NUR 230 Exam 1 SHERPATH
A nurse is caring for a patient who has just had major abdominal surgery to resect a portion of
his colon. What is the most reliable sign that the patient has significant postoperative pain - ANS
-the patient rates his pain a 7 on a scale of 0-10
\A patient is prescribed continuous oxygen saturation monitoring. The nurse would confirm that
the alarms have been set to which limits - ANS -low of 85% and high of 100%
\A patient with a herniated disc is scheduled for surgery to fuse two vertebrae in her cervical
spine. Which activity is most likely to be a palliative factor for this patient - ANS -performing
neck, back, and shoulder exercises prescribed by a physical therapist
\An increase in body temperature may be an indication of which condition? - ANS -infection,
damage to hypothalamus, and vasoconstriction
\auscultate directly on skin - ANS -avoids obscured sounds
\behavioral pain scale - ANS -allows the nurse to choose from pain behaviors to rate the pain of
the patient and is not a self-reporting pain scale
\blood pressure follows a diurnal pattern, peaking at what time during the day - ANS
-midmorning
\blunt (fist) technique - ANS -tenderness of kidney
\descriptive pain scale - ANS -pain descriptions with which the patient can rate their
\direct (immediate) percussion technique - ANS -flat sound on spine
\dullness - ANS -heard over dense organs
\During an abdominal assessment, palpation occurs after auscultation for what reason - ANS
-palpation may increase intestinal activity
\During auscultation of the patient's chest, how should the nurse position the stethoscope to
minimize extraneous noises - ANS -position the head of the stethoscope between the 2nd and
3rd fingers and position on the patient's skin
\During the admissions process, the nurse initially assesses the patient's radial pulse primarily
for what purpose - ANS -establishment of a baseline as part of the patient's vital signs
\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? - ANS -continue
to count the patient's breaths for a full 60 seconds
\flatness - ANS -heard over the bones or muscles
\For which type of patient would the nurse use the tuning fork to further assess function - ANS
-patient with loss of hearing
\having a quiet environment - ANS -prevents distraction
\How does soap work - ANS -emulsifies fat and oil so that first and microorganisms can be
mechanically removed
\How should the nurse insert the otoscope speculum to best inspect the auditory canal and
prevent injury in an adult patient - ANS -tilt the patient's head slightly toward the opposite ear
before inserting the otoscope speculum
, \how should the nurse position the patient to assess deep tendon reflexes - ANS -position the
patient's extremity so the tendon is slightly stretched, manipulate the patients joint being tested
away from you
\hyper resonance - ANS -heard over hyper inflated (emphysematous) lungs
\hypothermia - ANS -describes the condition of having abnormally low body temperature and is
not a temperature-regulating reaction
\If a nurse needs to repeat a blood pressure, what is the most appropriate action to avoid falsely
high measurement - ANS -support the arm at heart level and wait at least 1 minute before
repeating the blood pressure measurement
\In which situation would it be appropriate for the nurse to use and antiseptic hand rub to
perform hand hygiene - ANS -the nurse's hands are not visibly soiled
\inadequate oxygenation to the body will cause the radial pulse to become - ANS -tachycardiac
\indirect (mediate) percussion technique - ANS -resonance of lungs
\Jaeger chart - ANS -assesses near vision but held 14 inches from face
\list the steps for indirect percussion technique in order - ANS -1. expose patient's skin by
removing gown as needed
2. place middle finger of nondominant hand firmly on patient's skin
3. Keep the fingers of the non dominant hand fanned out and off the surface of the skin
4. snap the wrist of the dominant hand downward
5. with dominant hand, strike the middle finger of non dominant hand
\listen to one sound at a time - ANS -distinguishes between two sounds
\numeric pain scale - ANS -numbers with which the patient can rate their pain
\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 - ANS -count breaths for 60 seconds
\pain scale for infant - ANS -cries scale
\pain scale for older adult - ANS -self-report pain scale
\pyrexia - ANS -fever response, triggered by the production and release of prostaglandins; not
related to temperature regulation
\resonance - ANS -heard over the lungs
\shivering - ANS -results from contraction and relaxation of the skeletal muscles, warming the
body
\Snellen chart - ANS -assess far vision, mounted on a wall 20 feet from patient
\take time for auscultation - ANS -important to identify characteristics
\the best way to measure respirations is to count the breathe for ____ seconds and multiply by 2
- ANS -30
\the nurse can best determine the effect of crying on a patient's apical pulse by doing what -
ANS -comparing the patient's post-crying apical pulse rate with her baseline or previous rate
\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? - ANS -minimize the
effect of anxiety
\the nurse is discussing the guidelines for proper use of PPE by NAP. which statement made by
the NAP requires follow-up by the nurse - ANS -I really dislike wearing a mask, so it's the first
thing I take off
A nurse is caring for a patient who has just had major abdominal surgery to resect a portion of
his colon. What is the most reliable sign that the patient has significant postoperative pain - ANS
-the patient rates his pain a 7 on a scale of 0-10
\A patient is prescribed continuous oxygen saturation monitoring. The nurse would confirm that
the alarms have been set to which limits - ANS -low of 85% and high of 100%
\A patient with a herniated disc is scheduled for surgery to fuse two vertebrae in her cervical
spine. Which activity is most likely to be a palliative factor for this patient - ANS -performing
neck, back, and shoulder exercises prescribed by a physical therapist
\An increase in body temperature may be an indication of which condition? - ANS -infection,
damage to hypothalamus, and vasoconstriction
\auscultate directly on skin - ANS -avoids obscured sounds
\behavioral pain scale - ANS -allows the nurse to choose from pain behaviors to rate the pain of
the patient and is not a self-reporting pain scale
\blood pressure follows a diurnal pattern, peaking at what time during the day - ANS
-midmorning
\blunt (fist) technique - ANS -tenderness of kidney
\descriptive pain scale - ANS -pain descriptions with which the patient can rate their
\direct (immediate) percussion technique - ANS -flat sound on spine
\dullness - ANS -heard over dense organs
\During an abdominal assessment, palpation occurs after auscultation for what reason - ANS
-palpation may increase intestinal activity
\During auscultation of the patient's chest, how should the nurse position the stethoscope to
minimize extraneous noises - ANS -position the head of the stethoscope between the 2nd and
3rd fingers and position on the patient's skin
\During the admissions process, the nurse initially assesses the patient's radial pulse primarily
for what purpose - ANS -establishment of a baseline as part of the patient's vital signs
\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? - ANS -continue
to count the patient's breaths for a full 60 seconds
\flatness - ANS -heard over the bones or muscles
\For which type of patient would the nurse use the tuning fork to further assess function - ANS
-patient with loss of hearing
\having a quiet environment - ANS -prevents distraction
\How does soap work - ANS -emulsifies fat and oil so that first and microorganisms can be
mechanically removed
\How should the nurse insert the otoscope speculum to best inspect the auditory canal and
prevent injury in an adult patient - ANS -tilt the patient's head slightly toward the opposite ear
before inserting the otoscope speculum
, \how should the nurse position the patient to assess deep tendon reflexes - ANS -position the
patient's extremity so the tendon is slightly stretched, manipulate the patients joint being tested
away from you
\hyper resonance - ANS -heard over hyper inflated (emphysematous) lungs
\hypothermia - ANS -describes the condition of having abnormally low body temperature and is
not a temperature-regulating reaction
\If a nurse needs to repeat a blood pressure, what is the most appropriate action to avoid falsely
high measurement - ANS -support the arm at heart level and wait at least 1 minute before
repeating the blood pressure measurement
\In which situation would it be appropriate for the nurse to use and antiseptic hand rub to
perform hand hygiene - ANS -the nurse's hands are not visibly soiled
\inadequate oxygenation to the body will cause the radial pulse to become - ANS -tachycardiac
\indirect (mediate) percussion technique - ANS -resonance of lungs
\Jaeger chart - ANS -assesses near vision but held 14 inches from face
\list the steps for indirect percussion technique in order - ANS -1. expose patient's skin by
removing gown as needed
2. place middle finger of nondominant hand firmly on patient's skin
3. Keep the fingers of the non dominant hand fanned out and off the surface of the skin
4. snap the wrist of the dominant hand downward
5. with dominant hand, strike the middle finger of non dominant hand
\listen to one sound at a time - ANS -distinguishes between two sounds
\numeric pain scale - ANS -numbers with which the patient can rate their pain
\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 - ANS -count breaths for 60 seconds
\pain scale for infant - ANS -cries scale
\pain scale for older adult - ANS -self-report pain scale
\pyrexia - ANS -fever response, triggered by the production and release of prostaglandins; not
related to temperature regulation
\resonance - ANS -heard over the lungs
\shivering - ANS -results from contraction and relaxation of the skeletal muscles, warming the
body
\Snellen chart - ANS -assess far vision, mounted on a wall 20 feet from patient
\take time for auscultation - ANS -important to identify characteristics
\the best way to measure respirations is to count the breathe for ____ seconds and multiply by 2
- ANS -30
\the nurse can best determine the effect of crying on a patient's apical pulse by doing what -
ANS -comparing the patient's post-crying apical pulse rate with her baseline or previous rate
\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? - ANS -minimize the
effect of anxiety
\the nurse is discussing the guidelines for proper use of PPE by NAP. which statement made by
the NAP requires follow-up by the nurse - ANS -I really dislike wearing a mask, so it's the first
thing I take off
