Exam 1: NUR 101/ NUR101 (Latest
2026/ 2027 Update) Health
Assessment | Questions &
Answers| Grade A| 100% Correct
(Verified Elaborations)- Fortis
A patient tells the nurse, Im having a lot of pain in my hip. Which response by the nurse is open-
ended and would stimulate the patient to provide the most complete data? Choose all that are
correct.
1) Is your pain severe?
2) Tell me about your pain.
3) When did you first notice this pain?
4) How would you describe your pain?
ANS:
2) Tell me about your pain.
4) How would you describe your pain?
The responses Tell me about your pain and How would you describe your pain? are open-ended
responses that stimulate conversation. Although it is important information, the question Is your
pain severe? prompts a yes or no response. When did you first notice this pain?also important
informationis likely to stimulate a brief, factual answer. Such questions allow the nurse to control
the patients response. Limiting the response might lead to an incomplete assessment.
, Exam 1: NUR 101/ NUR101 (Latest
2026/ 2027 Update) Health
Assessment | Questions &
Answers| Grade A| 100% Correct
(Verified Elaborations)- Fortis
A clients vital signs at the beginning of the shift are as follows: oral temperature 99.3F (37C),
heart rate 82 beats/min, respiratory rate 14 breaths/min, and blood pressure 118/76 mm Hg. Four
hours later the clients oral temperature is 102.2F (39C). Based on the temperature change, the
nurse should anticipate the clients heart rate would be how many beats/min?
1) 62
2) 82
3) 102
4) 122
ANS: 3) 102
Heart rate increases about 10 beats per minute for each degree of temperature to meet increased
metabolic needs and compensate for peripheral dilation.
The nurse is assessing vital signs for a client after surgical procedure on the left leg. IV fluids are
infusing. It would be most important for the nurse to
1) Compare the left pedal pulse with the right pedal pulse
2) Count the clients respiratory rate for 1 full minute
3) Take the blood pressure in the arm without an IV
, Exam 1: NUR 101/ NUR101 (Latest
2026/ 2027 Update) Health
Assessment | Questions &
Answers| Grade A| 100% Correct
(Verified Elaborations)- Fortis
4) Take an oral temperature with an electronic thermometer
ANS: 1) Compare the left pedal pulse with the right pedal pulse
For a client having surgery on the leg, the most important data would be whether the circulation
has been compromised because of the surgery. This can be done only by comparing one leg with
the other. The nurse would, of course, count the respiratory rate for 1 full minute and take the BP
in the arm without the IV. Oral temperatures are commonly obtained using electronic
thermometers.
The nurse hears rhonchi when auscultating a clients lungs. Which nursing intervention would be
appropriate for the nurse to implement before reassessing lung sounds?
1) Have the client take several deep breaths.
2) Request the client take a deep breath and cough.
3) Take the clients blood pressure and apical pulse.
4) Count the clients respiratory rate for 1 minute.
ANS: 2) Request the client take a deep breath and cough.
Rhonchi are caused by secretions in the large airways and may clear with coughing. This is how
you differentiate between rhonchi and other adventitious sounds. Deep breathing will not help to
, Exam 1: NUR 101/ NUR101 (Latest
2026/ 2027 Update) Health
Assessment | Questions &
Answers| Grade A| 100% Correct
(Verified Elaborations)- Fortis
clear rhonchi. Taking the blood pressure and apical pulse and counting the respiratory rate are
not effective for clearing rhonchi and would not be sufficient for the nurse to identify whether
the sounds were, indeed, rhonchi.
Which of the following sets of vital signs are all within normal limits for patients at rest?
1) Infant: T 98.8F (rectal), HR 160, RR 16, BP 120/54
2) Adolescent: T 98.2F (oral), HR 80, RR 18, BP 108/68
3) Adult: T 99.6F (oral), HR 48, RR 22, BP 130/84
4) Older adult: T 98.6F (oral), HR 110, RR 28, BP 170/95
ANS: 2) Adolescent: T 98.2F (oral), HR 80, RR 18, BP 108/68
All of the adolescents vital signs are within normal parameters for the age. The infants
temperature is below normal for a rectal reading because the core temperature is approximately 1
degree higher than readings from other sites. The heart rate (HR) for an infant is high, the
respiratory rate (RR) is low, and the blood pressure (BP) is high for the age. For the typical adult,
the temperature is high, the HR is low, the RR is high, and the BP is elevated for the age. For the
older adult, the temperature is high-end normal, the HR is high, the RR is high, and the BP is
high for the age.
2026/ 2027 Update) Health
Assessment | Questions &
Answers| Grade A| 100% Correct
(Verified Elaborations)- Fortis
A patient tells the nurse, Im having a lot of pain in my hip. Which response by the nurse is open-
ended and would stimulate the patient to provide the most complete data? Choose all that are
correct.
1) Is your pain severe?
2) Tell me about your pain.
3) When did you first notice this pain?
4) How would you describe your pain?
ANS:
2) Tell me about your pain.
4) How would you describe your pain?
The responses Tell me about your pain and How would you describe your pain? are open-ended
responses that stimulate conversation. Although it is important information, the question Is your
pain severe? prompts a yes or no response. When did you first notice this pain?also important
informationis likely to stimulate a brief, factual answer. Such questions allow the nurse to control
the patients response. Limiting the response might lead to an incomplete assessment.
, Exam 1: NUR 101/ NUR101 (Latest
2026/ 2027 Update) Health
Assessment | Questions &
Answers| Grade A| 100% Correct
(Verified Elaborations)- Fortis
A clients vital signs at the beginning of the shift are as follows: oral temperature 99.3F (37C),
heart rate 82 beats/min, respiratory rate 14 breaths/min, and blood pressure 118/76 mm Hg. Four
hours later the clients oral temperature is 102.2F (39C). Based on the temperature change, the
nurse should anticipate the clients heart rate would be how many beats/min?
1) 62
2) 82
3) 102
4) 122
ANS: 3) 102
Heart rate increases about 10 beats per minute for each degree of temperature to meet increased
metabolic needs and compensate for peripheral dilation.
The nurse is assessing vital signs for a client after surgical procedure on the left leg. IV fluids are
infusing. It would be most important for the nurse to
1) Compare the left pedal pulse with the right pedal pulse
2) Count the clients respiratory rate for 1 full minute
3) Take the blood pressure in the arm without an IV
, Exam 1: NUR 101/ NUR101 (Latest
2026/ 2027 Update) Health
Assessment | Questions &
Answers| Grade A| 100% Correct
(Verified Elaborations)- Fortis
4) Take an oral temperature with an electronic thermometer
ANS: 1) Compare the left pedal pulse with the right pedal pulse
For a client having surgery on the leg, the most important data would be whether the circulation
has been compromised because of the surgery. This can be done only by comparing one leg with
the other. The nurse would, of course, count the respiratory rate for 1 full minute and take the BP
in the arm without the IV. Oral temperatures are commonly obtained using electronic
thermometers.
The nurse hears rhonchi when auscultating a clients lungs. Which nursing intervention would be
appropriate for the nurse to implement before reassessing lung sounds?
1) Have the client take several deep breaths.
2) Request the client take a deep breath and cough.
3) Take the clients blood pressure and apical pulse.
4) Count the clients respiratory rate for 1 minute.
ANS: 2) Request the client take a deep breath and cough.
Rhonchi are caused by secretions in the large airways and may clear with coughing. This is how
you differentiate between rhonchi and other adventitious sounds. Deep breathing will not help to
, Exam 1: NUR 101/ NUR101 (Latest
2026/ 2027 Update) Health
Assessment | Questions &
Answers| Grade A| 100% Correct
(Verified Elaborations)- Fortis
clear rhonchi. Taking the blood pressure and apical pulse and counting the respiratory rate are
not effective for clearing rhonchi and would not be sufficient for the nurse to identify whether
the sounds were, indeed, rhonchi.
Which of the following sets of vital signs are all within normal limits for patients at rest?
1) Infant: T 98.8F (rectal), HR 160, RR 16, BP 120/54
2) Adolescent: T 98.2F (oral), HR 80, RR 18, BP 108/68
3) Adult: T 99.6F (oral), HR 48, RR 22, BP 130/84
4) Older adult: T 98.6F (oral), HR 110, RR 28, BP 170/95
ANS: 2) Adolescent: T 98.2F (oral), HR 80, RR 18, BP 108/68
All of the adolescents vital signs are within normal parameters for the age. The infants
temperature is below normal for a rectal reading because the core temperature is approximately 1
degree higher than readings from other sites. The heart rate (HR) for an infant is high, the
respiratory rate (RR) is low, and the blood pressure (BP) is high for the age. For the typical adult,
the temperature is high, the HR is low, the RR is high, and the BP is elevated for the age. For the
older adult, the temperature is high-end normal, the HR is high, the RR is high, and the BP is
high for the age.
