the client.
4. Teach the client lifestyle modifications to decrease blood pressure.

7. The nurse teaches a client who is newly diagnosed with coronary artery disease. Which instruction does the nurse include to minimize complications of this disease?

1. “Rest is the best medicine at this time. Do not start an exercise program.”
2. “You are a man; therefore there is nothing you can do to minimize your risks.”
3. “You should talk to your provider about medications to help you quit smoking.”
4. “Decreasing the carbohydrates in your diet will help you lose weight.”

8. The nurse is caring for a client who has had surgery the previous day. The client tells the nurse, “Breathing in using this thing (incentive spirometer) is a ridiculous waste of time.” What is the nurse’s best response?

1. “The spirometer will help you cough effectively.”
2. “The spirometer will help your lungs expand.”
3. “The spirometer will help prevent blood clots.”
4. “The spirometer will improve blood flow in your lungs.”

9. The nurse is assessing a client before surgery. Which assessments contraindicate the client having surgery as scheduled? (Select all that apply.)

1. Potassium level of 2.8 mEq/L
2. International normalized ratio (INR) of 4
3. Prothrombin time (PTT) of 30 seconds
4. Calcium level of 8.8 mEq/dL
5. Positive pregnancy test