Pre Assessment Quiz Week 3 RN Capstone Review (Med Surg) Questions with
Verified Answers
A nurse is receiving a transfer report for a client who has The client opens his eyes when spoken to
a head injury. The client has a Glasgow coma scale of
three for eye-opening five for best verbal response and Rational: a GCS of 3-5-5 indicates that the client opens
five for best motor response which of the following is the his eyes in response to speech, is oriented, and is able to
appropriate conclusion based on this data? localize pain.
Auscultate for wheezing
A nurse in the emergency department is caring for a client Rational: when using the airway, breathing, circulation
who has anaphylaxis following a bee sting. Which of the approach to client care, the nurse should place the priority
following action should the nurse take first? on assessing the clients respiratory status. Bronchial, con-
tortion, or closure of the upper airway may occur, which
places the client at risk for respiratory arrest.
A nurse is admitting a client from a provider oflce. Click
Vital signs on admission and every four hours
to highlight the providers prescriptions. The nurse should
Stool culture, and sensitivity
implement first.
Urine culture and sensitivity
Dextrose 5% in 0.45% sodium chloride IV at 125 ML/hour
View available exhibits for all needed information
A nurse is assessing a client for hypoxemia during an asth- Agitation
ma attack. Which of the following manifestation should Rational: the nurse should expect agitation due to neuro-
the nurse expect? logical changes from poor oxygen exchange
Hematemesis
A nurse is assessing a client who has peptic ulcer disease. Rational: when using the urgent verse non-urgent ap-
Which of the following findings should the nurse identify proach to client care, the nurse should determine that the
as a priority? priority finding is hematemesis, which indicates massive
bleeding
Barrel
A nurse is assessing a client who has COPD. The nurse
Rational: A client who has COPD uses accessory muscles to
should expect the clients chest to be in which of the
assist with respiratory ettort. The use of those accessory
following shapes.
muscles causes the chest wall to eventually increase in
1/6
, Pre Assessment Quiz Week 3 RN Capstone Review (Med Surg) Questions with
Verified Answers
anterior and posterior diameter, making it appear barrel
shaped
A nurse is monitoring a client who has a chest tube in
Reposition the client
place connected to wall suction due to right sided pneu-
Rational: the nursery repositioning the client is an appro-
mothorax. The client complains of chest burning. Which
priate action to relieve chest burning from the chest tube
of the following action should the nurse take?
Play suction equipment at bedside
A nurse is caring for a client who has a right sided acoustic Rational: cranial nerves, nine and ten innervate the mus-
neuroma, resulting in impairment of cranial nerves nine cles of the soft palate larynx and fairings. Impairment of
and 10 which of the following action should the nurse these nerves places the client at risk for aspiration, making
take? it necessary for the nurse to have access to suction for the
client.
A nurse in a clinic is teaching information about cervical Postcoital bleeding may occur
polyps with a client who has a new diagnosis which of Rational: the client may experience postcoital bleeding,
the following information should the nurse include in the because the polyps are soft, fragile, and bleed when
teaching? touched.
Take blood pressure on clients non-attected arm
Rational:
A nurse is caring for a client who is post operative. Follow
The nurse should plan to only take blood pressures, give
your right side and vasectomy and has a drain connected
injections, or perform venipunctures on the clients, non-af-
to portable drainage evacuator which of the following
fected arm to avoid compromising circulation. The nurse
action should the nurse take
should instruct other statt to follow these precautions as
well.
A nurse is caring for a client who has essential venous Place the client on his left side in Trendelenburg position
catheter and suddenly develops chest pain, dyspnea, Rational:
dizziness, and tachycardia. The nurse suspects air em- This position helps trap the air in the apex of the right
bolism and clamp the catheter immediately. What other atrium rather than allowing it to enter the right ventricle
action should the nurse take at this time? and move to the pulmonary arterial system
2/6
Verified Answers
A nurse is receiving a transfer report for a client who has The client opens his eyes when spoken to
a head injury. The client has a Glasgow coma scale of
three for eye-opening five for best verbal response and Rational: a GCS of 3-5-5 indicates that the client opens
five for best motor response which of the following is the his eyes in response to speech, is oriented, and is able to
appropriate conclusion based on this data? localize pain.
Auscultate for wheezing
A nurse in the emergency department is caring for a client Rational: when using the airway, breathing, circulation
who has anaphylaxis following a bee sting. Which of the approach to client care, the nurse should place the priority
following action should the nurse take first? on assessing the clients respiratory status. Bronchial, con-
tortion, or closure of the upper airway may occur, which
places the client at risk for respiratory arrest.
A nurse is admitting a client from a provider oflce. Click
Vital signs on admission and every four hours
to highlight the providers prescriptions. The nurse should
Stool culture, and sensitivity
implement first.
Urine culture and sensitivity
Dextrose 5% in 0.45% sodium chloride IV at 125 ML/hour
View available exhibits for all needed information
A nurse is assessing a client for hypoxemia during an asth- Agitation
ma attack. Which of the following manifestation should Rational: the nurse should expect agitation due to neuro-
the nurse expect? logical changes from poor oxygen exchange
Hematemesis
A nurse is assessing a client who has peptic ulcer disease. Rational: when using the urgent verse non-urgent ap-
Which of the following findings should the nurse identify proach to client care, the nurse should determine that the
as a priority? priority finding is hematemesis, which indicates massive
bleeding
Barrel
A nurse is assessing a client who has COPD. The nurse
Rational: A client who has COPD uses accessory muscles to
should expect the clients chest to be in which of the
assist with respiratory ettort. The use of those accessory
following shapes.
muscles causes the chest wall to eventually increase in
1/6
, Pre Assessment Quiz Week 3 RN Capstone Review (Med Surg) Questions with
Verified Answers
anterior and posterior diameter, making it appear barrel
shaped
A nurse is monitoring a client who has a chest tube in
Reposition the client
place connected to wall suction due to right sided pneu-
Rational: the nursery repositioning the client is an appro-
mothorax. The client complains of chest burning. Which
priate action to relieve chest burning from the chest tube
of the following action should the nurse take?
Play suction equipment at bedside
A nurse is caring for a client who has a right sided acoustic Rational: cranial nerves, nine and ten innervate the mus-
neuroma, resulting in impairment of cranial nerves nine cles of the soft palate larynx and fairings. Impairment of
and 10 which of the following action should the nurse these nerves places the client at risk for aspiration, making
take? it necessary for the nurse to have access to suction for the
client.
A nurse in a clinic is teaching information about cervical Postcoital bleeding may occur
polyps with a client who has a new diagnosis which of Rational: the client may experience postcoital bleeding,
the following information should the nurse include in the because the polyps are soft, fragile, and bleed when
teaching? touched.
Take blood pressure on clients non-attected arm
Rational:
A nurse is caring for a client who is post operative. Follow
The nurse should plan to only take blood pressures, give
your right side and vasectomy and has a drain connected
injections, or perform venipunctures on the clients, non-af-
to portable drainage evacuator which of the following
fected arm to avoid compromising circulation. The nurse
action should the nurse take
should instruct other statt to follow these precautions as
well.
A nurse is caring for a client who has essential venous Place the client on his left side in Trendelenburg position
catheter and suddenly develops chest pain, dyspnea, Rational:
dizziness, and tachycardia. The nurse suspects air em- This position helps trap the air in the apex of the right
bolism and clamp the catheter immediately. What other atrium rather than allowing it to enter the right ventricle
action should the nurse take at this time? and move to the pulmonary arterial system
2/6
