NUR 101 Exam 1 – Questions With Complete
Solutions
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Terms in this set (202)
A patient tells the nurse, Im ANS:
having a lot of pain in my 2) Tell me about your pain.
hip. Which response by the 4) How would you describe your pain?
nurse is open-ended and
would stimulate the patient The responses Tell me about your pain and How would
to provide the most you describe your pain? are open-ended responses
complete data? Choose all that stimulate conversation. Although it is important
that are correct. information, the question Is your pain severe? prompts a
1) Is your pain severe? yes or no response. When did you first notice this pain?
2) Tell me about your pain. also important informationis likely to stimulate a brief,
3) When did you first notice factual answer. Such questions allow the nurse to
this pain? control the patients response. Limiting the response
4) How would you describe might lead to an incomplete assessment.
your pain?
,A clients vital signs at the ANS: 3) 102
beginning of the shift are as
follows: oral temperature Heart rate increases about 10 beats per minute for each
99.3F (37C), heart rate 82 degree of temperature to meet increased metabolic
beats/min, respiratory rate needs and compensate for peripheral dilation.
14 breaths/min, and blood
pressure 118/76 mm Hg.
Four hours later the clients
oral temperature is 102.2F
(39C). Based on the
temperature change, the
nurse should anticipate the
clients heart rate would be
how many beats/min?
1) 62
2) 82
3) 102
4) 122
The nurse is assessing vital ANS: 1) Compare the left pedal pulse with the right
signs for a client after pedal pulse
surgical procedure on the
left leg. IV fluids are For a client having surgery on the leg, the most
infusing. It would be most important data would be whether the circulation has
important for the nurse to been compromised because of the surgery. This can be
done only by comparing one leg with the other. The
1) Compare the left pedal nurse would, of course, count the respiratory rate for 1
pulse with the right pedal full minute and take the BP in the arm without the IV.
pulse Oral temperatures are commonly obtained using
2) Count the clients electronic thermometers.
respiratory rate for 1 full
minute
3) Take the blood pressure
in the arm without an IV
4) Take an oral temperature
with an electronic
thermometer
,The nurse hears rhonchi ANS: 2) Request the client take a deep breath and
when auscultating a clients cough.
lungs. Which nursing
intervention would be Rhonchi are caused by secretions in the large airways
appropriate for the nurse to and may clear with coughing. This is how you
implement before differentiate between rhonchi and other adventitious
reassessing lung sounds? sounds. Deep breathing will not help to clear rhonchi.
Taking the blood pressure and apical pulse and
1) Have the client take counting the respiratory rate are not effective for
several deep breaths. clearing rhonchi and would not be sufficient for the
2) Request the client take a nurse to identify whether the sounds were, indeed,
deep breath and cough. rhonchi.
3) Take the clients blood
pressure and apical pulse.
4) Count the clients
respiratory rate for 1 minute.
Which of the following sets ANS: 2) Adolescent: T 98.2F (oral), HR 80, RR 18, BP
of vital signs are all within 108/68
normal limits for patients at
rest? All of the adolescents vital signs are within normal
parameters for the age. The infants temperature is
1) Infant: T 98.8F (rectal), HR below normal for a rectal reading because the core
160, RR 16, BP 120/54 temperature is approximately 1 degree higher than
2) Adolescent: T 98.2F readings from other sites. The heart rate (HR) for an
(oral), HR 80, RR 18, BP infant is high, the respiratory rate (RR) is low, and the
108/68 blood pressure (BP) is high for the age. For the typical
3) Adult: T 99.6F (oral), HR adult, the temperature is high, the HR is low, the RR is
48, RR 22, BP 130/84 high, and the BP is elevated for the age. For the older
4) Older adult: T 98.6F adult, the temperature is high-end normal, the HR is
(oral), HR 110, RR 28, BP high, the RR is high, and the BP is high for the age.
170/95
, The nurse assesses the ANS: 1)Decreased blood pressure (BP) after standing up
following changes in a
clients vital signs. Which A drop in the clients blood pressure when standing
client situation should be indicates orthostatic hypotension, and the cause should
reported to the primary be investigated. The changes in vital signs indicated in
care provider? the other options are normal changes for the situations.
PTS:1DIF:ModerateREF:p. 439 for hypotension
1)Decreased blood information but should read content about all of the
pressure (BP) after standing vital signs
up
2)Decreased temperature
after a period of
diaphoresis
3)Increased heart rate after
walking down the hall
4)Increased respiratory rate
when the heart rate
increases
The clients temperature is ANS: 2) 38.4C
101.1F. Which is the correct
conversion to centigrade? To convert Fahrenheit to centigrade, subtract 32 from
the temperature, and multiply by 5/9.
1)38.0C
2)38.4C
3)38.8C
4)39.2C
The client has had a fever, ANS: 4) Remittent
ranging from 99.8F orally to
103F orally, over the last 24 Remittent fevers fluctuate widely over a 24-hour period.
hours. The clients fever Constant fevers stay above normal with only slight
would be classified as fluctuations. Intermittent fevers alternate between
normal or subnormal temperatures with periods of
1)Constant fever. Relapsing fevers alternate between periods of
2)Intermittent fever and periods of normal temperature, each phase
3)Relapsing lasting 1 to 2 days.
4)Remittent
Solutions
Save
Terms in this set (202)
A patient tells the nurse, Im ANS:
having a lot of pain in my 2) Tell me about your pain.
hip. Which response by the 4) How would you describe your pain?
nurse is open-ended and
would stimulate the patient The responses Tell me about your pain and How would
to provide the most you describe your pain? are open-ended responses
complete data? Choose all that stimulate conversation. Although it is important
that are correct. information, the question Is your pain severe? prompts a
1) Is your pain severe? yes or no response. When did you first notice this pain?
2) Tell me about your pain. also important informationis likely to stimulate a brief,
3) When did you first notice factual answer. Such questions allow the nurse to
this pain? control the patients response. Limiting the response
4) How would you describe might lead to an incomplete assessment.
your pain?
,A clients vital signs at the ANS: 3) 102
beginning of the shift are as
follows: oral temperature Heart rate increases about 10 beats per minute for each
99.3F (37C), heart rate 82 degree of temperature to meet increased metabolic
beats/min, respiratory rate needs and compensate for peripheral dilation.
14 breaths/min, and blood
pressure 118/76 mm Hg.
Four hours later the clients
oral temperature is 102.2F
(39C). Based on the
temperature change, the
nurse should anticipate the
clients heart rate would be
how many beats/min?
1) 62
2) 82
3) 102
4) 122
The nurse is assessing vital ANS: 1) Compare the left pedal pulse with the right
signs for a client after pedal pulse
surgical procedure on the
left leg. IV fluids are For a client having surgery on the leg, the most
infusing. It would be most important data would be whether the circulation has
important for the nurse to been compromised because of the surgery. This can be
done only by comparing one leg with the other. The
1) Compare the left pedal nurse would, of course, count the respiratory rate for 1
pulse with the right pedal full minute and take the BP in the arm without the IV.
pulse Oral temperatures are commonly obtained using
2) Count the clients electronic thermometers.
respiratory rate for 1 full
minute
3) Take the blood pressure
in the arm without an IV
4) Take an oral temperature
with an electronic
thermometer
,The nurse hears rhonchi ANS: 2) Request the client take a deep breath and
when auscultating a clients cough.
lungs. Which nursing
intervention would be Rhonchi are caused by secretions in the large airways
appropriate for the nurse to and may clear with coughing. This is how you
implement before differentiate between rhonchi and other adventitious
reassessing lung sounds? sounds. Deep breathing will not help to clear rhonchi.
Taking the blood pressure and apical pulse and
1) Have the client take counting the respiratory rate are not effective for
several deep breaths. clearing rhonchi and would not be sufficient for the
2) Request the client take a nurse to identify whether the sounds were, indeed,
deep breath and cough. rhonchi.
3) Take the clients blood
pressure and apical pulse.
4) Count the clients
respiratory rate for 1 minute.
Which of the following sets ANS: 2) Adolescent: T 98.2F (oral), HR 80, RR 18, BP
of vital signs are all within 108/68
normal limits for patients at
rest? All of the adolescents vital signs are within normal
parameters for the age. The infants temperature is
1) Infant: T 98.8F (rectal), HR below normal for a rectal reading because the core
160, RR 16, BP 120/54 temperature is approximately 1 degree higher than
2) Adolescent: T 98.2F readings from other sites. The heart rate (HR) for an
(oral), HR 80, RR 18, BP infant is high, the respiratory rate (RR) is low, and the
108/68 blood pressure (BP) is high for the age. For the typical
3) Adult: T 99.6F (oral), HR adult, the temperature is high, the HR is low, the RR is
48, RR 22, BP 130/84 high, and the BP is elevated for the age. For the older
4) Older adult: T 98.6F adult, the temperature is high-end normal, the HR is
(oral), HR 110, RR 28, BP high, the RR is high, and the BP is high for the age.
170/95
, The nurse assesses the ANS: 1)Decreased blood pressure (BP) after standing up
following changes in a
clients vital signs. Which A drop in the clients blood pressure when standing
client situation should be indicates orthostatic hypotension, and the cause should
reported to the primary be investigated. The changes in vital signs indicated in
care provider? the other options are normal changes for the situations.
PTS:1DIF:ModerateREF:p. 439 for hypotension
1)Decreased blood information but should read content about all of the
pressure (BP) after standing vital signs
up
2)Decreased temperature
after a period of
diaphoresis
3)Increased heart rate after
walking down the hall
4)Increased respiratory rate
when the heart rate
increases
The clients temperature is ANS: 2) 38.4C
101.1F. Which is the correct
conversion to centigrade? To convert Fahrenheit to centigrade, subtract 32 from
the temperature, and multiply by 5/9.
1)38.0C
2)38.4C
3)38.8C
4)39.2C
The client has had a fever, ANS: 4) Remittent
ranging from 99.8F orally to
103F orally, over the last 24 Remittent fevers fluctuate widely over a 24-hour period.
hours. The clients fever Constant fevers stay above normal with only slight
would be classified as fluctuations. Intermittent fevers alternate between
normal or subnormal temperatures with periods of
1)Constant fever. Relapsing fevers alternate between periods of
2)Intermittent fever and periods of normal temperature, each phase
3)Relapsing lasting 1 to 2 days.
4)Remittent
