NUR 106 FINAL EXAM ACTUAL QUESTIONS AND
SOLUTIONS GRADED A+
✔✔vital signs - ✔✔Measurements of the body's most basic functions and useful in
detecting or monitoring medical problems.
✔✔When must vital signs be assessed? - ✔✔New patient, patient status q4h, q8h, etc.,
worsening condition or new condition present, prior to patient transfer or discharge.
✔✔Basic ranges for vital signs - ✔✔Temperature= 98.6 F
Blood pressure= 120/80
Pulse= 60-100 beat/min
Respirations= 16-20 breaths/min
✔✔Thermometer locations - ✔✔Axillary- armpit
oral- mouth
rectal- anus
tympanic- ear
Temporal- forehead
✔✔Where is the most accurate place to check for core temperature? - ✔✔Rectal
✔✔Where do you place the thermometer for oral temp? - ✔✔Deep in the sublingual
pocket
✔✔How far do you insert rectal thermometer? - ✔✔1 in for infant to 3 years old
1.5 in for adult
✔✔pulse locations - ✔✔BRACHIAL:, at the inner aspect of the biceps muscles of the
arm or medially in the antecubital space
RADIAL:, where the radial artery runs along the radial bone, on the thumb side of the
inner aspect of the wrist
FEMORAL, where the femoral artery passes alongside the inguinal ligament
POPLITEAL:, where the popliteal artery passes behind the knees
POSTERIOR TIBIAL: on the medial surface of the ankle where the posterior tibial artery
passes behind the medial malleolus.
PEDIAL: (dorsalis pedis), where the dorsalis pedis artery passes over the bones of the
foot, on an imaginary line
✔✔Where do you check the apical pulse? - ✔✔5th intercostal space, left midclavicular
line
✔✔What other names does apical pulse go by? - ✔✔Point of maximal intensity, PMI,
apex, mitral
,✔✔What does PQRSTU stand for? - ✔✔Pain
Quality
Radiates
Severity
Time
U- YOU how does it affect you?
✔✔What is the 5th vital sign? - ✔✔pain
✔✔Environmental Assessment - ✔✔Bed low and locked
Side rails up
Commode within distance
patient have their call light
Tubing in proper placement
Is IV attached and proper rate
Bedside table within reach
✔✔Situational Assessment - ✔✔Level of consciousness: Patients status: Are they up
and awake
Able to answer name and date of birth verification?
What time is it?
Where are you?
ANO x3 is typical
✔✔3 phases of communication - ✔✔Orientation- State who you are and what you are
there to do
working- Actually performing im gonna do your ____,
termination- Done with process, ask patient if they have any questions, give them their
call light
✔✔Head to toe assessment Key points - ✔✔i. Breath and heart sounds under the gown
ii. Listen to bowels before palpation
iii. Pedal and radial pulses
iv. Turgor- clavicle
✔✔Head to toe assessment techniques - ✔✔Inspection
Palpation
Percussion
Auscultation
✔✔What must be verified with each patient as soon as you greet them? - ✔✔Name and
date of birth, (check wrist band to verify)
✔✔HEENT Assessment - ✔✔Evaluation of head, eyes, ears, nose, throat.
, ✔✔What does PERLA stand for? - ✔✔pupils equal, round, reactive to light and
accommodation
✔✔Cardinal movements check for what cranial nerve? - ✔✔Cranial nerve III oculomotor
✔✔Skin Assessment - ✔✔color, moisture, temperature, texture, turgor, vascularity,
edema, lesions
✔✔capillary refill - ✔✔A test that evaluates distal circulatory system function by
squeezing (blanching) blood from an area such as a nail bed and watching the speed of
its return after releasing the pressure. After blanching nail bed, color should return to
normal withing <3 secs
✔✔skin turgor - ✔✔Measure of hydration, which tests how quickly the skin returns to its
normal position after being pinched. Most accurate place is the collar bone
✔✔5 points for heart pulse - ✔✔Aortic
Pulmonic
Erbs point
Tricuspid
Apical
✔✔Korotkoff sounds - ✔✔series of sounds that correspond to changes in blood flow
through an artery as pressure is released
✔✔The lub-dub heart sounds heard during auscultation of the heart are associated with
- ✔✔the sound made by the heart valves as they close.
✔✔The S1 heart sound represents: - ✔✔closure of the mitral and tricuspid valves; AV
valves, "Lub"
✔✔The S2 heart sound represents: - ✔✔closing of the aortic and pulmonic valves
(semilunar valves).
✔✔Normal breath sounds - ✔✔bronchial, bronchovesicular, vesicular
✔✔Abdomen order of assessment - ✔✔inspection (visual), auscultation (with
stethoscope, RLQ>RUQ>LUQ>LLQ), percussion, palpation
✔✔What are contractures? - ✔✔a condition of shortening and hardening of muscles,
tendons, or other tissue, often leading to deformity and rigidity of joints.
✔✔Contusions - ✔✔Bruise
SOLUTIONS GRADED A+
✔✔vital signs - ✔✔Measurements of the body's most basic functions and useful in
detecting or monitoring medical problems.
✔✔When must vital signs be assessed? - ✔✔New patient, patient status q4h, q8h, etc.,
worsening condition or new condition present, prior to patient transfer or discharge.
✔✔Basic ranges for vital signs - ✔✔Temperature= 98.6 F
Blood pressure= 120/80
Pulse= 60-100 beat/min
Respirations= 16-20 breaths/min
✔✔Thermometer locations - ✔✔Axillary- armpit
oral- mouth
rectal- anus
tympanic- ear
Temporal- forehead
✔✔Where is the most accurate place to check for core temperature? - ✔✔Rectal
✔✔Where do you place the thermometer for oral temp? - ✔✔Deep in the sublingual
✔✔How far do you insert rectal thermometer? - ✔✔1 in for infant to 3 years old
1.5 in for adult
✔✔pulse locations - ✔✔BRACHIAL:, at the inner aspect of the biceps muscles of the
arm or medially in the antecubital space
RADIAL:, where the radial artery runs along the radial bone, on the thumb side of the
inner aspect of the wrist
FEMORAL, where the femoral artery passes alongside the inguinal ligament
POPLITEAL:, where the popliteal artery passes behind the knees
POSTERIOR TIBIAL: on the medial surface of the ankle where the posterior tibial artery
passes behind the medial malleolus.
PEDIAL: (dorsalis pedis), where the dorsalis pedis artery passes over the bones of the
foot, on an imaginary line
✔✔Where do you check the apical pulse? - ✔✔5th intercostal space, left midclavicular
line
✔✔What other names does apical pulse go by? - ✔✔Point of maximal intensity, PMI,
apex, mitral
,✔✔What does PQRSTU stand for? - ✔✔Pain
Quality
Radiates
Severity
Time
U- YOU how does it affect you?
✔✔What is the 5th vital sign? - ✔✔pain
✔✔Environmental Assessment - ✔✔Bed low and locked
Side rails up
Commode within distance
patient have their call light
Tubing in proper placement
Is IV attached and proper rate
Bedside table within reach
✔✔Situational Assessment - ✔✔Level of consciousness: Patients status: Are they up
and awake
Able to answer name and date of birth verification?
What time is it?
Where are you?
ANO x3 is typical
✔✔3 phases of communication - ✔✔Orientation- State who you are and what you are
there to do
working- Actually performing im gonna do your ____,
termination- Done with process, ask patient if they have any questions, give them their
call light
✔✔Head to toe assessment Key points - ✔✔i. Breath and heart sounds under the gown
ii. Listen to bowels before palpation
iii. Pedal and radial pulses
iv. Turgor- clavicle
✔✔Head to toe assessment techniques - ✔✔Inspection
Palpation
Percussion
Auscultation
✔✔What must be verified with each patient as soon as you greet them? - ✔✔Name and
date of birth, (check wrist band to verify)
✔✔HEENT Assessment - ✔✔Evaluation of head, eyes, ears, nose, throat.
, ✔✔What does PERLA stand for? - ✔✔pupils equal, round, reactive to light and
accommodation
✔✔Cardinal movements check for what cranial nerve? - ✔✔Cranial nerve III oculomotor
✔✔Skin Assessment - ✔✔color, moisture, temperature, texture, turgor, vascularity,
edema, lesions
✔✔capillary refill - ✔✔A test that evaluates distal circulatory system function by
squeezing (blanching) blood from an area such as a nail bed and watching the speed of
its return after releasing the pressure. After blanching nail bed, color should return to
normal withing <3 secs
✔✔skin turgor - ✔✔Measure of hydration, which tests how quickly the skin returns to its
normal position after being pinched. Most accurate place is the collar bone
✔✔5 points for heart pulse - ✔✔Aortic
Pulmonic
Erbs point
Tricuspid
Apical
✔✔Korotkoff sounds - ✔✔series of sounds that correspond to changes in blood flow
through an artery as pressure is released
✔✔The lub-dub heart sounds heard during auscultation of the heart are associated with
- ✔✔the sound made by the heart valves as they close.
✔✔The S1 heart sound represents: - ✔✔closure of the mitral and tricuspid valves; AV
valves, "Lub"
✔✔The S2 heart sound represents: - ✔✔closing of the aortic and pulmonic valves
(semilunar valves).
✔✔Normal breath sounds - ✔✔bronchial, bronchovesicular, vesicular
✔✔Abdomen order of assessment - ✔✔inspection (visual), auscultation (with
stethoscope, RLQ>RUQ>LUQ>LLQ), percussion, palpation
✔✔What are contractures? - ✔✔a condition of shortening and hardening of muscles,
tendons, or other tissue, often leading to deformity and rigidity of joints.
✔✔Contusions - ✔✔Bruise
