Med-Surg 555 Exam 1 UPDATED ACTUAL Questions and
CORRECT Answers
Mr. Johnson is a 63-year old gentleman who is c. Temporally
hospitalized for pneumonia. He has history of heart
failure and hypertension. He looks dyspneic and is Orally: not appropriate since he is a mouth-breathing with shortness of
mouth-breathing. To establish a baseline assessment for breath.Tympanic: not appropriate since he wearing hearing aids.Rectally: not
Mr. Johnson, the nurse asks you to measure his vital signs. indicated since a non-invasive route (temporal) is available.
Inspect Mr. Johnson in the image below and decide what
temperature route should use to obtain his temperature:
a. Orally
b. Tympanically
c. Temporally
d. Rectally
Normally, Mr. Johnson's lowest body temperature would c. 3 AM
be around:
a. 7 PM
b. 2 PM
c. 3 AM
d. 12 PM
After you assess the vital signs of Mr. Johnson, which of b. respiration rate= 28 breaths per minute
his vital signs must you address and report to the nurse
immediately: All VS normal except RR.
a. heart rate= 72 beats per minute
b. respiration rate= 28 breaths per minute
c. blood pressure= 135/87 mmHg
d. Temperature= 37.2C (99F) Oral
Based on Mr. Johnson's vital signs(Heart rate = 72 beats a. administer oxygen via nasal cannula
per minute Respiration rate = 28 breaths per minute
Blood pressure = 135/87 mmHg. Tylenol is not indicated since there is no fever.Holding BP medication is not
Temperature = 37.2° C (99° F) Oral), you expect the nurse indicated since BP is not low.Documentation is not enough, an action is indicated
to: due to high RR.
a. administer oxygen via nasal cannula.
b. administer the ordered Tylenol (Acetaminophen).
c. hold Mr. Johnson's next BP medication dose.
d. document the vital signs as normal.
,Based on Mr. Johnson's vital sign(Heart rate = 72 beats c. tachypnea
per minute Respiration rate = 28 breaths per minute
Blood pressure = 135/87 mmHg.
Temperature = 37.2° C (99° F) Oral), he is having:
a. Hyperthermia.
b. Hypotension.
c. Tachypnea.
d. Bradycardia.
After administration of oxygen, which of the following c. Oxygen saturation 96%
signs indicates that the oxygen therapy has been
successful?
a. BP 130/82 mmHg.
b. Temp 99.8 F.
c. Oxygen saturation 96%.
d. Respiration rate 24 bpm.
Knowing that Mr. Johnson has a history of heart failure, c. apical pulse
which has led atrial fibrillation dysrhythmia, to accurately
measure his pulse, should assess his:
a. radial pulse.
b. brachial pulse.
c. apical pulse.
d. Dorsalis pedis pulse.
Due to his history of dysrhythmia, you suspect that Mr. c. assess his apical pulse and radial pulse for the same minute and subtract the
Johnson will have pulse deficit. To measure his pulse difference.
deficit, you should:
a. subtract 60 from his pulse rate.
b. subtract his pulse rate from 100.
c. assess his apical pulse and radial pulse for the same
minute and subtract the difference.
d. assess his apical pulse and 30 minutes later assessing
his carotid pulse and subtract the difference.
To assess Mr. Johnson's apical pulse, you should place the a. at 5th intercostal space (ICS) and midclavicular line.
stethoscope on his point of maximum impulse (PMI),
which is located:
a. at 5th intercostal space (ICS) and midclavicular line.
b. at 2nd intercostal space (ICS) and left sternal edge.
c. at 2nd intercostal space (ICS) and right sternal edge.
d. at 4th intercostal space (ICS) and midaxillary line.
, Knowing that Mr. Johnson has a history of heart failure b. weak, 1+, and irregular.
and dysrhythmia, you expect his radial pulse to be:
a. bounding, 4+, and regular.
b. weak, 1+, and irregular.
c. normal, 2+, and regular.
d. Absent.
Mr. Johnson's BP measures 135/87 mmHg. His mean b. 103 mmHg.
arterial pressure (MAP) measures:
a. 48 mmHg.
b. 103 mmHg.
c. 119 mmHg.
d. 111 mmHg.
If you use a child BP cuff, you anticipate that Mr. Johnson's b. false high.
BP would be:
a. false low.
b. false high.
c. accurate.
d. with high pulse pressure.
Which of the following BP readings of Mr. Johnson d. 146/88 when lying down and 130/78 when standing.
indicates that he is experiencing orthostatic
hypotension?
a. 118/68 when standing and 110/72 when lying down.
b. 140/80, HR 82 bpm when sitting and 136/76, HR 98
bpm when standing.
c. 126/72 lying down and 133/80 when sitting.
d. 146/88 when lying down and 130/78 when standing.
Since pneumonia can be transmitted directly from Mr. a. true
Johnson to another person, it is considered a
communicable disease.
a. true
b. false
The most effective way to prevent the spread of Mr. a. practicing good hand hygiene.
Johnson's pneumonia is:
a. practicing good hand hygiene.
b. wearing gloves.
c. placing clients in isolation.
d. providing private rooms for clients.
CORRECT Answers
Mr. Johnson is a 63-year old gentleman who is c. Temporally
hospitalized for pneumonia. He has history of heart
failure and hypertension. He looks dyspneic and is Orally: not appropriate since he is a mouth-breathing with shortness of
mouth-breathing. To establish a baseline assessment for breath.Tympanic: not appropriate since he wearing hearing aids.Rectally: not
Mr. Johnson, the nurse asks you to measure his vital signs. indicated since a non-invasive route (temporal) is available.
Inspect Mr. Johnson in the image below and decide what
temperature route should use to obtain his temperature:
a. Orally
b. Tympanically
c. Temporally
d. Rectally
Normally, Mr. Johnson's lowest body temperature would c. 3 AM
be around:
a. 7 PM
b. 2 PM
c. 3 AM
d. 12 PM
After you assess the vital signs of Mr. Johnson, which of b. respiration rate= 28 breaths per minute
his vital signs must you address and report to the nurse
immediately: All VS normal except RR.
a. heart rate= 72 beats per minute
b. respiration rate= 28 breaths per minute
c. blood pressure= 135/87 mmHg
d. Temperature= 37.2C (99F) Oral
Based on Mr. Johnson's vital signs(Heart rate = 72 beats a. administer oxygen via nasal cannula
per minute Respiration rate = 28 breaths per minute
Blood pressure = 135/87 mmHg. Tylenol is not indicated since there is no fever.Holding BP medication is not
Temperature = 37.2° C (99° F) Oral), you expect the nurse indicated since BP is not low.Documentation is not enough, an action is indicated
to: due to high RR.
a. administer oxygen via nasal cannula.
b. administer the ordered Tylenol (Acetaminophen).
c. hold Mr. Johnson's next BP medication dose.
d. document the vital signs as normal.
,Based on Mr. Johnson's vital sign(Heart rate = 72 beats c. tachypnea
per minute Respiration rate = 28 breaths per minute
Blood pressure = 135/87 mmHg.
Temperature = 37.2° C (99° F) Oral), he is having:
a. Hyperthermia.
b. Hypotension.
c. Tachypnea.
d. Bradycardia.
After administration of oxygen, which of the following c. Oxygen saturation 96%
signs indicates that the oxygen therapy has been
successful?
a. BP 130/82 mmHg.
b. Temp 99.8 F.
c. Oxygen saturation 96%.
d. Respiration rate 24 bpm.
Knowing that Mr. Johnson has a history of heart failure, c. apical pulse
which has led atrial fibrillation dysrhythmia, to accurately
measure his pulse, should assess his:
a. radial pulse.
b. brachial pulse.
c. apical pulse.
d. Dorsalis pedis pulse.
Due to his history of dysrhythmia, you suspect that Mr. c. assess his apical pulse and radial pulse for the same minute and subtract the
Johnson will have pulse deficit. To measure his pulse difference.
deficit, you should:
a. subtract 60 from his pulse rate.
b. subtract his pulse rate from 100.
c. assess his apical pulse and radial pulse for the same
minute and subtract the difference.
d. assess his apical pulse and 30 minutes later assessing
his carotid pulse and subtract the difference.
To assess Mr. Johnson's apical pulse, you should place the a. at 5th intercostal space (ICS) and midclavicular line.
stethoscope on his point of maximum impulse (PMI),
which is located:
a. at 5th intercostal space (ICS) and midclavicular line.
b. at 2nd intercostal space (ICS) and left sternal edge.
c. at 2nd intercostal space (ICS) and right sternal edge.
d. at 4th intercostal space (ICS) and midaxillary line.
, Knowing that Mr. Johnson has a history of heart failure b. weak, 1+, and irregular.
and dysrhythmia, you expect his radial pulse to be:
a. bounding, 4+, and regular.
b. weak, 1+, and irregular.
c. normal, 2+, and regular.
d. Absent.
Mr. Johnson's BP measures 135/87 mmHg. His mean b. 103 mmHg.
arterial pressure (MAP) measures:
a. 48 mmHg.
b. 103 mmHg.
c. 119 mmHg.
d. 111 mmHg.
If you use a child BP cuff, you anticipate that Mr. Johnson's b. false high.
BP would be:
a. false low.
b. false high.
c. accurate.
d. with high pulse pressure.
Which of the following BP readings of Mr. Johnson d. 146/88 when lying down and 130/78 when standing.
indicates that he is experiencing orthostatic
hypotension?
a. 118/68 when standing and 110/72 when lying down.
b. 140/80, HR 82 bpm when sitting and 136/76, HR 98
bpm when standing.
c. 126/72 lying down and 133/80 when sitting.
d. 146/88 when lying down and 130/78 when standing.
Since pneumonia can be transmitted directly from Mr. a. true
Johnson to another person, it is considered a
communicable disease.
a. true
b. false
The most effective way to prevent the spread of Mr. a. practicing good hand hygiene.
Johnson's pneumonia is:
a. practicing good hand hygiene.
b. wearing gloves.
c. placing clients in isolation.
d. providing private rooms for clients.
