NURS 101 Fundamentals of Nursing Practice Exam 1: Questions & Answers: Updated A+ Score Solution

A respiratory rate of greater than 20 breaths per minute is tachypnea. A blood pressure of 140/90 is considered hypertension. Pulse greater than 100 beats per minute is tachycardia. Frequent bowel sounds refer to hyper-active bowel sounds. Formulating a nursing diagnosis is a joint function of: A. Patient and relatives B. Nurse and patient C. Doctor and family D. Nurse and doctor (Ans- B. Nurse and patient Although diagnosing is basically the nurse's responsibility, input from the patient is essential to formulate the correct nursing diagnosis. The nurse listens to Mrs. Sullen's lungs and notes a hissing sound or musical sound. The nurse documents this as: A. Wheezes B. Rhonchi C. Gurgles D. Vesicular (Ans- A. WheezesWheezes are indicated by continuous, lengthy, musical; heard during inspiration or expiration. Rhonchi are usually coarse breath sounds. Gurgles are loud gurgling, bubbling sound. Vesicular breath sounds are low pitch, soft intensity on expiration. Becky is on NPO since midnight as preparation for blood test. Adrenocortical response is activated. Which of the following is an expected response? A. Low blood pressure B. Warm, dry skin C. Decreased serum sodium levels D. Decreased urine output (Ans- D. Decreased urine output Adreno-cortical response involves release of aldosterone that leads to retention of sodium and water. This results to decreased urine output. When performing an abdominal examination, the patient should be in a supine position with the head of the bed at what position? A. 30 degrees B. 90 degrees C. 45 degrees D. 0 degree (Ans- D. 0 degreeThe patient should be positioned with the head of the bed completely flattened to perform an abdominal examination. If the head of the bed is elevated, the abdominal muscles and organs can be bunched up, altering the findings. Which of the following is inappropriate nursing action when administering NGT feeding? A. Place the feeding 20 inches above the point of insertion of NGT B. Introduce the feeding slowly C. Instill 60ml of water into the NGT after feeding D. Assist the patient in fowler's position (Ans- A. Place the feeding 20 inches above the point of insertion of NGT