NRSG 2220-Exam 1 (Mod 1-5) Questions
and Answers
Question 1
When performing an abdominal assessment, the nurse uses a different order of
techniques than with other systems. Which of the following represents this order?
Correct Answer
In an abdominal assessment, start with inspection, then auscultation, percussion,
and palpation. This is the preferred approach because palpation and percussion
before auscultation may alter the sounds heard.
Question 2
BP Cuff Size
Correct Answer
Bladder width should be 40% of circumference of arm.
Bladder length should enclose 2/3 of the upper arm
Question 3
Surface Temperature can be found at:
Correct Answer
Oral, axillary, forehead
Page 1 of 57
,Question 4
What tools do I use to assess pain? (4)
Correct Answer
-Wong Baker: Faces Pain Rating Scale: Helpful with children, older adults, those who
can't read or have language barrier (based on smiley faces) Also has multiple
different languages. Also includes how much pain interferes with daily life
-0-10 Numeric Pain Distress scale: In addition to numbers, includes color (red-
yellow-green)
-Visual Analogue Scale: No numbers, continuous line from no pain to excruciating
pain. Given a pen/pencil to mark where their pain is and then reassess after
interventions. Not widely used
-Abbey pain scale: Used with patients who have dementia or cannot verbalize, filled
out by clinician who answers specific questions, assesses 6 aspects then added up
to a final score.
Question 5
How do I relieve pain? (2)
Correct Answer
Pharmacologic- analgesics OR non pharmacological
Question 6
Healthy hair=
(general survey)
Correct Answer
Healthy protein stores in body
Question 7
You should never diagnose hypertension with _____
Correct Answer
with a single BP reading. Must have 3 readings on different times and days
Page 2 of 57
,Question 8
COLD ERA
Correct Answer
C:haracter of the compaint
O:nset of the symptom
L:ocation of the complaint
D:uration of the problem
E:xacerbated by what?
R:elieved by what?
A:ssociated symptoms problem
Question 9
The nurse manager hears a nurse and a nurse aide talking about a female client who
reports pain of 8 out of 10 on a 1-10 after a Caesarean birth to deliver twins. The
nurse states, "I don't believe this client has any pain at all. I'm sure she is just drug
seeking." What is the appropriate nurse manager action?
Correct Answer
Research has shown that treatment bias may delay pain-relieving measures. The
nurse manager should privately and professionally educate the nurse, and then
subsequently educate the nurse aide. Addressing the concern quickly is important
so the client can receive appropriate care and pain management. Entering the
conversation is not the best action to educate the nurse and disciplinary action
doesn't help to immediately address the current situation.
Question 10
C-Diff
Correct Answer
Spore
Protective outer shield that protects from cleaning and germicides.
Easily spread, can survive for long periods of time on fomites (bedside tables)
Page 3 of 57
, Question 11
Auscultatory gap
Correct Answer
Seen in hypertension and other cardiac illness pt's
Question 12
What are some nonpharmacologic pain relief measures?
Correct Answer
Distraction, music, humor, imagery, relaxation, cutaneous stimulation, therapeutic
touch
Question 13
Normal respiration count
Correct Answer
12-20 breaths/minutes
Question 14
Temperature documentation
Correct Answer
Document # and the route, if route isn't document its assumed its oral
Question 15
Percussion relative sounds
Correct Answer
Loudest over air, moderate over fluid, and soft sound over solid structures
Page 4 of 57
and Answers
Question 1
When performing an abdominal assessment, the nurse uses a different order of
techniques than with other systems. Which of the following represents this order?
Correct Answer
In an abdominal assessment, start with inspection, then auscultation, percussion,
and palpation. This is the preferred approach because palpation and percussion
before auscultation may alter the sounds heard.
Question 2
BP Cuff Size
Correct Answer
Bladder width should be 40% of circumference of arm.
Bladder length should enclose 2/3 of the upper arm
Question 3
Surface Temperature can be found at:
Correct Answer
Oral, axillary, forehead
Page 1 of 57
,Question 4
What tools do I use to assess pain? (4)
Correct Answer
-Wong Baker: Faces Pain Rating Scale: Helpful with children, older adults, those who
can't read or have language barrier (based on smiley faces) Also has multiple
different languages. Also includes how much pain interferes with daily life
-0-10 Numeric Pain Distress scale: In addition to numbers, includes color (red-
yellow-green)
-Visual Analogue Scale: No numbers, continuous line from no pain to excruciating
pain. Given a pen/pencil to mark where their pain is and then reassess after
interventions. Not widely used
-Abbey pain scale: Used with patients who have dementia or cannot verbalize, filled
out by clinician who answers specific questions, assesses 6 aspects then added up
to a final score.
Question 5
How do I relieve pain? (2)
Correct Answer
Pharmacologic- analgesics OR non pharmacological
Question 6
Healthy hair=
(general survey)
Correct Answer
Healthy protein stores in body
Question 7
You should never diagnose hypertension with _____
Correct Answer
with a single BP reading. Must have 3 readings on different times and days
Page 2 of 57
,Question 8
COLD ERA
Correct Answer
C:haracter of the compaint
O:nset of the symptom
L:ocation of the complaint
D:uration of the problem
E:xacerbated by what?
R:elieved by what?
A:ssociated symptoms problem
Question 9
The nurse manager hears a nurse and a nurse aide talking about a female client who
reports pain of 8 out of 10 on a 1-10 after a Caesarean birth to deliver twins. The
nurse states, "I don't believe this client has any pain at all. I'm sure she is just drug
seeking." What is the appropriate nurse manager action?
Correct Answer
Research has shown that treatment bias may delay pain-relieving measures. The
nurse manager should privately and professionally educate the nurse, and then
subsequently educate the nurse aide. Addressing the concern quickly is important
so the client can receive appropriate care and pain management. Entering the
conversation is not the best action to educate the nurse and disciplinary action
doesn't help to immediately address the current situation.
Question 10
C-Diff
Correct Answer
Spore
Protective outer shield that protects from cleaning and germicides.
Easily spread, can survive for long periods of time on fomites (bedside tables)
Page 3 of 57
, Question 11
Auscultatory gap
Correct Answer
Seen in hypertension and other cardiac illness pt's
Question 12
What are some nonpharmacologic pain relief measures?
Correct Answer
Distraction, music, humor, imagery, relaxation, cutaneous stimulation, therapeutic
touch
Question 13
Normal respiration count
Correct Answer
12-20 breaths/minutes
Question 14
Temperature documentation
Correct Answer
Document # and the route, if route isn't document its assumed its oral
Question 15
Percussion relative sounds
Correct Answer
Loudest over air, moderate over fluid, and soft sound over solid structures
Page 4 of 57
