NUR 131: Test 1 || Zero Flaw on Answers.
which of the following are components of the general survey? correct answers observing
physical appearance, evaluting level of consciousness, assessing speech
in what order are vital signs documented? correct answers T-P-R-SBP/DBP
prior to obtaining temp, what questions/assessments are essential? correct answers ask if patient
had anything hot or cold to drink
the nurse assesses an oral temp of 94.9 F and verifies the patient has not had anything to eat or
drink. which of the following medical terms describes this finding? correct answers hypothermia
which of the following temperature methods has a normal value of 99.6 (+ or - 1 degree)? correct
answers temporal and rectal
a patient in the intensive care unit has an order for rectal temp monitoring. the nurse knows rectal
temperatures can stimulate the vagus nerve in the rectum. Which of the following would be a
contraindication to assessing a rectal temp? correct answers cardiac disease, platelet count is very
low (clotting is impaired), there are hemorrhoids
pulse is reflective of the heart rate and is counted as beats per min. There are various sites around
the body. what type of vessel is being palpated? correct answers artery
the patient is taking digoxin, a medication affecting heart rate. the patient also has an irregular
heart rhythm. which of the following methods would be appropriate to assess heart rate? correct
answers auscultate the apical pulse for 60 secs
the nurse assesses a pulse of 106 bpm. the medical term describing this is? correct answers
tachycardia
, the nurse assess a pulse of 120 bpm. which of the following is the likely cause? correct answers
pyrexia, sedating meds/narcotics, hypervolemia
the nurse is observing a nursing assistant palpating a radial pulse. which of the following actions
made by the nursing assistant would require intervention by the nurse? correct answers the
nursing assistant palpates the radial pulse using his thumb on the inside of the patients wrist just
below the base of the patients thumb
which of the following are correct regarding auscultation bf an apical pulse ? correct answers
auscultate using the diaphragm of the stethoscope and at the 5th intercostal space, left
midclavicular line
which of the following is true regarding assessment of RR? correct answers the nurse should
count the respiration's without the patients knowledge
the nurse assess one respiration as one inhalation and one exhalation. the total count after 60
seconds was 24. the nurse would document as ? correct answers tachypnea (higher than 20)
a patient has a respiratory rate of 9 per min. the nurse understands this is likely related to? (12-
20) correct answers sedating meds
the nurses assesses a patients pulse oximetery and notes an oxygen saturation of 89%. the patient
appears to be having difficulty breathing. what position should the nurse place the patient in ?
correct answers fowler's
the nurse understands that which of the following would result in a blood pressure reading of
90/40 mmHg? correct answers hemorrhage (excess bleeding)
which of the following is true regarding cultural groups and pain? correct answers korean culture
are stoic and slow to express emotional distress from pain. may need to monitor for nonverbal
cues of pain
which of the following are components of the general survey? correct answers observing
physical appearance, evaluting level of consciousness, assessing speech
in what order are vital signs documented? correct answers T-P-R-SBP/DBP
prior to obtaining temp, what questions/assessments are essential? correct answers ask if patient
had anything hot or cold to drink
the nurse assesses an oral temp of 94.9 F and verifies the patient has not had anything to eat or
drink. which of the following medical terms describes this finding? correct answers hypothermia
which of the following temperature methods has a normal value of 99.6 (+ or - 1 degree)? correct
answers temporal and rectal
a patient in the intensive care unit has an order for rectal temp monitoring. the nurse knows rectal
temperatures can stimulate the vagus nerve in the rectum. Which of the following would be a
contraindication to assessing a rectal temp? correct answers cardiac disease, platelet count is very
low (clotting is impaired), there are hemorrhoids
pulse is reflective of the heart rate and is counted as beats per min. There are various sites around
the body. what type of vessel is being palpated? correct answers artery
the patient is taking digoxin, a medication affecting heart rate. the patient also has an irregular
heart rhythm. which of the following methods would be appropriate to assess heart rate? correct
answers auscultate the apical pulse for 60 secs
the nurse assesses a pulse of 106 bpm. the medical term describing this is? correct answers
tachycardia
, the nurse assess a pulse of 120 bpm. which of the following is the likely cause? correct answers
pyrexia, sedating meds/narcotics, hypervolemia
the nurse is observing a nursing assistant palpating a radial pulse. which of the following actions
made by the nursing assistant would require intervention by the nurse? correct answers the
nursing assistant palpates the radial pulse using his thumb on the inside of the patients wrist just
below the base of the patients thumb
which of the following are correct regarding auscultation bf an apical pulse ? correct answers
auscultate using the diaphragm of the stethoscope and at the 5th intercostal space, left
midclavicular line
which of the following is true regarding assessment of RR? correct answers the nurse should
count the respiration's without the patients knowledge
the nurse assess one respiration as one inhalation and one exhalation. the total count after 60
seconds was 24. the nurse would document as ? correct answers tachypnea (higher than 20)
a patient has a respiratory rate of 9 per min. the nurse understands this is likely related to? (12-
20) correct answers sedating meds
the nurses assesses a patients pulse oximetery and notes an oxygen saturation of 89%. the patient
appears to be having difficulty breathing. what position should the nurse place the patient in ?
correct answers fowler's
the nurse understands that which of the following would result in a blood pressure reading of
90/40 mmHg? correct answers hemorrhage (excess bleeding)
which of the following is true regarding cultural groups and pain? correct answers korean culture
are stoic and slow to express emotional distress from pain. may need to monitor for nonverbal
cues of pain
