Nurs 311 Exam With Answers Graded A+
What will the nurse instruct nursing assistive personnel (NAP) to do when
measuring a patient's rectal temperature using an electronic thermometer? -
ANSWER>>Use the probe with the red tip.
what contraindicates taking a rectal temperature measurement -
ANSWER>>Patient has painful and swollen hemorrhoids.
Which nursing action best evaluates the effectiveness of an antipyretic
medication in a patient with an oral temperature of 101.6°F? - ANSWER>>Assess
oral temperature 30 minutes after the agent is administered.
Which instruction might the nurse give to nursing assistive personal (NAP) that is
applicable only to tympanic temperature assessment? - ANSWER>>Gently tug the
pinna backward, up, and out before inserting the probe.
Which instruction might the nurse give to nursing assistive personnel (NAP) that is
applicable only to temporal artery temperature assessment? - ANSWER>>Place
the sensor flush on the patient's forehead.
During the admissions process, the nurse initially assesses the patient's radial
pulse primarily for what purpose? - ANSWER>>Establishment of a baseline as part
of the patient's vital signs
What will the nurse instruct nursing assistive personal (NAP) to do when
measuring an adult patient's radial pulse? - ANSWER>>Palpate the patient's inner
wrist on the thumb side with the fingertips of your two middle fingers.
What is the nurse's priority action if a patient's radial pulse has an irregular
rhythm? - ANSWER>>Assess the patient for a pulse deficit.
,Inadequate oxygenation to the body will cause the radial pulse to become: -
ANSWER>>Tachycardic
Which action would best assess the effect of exercise on a patient's radial pulse
measurement? - ANSWER>>Measuring the patient's radial pulse before and after
exercise
Which action can the nurse take to keep a patient from consciously controlling his
or her breathing during an assessment? - ANSWER>>Assess respiration after
measuring the pulse.
On the last assessment of a patient's respiration, her respiratory rate was 10
breaths per minute. What should the nurse do when conducting the next
assessment of this patient's respiratory rate? - ANSWER>>Count breaths for 60
seconds.
When measuring a patient's respiratory rate, the nurse will count the number of
completed respiratory cycles per minute. What is the definition of a respiratory
cycle? - ANSWER>>The number of inspirations and expirations per minute.
During the assessment of a patient's respiratory rate, when the second hand
reaches the 15-second mark, the respiratory count is 8. What should the nurse do
at this time? - ANSWER>>Continue to count the patient's breaths for a full 60
seconds.
The nurse plans to assess a patient's respiratory rate; however, the patient has
just returned from ambulating to the bathroom. What should the nurse do to
minimize the effect of exercise on the patient's respiratory rate? -
ANSWER>>Encourage the patient to rest for 10 minutes before assessing
respiration.
, The nurse is preparing to assess a patient's blood pressure. What would cause the
blood pressure reading to be inaccurately high? - ANSWER>>Blood pressure cuff
is too loose around the arm
What would cause the nurse to delay the assessment of a patient's blood
pressure? - ANSWER>>Patient has just finished having a cigarette
The nurse has just measured a patient's blood pressure and is waiting 2 minutes
to measure the pressure again. What is the purpose of taking two
measurements? - ANSWER>>Minimize the effect of anxiety
The nurse is teaching a patient about ways to reduce blood pressure. What will
the nurse include in these instructions? - ANSWER>>Ensure that your diet has an
adequate daily intake of calcium.
Where should the nurse measure the blood pressure of a patient recovering from
a left-sided mastectomy? - ANSWER>>Use the right arm to take the blood
pressure.
The nurse is planning to measure a patient's blood pressure. What does the
systolic measurement represent? - ANSWER>>The pressure exerted against the
arterial wall.
You have assigned a new nursing assistive personnel (NAP) to take routine vital
signs. You notice that the NAP's last three patients have had unusually low blood
pressure that you have had to confirm. What is the most likely reason the NAP is
obtaining falsely low blood pressure readings? - ANSWER>>The blood pressure
cuff is too wide for arm circumference.
What should the nurse do if the patient's blood pressure is not within normal
limits? - ANSWER>>This is the correct response, because the patient must be
assessed for possible cardiovascular problems.
What will the nurse instruct nursing assistive personnel (NAP) to do when
measuring a patient's rectal temperature using an electronic thermometer? -
ANSWER>>Use the probe with the red tip.
what contraindicates taking a rectal temperature measurement -
ANSWER>>Patient has painful and swollen hemorrhoids.
Which nursing action best evaluates the effectiveness of an antipyretic
medication in a patient with an oral temperature of 101.6°F? - ANSWER>>Assess
oral temperature 30 minutes after the agent is administered.
Which instruction might the nurse give to nursing assistive personal (NAP) that is
applicable only to tympanic temperature assessment? - ANSWER>>Gently tug the
pinna backward, up, and out before inserting the probe.
Which instruction might the nurse give to nursing assistive personnel (NAP) that is
applicable only to temporal artery temperature assessment? - ANSWER>>Place
the sensor flush on the patient's forehead.
During the admissions process, the nurse initially assesses the patient's radial
pulse primarily for what purpose? - ANSWER>>Establishment of a baseline as part
of the patient's vital signs
What will the nurse instruct nursing assistive personal (NAP) to do when
measuring an adult patient's radial pulse? - ANSWER>>Palpate the patient's inner
wrist on the thumb side with the fingertips of your two middle fingers.
What is the nurse's priority action if a patient's radial pulse has an irregular
rhythm? - ANSWER>>Assess the patient for a pulse deficit.
,Inadequate oxygenation to the body will cause the radial pulse to become: -
ANSWER>>Tachycardic
Which action would best assess the effect of exercise on a patient's radial pulse
measurement? - ANSWER>>Measuring the patient's radial pulse before and after
exercise
Which action can the nurse take to keep a patient from consciously controlling his
or her breathing during an assessment? - ANSWER>>Assess respiration after
measuring the pulse.
On the last assessment of a patient's respiration, her respiratory rate was 10
breaths per minute. What should the nurse do when conducting the next
assessment of this patient's respiratory rate? - ANSWER>>Count breaths for 60
seconds.
When measuring a patient's respiratory rate, the nurse will count the number of
completed respiratory cycles per minute. What is the definition of a respiratory
cycle? - ANSWER>>The number of inspirations and expirations per minute.
During the assessment of a patient's respiratory rate, when the second hand
reaches the 15-second mark, the respiratory count is 8. What should the nurse do
at this time? - ANSWER>>Continue to count the patient's breaths for a full 60
seconds.
The nurse plans to assess a patient's respiratory rate; however, the patient has
just returned from ambulating to the bathroom. What should the nurse do to
minimize the effect of exercise on the patient's respiratory rate? -
ANSWER>>Encourage the patient to rest for 10 minutes before assessing
respiration.
, The nurse is preparing to assess a patient's blood pressure. What would cause the
blood pressure reading to be inaccurately high? - ANSWER>>Blood pressure cuff
is too loose around the arm
What would cause the nurse to delay the assessment of a patient's blood
pressure? - ANSWER>>Patient has just finished having a cigarette
The nurse has just measured a patient's blood pressure and is waiting 2 minutes
to measure the pressure again. What is the purpose of taking two
measurements? - ANSWER>>Minimize the effect of anxiety
The nurse is teaching a patient about ways to reduce blood pressure. What will
the nurse include in these instructions? - ANSWER>>Ensure that your diet has an
adequate daily intake of calcium.
Where should the nurse measure the blood pressure of a patient recovering from
a left-sided mastectomy? - ANSWER>>Use the right arm to take the blood
pressure.
The nurse is planning to measure a patient's blood pressure. What does the
systolic measurement represent? - ANSWER>>The pressure exerted against the
arterial wall.
You have assigned a new nursing assistive personnel (NAP) to take routine vital
signs. You notice that the NAP's last three patients have had unusually low blood
pressure that you have had to confirm. What is the most likely reason the NAP is
obtaining falsely low blood pressure readings? - ANSWER>>The blood pressure
cuff is too wide for arm circumference.
What should the nurse do if the patient's blood pressure is not within normal
limits? - ANSWER>>This is the correct response, because the patient must be
assessed for possible cardiovascular problems.
