NURS 226 exam 2 Questions and Correct
Answers
An older client has an oral temperature reading of 97.2 degrees F. The nurse realizes that
this clients low temperature could be due to which observation?
Loss of subcutaneous fat is noted
The nurse is preparing to measure a clients temperature. What is the first thing that the
nurse should do to ensure an accurate temperature reading?
Assess that the equipment used is working properly
The nurse needs to measure the temperature of a client who has a history of heart disease
and has eaten a bowl of vegetable soup 45 minutes ago. Which site should the nurse use?
Oral
While waiting for the physician to respond regarding a clients elevated temperature, what
can the nurse do to assist the client?
Increase fluid intake
While assessing the dorsalis pedis pulse of a client, the nurse determines that the pulse is
absent. However, the extremity is warm and pink with nail beds blanching at 2 to 3 seconds
of capillary refilling time. How would the nurse explain these findings?
Too much pressure was applied over the pulse site
,The RN assesses a client who is recovering from femoral popliteal bypass surgery and
discovers that it is difficult to assess the dorsalis pedis pulses. Which nursing intervention
would be most appropriate for the nurse to use?
Obtain a Doppler ultrasound stethoscope
When assessing a clients peripheral pulse, the health care provider is also assessing which
of the following?
Rhythm
The nurse is going to assess the apical-radial pulse of a client with a cardiovascular
disorder. Which rationale did the RN use to make this decision?
The thrust of blood from the heart is too feeble for the wave to be felt at the peripheral pulse
sight
A client is unconscious and in respiratory distress after being in a motor vehicle crash.
Which should the nurse realize as being a factor that caused a change in this clients
respiratory rate?
Increased intracranial pressure
The nurse needs to assess a clients respiratory status. Which client position would be the
best for this assessment?
Semi-fowlers
A client is being treated for congestive heart failure. Which physical finding would lead the
RN to believe the clients condition has not been improved?
,Wheezing of breath sounds in all four lobes
Which determinant of blood pressure would explain a clients blood pressure reading
120/100?
Peripheral vascular resistance
The nurse is assessing a clients blood pressure. What should the nurse hear during phase 2
of Korotkoff's sounds?
A muffled, whooshing, or swishing sound
The nurse is preparing to assess a clients blood pressure. Which artery will the nurse use
for this assessment?
Brachial
In the palpatory method of blood pressure determination, instead of listening for the blood
flow sounds, light to moderate pressure is used over the artery as the pressure in the cuff is
released. When will the nurse read the pressure?
When the first pulsation is felt
Which condition would lead the RN to choose the dorsalis pedis pulse site for further
assessing a clients status?
Toes cold to the touch
When assessing a clients oxygen saturation reading, the nurse realizes that what will affect
this reading?
Activity
, As the RN is suctioning a client, the pulse oximetry reading drops to 83%. What should the
nurse do?
Stop suctioning and give supplemental oxygen
The RN needs vital signs assessed for four clients. Which client should the nurse address
and not assign to the UAP?
Cardiac catheterization client returning to the nursing unit
Prior to assessing a clients blood pressure, the nurse reviews factors that could affect the
reading. Which factors could impact blood pressure? (Select all that apply).
Stress
Race
Obesity
Medications
The nurse is planning to assess a client's pulse. What characteristics should the nurse
include in this assessment? (Select all that apply).
Rate
Rhythm
Volume
When assessing a clients respirations, the nurse realizes that the respiratory centers and
chemoreceptors respond to changes in which factors? (Select all that apply).
Answers
An older client has an oral temperature reading of 97.2 degrees F. The nurse realizes that
this clients low temperature could be due to which observation?
Loss of subcutaneous fat is noted
The nurse is preparing to measure a clients temperature. What is the first thing that the
nurse should do to ensure an accurate temperature reading?
Assess that the equipment used is working properly
The nurse needs to measure the temperature of a client who has a history of heart disease
and has eaten a bowl of vegetable soup 45 minutes ago. Which site should the nurse use?
Oral
While waiting for the physician to respond regarding a clients elevated temperature, what
can the nurse do to assist the client?
Increase fluid intake
While assessing the dorsalis pedis pulse of a client, the nurse determines that the pulse is
absent. However, the extremity is warm and pink with nail beds blanching at 2 to 3 seconds
of capillary refilling time. How would the nurse explain these findings?
Too much pressure was applied over the pulse site
,The RN assesses a client who is recovering from femoral popliteal bypass surgery and
discovers that it is difficult to assess the dorsalis pedis pulses. Which nursing intervention
would be most appropriate for the nurse to use?
Obtain a Doppler ultrasound stethoscope
When assessing a clients peripheral pulse, the health care provider is also assessing which
of the following?
Rhythm
The nurse is going to assess the apical-radial pulse of a client with a cardiovascular
disorder. Which rationale did the RN use to make this decision?
The thrust of blood from the heart is too feeble for the wave to be felt at the peripheral pulse
sight
A client is unconscious and in respiratory distress after being in a motor vehicle crash.
Which should the nurse realize as being a factor that caused a change in this clients
respiratory rate?
Increased intracranial pressure
The nurse needs to assess a clients respiratory status. Which client position would be the
best for this assessment?
Semi-fowlers
A client is being treated for congestive heart failure. Which physical finding would lead the
RN to believe the clients condition has not been improved?
,Wheezing of breath sounds in all four lobes
Which determinant of blood pressure would explain a clients blood pressure reading
120/100?
Peripheral vascular resistance
The nurse is assessing a clients blood pressure. What should the nurse hear during phase 2
of Korotkoff's sounds?
A muffled, whooshing, or swishing sound
The nurse is preparing to assess a clients blood pressure. Which artery will the nurse use
for this assessment?
Brachial
In the palpatory method of blood pressure determination, instead of listening for the blood
flow sounds, light to moderate pressure is used over the artery as the pressure in the cuff is
released. When will the nurse read the pressure?
When the first pulsation is felt
Which condition would lead the RN to choose the dorsalis pedis pulse site for further
assessing a clients status?
Toes cold to the touch
When assessing a clients oxygen saturation reading, the nurse realizes that what will affect
this reading?
Activity
, As the RN is suctioning a client, the pulse oximetry reading drops to 83%. What should the
nurse do?
Stop suctioning and give supplemental oxygen
The RN needs vital signs assessed for four clients. Which client should the nurse address
and not assign to the UAP?
Cardiac catheterization client returning to the nursing unit
Prior to assessing a clients blood pressure, the nurse reviews factors that could affect the
reading. Which factors could impact blood pressure? (Select all that apply).
Stress
Race
Obesity
Medications
The nurse is planning to assess a client's pulse. What characteristics should the nurse
include in this assessment? (Select all that apply).
Rate
Rhythm
Volume
When assessing a clients respirations, the nurse realizes that the respiratory centers and
chemoreceptors respond to changes in which factors? (Select all that apply).
