Med-Surg NSG 555 Exam 1 – Questions With Detailed
Solutions
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Terms in this set (551)
Mr. Johnson is a 63-year old c. Temporally
gentleman who is
hospitalized for pneumonia. Orally: not appropriate since he is a mouth-breathing with
He has history of heart shortness of breath.Tympanic: not appropriate since he
failure and hypertension. He wearing hearing aids.Rectally: not indicated since a non-
looks dyspneic and is invasive route (temporal) is available.
mouth-breathing. To
establish a baseline
assessment for Mr. Johnson,
the nurse asks you to
measure his vital signs.
Inspect Mr. Johnson in the
image below and decide
what temperature route
should use to obtain his
temperature:
a. Orally
b. Tympanically
c. Temporally
d. Rectally
Normally, Mr. Johnson's c. 3 AM
lowest body temperature
would be around:
a. 7 PM
b. 2 PM
c. 3 AM
d. 12 PM
,After you assess the vital b. respiration rate= 28 breaths per minute
signs of Mr. Johnson, which
of his vital signs must you All VS normal except RR.
address and report to the
nurse immediately:
a. heart rate= 72 beats per
minute
b. respiration rate= 28
breaths per minute
c. blood pressure= 135/87
mmHg
d. Temperature= 37.2C (99F)
Oral
Based on Mr. Johnson's vital a. administer oxygen via nasal cannula
signs(Heart rate = 72 beats
per minute Respiration rate = Tylenol is not indicated since there is no fever.Holding BP
28 breaths per minute medication is not indicated since BP is not
Blood pressure = 135/87 low.Documentation is not enough, an action is indicated
mmHg. due to high RR.
Temperature = 37.2° C (99° F)
Oral), you expect the nurse
to:
a. administer oxygen via
nasal cannula.
b. administer the ordered
Tylenol (Acetaminophen).
c. hold Mr. Johnson's next BP
medication dose.
d. document the vital signs
as normal.
,Based on Mr. Johnson's vital c. tachypnea
sign(Heart rate = 72 beats
per minute Respiration rate =
28 breaths per minute
Blood pressure = 135/87
mmHg.
Temperature = 37.2° C (99° F)
Oral), he is having:
a. Hyperthermia.
b. Hypotension.
c. Tachypnea.
d. Bradycardia.
After administration of c. Oxygen saturation 96%
oxygen, which of the
following signs indicates that
the oxygen therapy has
been successful?
a. BP 130/82 mmHg.
b. Temp 99.8 F.
c. Oxygen saturation 96%.
d. Respiration rate 24 bpm.
Knowing that Mr. Johnson c. apical pulse
has a history of heart failure,
which has led atrial
fibrillation dysrhythmia, to
accurately measure his
pulse, should assess his:
a. radial pulse.
b. brachial pulse.
c. apical pulse.
d. Dorsalis pedis pulse.
, Due to his history of c. assess his apical pulse and radial pulse for the same
dysrhythmia, you suspect minute and subtract the difference.
that Mr. Johnson will have
pulse deficit. To measure his
pulse deficit, you should:
a. subtract 60 from his pulse
rate.
b. subtract his pulse rate
from 100.
c. assess his apical pulse and
radial pulse for the same
minute and subtract the
difference.
d. assess his apical pulse and
30 minutes later assessing his
carotid pulse and subtract
the difference.
To assess Mr. Johnson's a. at 5th intercostal space (ICS) and midclavicular line.
apical pulse, you should
place the stethoscope on his
point of maximum impulse
(PMI), which is located:
a. at 5th intercostal space
(ICS) and midclavicular line.
b. at 2nd intercostal space
(ICS) and left sternal edge.
c. at 2nd intercostal space
(ICS) and right sternal edge.
d. at 4th intercostal space
(ICS) and midaxillary line.
Knowing that Mr. Johnson b. weak, 1+, and irregular.
has a history of heart failure
and dysrhythmia, you expect
his radial pulse to be:
a. bounding, 4+, and regular.
b. weak, 1+, and irregular.
c. normal, 2+, and regular.
d. Absent.
Solutions
Save
Terms in this set (551)
Mr. Johnson is a 63-year old c. Temporally
gentleman who is
hospitalized for pneumonia. Orally: not appropriate since he is a mouth-breathing with
He has history of heart shortness of breath.Tympanic: not appropriate since he
failure and hypertension. He wearing hearing aids.Rectally: not indicated since a non-
looks dyspneic and is invasive route (temporal) is available.
mouth-breathing. To
establish a baseline
assessment for Mr. Johnson,
the nurse asks you to
measure his vital signs.
Inspect Mr. Johnson in the
image below and decide
what temperature route
should use to obtain his
temperature:
a. Orally
b. Tympanically
c. Temporally
d. Rectally
Normally, Mr. Johnson's c. 3 AM
lowest body temperature
would be around:
a. 7 PM
b. 2 PM
c. 3 AM
d. 12 PM
,After you assess the vital b. respiration rate= 28 breaths per minute
signs of Mr. Johnson, which
of his vital signs must you All VS normal except RR.
address and report to the
nurse immediately:
a. heart rate= 72 beats per
minute
b. respiration rate= 28
breaths per minute
c. blood pressure= 135/87
mmHg
d. Temperature= 37.2C (99F)
Oral
Based on Mr. Johnson's vital a. administer oxygen via nasal cannula
signs(Heart rate = 72 beats
per minute Respiration rate = Tylenol is not indicated since there is no fever.Holding BP
28 breaths per minute medication is not indicated since BP is not
Blood pressure = 135/87 low.Documentation is not enough, an action is indicated
mmHg. due to high RR.
Temperature = 37.2° C (99° F)
Oral), you expect the nurse
to:
a. administer oxygen via
nasal cannula.
b. administer the ordered
Tylenol (Acetaminophen).
c. hold Mr. Johnson's next BP
medication dose.
d. document the vital signs
as normal.
,Based on Mr. Johnson's vital c. tachypnea
sign(Heart rate = 72 beats
per minute Respiration rate =
28 breaths per minute
Blood pressure = 135/87
mmHg.
Temperature = 37.2° C (99° F)
Oral), he is having:
a. Hyperthermia.
b. Hypotension.
c. Tachypnea.
d. Bradycardia.
After administration of c. Oxygen saturation 96%
oxygen, which of the
following signs indicates that
the oxygen therapy has
been successful?
a. BP 130/82 mmHg.
b. Temp 99.8 F.
c. Oxygen saturation 96%.
d. Respiration rate 24 bpm.
Knowing that Mr. Johnson c. apical pulse
has a history of heart failure,
which has led atrial
fibrillation dysrhythmia, to
accurately measure his
pulse, should assess his:
a. radial pulse.
b. brachial pulse.
c. apical pulse.
d. Dorsalis pedis pulse.
, Due to his history of c. assess his apical pulse and radial pulse for the same
dysrhythmia, you suspect minute and subtract the difference.
that Mr. Johnson will have
pulse deficit. To measure his
pulse deficit, you should:
a. subtract 60 from his pulse
rate.
b. subtract his pulse rate
from 100.
c. assess his apical pulse and
radial pulse for the same
minute and subtract the
difference.
d. assess his apical pulse and
30 minutes later assessing his
carotid pulse and subtract
the difference.
To assess Mr. Johnson's a. at 5th intercostal space (ICS) and midclavicular line.
apical pulse, you should
place the stethoscope on his
point of maximum impulse
(PMI), which is located:
a. at 5th intercostal space
(ICS) and midclavicular line.
b. at 2nd intercostal space
(ICS) and left sternal edge.
c. at 2nd intercostal space
(ICS) and right sternal edge.
d. at 4th intercostal space
(ICS) and midaxillary line.
Knowing that Mr. Johnson b. weak, 1+, and irregular.
has a history of heart failure
and dysrhythmia, you expect
his radial pulse to be:
a. bounding, 4+, and regular.
b. weak, 1+, and irregular.
c. normal, 2+, and regular.
d. Absent.
