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NURS 112 ACTUAL EXAM
A nurse is filling out an incident report after an older adult client fell while
attempting to transfer from her bed to a commode. Which health problem should
the nurse consider when client falls occur? - ANSWER-orthostatic hypotension
A nurse is assessing the blood pressure of a client using the Korotkoff sound
technique. The nurse notes that the phase I sound disappears for 2 seconds. What
should the nurse document on the progress record? - ANSWER-There is an
auscultatory gap.
A nurse is assessing the blood pressure of a team of healthy athletes at the heath
care facility. Which observation can be made by the nurse and athletes by
measuring the blood pressure? - ANSWER-the ability of the arteries to stretch
A nurse is assessing the pulse volume of a client with influenza. The nurse notes
that the client has a thready pulse. Which of the following is a description of a
thready pulse? - ANSWER-Pulse is felt with difficulty and disappears with slight
pressure.
,A pulse deficit is the difference between: - ANSWER-the apical pulse and the
radial pulse rates.
The nurse has just measured an adult client's oral temperature and obtained a result
of 102.4ºF (39.1ºC). The client states, "I just finished my coffee right before you
came in. Can I have another cup?" Which response by the nurse is most
appropriate? - ANSWER-"I will bring you another cup when I return in 30 minutes
to reassess your temperature. Please do not drink any other beverages until I
return."
During measurement of a rectal temperature, the thermometer probe should be
inserted about 1.5 inches (3.8 cm) in an adult and 0.5 inches (1.3 cm) in an infant. -
ANSWER-true
The nurse is taking the apical pulse of a 6-month-old infant. Upon completion, the
nurse tells the parent the baby's pulse is 140 beats per minute. The parent is
concerned, stating, "That seems kind of high!" The nurse responds: - ANSWER-"I
know it seems fast, but normal infant heart rates are 100-160 beats per minute."
A nurse is caring for an adult with fever. The nurse determines that which site is
most ideal for obtaining the client's core body temperature? - ANSWER-rectum
A nurse is assessing an apical pulse on a cardiac client. The client is taking
digoxin, which is a cardiac medication. The nurse can anticipate that the digoxin
will: - ANSWER-decrease the apical pulse
The nurse takes a client's vital signs and notes a blood pressure of 88/56 mm Hg
with a pulse rate of 60 beats/min. Which action should the nurse take first? -
ANSWER-Assess the client for dizziness.
,A nurse is calculating the cardiac output of an adult with a stroke volume of 75 mL
(75 × 109/L) and a pulse of 78 beats/min. What number would the nurse document
for this assessment? - ANSWER-5,850 mL (5,850 × 10^9/L)
A nurse is assessing the respirations of a 60-year-old female client and finds that
the client's breaths are so shallow that the respirations cannot be counted. What
would be the appropriate initial nursing intervention in this situation? - ANSWER-
Auscultate the lung sounds and count respirations.
A nurse needs to assess the temperature of a client with high fever. Which site will
most closely reflect core body temperature of the client? - ANSWER-rectum
Which client's blood pressure best describes the condition called hypotension? -
ANSWER-The systolic reading is below 100 and diastolic reading is below 60.
The student nurse is having difficulty feeling the pedal pulse of the client with a
fractured leg. What should the nurse do next? - ANSWER-Use the Doppler
ultrasound device.
When administering beta blocker medications, the physician adds an order to hold
medication when the client is bradycardic. Which statement explains this order? -
ANSWER-The client's pulse rate is below 60 beats per minute.
The nurse is assessing a client's blood pressure and is having difficulty hearing
Korotkoff sounds. What is the most appropriate nursing action? - ANSWER-ask
the client to make a fist after cuff inflation
, The nurse has palpated the client's radial artery and identified a heart rate of 88
beats per minute with an irregular rate. What is the nurse's most appropriate
action? - ANSWER-Auscultate the client's apical heart rate.
A nurse needs to measure the blood pressure of a client who has just undergone a
bilateral mastectomy. How should the nurse measure the blood pressure? -
ANSWER-Over the client's thigh
The nurse is caring for a client with pneumonia who requires administration of
medications. When does the nurse document administration in the medication
administration record (MAR)? - ANSWER-after completion of administration of
each drug
explanation: The nurse documents administration after giving medications each
time. The nurse never documents administration of medications ahead of delivery,
nor does the nurse document during the actual delivery time. Nurses do not wait
until the end of the shift to document medication administration.
The nurse is preparing to give medications to a client with high blood pressure.
The prescription indicates that the client is to have the combination drug
dextroamphetamine saccharate-amphetamine aspartate monohydrate-
dextroamphetamine sulfate-amphetamine sulfate 40 mg by mouth twice daily.
What is the appropriate nursing action? - ANSWER-Contact the health care
provider for clarification of the prescription.
explanation: Before administering the medication, the nurse should immediately
contact the health care provider to verify the prescription; no one else can verify
the prescription. The combination drug dextroamphetamine saccharate-
amphetamine aspartate monohydrate-dextroamphetamine sulfate-amphetamine
sulfate and the drug propranolol are medications that have look-alike and sound-
alike properties, but are very different in indication and dosage.