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NUR 204
NUR 204/ NUR204 Exam 1 | Questions &
Answers| Grade A| 100% Correct (Verified
Solutions) (2025/ 2026 Update)
1. Which clinical patient scenario is associated with the most
critical need for the nurse to obtain vital signs?
a. Ambulating for the first time after surgery
b. Complaining of pressure in the chest
c. Completing ambulating 100 feet after a stroke
d. Complaining of hunger while NPO (nothing by mouth): B
Chest pressure is a classic sign of a heart attack, and vital signs
should be checked immediately. Vital signs may be monitored before,
during, or after activity, but this is not the most critical need. Unless the
vital signs have changed drastically, not having baseline values before
ambulation makes it hard to interpret vital signs after activity.
Hunger is not a critical indicator for the need for obtaining vital signs.
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NUR 204
2. The nurse understands that which statement is correct
regarding respiratory rates?
a. Infants have a lower respiratory rate than adults.
b. Healthy adults breathe between 12 and 20 times a minute.
c. A compensatory response to a fever is to breathe at a slower
rate.
d. An increase in intracranial pressure results in an increased
rate.: B
The normal respiratory rate for a healthy adult is 12 to 20 BPM. Infants
have a higher respiratory rate than adults. A fever increases the
metabolic rate and results in a higher rate. Intracranial pressure
decreases the respiratory rate
3. The nurse is caring for a patient who has a blood pressure of
184/110. An hour after administering an antihypertensive
medication, the nurse returns to recheck the blood pressure, only
to find the patient in the chair pale, sweaty, and feeling faint.
Which is the expected explanation for the nurse's observations?
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NUR 204
a. The blood pressure is 184/110; the medication has not had an
effect.
b. The blood pressure is 118/76; the sudden drop has caused the
signs.
c. The blood pressure is 174/96; the medication has made the
patient sick.
d. The blood pressure is 130/82; the symptoms are from another
cause.: B
The symptoms are indicative of a sudden drop in the blood pressure;
an alteration in dose or medication may be needed.
4. It is 6 a.m. and the unlicensed assistive personnel reports to
the nurse that the patient has a temperature of 96.7° F (35.9° C)
tympanic. Which factor explains this reading?
a. The patient's room is cold.
b. The patient was drinking cold water.
c. The patient is exhibiting a normal circadian rhythm.
d. The patient just completed a warm shower.: C
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NUR 204
Normal circadian rhythms cause a lower temperature in the early
morning and higher temperature in the late afternoon. A cool room
would initially cause compensatory mechanisms such as shivering and
a feeling of being cold. Cold water could affect temperature if an oral
thermometer was used. A warm shower would not cause a decrease in
temperature unless there was a delay in drying the skin and dressing
5. The nurse notes that the patient has an irregular pulse. What
action does the nurse take first?
a. Obtain the patient's blood pressure.
b. Ask another nurse to take the pulse.
c. Assess the pulse for a full minute.
d. Finish the rest of the vital signs: C
Assessing the pulse for a full minute is needed for an accurate count—
counting the pulse for a fraction of a minute and then multiplying the
value to equal a minute count will give an inaccurate count if the pulse
is irregular. The other actions are not needed.
NUR 204
NUR 204
NUR 204/ NUR204 Exam 1 | Questions &
Answers| Grade A| 100% Correct (Verified
Solutions) (2025/ 2026 Update)
1. Which clinical patient scenario is associated with the most
critical need for the nurse to obtain vital signs?
a. Ambulating for the first time after surgery
b. Complaining of pressure in the chest
c. Completing ambulating 100 feet after a stroke
d. Complaining of hunger while NPO (nothing by mouth): B
Chest pressure is a classic sign of a heart attack, and vital signs
should be checked immediately. Vital signs may be monitored before,
during, or after activity, but this is not the most critical need. Unless the
vital signs have changed drastically, not having baseline values before
ambulation makes it hard to interpret vital signs after activity.
Hunger is not a critical indicator for the need for obtaining vital signs.
NUR 204
, 2
NUR 204
2. The nurse understands that which statement is correct
regarding respiratory rates?
a. Infants have a lower respiratory rate than adults.
b. Healthy adults breathe between 12 and 20 times a minute.
c. A compensatory response to a fever is to breathe at a slower
rate.
d. An increase in intracranial pressure results in an increased
rate.: B
The normal respiratory rate for a healthy adult is 12 to 20 BPM. Infants
have a higher respiratory rate than adults. A fever increases the
metabolic rate and results in a higher rate. Intracranial pressure
decreases the respiratory rate
3. The nurse is caring for a patient who has a blood pressure of
184/110. An hour after administering an antihypertensive
medication, the nurse returns to recheck the blood pressure, only
to find the patient in the chair pale, sweaty, and feeling faint.
Which is the expected explanation for the nurse's observations?
NUR 204
, 3
NUR 204
a. The blood pressure is 184/110; the medication has not had an
effect.
b. The blood pressure is 118/76; the sudden drop has caused the
signs.
c. The blood pressure is 174/96; the medication has made the
patient sick.
d. The blood pressure is 130/82; the symptoms are from another
cause.: B
The symptoms are indicative of a sudden drop in the blood pressure;
an alteration in dose or medication may be needed.
4. It is 6 a.m. and the unlicensed assistive personnel reports to
the nurse that the patient has a temperature of 96.7° F (35.9° C)
tympanic. Which factor explains this reading?
a. The patient's room is cold.
b. The patient was drinking cold water.
c. The patient is exhibiting a normal circadian rhythm.
d. The patient just completed a warm shower.: C
NUR 204
, 4
NUR 204
Normal circadian rhythms cause a lower temperature in the early
morning and higher temperature in the late afternoon. A cool room
would initially cause compensatory mechanisms such as shivering and
a feeling of being cold. Cold water could affect temperature if an oral
thermometer was used. A warm shower would not cause a decrease in
temperature unless there was a delay in drying the skin and dressing
5. The nurse notes that the patient has an irregular pulse. What
action does the nurse take first?
a. Obtain the patient's blood pressure.
b. Ask another nurse to take the pulse.
c. Assess the pulse for a full minute.
d. Finish the rest of the vital signs: C
Assessing the pulse for a full minute is needed for an accurate count—
counting the pulse for a fraction of a minute and then multiplying the
value to equal a minute count will give an inaccurate count if the pulse
is irregular. The other actions are not needed.
NUR 204
