NUR 134 Final Exam Review
1. A 35 year old patient who is 4 days post hysterectomy days to the nurse "I wonder if
after all this surgery, I will still feel like a woman?" Which of the following responses
would most likely encourage the patient to expand on this and express her concern in
more specific terms?
A. "When did you begin to wonder about this?"
B. "Do you want more children?"
C. "Feel like a woman..."
D. Remaining Silent - ANS C
The nurse is paraphrasing what was said in their own words to make sure information
has been accurately received. It allows the patient the opportunity to continue to discuss
what they are really thinking.
\10. In the situation listed above which of the following is the best explanation for this
blood pressure reading? (Refer to question 8)
A. I the nurse was probably using equipment that was not functioning properly
B. The nurse noted an Auscultatory gap and a definite 4th diastolic sound
C. The nurse is unable to accurately take a blood pressure reading
D. The patient had most likely been exercising just prior to obtaining the blood pressure
reading - ANS B
An auscultatory gap can occur when sound completely disappears then returns at a
lower level the true systolic blood pressure is the higher reading the fourth diastolic
sound is the distinct muffling of sound
\11. You are assigned to care for a 77-year-old in a long-term care facility. When you enter
his room to take his vital signs you note that the fan is on high speed and blowing
directly over him. He is perspiring and the bed linens are damp. What type of value would
you expect to find when you take his temperature?
A. A temperature lower than 97
B. A temperature that has remain elevated for several hours
C. A normal 98.6° temperature
D. And elevated value but one slightly lower than an earlier value - ANS D
The body is trying to lower the body temperature by evaporation which would cause the
perspiration
\12. When obtaining a blood pressure measurement, the most appropriate nursing action
is to:
,A. Obtain the proper equipment place the patient in a comfortable position and record the
appropriate information in the patient's chart
B. Measure the patients arm if you are uncertain of the size of the cuff to use
C. Have the patient recline or sit comfortably in a chair with the forearm at the level of the
heart
D. Document the measurement which extremity was used and the position the patient
was in during the measurement - ANS A
Since the question ass which action is most appropriate when obtaining a blood
pressure this answer is correct it is the most complete of the four answers
\13. The oral route for taking a temperature is most appropriate for which of the following
patients?
A. And alert and cooperative school age child
B. A two-year-old child in good health
C. A confused adult
D. A comatose teenager - ANS A
If the patient is alert and cooperative and able to follow directions in oral site is
appropriate
\14. The nurse checks a postoperative patients early morning vital signs and notes a
radio pulse rate of 100 bpm, regular rhythm. The patient is lying in bed and has not been
out of bed all night. An answer of "yes" by the patient to which of the following questions
asked by the nurse would account for this pulse rate?
A. Are you experiencing pain now?
B. Have you received medication for your temperature this morning?
C. Have you had anything cold to drink in the last 20 minutes?
D. Did you just wake up from a sleep? - ANS A
Acute pain can cause sympathetic nervous system activation, which releases
epinephrine, which can elevate pulse rate. Remember that chronic pain is regulated by
the non-sympathetic nervous system, therefore the pulse rate will not be elevated.
\15.
The patient had a bowel resection this morning and returned from the operating room
four hours ago. His postoperative orders are that vital signs should be taken every 15
minutes for the first hour and then every hour for four hours. During the assessment the
nurse notes the patient's vital signs to be: temperature 97, pulse 120 and weak,
respirations 24, blood pressure 100/60. The most appropriate nursing intervention would
be:
A. Document the vital signs in the computer
B. Have the nursing assistant recheck the vital signs again in one hour
C. Have another nurse assessed vital signs at the next order time
D. Reassess the vital signs in five minutes and notify the physician of the changes - ANS
D
, The vital sign values indicate that there is a problem. The nurse would not want to wait
an hour before rechecking the vital signs. Notifying the physician is an appropriate
action.
\16. The nursing assistant working with a team of elderly residents in a long-term care
facility reports the following list of vital signs at 7:00 AM
Patient 1 T: 97.3; P 82; R 20
Patient 2 T 99.8; P 92; R 22
Patient 3 T 98; P 62; R 12
Which of the following will be the most appropriate nursing care measures indicated by
these vital signs?
A. Retake all vital signs to assure accuracy
B. Provide a warming blanket for patient one
C. Call the physician to obtain a medication for patient to use temperature and pulse and
report to abnormal pulse of patient three
D. Compare patient to use vital signs with the previous readings and recheck them in 30
to 60 minutes - ANS D
This patient has a slight elevation. We need to check previous readings to see if this has
increased or decreased. Rechecking within an hour would determine if the temperature is
increasing at which point measures for medication could be taken if needed
\17. A patient complains of severe abdominal pain. When assessing the vital signs, the
nurse would not be surprised to find:
A An increase in the pulse rate
B. A decrease in body temperature
C. A decrease in blood pressure
D. An increase in body temperature - ANS A
The pulse often increases when an individual is experiencing pain
\18. You take the patient's temperature and note a reading of 102.8° orally. Which of the
following would be the most important nursing action to include in the plan of care?
A. Cover the patient warmly and increase the environmental temperature in case he has a
chill.
B. Remove all of the patients covers, apply ice packs to the axillae and turn on the fan
C. Cover lightly and provide comfort measures. Encourage bed rest and high fluid intake.
D. Check the temperature every 15 minutes for the next hour and record changes. - ANS
C
Covering lightly will not produce chilling or overheating, that's maintaining the present
temperature. Bedrest reduces the body's metabolism, that's less heat is produced
\19. Which of the following statements would be most useful in the assessment of the
patients urinary elimination?
A. Do you void every hour?
1. A 35 year old patient who is 4 days post hysterectomy days to the nurse "I wonder if
after all this surgery, I will still feel like a woman?" Which of the following responses
would most likely encourage the patient to expand on this and express her concern in
more specific terms?
A. "When did you begin to wonder about this?"
B. "Do you want more children?"
C. "Feel like a woman..."
D. Remaining Silent - ANS C
The nurse is paraphrasing what was said in their own words to make sure information
has been accurately received. It allows the patient the opportunity to continue to discuss
what they are really thinking.
\10. In the situation listed above which of the following is the best explanation for this
blood pressure reading? (Refer to question 8)
A. I the nurse was probably using equipment that was not functioning properly
B. The nurse noted an Auscultatory gap and a definite 4th diastolic sound
C. The nurse is unable to accurately take a blood pressure reading
D. The patient had most likely been exercising just prior to obtaining the blood pressure
reading - ANS B
An auscultatory gap can occur when sound completely disappears then returns at a
lower level the true systolic blood pressure is the higher reading the fourth diastolic
sound is the distinct muffling of sound
\11. You are assigned to care for a 77-year-old in a long-term care facility. When you enter
his room to take his vital signs you note that the fan is on high speed and blowing
directly over him. He is perspiring and the bed linens are damp. What type of value would
you expect to find when you take his temperature?
A. A temperature lower than 97
B. A temperature that has remain elevated for several hours
C. A normal 98.6° temperature
D. And elevated value but one slightly lower than an earlier value - ANS D
The body is trying to lower the body temperature by evaporation which would cause the
perspiration
\12. When obtaining a blood pressure measurement, the most appropriate nursing action
is to:
,A. Obtain the proper equipment place the patient in a comfortable position and record the
appropriate information in the patient's chart
B. Measure the patients arm if you are uncertain of the size of the cuff to use
C. Have the patient recline or sit comfortably in a chair with the forearm at the level of the
heart
D. Document the measurement which extremity was used and the position the patient
was in during the measurement - ANS A
Since the question ass which action is most appropriate when obtaining a blood
pressure this answer is correct it is the most complete of the four answers
\13. The oral route for taking a temperature is most appropriate for which of the following
patients?
A. And alert and cooperative school age child
B. A two-year-old child in good health
C. A confused adult
D. A comatose teenager - ANS A
If the patient is alert and cooperative and able to follow directions in oral site is
appropriate
\14. The nurse checks a postoperative patients early morning vital signs and notes a
radio pulse rate of 100 bpm, regular rhythm. The patient is lying in bed and has not been
out of bed all night. An answer of "yes" by the patient to which of the following questions
asked by the nurse would account for this pulse rate?
A. Are you experiencing pain now?
B. Have you received medication for your temperature this morning?
C. Have you had anything cold to drink in the last 20 minutes?
D. Did you just wake up from a sleep? - ANS A
Acute pain can cause sympathetic nervous system activation, which releases
epinephrine, which can elevate pulse rate. Remember that chronic pain is regulated by
the non-sympathetic nervous system, therefore the pulse rate will not be elevated.
\15.
The patient had a bowel resection this morning and returned from the operating room
four hours ago. His postoperative orders are that vital signs should be taken every 15
minutes for the first hour and then every hour for four hours. During the assessment the
nurse notes the patient's vital signs to be: temperature 97, pulse 120 and weak,
respirations 24, blood pressure 100/60. The most appropriate nursing intervention would
be:
A. Document the vital signs in the computer
B. Have the nursing assistant recheck the vital signs again in one hour
C. Have another nurse assessed vital signs at the next order time
D. Reassess the vital signs in five minutes and notify the physician of the changes - ANS
D
, The vital sign values indicate that there is a problem. The nurse would not want to wait
an hour before rechecking the vital signs. Notifying the physician is an appropriate
action.
\16. The nursing assistant working with a team of elderly residents in a long-term care
facility reports the following list of vital signs at 7:00 AM
Patient 1 T: 97.3; P 82; R 20
Patient 2 T 99.8; P 92; R 22
Patient 3 T 98; P 62; R 12
Which of the following will be the most appropriate nursing care measures indicated by
these vital signs?
A. Retake all vital signs to assure accuracy
B. Provide a warming blanket for patient one
C. Call the physician to obtain a medication for patient to use temperature and pulse and
report to abnormal pulse of patient three
D. Compare patient to use vital signs with the previous readings and recheck them in 30
to 60 minutes - ANS D
This patient has a slight elevation. We need to check previous readings to see if this has
increased or decreased. Rechecking within an hour would determine if the temperature is
increasing at which point measures for medication could be taken if needed
\17. A patient complains of severe abdominal pain. When assessing the vital signs, the
nurse would not be surprised to find:
A An increase in the pulse rate
B. A decrease in body temperature
C. A decrease in blood pressure
D. An increase in body temperature - ANS A
The pulse often increases when an individual is experiencing pain
\18. You take the patient's temperature and note a reading of 102.8° orally. Which of the
following would be the most important nursing action to include in the plan of care?
A. Cover the patient warmly and increase the environmental temperature in case he has a
chill.
B. Remove all of the patients covers, apply ice packs to the axillae and turn on the fan
C. Cover lightly and provide comfort measures. Encourage bed rest and high fluid intake.
D. Check the temperature every 15 minutes for the next hour and record changes. - ANS
C
Covering lightly will not produce chilling or overheating, that's maintaining the present
temperature. Bedrest reduces the body's metabolism, that's less heat is produced
\19. Which of the following statements would be most useful in the assessment of the
patients urinary elimination?
A. Do you void every hour?
