NUR-211 TEST 2 EXAM WITH
CORRECT ANSWERS 2025
A client is in the emergency department reporting a brief episode
during which he was dizzy, unable to speak, and felt like his legs
were very heavy. Currently the client's neurologic examination is
normal. About what drug should the nurse plan to teach the
client?
a. Alteplase (Activase)
b. Clopidogrel (Plavix)
c. Heparin sodium
d. Mannitol (Osmitrol) correct answers >> ANS: B
This client's manifestations are consistent with a transient
ischemic attack, and the client would be prescribed aspirin or
clopidogrel on discharge. Alteplase is used for ischemic stroke.
Heparin and mannitol are not used for this condition.
A client had an embolic stroke and is having an echocardiogram.
When the client asks why the provider ordered "a test on my
heart," how should the nurse respond?
a. "Most of these types of blood clots come from the heart."
b. "Some of the blood clots may have gone to your heart too."
c. "We need to see if your heart is strong enough for therapy."
d. "Your heart may have been damaged in the stroke too."
correct answers >> ANS:A
An embolic stroke is caused when blood clots travel from one
area of the body to the brain. The most common source of the
clots is the heart. The other statements are inaccurate.
,A nurse receives a report on a client who had a left-sided stroke
and has homonymous hemianopsia. What action by the nurse is
most appropriate for this client?
a. Assess for bladder retention and/or incontinence.
b. Listen to the client's lungs after eating or drinking.
c. Prop the client's right side up when sitting in a chair.
d. Rotate the client's meal tray when the client stops eating.
correct answers >> ANS:D
This condition is blindness on the same side of both eyes. The
client must turn his or her head to see the entire visual field. The
client may not see all the food on the tray, so the nurse rotates it
so uneaten food is now within the visual field. This condition is not
related to bladder function, difficulty swallowing, or lack of trunk
control.
A client with a stroke is being evaluated for fibrinolytic therapy.
What information from the client or family is most important for
the nurse to obtain?
a. Loss of bladder control
b. Other medical conditions
c. Progression of symptoms
d. Time of symptom onset correct answers >> ANS:D
The time limit for initiating fibrinolytic therapy for a stroke is 3 to
4.5 hours, so the exact time of symptom onset is the most
important information for this client. The other information is not
as critical.
A client is being prepared for a mechanical embolectomy. What
action by the nurse takes priority?
,a. Assess for contraindications to fibrinolytics.
b. Ensure that informed consent is on the chart.
c. Perform a full neurologic assessment.
d. Review the client's medication lists. correct answers >>
ANS:B
For this invasive procedure, the client needs to give informed
consent. The nurse ensures that this is on the chart prior to the
procedure beginning. Fibrinolytics are not used. A neurologic
assessment and medication review are important, but the consent
is the priority.
A client had an embolectomy for an arteriovenous malformation
(AVM). The client is now reporting a severe headache and has
vomited. What action by the nurse takes priority?
a. Administer pain medication.
b. Assess the client's vital signs.
c. Notify the Rapid Response Team.
d. Raise the head of the bed. correct answers >> ANS:C
This client may be experiencing a rebleed from the AVM. The
most important action is to call the Rapid Response Team as this
is an emergency. The nurse can assess vital signs while someone
else notifies the Team, but getting immediate medical attention is
the priority. Administering pain medication may not be warranted
if the client must return to surgery. The optimal position for the
client with an AVM has not been determined, but calling the Rapid
Response Team takes priority over positioning.
A student nurse is preparing morning medications for a client who
had a stroke. The student plans to hold the docusate sodium
, (Colace) because the client had a large stool earlier. What action
by the supervising nurse is best?
a. Have the student ask the client if it is desired or not.
b. Inform the student that the docusate should be given.
c. Tell the student to document the rationale.
d. Tell the student to give it unless the client refuses. correct
answers >> ANS:B
Stool softeners should be given to clients with neurologic
disorders in order to prevent an elevation in intracranial pressure
that accompanies the Valsalva maneuver when constipated. The
supervising nurse should instruct the student to administer the
docusate. The other options are not appropriate. The medication
could be held for diarrhea.
A client experiences impaired swallowing after a stroke and has
worked with speech-language pathology on eating. What nursing
assessment best indicates that a priority goal for this problem has
been met?
a. Chooses preferred items from the menu
b. Eats 75% to 100% of all meals and snacks
c. Has clear lung sounds on auscultation
d. Gains 2 pounds after 1 week correct answers >> ANS:C
Impaired swallowing can lead to aspiration, so the priority goal for
this problem is no aspiration. Clear lung sounds is the best
indicator that aspiration has not occurred. Choosing menu items
is not related to this problem. Eating meals does not indicate the
client is not still aspirating. A weight gain indicates improved
nutrition but still does not show a lack of aspiration.
CORRECT ANSWERS 2025
A client is in the emergency department reporting a brief episode
during which he was dizzy, unable to speak, and felt like his legs
were very heavy. Currently the client's neurologic examination is
normal. About what drug should the nurse plan to teach the
client?
a. Alteplase (Activase)
b. Clopidogrel (Plavix)
c. Heparin sodium
d. Mannitol (Osmitrol) correct answers >> ANS: B
This client's manifestations are consistent with a transient
ischemic attack, and the client would be prescribed aspirin or
clopidogrel on discharge. Alteplase is used for ischemic stroke.
Heparin and mannitol are not used for this condition.
A client had an embolic stroke and is having an echocardiogram.
When the client asks why the provider ordered "a test on my
heart," how should the nurse respond?
a. "Most of these types of blood clots come from the heart."
b. "Some of the blood clots may have gone to your heart too."
c. "We need to see if your heart is strong enough for therapy."
d. "Your heart may have been damaged in the stroke too."
correct answers >> ANS:A
An embolic stroke is caused when blood clots travel from one
area of the body to the brain. The most common source of the
clots is the heart. The other statements are inaccurate.
,A nurse receives a report on a client who had a left-sided stroke
and has homonymous hemianopsia. What action by the nurse is
most appropriate for this client?
a. Assess for bladder retention and/or incontinence.
b. Listen to the client's lungs after eating or drinking.
c. Prop the client's right side up when sitting in a chair.
d. Rotate the client's meal tray when the client stops eating.
correct answers >> ANS:D
This condition is blindness on the same side of both eyes. The
client must turn his or her head to see the entire visual field. The
client may not see all the food on the tray, so the nurse rotates it
so uneaten food is now within the visual field. This condition is not
related to bladder function, difficulty swallowing, or lack of trunk
control.
A client with a stroke is being evaluated for fibrinolytic therapy.
What information from the client or family is most important for
the nurse to obtain?
a. Loss of bladder control
b. Other medical conditions
c. Progression of symptoms
d. Time of symptom onset correct answers >> ANS:D
The time limit for initiating fibrinolytic therapy for a stroke is 3 to
4.5 hours, so the exact time of symptom onset is the most
important information for this client. The other information is not
as critical.
A client is being prepared for a mechanical embolectomy. What
action by the nurse takes priority?
,a. Assess for contraindications to fibrinolytics.
b. Ensure that informed consent is on the chart.
c. Perform a full neurologic assessment.
d. Review the client's medication lists. correct answers >>
ANS:B
For this invasive procedure, the client needs to give informed
consent. The nurse ensures that this is on the chart prior to the
procedure beginning. Fibrinolytics are not used. A neurologic
assessment and medication review are important, but the consent
is the priority.
A client had an embolectomy for an arteriovenous malformation
(AVM). The client is now reporting a severe headache and has
vomited. What action by the nurse takes priority?
a. Administer pain medication.
b. Assess the client's vital signs.
c. Notify the Rapid Response Team.
d. Raise the head of the bed. correct answers >> ANS:C
This client may be experiencing a rebleed from the AVM. The
most important action is to call the Rapid Response Team as this
is an emergency. The nurse can assess vital signs while someone
else notifies the Team, but getting immediate medical attention is
the priority. Administering pain medication may not be warranted
if the client must return to surgery. The optimal position for the
client with an AVM has not been determined, but calling the Rapid
Response Team takes priority over positioning.
A student nurse is preparing morning medications for a client who
had a stroke. The student plans to hold the docusate sodium
, (Colace) because the client had a large stool earlier. What action
by the supervising nurse is best?
a. Have the student ask the client if it is desired or not.
b. Inform the student that the docusate should be given.
c. Tell the student to document the rationale.
d. Tell the student to give it unless the client refuses. correct
answers >> ANS:B
Stool softeners should be given to clients with neurologic
disorders in order to prevent an elevation in intracranial pressure
that accompanies the Valsalva maneuver when constipated. The
supervising nurse should instruct the student to administer the
docusate. The other options are not appropriate. The medication
could be held for diarrhea.
A client experiences impaired swallowing after a stroke and has
worked with speech-language pathology on eating. What nursing
assessment best indicates that a priority goal for this problem has
been met?
a. Chooses preferred items from the menu
b. Eats 75% to 100% of all meals and snacks
c. Has clear lung sounds on auscultation
d. Gains 2 pounds after 1 week correct answers >> ANS:C
Impaired swallowing can lead to aspiration, so the priority goal for
this problem is no aspiration. Clear lung sounds is the best
indicator that aspiration has not occurred. Choosing menu items
is not related to this problem. Eating meals does not indicate the
client is not still aspirating. A weight gain indicates improved
nutrition but still does not show a lack of aspiration.
