NUR 1020 Exam 2 | Full Questions and Answers | 2026 Update | 100% Correct.
Correct
Incorrect
Questions and answers
1 of 40
Term
The patient requires routine temperature assessment but is confused,
easily agitated, and has a history of seizures. Which route will the nurse
use to obtain the patient's temperature?
a. Oral
b. Rectal
c. Axillary
d. Tympanic
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ANS: D
The tympanic route is easily accessible, requires minimal patient repositioning,
and often can be used without disturbing the patient. It also has a very rapid
measurement time. Oral temperatures require patient cooperation and are not
recommended for patients with a history of seizures. Rectal temperatures
, require positioning and may increase patient agitation.
Axillary temperatures need long measurement times and continuous
positioning. The patient's agitation state may not allow for long periods of
attention.
ANS: C
The heart continues to deliver blood through the carotid artery to the brain as long
as possible. The carotid pulse is easily accessible during physiological shock or
cardiac arrest. The radial pulse is used to assess peripheral circulation or to assess
the status of circulation to the hand. The brachial site is used to assess the status of
circulation to the lower arm. The apical pulse is used to auscultate the apical area.
ANS: C
Convection is the transfer of heat away from the body by air movement. Conduction
is the transfer of heat from one object to another with direct contact. Radiation is
the transfer of heat from the surface of one object to the surface of another without
direct contact between the two. Evaporation is the transfer of heat energy when a
liquid is changed to a gas.
ANS: C
Insomnia is experienced when the patient has chronic difficulty falling asleep,
frequent awakenings from sleep, and/or short sleep or nonrestorative sleep. It is the
most common sleep-related complaint and includes symptoms such as irritability,
excessive daytime sleepiness, not being able to fall asleep, and fatigue. Anxiety is a
vague, uneasy feeling of discomfort or dread accompanied by an autonomic
response. Fatigue is an overwhelming sustained sense of exhaustion with decreased
capacity for physical and mental work at a usual level. Sleep deprivation is a
condition caused by dyssomnia and includes symptoms caused by illness,
emotional distress, or medications.
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2 of 40
,Term
A nurse develops a nursing diagnostic statement for a patient with a
medical diagnosis of pneumonia with chest x-ray results of lower lobe
infiltrates. Which nursing diagnosis did the nurse write?
a. Ineffective breathing pattern related to pneumonia
b. Risk for infection related to chest x-ray procedure
c. Risk for deficient fluid volume related to dehydration
d. Impaired gas exchange related to alveolar-capillary membrane
changes
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ANS: A, B, C
Apnea—Respirations cease for several seconds. Persistent cessation results in
respiratory arrest. Tachypnea—Rate of breathing is regular but abnormally rapid
(greater than 20 breaths/min). Kussmaul's—Respirations are abnormally deep,
regular, and increased in rate. Hyperventilation—Rate and depth of respirations
increase; breaths are not labored.
Hypocarbia sometimes occurs. Cheyne-Stokes—Respiratory rate and depth are
irregular, characterized by alternating periods of apnea and hyperventilation. Biot's
—Respirations are abnormally shallow for 2 to 3 breaths followed by irregular
period of apnea.
ANS: D
The related to factor of alveolar-capillary membrane changes is accurately
written because it is a patient response to the disease process of pneumonia
that the nurse can treat. The related to factor should be the cause of the
problem (nursing diagnosis) that a nurse can address. The related to factors of
dehydration and pneumonia are all medical diagnoses that the nurse cannot
change. A diagnostic test or a chronic dysfunction is not an etiology or a
condition that a nursing intervention is able to treat
, ANS: A
The diagnostic process flows from the assessment process (observing and
gathering data) and includes decision-making steps. These steps include data
clustering, identifying patient health problems, and formulating the diagnosis
(diagnosis is written as problem or NANDA-I approved diagnosis then etiology or
cause).
ANS: A
A goal is a broad statement of desired change; the patient will increase activity level
is a broad statement. Turning is the expected outcome. When determining goals, the
nurse needs to ensure that the goal is individualized and realistic for the patient.
Since the patient is on bed rest, using a walker and bedside commode is
contraindicated.
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3 of 40
Term
A patient's plan of care includes the goal of increasing mobility this
shift. As the patient is ambulating to the bathroom at the beginning of
the shift, the patient falls. Which initial action will the nurse take next to
most effectively revise the plan of care?
a. Consult physical therapy.
b. Establish a new plan of care.
c. Set new priorities for the patient.
d. Assess the patient.
Give this one a try later!
Correct
Incorrect
Questions and answers
1 of 40
Term
The patient requires routine temperature assessment but is confused,
easily agitated, and has a history of seizures. Which route will the nurse
use to obtain the patient's temperature?
a. Oral
b. Rectal
c. Axillary
d. Tympanic
Give this one a try later!
ANS: D
The tympanic route is easily accessible, requires minimal patient repositioning,
and often can be used without disturbing the patient. It also has a very rapid
measurement time. Oral temperatures require patient cooperation and are not
recommended for patients with a history of seizures. Rectal temperatures
, require positioning and may increase patient agitation.
Axillary temperatures need long measurement times and continuous
positioning. The patient's agitation state may not allow for long periods of
attention.
ANS: C
The heart continues to deliver blood through the carotid artery to the brain as long
as possible. The carotid pulse is easily accessible during physiological shock or
cardiac arrest. The radial pulse is used to assess peripheral circulation or to assess
the status of circulation to the hand. The brachial site is used to assess the status of
circulation to the lower arm. The apical pulse is used to auscultate the apical area.
ANS: C
Convection is the transfer of heat away from the body by air movement. Conduction
is the transfer of heat from one object to another with direct contact. Radiation is
the transfer of heat from the surface of one object to the surface of another without
direct contact between the two. Evaporation is the transfer of heat energy when a
liquid is changed to a gas.
ANS: C
Insomnia is experienced when the patient has chronic difficulty falling asleep,
frequent awakenings from sleep, and/or short sleep or nonrestorative sleep. It is the
most common sleep-related complaint and includes symptoms such as irritability,
excessive daytime sleepiness, not being able to fall asleep, and fatigue. Anxiety is a
vague, uneasy feeling of discomfort or dread accompanied by an autonomic
response. Fatigue is an overwhelming sustained sense of exhaustion with decreased
capacity for physical and mental work at a usual level. Sleep deprivation is a
condition caused by dyssomnia and includes symptoms caused by illness,
emotional distress, or medications.
Don't know?
2 of 40
,Term
A nurse develops a nursing diagnostic statement for a patient with a
medical diagnosis of pneumonia with chest x-ray results of lower lobe
infiltrates. Which nursing diagnosis did the nurse write?
a. Ineffective breathing pattern related to pneumonia
b. Risk for infection related to chest x-ray procedure
c. Risk for deficient fluid volume related to dehydration
d. Impaired gas exchange related to alveolar-capillary membrane
changes
Give this one a try later!
ANS: A, B, C
Apnea—Respirations cease for several seconds. Persistent cessation results in
respiratory arrest. Tachypnea—Rate of breathing is regular but abnormally rapid
(greater than 20 breaths/min). Kussmaul's—Respirations are abnormally deep,
regular, and increased in rate. Hyperventilation—Rate and depth of respirations
increase; breaths are not labored.
Hypocarbia sometimes occurs. Cheyne-Stokes—Respiratory rate and depth are
irregular, characterized by alternating periods of apnea and hyperventilation. Biot's
—Respirations are abnormally shallow for 2 to 3 breaths followed by irregular
period of apnea.
ANS: D
The related to factor of alveolar-capillary membrane changes is accurately
written because it is a patient response to the disease process of pneumonia
that the nurse can treat. The related to factor should be the cause of the
problem (nursing diagnosis) that a nurse can address. The related to factors of
dehydration and pneumonia are all medical diagnoses that the nurse cannot
change. A diagnostic test or a chronic dysfunction is not an etiology or a
condition that a nursing intervention is able to treat
, ANS: A
The diagnostic process flows from the assessment process (observing and
gathering data) and includes decision-making steps. These steps include data
clustering, identifying patient health problems, and formulating the diagnosis
(diagnosis is written as problem or NANDA-I approved diagnosis then etiology or
cause).
ANS: A
A goal is a broad statement of desired change; the patient will increase activity level
is a broad statement. Turning is the expected outcome. When determining goals, the
nurse needs to ensure that the goal is individualized and realistic for the patient.
Since the patient is on bed rest, using a walker and bedside commode is
contraindicated.
Don't know?
3 of 40
Term
A patient's plan of care includes the goal of increasing mobility this
shift. As the patient is ambulating to the bathroom at the beginning of
the shift, the patient falls. Which initial action will the nurse take next to
most effectively revise the plan of care?
a. Consult physical therapy.
b. Establish a new plan of care.
c. Set new priorities for the patient.
d. Assess the patient.
Give this one a try later!
