1) A client who has a head injury is transported to the emergency department. Which assessment does the emergency department nurse perform immediately?
A. Pupil response
B. Motor function
C. Respiratory status
D. 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?
A. Administer prescribed diphenhydramine (Benadryl).
B. Continue to monitor the client’s vital signs.
C. Stop the infusion of packed red blood cells.
D. 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?
A. Pedal edema is not present in the lower legs.
B. No complaints of sexual dysfunction occur.
C. No indication of renal impairment is present.
D. 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?
A. Poor left-sided motor control
B. Paralysis or contractures on the right side
C. Limited visual perception of the left fields
D. 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?
A. “Apply antiembolism stockings before getting out of bed in the morning.”
B. “Clean venous ulcers with Betadine before applying a dressing.”
C. “Take 1 low-dose aspirin (81 mg) daily to prevent inflammation.”
D. “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