EXAM 1 NURS-108 QUESTIONS WITH ACCURATE
ANSWERS
1st step in nursing process is called? correct answer Assess, involves gathering
info about pts condition
3rd step in the nursing process is called? correct answer Plan, setting goals and
outcomes, while identifying appropriate nursing actions and predicted outcomes.
A female client came in with a creatinine value of 1.2 mg/dL. Is this range normal?
Would it be different if she was a male? correct answer No. Its not.
It would change if it was a male, the male upper end is 1.2 mg/dL.
ABCDE of lesions correct answer A = asymmetry
B = border irregularity
C = color variation
D = diameter >6mm
E = evolution over time
ABCDE Pain Assessment correct answer - Ask about pain regularly & assess for it
systematically
- Believe reports of pain and what relieves it
- Choose pain control individualized to the pt and setting
- Deliver interventions in a timely, logical and coordinated fashion
- Empower pts & enable them to control as much as possible
,Acceptable ranges of heart rate correct answer Infant: 120-160
Toddler: 90-140
Preschooler: 80-110
School-age child: 75-100
Adolescent: 60-90
Adult: 60-100
Acceptable ranges of respiratory rate correct answer Adolescent 16-20
Adult 12-20
Newborn 30-60
Infant 30-50
Toddler 25-32
Child 20-30
Accurately record vital signs correct answer BP: 120/80 P: 76 R: 12 T: 98.6
Activated PTT (APTT) correct answer 30-40 seconds
An irrregular pulse rhythm is defined as: correct answer dysrhythmia
ANA is used for? correct answer Nurses Standards of Practice.
Anticipate & Prevent Complications correct answer 1. Identify risks to the patient.
2. Adapt interventions to the situation.
,3. Evaluate the relative benefit of a treatment vs. the risk.
4. Initiate risk prevention measures.
*look at benefit v. risk
*be aware for risk prevention
apnea vs dyspnea correct answer apnea = temporary cessation of respiration
dyspnea = gasping or labored breathing
Approach of Nursing Assessments correct answer .Conducting a comprehensive
assessment that is problem-oriented.
Conducting an assessment that is comprehensive
using a structured database.
Appropriately delegate measurement of vital signs to nursing assistant personnel
correct answer You can delegate TPR with stable pts.
As a nurse what ways can you reduce a fever? correct answer Aspirin or
acetaminophen; use abx if bacterial infection
Nonpharmacologic
Cooling blankets
Cool sponge baths - Cool packs are NOT used since they shivering increased heat
Auscultate correct answer To listen to sounds within an organ with a stethoscope.
back channeling correct answer includes active listening prompts such as "all
right", "go on", or ""uh-huh".
, basal cell carcinoma correct answer Most common and least severe type of skin
cancer; often characterized by light or pearly nodules.
.5-1 cm crusty lesions that is flat and raised with widely dilated blood vessels
within the lesion
Body temperature is defined as: correct answer Heat produced - heat lost = body
temperature
Acceptable temperature range
98.6° F to 100.4° F or 36° C to 38° C
Bradypnea can be caused by correct answer Decreased cardiac output
Ineffective peripheral tissue perfusion
Fluid volume deficit
BUN normal range correct answer 10-20 mg/dL
caring touch correct answer a form of nonverbal communication; holding a
patient's hand, giving a back massage, etc.
Chloride normal range correct answer 98-106 mEq/L
Classify the patients problems in three priority levels: correct answer High Priority
- immediate threat
Intermediate - nonlife-threatening
Low Priority - actual or potential problems not related to pt illness or disease.
ANSWERS
1st step in nursing process is called? correct answer Assess, involves gathering
info about pts condition
3rd step in the nursing process is called? correct answer Plan, setting goals and
outcomes, while identifying appropriate nursing actions and predicted outcomes.
A female client came in with a creatinine value of 1.2 mg/dL. Is this range normal?
Would it be different if she was a male? correct answer No. Its not.
It would change if it was a male, the male upper end is 1.2 mg/dL.
ABCDE of lesions correct answer A = asymmetry
B = border irregularity
C = color variation
D = diameter >6mm
E = evolution over time
ABCDE Pain Assessment correct answer - Ask about pain regularly & assess for it
systematically
- Believe reports of pain and what relieves it
- Choose pain control individualized to the pt and setting
- Deliver interventions in a timely, logical and coordinated fashion
- Empower pts & enable them to control as much as possible
,Acceptable ranges of heart rate correct answer Infant: 120-160
Toddler: 90-140
Preschooler: 80-110
School-age child: 75-100
Adolescent: 60-90
Adult: 60-100
Acceptable ranges of respiratory rate correct answer Adolescent 16-20
Adult 12-20
Newborn 30-60
Infant 30-50
Toddler 25-32
Child 20-30
Accurately record vital signs correct answer BP: 120/80 P: 76 R: 12 T: 98.6
Activated PTT (APTT) correct answer 30-40 seconds
An irrregular pulse rhythm is defined as: correct answer dysrhythmia
ANA is used for? correct answer Nurses Standards of Practice.
Anticipate & Prevent Complications correct answer 1. Identify risks to the patient.
2. Adapt interventions to the situation.
,3. Evaluate the relative benefit of a treatment vs. the risk.
4. Initiate risk prevention measures.
*look at benefit v. risk
*be aware for risk prevention
apnea vs dyspnea correct answer apnea = temporary cessation of respiration
dyspnea = gasping or labored breathing
Approach of Nursing Assessments correct answer .Conducting a comprehensive
assessment that is problem-oriented.
Conducting an assessment that is comprehensive
using a structured database.
Appropriately delegate measurement of vital signs to nursing assistant personnel
correct answer You can delegate TPR with stable pts.
As a nurse what ways can you reduce a fever? correct answer Aspirin or
acetaminophen; use abx if bacterial infection
Nonpharmacologic
Cooling blankets
Cool sponge baths - Cool packs are NOT used since they shivering increased heat
Auscultate correct answer To listen to sounds within an organ with a stethoscope.
back channeling correct answer includes active listening prompts such as "all
right", "go on", or ""uh-huh".
, basal cell carcinoma correct answer Most common and least severe type of skin
cancer; often characterized by light or pearly nodules.
.5-1 cm crusty lesions that is flat and raised with widely dilated blood vessels
within the lesion
Body temperature is defined as: correct answer Heat produced - heat lost = body
temperature
Acceptable temperature range
98.6° F to 100.4° F or 36° C to 38° C
Bradypnea can be caused by correct answer Decreased cardiac output
Ineffective peripheral tissue perfusion
Fluid volume deficit
BUN normal range correct answer 10-20 mg/dL
caring touch correct answer a form of nonverbal communication; holding a
patient's hand, giving a back massage, etc.
Chloride normal range correct answer 98-106 mEq/L
Classify the patients problems in three priority levels: correct answer High Priority
- immediate threat
Intermediate - nonlife-threatening
Low Priority - actual or potential problems not related to pt illness or disease.
