NURSC475 QUIZ 2 COMPREHENSIVE SCRIPT
2026 FULL STUDY GUIDE COMPLETE
RESPONSES
◉ Which nursing diagnosis has the highest priority when planning
care for a client with an indwelling urinary catheter?
A. Self-care deficit
B. Functional incontinence
C. Fluid volume deficit
D. High risk for infection Answer: D
Rationale: Indwelling urinary catheters are a major source of
infection. Options A and B are both problems that may require an
indwelling catheter. Option C is not affected by an indwelling
catheter.
◉ A client has a nursing diagnosis of Altered sleep patterns related
to nocturia. Which client instruction is important for the nurse to
provide?
A. Decrease intake of fluids after the evening meal.
B. Drink a glass of cranberry juice every day.
C. Drink a glass of warm decaffeinated beverage at bedtime.
D. Consult the health care provider about a sleeping pill. Answer: A
,Rationale: Nocturia is urination during the night. Option A is helpful
to decrease the production of urine, thus decreasing the need to void
at night. Option B helps prevent bladder infections. Option C may
promote sleep, but the fluid will contribute to nocturia. Option D
may result in urinary incontinence if the client is sedated and does
not awaken to void.
◉ When performing sterile wound care in the acute care setting, the
nurse obtains a bottle of normal saline from the bedside table that is
labeled "opened" and dated 48 hours prior to the current date.
Which is the best action for the nurse to take?
A. Use the normal saline solution once more and then discard.
B. Obtain a new sterile syringe to draw up the labeled saline
solution.
C. Use the saline solution and then relabel the bottle with the current
date.
D. Discard the saline solution and obtain a new unopened bottle.
Answer: D
Rationale: Solutions labeled as opened within 24 hours may be used
for clean procedures, but only newly opened solutions are
considered sterile. This solution is not newly opened and is out of
date, so it should be discarded. Options A, B, and C describe
incorrect procedures.
,◉ Based on the nursing diagnosis of risk for infection, which
intervention is best for the nurse to implement when providing care
for an older incontinent client?
A. Maintain standard precautions.
B. Initiate contact isolation measures.
C. Insert an indwelling urinary catheter.
D. Instruct client in the use of adult diapers. Answer: A
Rationale: The best action to decrease the risk of infection in
vulnerable clients is handwashing. Option B is not necessary unless
the client has an infection. Option C increases the risk of infection.
Option D does not reduce the risk of infection.
◉ When taking a client's blood pressure, the nurse is unable to
distinguish the point at which the first sound was heard. Which is
the best action for the nurse to take?
A. Deflate the cuff completely and immediately reattempt the
reading.
B. Reinflate the cuff completely and leave it inflated for 90 to 110
seconds before taking the second reading.
C. Deflate the cuff to zero and wait 30 to 60 seconds before
reattempting the reading.
D. Document the exact level visualized on the sphygmomanometer
where the first fluctuation was seen. Answer: C
Rationale: Deflating the cuff for 30 to 60 seconds allows blood flow
to return to the extremity so that an accurate reading can be
, obtained on that extremity a second time. Option A could result in a
falsely high reading. Option B reduces circulation, causes pain, and
could alter the reading. Option D is not an accurate method of
assessing blood pressure.
◉ A client's blood pressure reading is 156/94 mm Hg. Which action
should the nurse take first?
A. Tell the client that the blood pressure is high and that the reading
needs to be verified by another nurse.
B. Contact the health care provider to report the reading and obtain
a prescription for an antihypertensive medication.
C. Replace the cuff with a larger one to ensure an ample fit for the
client to increase arm comfort.
D. Compare the current reading with the client's previously
documented blood pressure readings. Answer: D
Rationale: Comparing this reading with previous readings will
provide information about what is normal for this client; this action
should be taken first. Option A might unnecessarily alarm the client.
Option B is premature. Further assessment is needed to determine if
the reading is abnormal for this client. Option C could falsely
decrease the reading and is not the correct procedure for obtaining a
blood pressure reading.
◉ A nurse stops at a motor vehicle collision site to render aid until
the emergency personnel arrive and applies pressure to a groin
wound that is bleeding profusely. Later the client has to have the leg
2026 FULL STUDY GUIDE COMPLETE
RESPONSES
◉ Which nursing diagnosis has the highest priority when planning
care for a client with an indwelling urinary catheter?
A. Self-care deficit
B. Functional incontinence
C. Fluid volume deficit
D. High risk for infection Answer: D
Rationale: Indwelling urinary catheters are a major source of
infection. Options A and B are both problems that may require an
indwelling catheter. Option C is not affected by an indwelling
catheter.
◉ A client has a nursing diagnosis of Altered sleep patterns related
to nocturia. Which client instruction is important for the nurse to
provide?
A. Decrease intake of fluids after the evening meal.
B. Drink a glass of cranberry juice every day.
C. Drink a glass of warm decaffeinated beverage at bedtime.
D. Consult the health care provider about a sleeping pill. Answer: A
,Rationale: Nocturia is urination during the night. Option A is helpful
to decrease the production of urine, thus decreasing the need to void
at night. Option B helps prevent bladder infections. Option C may
promote sleep, but the fluid will contribute to nocturia. Option D
may result in urinary incontinence if the client is sedated and does
not awaken to void.
◉ When performing sterile wound care in the acute care setting, the
nurse obtains a bottle of normal saline from the bedside table that is
labeled "opened" and dated 48 hours prior to the current date.
Which is the best action for the nurse to take?
A. Use the normal saline solution once more and then discard.
B. Obtain a new sterile syringe to draw up the labeled saline
solution.
C. Use the saline solution and then relabel the bottle with the current
date.
D. Discard the saline solution and obtain a new unopened bottle.
Answer: D
Rationale: Solutions labeled as opened within 24 hours may be used
for clean procedures, but only newly opened solutions are
considered sterile. This solution is not newly opened and is out of
date, so it should be discarded. Options A, B, and C describe
incorrect procedures.
,◉ Based on the nursing diagnosis of risk for infection, which
intervention is best for the nurse to implement when providing care
for an older incontinent client?
A. Maintain standard precautions.
B. Initiate contact isolation measures.
C. Insert an indwelling urinary catheter.
D. Instruct client in the use of adult diapers. Answer: A
Rationale: The best action to decrease the risk of infection in
vulnerable clients is handwashing. Option B is not necessary unless
the client has an infection. Option C increases the risk of infection.
Option D does not reduce the risk of infection.
◉ When taking a client's blood pressure, the nurse is unable to
distinguish the point at which the first sound was heard. Which is
the best action for the nurse to take?
A. Deflate the cuff completely and immediately reattempt the
reading.
B. Reinflate the cuff completely and leave it inflated for 90 to 110
seconds before taking the second reading.
C. Deflate the cuff to zero and wait 30 to 60 seconds before
reattempting the reading.
D. Document the exact level visualized on the sphygmomanometer
where the first fluctuation was seen. Answer: C
Rationale: Deflating the cuff for 30 to 60 seconds allows blood flow
to return to the extremity so that an accurate reading can be
, obtained on that extremity a second time. Option A could result in a
falsely high reading. Option B reduces circulation, causes pain, and
could alter the reading. Option D is not an accurate method of
assessing blood pressure.
◉ A client's blood pressure reading is 156/94 mm Hg. Which action
should the nurse take first?
A. Tell the client that the blood pressure is high and that the reading
needs to be verified by another nurse.
B. Contact the health care provider to report the reading and obtain
a prescription for an antihypertensive medication.
C. Replace the cuff with a larger one to ensure an ample fit for the
client to increase arm comfort.
D. Compare the current reading with the client's previously
documented blood pressure readings. Answer: D
Rationale: Comparing this reading with previous readings will
provide information about what is normal for this client; this action
should be taken first. Option A might unnecessarily alarm the client.
Option B is premature. Further assessment is needed to determine if
the reading is abnormal for this client. Option C could falsely
decrease the reading and is not the correct procedure for obtaining a
blood pressure reading.
◉ A nurse stops at a motor vehicle collision site to render aid until
the emergency personnel arrive and applies pressure to a groin
wound that is bleeding profusely. Later the client has to have the leg
