NURS 101 Brief Questions with Adequately Approved
Answers Graded A++ Pass
A student nurse is assessing the blood pressure of a client with the client's arm unsupported.
What are the expected errors in the obtained readings? - CORRECT ANSWER ✔️✔️ -False High
Rationale: If the client's arm is unsupported, or if the arm is below the heart level, the resulting
outcome is a false high reading. Application of the stethoscope too firmly against antecubital
fossa will result in a false low diastolic reading. Repeated assessments of blood pressure too
often result in a false high systolic reading. Deflating the cuff too slowly results in a false high
diastolic reading.
The nurse is caring for a surgical client who develops a wound infection during hospitalization.
How is this type of infection classified? - CORRECT ANSWER ✔️✔️ -Nosocomial
Rationale: A nosocomial infection is acquired in a health care setting. This is also referred to as a
hospital-acquired infection. It is a result of poor infection control procedures such as a failure to
wash hands between clients. A primary infection is synonymous with initial infection. A
secondary infection is made possible by a primary infection that lowers the host's resistance and
causes an infection by another kind of organism. A superinfection is a new infection caused by
an organism different from that which caused the initial infection. The microbe responsible is
usually resistant to the treatment given for the initial infection.
When to measure vital signs - CORRECT ANSWER ✔️✔️ --On admission to a healthcare facility
-When assessing pts during home care visit
,-In hospital during routine schedule according to health care provider order or standard of
practice
-Before, during, & after surgical procedure/invasive diagnostic procedure
-Before/during/after blood transfusion products
-Before/during/after admin of med or therapies that affect cardiovascular, respiratory, or temp
control function
-When pt condition changes (ex. loss of consciousness)
-Before/during/after interventions influencing VS (ex. ambulation, before/after ROM exercises
-When pt reports nonspecific symptoms of physical distress (ex. feeling 'funny' or 'different')
Normal Temperature Ranges - CORRECT ANSWER ✔️✔️ -36C- 38C (96.8F - 100.4F)
-Average oral temp = 37C (98.6F)
-Temp controlled by hypothalamus
Patterns of Fever - CORRECT ANSWER ✔️✔️ -Sustained- constant body temp continuously
above 100.4F- little fluctuation
Intermittent- Fever spikes mixed with reg temp levels-returns to acceptable value at least once in
24 hrs
Remittent- Spikes and falls w/o return to acceptable level
, Relapsing- Periods of febrile episodes mixed with acceptable values sometimes longer than 24
hrs
Classifications of Hypothermia - CORRECT ANSWER ✔️✔️ -Mild- 34-36C // 93.2 - 96.8F
Moderate- 30-40C // 86-93.2F
Severe- >30C // >86F
Heatstroke - CORRECT ANSWER ✔️✔️ -a dangerous condition in which the body loses its
ability to cool itself through perspiration (40.2C // 104.4f)
Na+ and K+ depletion, elevated pulse, low BP
--mgmt = fluid/electrolyte support, cooling, rest
Oral Temp Site Advantages & Limitation - CORRECT ANSWER ✔️✔️ -Advantages: easy
access/no position change req, comfortable for pt, provides accurate surface reading, reflects
rapid change in core temp, reliable for intubated patients
Limitations- delay in measurement if pt ingests hot/cold fluid/food/smoked/chewed gum, not
used if pt had oral surgery, trauma, shaking/chills, hist of seizure, not used in infants, small
children, confused/uncooperative pt, risk of bodily fluid exposure
Tympanic Temp Site Advantages & Limitations - CORRECT ANSWER ✔️✔️ -Advantages- easy
access, obtained w/o disturbing, used for pt with tachypnea w.o affecting breathing, quick
Answers Graded A++ Pass
A student nurse is assessing the blood pressure of a client with the client's arm unsupported.
What are the expected errors in the obtained readings? - CORRECT ANSWER ✔️✔️ -False High
Rationale: If the client's arm is unsupported, or if the arm is below the heart level, the resulting
outcome is a false high reading. Application of the stethoscope too firmly against antecubital
fossa will result in a false low diastolic reading. Repeated assessments of blood pressure too
often result in a false high systolic reading. Deflating the cuff too slowly results in a false high
diastolic reading.
The nurse is caring for a surgical client who develops a wound infection during hospitalization.
How is this type of infection classified? - CORRECT ANSWER ✔️✔️ -Nosocomial
Rationale: A nosocomial infection is acquired in a health care setting. This is also referred to as a
hospital-acquired infection. It is a result of poor infection control procedures such as a failure to
wash hands between clients. A primary infection is synonymous with initial infection. A
secondary infection is made possible by a primary infection that lowers the host's resistance and
causes an infection by another kind of organism. A superinfection is a new infection caused by
an organism different from that which caused the initial infection. The microbe responsible is
usually resistant to the treatment given for the initial infection.
When to measure vital signs - CORRECT ANSWER ✔️✔️ --On admission to a healthcare facility
-When assessing pts during home care visit
,-In hospital during routine schedule according to health care provider order or standard of
practice
-Before, during, & after surgical procedure/invasive diagnostic procedure
-Before/during/after blood transfusion products
-Before/during/after admin of med or therapies that affect cardiovascular, respiratory, or temp
control function
-When pt condition changes (ex. loss of consciousness)
-Before/during/after interventions influencing VS (ex. ambulation, before/after ROM exercises
-When pt reports nonspecific symptoms of physical distress (ex. feeling 'funny' or 'different')
Normal Temperature Ranges - CORRECT ANSWER ✔️✔️ -36C- 38C (96.8F - 100.4F)
-Average oral temp = 37C (98.6F)
-Temp controlled by hypothalamus
Patterns of Fever - CORRECT ANSWER ✔️✔️ -Sustained- constant body temp continuously
above 100.4F- little fluctuation
Intermittent- Fever spikes mixed with reg temp levels-returns to acceptable value at least once in
24 hrs
Remittent- Spikes and falls w/o return to acceptable level
, Relapsing- Periods of febrile episodes mixed with acceptable values sometimes longer than 24
hrs
Classifications of Hypothermia - CORRECT ANSWER ✔️✔️ -Mild- 34-36C // 93.2 - 96.8F
Moderate- 30-40C // 86-93.2F
Severe- >30C // >86F
Heatstroke - CORRECT ANSWER ✔️✔️ -a dangerous condition in which the body loses its
ability to cool itself through perspiration (40.2C // 104.4f)
Na+ and K+ depletion, elevated pulse, low BP
--mgmt = fluid/electrolyte support, cooling, rest
Oral Temp Site Advantages & Limitation - CORRECT ANSWER ✔️✔️ -Advantages: easy
access/no position change req, comfortable for pt, provides accurate surface reading, reflects
rapid change in core temp, reliable for intubated patients
Limitations- delay in measurement if pt ingests hot/cold fluid/food/smoked/chewed gum, not
used if pt had oral surgery, trauma, shaking/chills, hist of seizure, not used in infants, small
children, confused/uncooperative pt, risk of bodily fluid exposure
Tympanic Temp Site Advantages & Limitations - CORRECT ANSWER ✔️✔️ -Advantages- easy
access, obtained w/o disturbing, used for pt with tachypnea w.o affecting breathing, quick
