NURSING 108 MAIN EXAMS SET QUESTIONS AND
ANSWERS SURE A+
✔✔A registered nurse is assessing a patient with decreased respirations, cool skin, and
decreased muscle coordination. Which action made by the nurse supports the nurse's
diagnosis of hypothermia?
1. The nurse asks the patient about feeling feverish.
2. The nurse requests lab work to check the patient's iron levels.
3. The nurse checks the patient's urinary output, which is increased.
4. The nurse takes the patient's blood pressure, which shows hypotension. - ✔✔-The
nurse takes the patient's blood pressure, which shows hypotension.
✔✔A student nurse is describing the process of taking a patient's temperature to the
charge nurse. Which statement made by the student nurse indicates teaching has been
effective?
1. "I must determine the patient's baseline temperature."
2. "I will be alert to evaluate emotional changes in the patient."
3. "Patients usually cannot maintain normal body temperature."
4. "It does not matter whether the patient has taken medication." - ✔✔-"I must
determine the patient's baseline temperature."
✔✔A patient admitted to the hospital has been exposed to below-freezing temperatures
while attempting to engage in sports in extreme weather conditions. During assessment,
the nurse observes the patient is shivering and learns that the patient was not wearing
adequate clothing. The patient has a weak pulse, rapid heart rate and is slightly
delirious. What is the most appropriate nursing diagnosis for this patient?
1. Hyperthermia related to extreme physical activity, as evidenced by delirium.
2. Ineffective Thermoregulation, as evidenced by inability to complete physical
performance in below-freezing temperatures.
,3. Imbalanced Body Temperature with the risk factor of trauma to the body, as
evidenced by shivering due to exposure to below-freezing temperatures.
4. Hypothermia related to exposure to below-freezing temperature without adequate
clothing, as evidenced by a weak pulse and rapid heart rate. - ✔✔- Hypothermia related
to exposure to below-freezing temperature without adequate clothing, as evidenced by
a weak pulse and rapid heart rate.
✔✔Which statement made by the nurse shows an understanding of objective and
subjective data?
1. "Objective data is gathered through observation."
2. "Objective data is gathered through the patient."
3. "Subjective data is gathered from the patient."
4. "Subjective data is gathered through observation."
5. "Subjective data is gathered from the patient's relatives." - ✔✔-"Objective data is
gathered through observation."
-"Subjective data is gathered from the patient."
-"Subjective data is gathered from the patient's relatives."
✔✔The nurse assesses a patient who was admitted to the emergency department with
a core body temperature of 93.2 degrees F, after being exposed to freezing
temperatures for a long period of time. The nurse feels the patient's skin and documents
that it is cool to the touch. Which actions should the nurse take to confirm a nursing
diagnosis of hypothermia?
1. Check the patient's pulse
2. Observe the patient for shivering
3. Measure the patient's blood pressure
4. Notice whether the patient is very thirsty
5. Request a blood draw to check the patient's RBC count - ✔✔-Check the patient's
pulse
-Observe the patient for shivering
-Measure the patient's blood pressure
✔✔The nurse is taking care of a patient with a cervical spinal cord injury. The patient is
a quadriplegic with a C5 fracture. The patient is sweating profusely and is afebrile with a
temperature of 37 degrees Celsius. What does the nurse know about spinal cord
injuries and thermoregulation?
1. Patients with spinal cord injuries always have a normal body temperature.
2. Spinal cord injuries do not affect the ability of the brain to regulate sweating.
3. Disease or trauma to the brain or spinal cord can cause alterations in temperature
control.
4. Quadriplegics cannot change their circumstances to adjust their temperatures due to
motor limitations.
, 5. Patients with spinal cord injury can feel cold, even though their core temperature may
be normal. - ✔✔-Disease or trauma to the brain or spinal cord can cause alterations in
temperature control.
-Quadriplegics cannot change their circumstances to adjust their temperatures due to
motor limitations.
-Patients with spinal cord injury can feel cold, even though their core temperature may
be normal.
✔✔The nurse is educating a student nurse about appropriate sites to assess
temperature. Which statement made by the student nurse indicates the need for further
teaching?
1. "Rectal temperature readings are contraindicated for infant patients."
2. "I can get an accurate tympanic temperature reading on an unconscious patient."
3. "A patient who uses an oxygen mask may have an inaccurate temperature
measurement if taken by mouth."
4. "I can get an accurate temperature reading by placing the thermometer to the right of
the patient's axilla." - ✔✔"I can get an accurate temperature reading by placing the
thermometer to the right of the patient's axilla."
✔✔The nurse is teaching a class on appropriate temperature assessment questions.
Which statement made by the student nurse shows that the teaching has been
effective?
1. "I will ask the patient if he has been sleeping well."
2. "I will ask the patient if he has a family history of fevers."
3. "I will ask the patient if she has exercised within the last 24 hours."
4. "I will ask the patient if she remembers the last time she had a fever." - ✔✔-"I will ask
the patient if he has been sleeping well."
✔✔Which statement shows the proper relationship between a patient's condition and
temperature site selection?
1. "Because the patient has a low white blood cell count, she will not receive a rectal
temperature measurement."
2. "Because the pediatric patient is slightly perspiring, temperature measurement by the
temporal artery on the forehead will be contraindicated."
3. "The older adult patient has been sipping on water due to dehydration, but an
accurate oral temperature reading is still possible."
4. "The unconscious patient will benefit the most from temperature readings taken via
the oral route." - ✔✔-"Because the patient has a low white blood cell count, she will not
receive a rectal temperature measurement."
✔✔The student nurse discusses goals for thermoregulation with a patient. Which
statement made by the patient shows proper understanding of treatment outcomes?
ANSWERS SURE A+
✔✔A registered nurse is assessing a patient with decreased respirations, cool skin, and
decreased muscle coordination. Which action made by the nurse supports the nurse's
diagnosis of hypothermia?
1. The nurse asks the patient about feeling feverish.
2. The nurse requests lab work to check the patient's iron levels.
3. The nurse checks the patient's urinary output, which is increased.
4. The nurse takes the patient's blood pressure, which shows hypotension. - ✔✔-The
nurse takes the patient's blood pressure, which shows hypotension.
✔✔A student nurse is describing the process of taking a patient's temperature to the
charge nurse. Which statement made by the student nurse indicates teaching has been
effective?
1. "I must determine the patient's baseline temperature."
2. "I will be alert to evaluate emotional changes in the patient."
3. "Patients usually cannot maintain normal body temperature."
4. "It does not matter whether the patient has taken medication." - ✔✔-"I must
determine the patient's baseline temperature."
✔✔A patient admitted to the hospital has been exposed to below-freezing temperatures
while attempting to engage in sports in extreme weather conditions. During assessment,
the nurse observes the patient is shivering and learns that the patient was not wearing
adequate clothing. The patient has a weak pulse, rapid heart rate and is slightly
delirious. What is the most appropriate nursing diagnosis for this patient?
1. Hyperthermia related to extreme physical activity, as evidenced by delirium.
2. Ineffective Thermoregulation, as evidenced by inability to complete physical
performance in below-freezing temperatures.
,3. Imbalanced Body Temperature with the risk factor of trauma to the body, as
evidenced by shivering due to exposure to below-freezing temperatures.
4. Hypothermia related to exposure to below-freezing temperature without adequate
clothing, as evidenced by a weak pulse and rapid heart rate. - ✔✔- Hypothermia related
to exposure to below-freezing temperature without adequate clothing, as evidenced by
a weak pulse and rapid heart rate.
✔✔Which statement made by the nurse shows an understanding of objective and
subjective data?
1. "Objective data is gathered through observation."
2. "Objective data is gathered through the patient."
3. "Subjective data is gathered from the patient."
4. "Subjective data is gathered through observation."
5. "Subjective data is gathered from the patient's relatives." - ✔✔-"Objective data is
gathered through observation."
-"Subjective data is gathered from the patient."
-"Subjective data is gathered from the patient's relatives."
✔✔The nurse assesses a patient who was admitted to the emergency department with
a core body temperature of 93.2 degrees F, after being exposed to freezing
temperatures for a long period of time. The nurse feels the patient's skin and documents
that it is cool to the touch. Which actions should the nurse take to confirm a nursing
diagnosis of hypothermia?
1. Check the patient's pulse
2. Observe the patient for shivering
3. Measure the patient's blood pressure
4. Notice whether the patient is very thirsty
5. Request a blood draw to check the patient's RBC count - ✔✔-Check the patient's
pulse
-Observe the patient for shivering
-Measure the patient's blood pressure
✔✔The nurse is taking care of a patient with a cervical spinal cord injury. The patient is
a quadriplegic with a C5 fracture. The patient is sweating profusely and is afebrile with a
temperature of 37 degrees Celsius. What does the nurse know about spinal cord
injuries and thermoregulation?
1. Patients with spinal cord injuries always have a normal body temperature.
2. Spinal cord injuries do not affect the ability of the brain to regulate sweating.
3. Disease or trauma to the brain or spinal cord can cause alterations in temperature
control.
4. Quadriplegics cannot change their circumstances to adjust their temperatures due to
motor limitations.
, 5. Patients with spinal cord injury can feel cold, even though their core temperature may
be normal. - ✔✔-Disease or trauma to the brain or spinal cord can cause alterations in
temperature control.
-Quadriplegics cannot change their circumstances to adjust their temperatures due to
motor limitations.
-Patients with spinal cord injury can feel cold, even though their core temperature may
be normal.
✔✔The nurse is educating a student nurse about appropriate sites to assess
temperature. Which statement made by the student nurse indicates the need for further
teaching?
1. "Rectal temperature readings are contraindicated for infant patients."
2. "I can get an accurate tympanic temperature reading on an unconscious patient."
3. "A patient who uses an oxygen mask may have an inaccurate temperature
measurement if taken by mouth."
4. "I can get an accurate temperature reading by placing the thermometer to the right of
the patient's axilla." - ✔✔"I can get an accurate temperature reading by placing the
thermometer to the right of the patient's axilla."
✔✔The nurse is teaching a class on appropriate temperature assessment questions.
Which statement made by the student nurse shows that the teaching has been
effective?
1. "I will ask the patient if he has been sleeping well."
2. "I will ask the patient if he has a family history of fevers."
3. "I will ask the patient if she has exercised within the last 24 hours."
4. "I will ask the patient if she remembers the last time she had a fever." - ✔✔-"I will ask
the patient if he has been sleeping well."
✔✔Which statement shows the proper relationship between a patient's condition and
temperature site selection?
1. "Because the patient has a low white blood cell count, she will not receive a rectal
temperature measurement."
2. "Because the pediatric patient is slightly perspiring, temperature measurement by the
temporal artery on the forehead will be contraindicated."
3. "The older adult patient has been sipping on water due to dehydration, but an
accurate oral temperature reading is still possible."
4. "The unconscious patient will benefit the most from temperature readings taken via
the oral route." - ✔✔-"Because the patient has a low white blood cell count, she will not
receive a rectal temperature measurement."
✔✔The student nurse discusses goals for thermoregulation with a patient. Which
statement made by the patient shows proper understanding of treatment outcomes?
