NURS209 FINAL Survey New Exam With Verified Answers (A+)
A nurse working in a long-term care facility is caring for a client who is on bed rest and
requires frequent linen changes. Which of the following should the nurse identify as the
priority rationale for frequent linen changes?
Moisture from excessive diaphoresis can cause skin breakdown.
Moisture on the sheets can cause discomfort to the client.
It provides an opportunity to frequently evaluate the skin on the client's back side.
-It allows for the shifting of the client from side to side to promote the clearance of any
fluid that may accumulate in the lungs. - ANSWER Diaphoresis can contribute to skin
breakdown due to the moist environment it creates.
A nurse is going to auscultate a client's apical pulse at the point of maximal impulse
(PMI). The nurse should place the stethoscope in which of the following positions?
-Over the right midclavicular line
Over the angle of Louis
-Over the fifth intercostal space at the left midclavicular line
-Over the suprasternal notch - ANSWER - Over the fifth intercostal space at the left
midclavicular line
A nurse is obtaining vital signs from a client. Which of the following findings is the
priority for the nurse to report to the provider?
-Oral temperature 37.8° C (100° F)
-Respirations 30/min
-BP 148/88 mm Hg
-Radial pulse rate 45 beats/30 seconds - ANSWER Respiration 30/min
,A nurse is obtaining a client's vital signs. The client has a new onset of a temperature of
39° C (102° F). Which of the following other vital signs should the nurse expect?
An elevated pulse rate
A decreased blood pressure
An elevated blood pressure
A decreased pulse rate
ANSWER An elevated pulse rate
A nurse is taking an adult client's temperature rectally. Which of the following actions
should the nurse take?
-If any resistance is encountered as the thermometer is inserted, rotate the probe.
-Insert the probe to aim towards the client's pelvis
-Dip the probe about 0.58 cm (2 in) into a tube of lubricant
-Insert the probe about 2.5 cm (1 in) into the client's anus. -ANSWER-Insert the probe
about 2.5 cm (1 in) into the client's anus.
A nurse is taking a client's blood pressure and identifies the pressure reading on the
manometer when listening to the fourth Korotkoff sound. Which of the following does
this pressure reading correlate to?
It reflects the client's systolic pressure.
It is the second diastolic pressure to record.
It is the loudest of the Korotkoff sounds.
-It may not be followed by a fifth Korotkoff sound. - ANSWER It may not be followed by a
fifth Korotkoff sound.
A nurse is performing an assessment of a client's respiration. Which of the following
should the nurse do?
-Have the client lie flat in bed with the head on a pillow.
-Raise the head of the client's bed 45° to 60°.
,-Instruct the client to breathe shallowly.
- Ask the client to take several deep breaths before the measurement. - ANSWER Raise
the client's head 45° to 60°.
A nurse is going to document the difference between a client's systolic and diastolic
blood pressure. Which of the following terms describes this information as it is
documented?
-Auscultatory gap
-Pulse pressure
-Orthostatic hypotension
-Pulse deficit - ANSWER pulse pressure
The nurse is obtaining a client's oral temperature. Which of the following is the nurse's
best action?
-Position the probe in the posterior lingual pocket lateral to the midline
.-Position the probe resting on the lower lingual frenulum.
-Position the probe crossing centrally over the top of the client's tongue.
-Position the probe resting under the tongue just beyond the client's teeth. - ANSWER
Position the probe in the posterior lingual pocket lateral to the midline
The nurse is gathering data about a client's respiratory status. Which of the following
nursing actions would provide information about the depth of the client's breathing?
Monitor the amount of chest-wall movement during inspiration and expiration.
Count the number of breathing cycles observed over a minute.
Note whether or not expiration is longer than inspiration.
- Determine the exact volume of air the patient inhales and exhales. - ANSWER Observe
the extent of chest-wall expansion and contraction during inspiration and expiration.
Which of the following does a nurse perform when planning to take a client's
, temperature using a tympanic thermometer?
Select the correct answer
and
Attach the disposable probe cover
-check the external ear for redness
-pull the pinna back and upward gently.
-Replace the thermometer to its charger. - ANSWER Pu.ll the pinna back and upwards
gently
A nurse is going to take a client's blood pressure. Which of the following nursing actions
will provide an accurate blood pressure reading?
-Take the blood pressure early in the morning.
-Use an appropriate sized cuff on the client.
-Walk the client to the bathroom so that he can void.
Apply the cuff loosely around the client's arm. ANSWER Use a cuff that is an appropriate
size for the client.
A nurse is auscultating a client's apical pulse to hear the S1 and S2 heart sounds.
During which of the following will S2 heart sounds be heard?
When the atria contracts vigorously
As the ventricular walls contract
When the semilunar valves close
-As the mitral valve snaps open - ANSWER When the semilunar valves close
A nurse is establishing baseline for a client's respirations. Which of the following actions
should the nurse take?
-Instruct the client to breathe in and to exhale out as they normally do
A nurse working in a long-term care facility is caring for a client who is on bed rest and
requires frequent linen changes. Which of the following should the nurse identify as the
priority rationale for frequent linen changes?
Moisture from excessive diaphoresis can cause skin breakdown.
Moisture on the sheets can cause discomfort to the client.
It provides an opportunity to frequently evaluate the skin on the client's back side.
-It allows for the shifting of the client from side to side to promote the clearance of any
fluid that may accumulate in the lungs. - ANSWER Diaphoresis can contribute to skin
breakdown due to the moist environment it creates.
A nurse is going to auscultate a client's apical pulse at the point of maximal impulse
(PMI). The nurse should place the stethoscope in which of the following positions?
-Over the right midclavicular line
Over the angle of Louis
-Over the fifth intercostal space at the left midclavicular line
-Over the suprasternal notch - ANSWER - Over the fifth intercostal space at the left
midclavicular line
A nurse is obtaining vital signs from a client. Which of the following findings is the
priority for the nurse to report to the provider?
-Oral temperature 37.8° C (100° F)
-Respirations 30/min
-BP 148/88 mm Hg
-Radial pulse rate 45 beats/30 seconds - ANSWER Respiration 30/min
,A nurse is obtaining a client's vital signs. The client has a new onset of a temperature of
39° C (102° F). Which of the following other vital signs should the nurse expect?
An elevated pulse rate
A decreased blood pressure
An elevated blood pressure
A decreased pulse rate
ANSWER An elevated pulse rate
A nurse is taking an adult client's temperature rectally. Which of the following actions
should the nurse take?
-If any resistance is encountered as the thermometer is inserted, rotate the probe.
-Insert the probe to aim towards the client's pelvis
-Dip the probe about 0.58 cm (2 in) into a tube of lubricant
-Insert the probe about 2.5 cm (1 in) into the client's anus. -ANSWER-Insert the probe
about 2.5 cm (1 in) into the client's anus.
A nurse is taking a client's blood pressure and identifies the pressure reading on the
manometer when listening to the fourth Korotkoff sound. Which of the following does
this pressure reading correlate to?
It reflects the client's systolic pressure.
It is the second diastolic pressure to record.
It is the loudest of the Korotkoff sounds.
-It may not be followed by a fifth Korotkoff sound. - ANSWER It may not be followed by a
fifth Korotkoff sound.
A nurse is performing an assessment of a client's respiration. Which of the following
should the nurse do?
-Have the client lie flat in bed with the head on a pillow.
-Raise the head of the client's bed 45° to 60°.
,-Instruct the client to breathe shallowly.
- Ask the client to take several deep breaths before the measurement. - ANSWER Raise
the client's head 45° to 60°.
A nurse is going to document the difference between a client's systolic and diastolic
blood pressure. Which of the following terms describes this information as it is
documented?
-Auscultatory gap
-Pulse pressure
-Orthostatic hypotension
-Pulse deficit - ANSWER pulse pressure
The nurse is obtaining a client's oral temperature. Which of the following is the nurse's
best action?
-Position the probe in the posterior lingual pocket lateral to the midline
.-Position the probe resting on the lower lingual frenulum.
-Position the probe crossing centrally over the top of the client's tongue.
-Position the probe resting under the tongue just beyond the client's teeth. - ANSWER
Position the probe in the posterior lingual pocket lateral to the midline
The nurse is gathering data about a client's respiratory status. Which of the following
nursing actions would provide information about the depth of the client's breathing?
Monitor the amount of chest-wall movement during inspiration and expiration.
Count the number of breathing cycles observed over a minute.
Note whether or not expiration is longer than inspiration.
- Determine the exact volume of air the patient inhales and exhales. - ANSWER Observe
the extent of chest-wall expansion and contraction during inspiration and expiration.
Which of the following does a nurse perform when planning to take a client's
, temperature using a tympanic thermometer?
Select the correct answer
and
Attach the disposable probe cover
-check the external ear for redness
-pull the pinna back and upward gently.
-Replace the thermometer to its charger. - ANSWER Pu.ll the pinna back and upwards
gently
A nurse is going to take a client's blood pressure. Which of the following nursing actions
will provide an accurate blood pressure reading?
-Take the blood pressure early in the morning.
-Use an appropriate sized cuff on the client.
-Walk the client to the bathroom so that he can void.
Apply the cuff loosely around the client's arm. ANSWER Use a cuff that is an appropriate
size for the client.
A nurse is auscultating a client's apical pulse to hear the S1 and S2 heart sounds.
During which of the following will S2 heart sounds be heard?
When the atria contracts vigorously
As the ventricular walls contract
When the semilunar valves close
-As the mitral valve snaps open - ANSWER When the semilunar valves close
A nurse is establishing baseline for a client's respirations. Which of the following actions
should the nurse take?
-Instruct the client to breathe in and to exhale out as they normally do
