NUR 101 REVIEWED EXAM QUESTIONS AND ANSWERS

NUR 101 REVIEWED EXAM QUESTIONS AND ANSWERS A patient tells the nurse, Im having a lot of pain in my hip. Which response by the nurse is open-ended and would stimulate the patient to provide the most complete data? Choose all that are correct. 1) Is your pain severe? 2) Tell me about your pain. 3) When did you first notice this pain? 4) How would you describe your pain? - CORRECT ANSWER -ANS: 2) Tell me about your pain. 4) How would you describe your pain? The responses Tell me about your pain and How would you describe your pain? are open-ended responses that stimulate conversation. Although it is important information, the question Is your pain severe? prompts a yes or no response. When did you first notice this pain?also important informationis likely to stimulate a brief, factual answer. Such questions allow the nurse to control the patients response. Limiting the response might lead to an incomplete assessment. A clients vital signs at the beginning of the shift are as follows: oral temperature 99.3F (37C), heart rate 82 beats/min, respiratory rate 14 breaths/min, and blood pressure 118/76 mm Hg. Four hours later the clients oral temperature is 102.2F (39C). Based on the temperature change, the nurse should anticipate the clients heart rate would be how many beats/min? 1) 62 2) 82 3) 102 4) 122 - CORRECT ANSWER -ANS: 3) 102 Heart rate increases about 10 beats per minute for each degree of temperature to meet increased metabolic needs and compensate for peripheral dilation. The nurse is assessing vital signs for a client after surgical procedure on the left leg. IV fluids are infusing. It would be most important for the nurse to 1) Compare the left pedal pulse with the right pedal pulse 2) Count the clients respiratory rate for 1 full minute 3) Take the blood pressure in the arm without an IV 4) Take an oral temperature with an electronic thermometer - CORRECT ANSWER -ANS: 1) Compare the left pedal pulse with the right pedal pulse For a client having surgery on the leg, the most important data would be whether the circulation has been compromised because of the surgery. This can be done only by comparing one leg with the other. The nurse would, of course, count the respiratory rate for 1 full minute and take the BP in the arm without the IV. Oral temperatures are commonly obtained using electronic thermometers. The nurse hears rhonchi when auscultating a clients lungs. Which nursing intervention would be appropriate for the nurse to implement before reassessing lung sounds? 1) Have the client take several deep breaths. 2) Request the client take a deep breath and cough. 3) Take the clients blood pressure and apical pulse. 4) Count the clients respiratory rate for 1 minute. - CORRECT ANSWER -ANS: 2) Request the client take a deep breath and cough. Rhonchi are caused by secretions in the large airways and may clear with coughing. This is how you differentiate between rhonchi and other adventitious sounds. Deep breathing will not help to clear rhonchi. Taking the blood pressure and apical pulse and counting the respiratory rate are not effective