NUR 105 Midterm Exam Questions And
Answers Verified 100% Correct
1. When taking an axillary temperature, the nurse exposes only the axilla area.
What reasons does the nurse tell the client? - ANSWER -a. It keeps the client
warm
a. It maintains the client's dignity
1. When measuring a client's axillary temperature, the nurse would position the
thermometer at which location? - ANSWER -a. In the center of the axilla
1. The nurse prepares to obtain a rectal temperature on an adult client. To which
distance should the nurse insert the thermometer? - ANSWER -a. 1.5 in (3.75 cm)
1. The nurse would use which part of the hand when assessing the radial pulse? -
ANSWER -a. Pads of first, second, and third fingers
1. The nurse needs to assess the carotid arteries of the client. Which assessment
technique would be appropriate for the nurse to use? - ANSWER -a. Palpate one
artery at a time
1. The nurse is assessing a client's radial pulse and notes that the rate is somewhat
irregular. The nurse should count the pulse over which time frame? - ANSWER -a.
60 seconds
1. The nurse is to assess the pulse rate in an 18-month-old child. Which location
provides the most accurate result? - ANSWER -a. Apical
1. The nurse is preparing to measure an adult's radial pulse using a Doppler
device. Place the following steps of the procedure in the correct order. - ANSWER
-a. Apply conducting gel to the site where the pulse will be auscultated
b. Place the Doppler probe tip in the gel
c. Adjust the volume of the device, as needed
d. Maneuver the tip of the Doppler probe over the area until the pulse is heard
,e. Count the number of heartbeats for one full minute
f. Wipe the gel off of the client's skin
1. The nurse is attempting to assess a client's radial pulse. The pulse is weak,
irregular and unable to be counted. What action would the nurse take next? -
ANSWER -a. Assess the apical pulse
1. The nurse is preparing to assess the peripheral pulse of an adult client. Which
action is correct? - ANSWER -a. Lightly compress the client's radial artery using
the first, second, and third fingers
1. When measuring an apical pulse, what equipment would the nurse prepare to
have available? - ANSWER -a. Stethoscope
1. A group of students are reviewing information about taking an apical-radial
pulse. Which information is accurate? - ANSWER -Both rates are assessed
simultaneously
1. Prior to administering a heart medication, the nurse takes an apical pulse. For
how long should the nurse count the pulse? - ANSWER -a. 60 seconds and
multiply by 1
1. Over the course of a day, a nurse encounters many different clients whose pulse
rates she must measure. For which clients should she measure the apical pulse? -
ANSWER -a. A client who is on a medication that has dysrhythmia as a side effect
a. An older adult client, whose pulse when measured peripherally is found to be
extremely rapid
a. A healthy 8-year-old girl
1. A client's apical radial pulse reveals an apical pulse of 72 beats per minute and a
radial pulse of 60 beats per minute. How does the nurse document the pulse
deficit? - ANSWER -12
1. When obtaining a pulse rate for a client with an irregular heart rhythm, how
long does the nurse count? - ANSWER -1 minute
, 1. What is the best way for the nurse to promote comfort for the client when
assessing an apical pulse? - ANSWER -a. Holding the stethoscope's diaphragm
against the palm of the hand for a few seconds
1. The UAP reports to the nurse that the client's pulse is difficult to feel and is
skipping beats. What action should the nurse take? - ANSWER -a. Take an apical
pulse
1. Which action does the nurse include when measuring the client's pulse deficit? -
ANSWER -a. Measure the apical and radial pulse separately
1. Which client would require the nurse to obtain an apical radial pulse? -
ANSWER -a. Client with atrial fibrillation
1. A nurse is measuring the apical pulse of a client. Where should she place the
diaphragm of her stethoscope in this assessment? - ANSWER -a. Over the space
between the 5th and 6th ribs on the left midclavicular line
1. A nurse assesses a client's respiration and determines that the respiratory rate is
26 breaths per minute and shallow. Which term would the nurse use to document
this finding? - ANSWER -a. Tachypnea
1. A nurse is assessing a client's respirations and notes that the client's rate is
irregular. Which action by the nurse would be most appropriate? - ANSWER -a.
Count the respirations over a period of 1 minute
1. A nurse is assessing the respirations of a 9-month-old infant. The nurse would
obtain the respiratory rate by counting movement of which area? - ANSWER -a.
Abdomen
1. A nurse is having difficulty observing the rise and fall of a client's chest when
assessing respirations. Which action would be most appropriate? - ANSWER -a.
Put the stethoscope at the apical site and watch its movement
Answers Verified 100% Correct
1. When taking an axillary temperature, the nurse exposes only the axilla area.
What reasons does the nurse tell the client? - ANSWER -a. It keeps the client
warm
a. It maintains the client's dignity
1. When measuring a client's axillary temperature, the nurse would position the
thermometer at which location? - ANSWER -a. In the center of the axilla
1. The nurse prepares to obtain a rectal temperature on an adult client. To which
distance should the nurse insert the thermometer? - ANSWER -a. 1.5 in (3.75 cm)
1. The nurse would use which part of the hand when assessing the radial pulse? -
ANSWER -a. Pads of first, second, and third fingers
1. The nurse needs to assess the carotid arteries of the client. Which assessment
technique would be appropriate for the nurse to use? - ANSWER -a. Palpate one
artery at a time
1. The nurse is assessing a client's radial pulse and notes that the rate is somewhat
irregular. The nurse should count the pulse over which time frame? - ANSWER -a.
60 seconds
1. The nurse is to assess the pulse rate in an 18-month-old child. Which location
provides the most accurate result? - ANSWER -a. Apical
1. The nurse is preparing to measure an adult's radial pulse using a Doppler
device. Place the following steps of the procedure in the correct order. - ANSWER
-a. Apply conducting gel to the site where the pulse will be auscultated
b. Place the Doppler probe tip in the gel
c. Adjust the volume of the device, as needed
d. Maneuver the tip of the Doppler probe over the area until the pulse is heard
,e. Count the number of heartbeats for one full minute
f. Wipe the gel off of the client's skin
1. The nurse is attempting to assess a client's radial pulse. The pulse is weak,
irregular and unable to be counted. What action would the nurse take next? -
ANSWER -a. Assess the apical pulse
1. The nurse is preparing to assess the peripheral pulse of an adult client. Which
action is correct? - ANSWER -a. Lightly compress the client's radial artery using
the first, second, and third fingers
1. When measuring an apical pulse, what equipment would the nurse prepare to
have available? - ANSWER -a. Stethoscope
1. A group of students are reviewing information about taking an apical-radial
pulse. Which information is accurate? - ANSWER -Both rates are assessed
simultaneously
1. Prior to administering a heart medication, the nurse takes an apical pulse. For
how long should the nurse count the pulse? - ANSWER -a. 60 seconds and
multiply by 1
1. Over the course of a day, a nurse encounters many different clients whose pulse
rates she must measure. For which clients should she measure the apical pulse? -
ANSWER -a. A client who is on a medication that has dysrhythmia as a side effect
a. An older adult client, whose pulse when measured peripherally is found to be
extremely rapid
a. A healthy 8-year-old girl
1. A client's apical radial pulse reveals an apical pulse of 72 beats per minute and a
radial pulse of 60 beats per minute. How does the nurse document the pulse
deficit? - ANSWER -12
1. When obtaining a pulse rate for a client with an irregular heart rhythm, how
long does the nurse count? - ANSWER -1 minute
, 1. What is the best way for the nurse to promote comfort for the client when
assessing an apical pulse? - ANSWER -a. Holding the stethoscope's diaphragm
against the palm of the hand for a few seconds
1. The UAP reports to the nurse that the client's pulse is difficult to feel and is
skipping beats. What action should the nurse take? - ANSWER -a. Take an apical
pulse
1. Which action does the nurse include when measuring the client's pulse deficit? -
ANSWER -a. Measure the apical and radial pulse separately
1. Which client would require the nurse to obtain an apical radial pulse? -
ANSWER -a. Client with atrial fibrillation
1. A nurse is measuring the apical pulse of a client. Where should she place the
diaphragm of her stethoscope in this assessment? - ANSWER -a. Over the space
between the 5th and 6th ribs on the left midclavicular line
1. A nurse assesses a client's respiration and determines that the respiratory rate is
26 breaths per minute and shallow. Which term would the nurse use to document
this finding? - ANSWER -a. Tachypnea
1. A nurse is assessing a client's respirations and notes that the client's rate is
irregular. Which action by the nurse would be most appropriate? - ANSWER -a.
Count the respirations over a period of 1 minute
1. A nurse is assessing the respirations of a 9-month-old infant. The nurse would
obtain the respiratory rate by counting movement of which area? - ANSWER -a.
Abdomen
1. A nurse is having difficulty observing the rise and fall of a client's chest when
assessing respirations. Which action would be most appropriate? - ANSWER -a.
Put the stethoscope at the apical site and watch its movement
