NR 302 Week 2 Edapt
Complete Quiz Review
(Questions & Solutions)
2025
1
, 1. Multiple Choice
While conducting first-look observations, the nurse notes a well-
nourished 66-year-old sitting erect in no acute distress, spontaneously
smiling, and ANSing appropriately. These observations belong to which
domain of the general survey?
A. Mobility
B. Physical appearance
C. Body structure
D. Behavior
ANS: D
Rationale: Facial expression, mood/affect, and speech quality are
catalogued under behavior .
---
2. True/False
Counting a regular adult radial pulse for 15 seconds and multiplying by
four is an acceptable method in routine practice.
ANS: False
Rationale: Evidence-based guidelines recommend a 30-second count
(×2) for regular rhythms; 15 seconds magnifies error if even one beat is
missed.
---
3. Multiple Choice
Mrs. Patel (38 weeks’ gestation) arrives dizzy after standing. Which pair
of measurements constitutes a clinically significant orthostatic change?
A. BP drop 10 mm Hg systolic; HR rise 8 bpm
B. BP drop 20 mm Hg systolic; HR rise 22 bpm
C. BP drop 5 mm Hg diastolic; HR unchanged
D. BP drop 7 mm Hg systolic; HR rise 10 bpm
2
, ANS: B
Rationale: A ≥20 mm Hg systolic decrease and ≥20 bpm increase in HR
meet the definition of orthostatic hypotension.
---
4. Fill-in-the-Blank
When selecting a BP cuff, the inflatable bladder should encircle at least
____% of the client’s arm circumference to avoid false readings.
ANS: 80
Rationale: A bladder <80 % produces falsely high pressures.
---
5. Multiple Response (Select all)
Which findings collected during a general survey suggest immediate
priority assessment?
[ ] A. Odor of ammonia on breath
[ ] B. BMI 33 kg/m²
[ ] C. Use of accessory neck muscles to breathe
[ ] D. Disorientation to place
[ ] E. Well-healed tattoo on forearm
ANSs: A, C, D
Rationale: Ammonia odor (possible hepatic failure), labored
respirations, and acute confusion require prompt evaluation. Elevated
BMI and tattoos are non-urgent.
---
6. Multiple Choice
A neonate’s axillary temperature is 36.1 °C (97.0 °F). Which
interpretation is most appropriate ?
3
Complete Quiz Review
(Questions & Solutions)
2025
1
, 1. Multiple Choice
While conducting first-look observations, the nurse notes a well-
nourished 66-year-old sitting erect in no acute distress, spontaneously
smiling, and ANSing appropriately. These observations belong to which
domain of the general survey?
A. Mobility
B. Physical appearance
C. Body structure
D. Behavior
ANS: D
Rationale: Facial expression, mood/affect, and speech quality are
catalogued under behavior .
---
2. True/False
Counting a regular adult radial pulse for 15 seconds and multiplying by
four is an acceptable method in routine practice.
ANS: False
Rationale: Evidence-based guidelines recommend a 30-second count
(×2) for regular rhythms; 15 seconds magnifies error if even one beat is
missed.
---
3. Multiple Choice
Mrs. Patel (38 weeks’ gestation) arrives dizzy after standing. Which pair
of measurements constitutes a clinically significant orthostatic change?
A. BP drop 10 mm Hg systolic; HR rise 8 bpm
B. BP drop 20 mm Hg systolic; HR rise 22 bpm
C. BP drop 5 mm Hg diastolic; HR unchanged
D. BP drop 7 mm Hg systolic; HR rise 10 bpm
2
, ANS: B
Rationale: A ≥20 mm Hg systolic decrease and ≥20 bpm increase in HR
meet the definition of orthostatic hypotension.
---
4. Fill-in-the-Blank
When selecting a BP cuff, the inflatable bladder should encircle at least
____% of the client’s arm circumference to avoid false readings.
ANS: 80
Rationale: A bladder <80 % produces falsely high pressures.
---
5. Multiple Response (Select all)
Which findings collected during a general survey suggest immediate
priority assessment?
[ ] A. Odor of ammonia on breath
[ ] B. BMI 33 kg/m²
[ ] C. Use of accessory neck muscles to breathe
[ ] D. Disorientation to place
[ ] E. Well-healed tattoo on forearm
ANSs: A, C, D
Rationale: Ammonia odor (possible hepatic failure), labored
respirations, and acute confusion require prompt evaluation. Elevated
BMI and tattoos are non-urgent.
---
6. Multiple Choice
A neonate’s axillary temperature is 36.1 °C (97.0 °F). Which
interpretation is most appropriate ?
3
