NURS 125 Final
A patient on a medical- surgical floor reports having shortness of breath. The nurse needs to conduct
which type of assessment? - ANS A problem-based/focused assessment
For which patient is a shift assessment indicated? - ANS The person who had abdominal surgery
yesterday
K
Which of the following examples represents a secondary prevention level of health promotion? - ANS
Blood pressure screenings
C
Which of the following is an example of objective data? - ANS Vomiting
LO
A nurse suspects a patient is a victim of physical abuse. Which response by the nurse will most likely
encourage the patient to confide in the nurse? - ANS "I've seen people who have been hurt by their
significant others. Do you feel safe in your home?"
A patient answers questions quietly and appears sad. While answering questions about her marriage, she
YC
begins to cry. Which response by the nurse is appropriate in this situation? - ANS "I see that you are
upset. Is there something you'd like to discuss?"
A nurse is interviewing a patient. Which of the following questions is an open-ended question? - ANS
Can you tell me how you have been feeling?
D
When interviewing a patient to obtain a health history, asking if the patient has "dypsnea" can fall into
which of the following systems? - ANS Respiratory and Cardiovascular
U
A nurse asks a patient to rate their pain on a scale of "0-10". This is which part of the mnemonic for
symptom analysis of "OLD CARTS"? - ANS Severity
ST
When examining a patient, the nurse remembers to follow which principle of Standard Precautions? -
ANS Wear gloves when in contact with the patient's blood or other body fluids.
Which of the following is a correct statement regarding the technique LIGHT palpation? Light palpation
is - ANS Used to assess tenderness
The nurse is unable to hear the patient's breath sounds. To determine the cause of this problem the nurse
needs to ensure that the - ANS valve is open to the diaphragm on the head of the stethoscope.
, A nurse is preparing to take a patient's blood pressure. The blood pressure cuff is too narrow (small). How
accurate will this patient's blood pressure be using this blood pressure cuff? - ANS Higher than the
actual value
Where does the nurse attach the sensor probe of the pulse oximeter to measure a patient's oxygen
saturation? - ANS Around the patient's index fingernail
During a physical assessment of an elderly adult, the nurse has difficulty palpating the patient's dorsalis
pedis pulses. Which piece of equipment would be helpful during this assessment? - ANS Doppler
K
A patient on a cardiac floor is complaining of chest pain. The nurse needs to conduct which type of
assessment? - ANS A problem-based focused assessment
C
An example of Primary prevention of Health Promotion is: - ANS Immunizations
Which of the following is an example of subjective (symptoms) data? - ANS Headache
LO
Which of the following is one of the goals of Healthy People 2020? - ANS To promote quality of life &
healthy behaviors across all life stages
During a mental health assessment, a women begins to cry when the nurse asks about her marriage.
YC
Which action by the nurse is most therapeutic? - ANS " I see that you're upset. Can you discuss why
you're feeling this way?"
While collecting data on a patient, the nurse obtains vital signs. This is done PRIMARILY to - ANS
obtain baseline indicators of the patient's health status.
D
A nurse is about to take a patient's temperature. The patient has just finished a cup of hot coffee. The
nurse should : - ANS wait 10 minutes, then take the temperature.
U
To position an adult's ear correctly for a tympanic membrane temperature, the nurse should - ANS tug
the ear's helix in an upward direction.
ST
A nurse assesses an irregular pulse while counting for 15 seconds. What is the most appropriate action for
the nurse to take at this time? - ANS Count the patient's pulse for a full minute.
A nurse takes a patient's pulse. The nurse documents "80 beats per minute and regular"-
What does the "regular" refer to? - ANS Rhythm
A nurse is taking vital signs of an adult patient whose oxygen saturation is 96%. The patient's temperature
is 102 F, blood pressure is 120/77 pulse is 90 beats/min, and respiratory rate is 26 breaths/min. Which
factor may be contributing to the elevated respiratory rate? - ANS Temperature
Which actions by the nurse results in the patient's blood pressure measurement being falsely high?
A patient on a medical- surgical floor reports having shortness of breath. The nurse needs to conduct
which type of assessment? - ANS A problem-based/focused assessment
For which patient is a shift assessment indicated? - ANS The person who had abdominal surgery
yesterday
K
Which of the following examples represents a secondary prevention level of health promotion? - ANS
Blood pressure screenings
C
Which of the following is an example of objective data? - ANS Vomiting
LO
A nurse suspects a patient is a victim of physical abuse. Which response by the nurse will most likely
encourage the patient to confide in the nurse? - ANS "I've seen people who have been hurt by their
significant others. Do you feel safe in your home?"
A patient answers questions quietly and appears sad. While answering questions about her marriage, she
YC
begins to cry. Which response by the nurse is appropriate in this situation? - ANS "I see that you are
upset. Is there something you'd like to discuss?"
A nurse is interviewing a patient. Which of the following questions is an open-ended question? - ANS
Can you tell me how you have been feeling?
D
When interviewing a patient to obtain a health history, asking if the patient has "dypsnea" can fall into
which of the following systems? - ANS Respiratory and Cardiovascular
U
A nurse asks a patient to rate their pain on a scale of "0-10". This is which part of the mnemonic for
symptom analysis of "OLD CARTS"? - ANS Severity
ST
When examining a patient, the nurse remembers to follow which principle of Standard Precautions? -
ANS Wear gloves when in contact with the patient's blood or other body fluids.
Which of the following is a correct statement regarding the technique LIGHT palpation? Light palpation
is - ANS Used to assess tenderness
The nurse is unable to hear the patient's breath sounds. To determine the cause of this problem the nurse
needs to ensure that the - ANS valve is open to the diaphragm on the head of the stethoscope.
, A nurse is preparing to take a patient's blood pressure. The blood pressure cuff is too narrow (small). How
accurate will this patient's blood pressure be using this blood pressure cuff? - ANS Higher than the
actual value
Where does the nurse attach the sensor probe of the pulse oximeter to measure a patient's oxygen
saturation? - ANS Around the patient's index fingernail
During a physical assessment of an elderly adult, the nurse has difficulty palpating the patient's dorsalis
pedis pulses. Which piece of equipment would be helpful during this assessment? - ANS Doppler
K
A patient on a cardiac floor is complaining of chest pain. The nurse needs to conduct which type of
assessment? - ANS A problem-based focused assessment
C
An example of Primary prevention of Health Promotion is: - ANS Immunizations
Which of the following is an example of subjective (symptoms) data? - ANS Headache
LO
Which of the following is one of the goals of Healthy People 2020? - ANS To promote quality of life &
healthy behaviors across all life stages
During a mental health assessment, a women begins to cry when the nurse asks about her marriage.
YC
Which action by the nurse is most therapeutic? - ANS " I see that you're upset. Can you discuss why
you're feeling this way?"
While collecting data on a patient, the nurse obtains vital signs. This is done PRIMARILY to - ANS
obtain baseline indicators of the patient's health status.
D
A nurse is about to take a patient's temperature. The patient has just finished a cup of hot coffee. The
nurse should : - ANS wait 10 minutes, then take the temperature.
U
To position an adult's ear correctly for a tympanic membrane temperature, the nurse should - ANS tug
the ear's helix in an upward direction.
ST
A nurse assesses an irregular pulse while counting for 15 seconds. What is the most appropriate action for
the nurse to take at this time? - ANS Count the patient's pulse for a full minute.
A nurse takes a patient's pulse. The nurse documents "80 beats per minute and regular"-
What does the "regular" refer to? - ANS Rhythm
A nurse is taking vital signs of an adult patient whose oxygen saturation is 96%. The patient's temperature
is 102 F, blood pressure is 120/77 pulse is 90 beats/min, and respiratory rate is 26 breaths/min. Which
factor may be contributing to the elevated respiratory rate? - ANS Temperature
Which actions by the nurse results in the patient's blood pressure measurement being falsely high?
