NUR 101 Exam 1 Questions with Verified Correct
Answers
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.
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
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 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.
The nurse assesses the following changes in a clients vital signs. Which client situation
should be reported to the primary care provider?
1)Decreased blood pressure (BP) after standing up
2)Decreased temperature after a period of diaphoresis
3)Increased heart rate after walking down the hall
4)Increased respiratory rate when the heart rate increases
ANS: 1)Decreased blood pressure (BP) after standing up
A drop in the clients blood pressure when standing indicates orthostatic hypotension, and the
cause should be investigated. The changes in vital signs indicated in the other options are
normal changes for the situations.
PTS:1DIF:ModerateREF:p. 439 for hypotension information but should read content about
all of the vital signs
The clients temperature is 101.1F. Which is the correct conversion to centigrade?
1)38.0C
2)38.4C
Answers
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.
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
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 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.
The nurse assesses the following changes in a clients vital signs. Which client situation
should be reported to the primary care provider?
1)Decreased blood pressure (BP) after standing up
2)Decreased temperature after a period of diaphoresis
3)Increased heart rate after walking down the hall
4)Increased respiratory rate when the heart rate increases
ANS: 1)Decreased blood pressure (BP) after standing up
A drop in the clients blood pressure when standing indicates orthostatic hypotension, and the
cause should be investigated. The changes in vital signs indicated in the other options are
normal changes for the situations.
PTS:1DIF:ModerateREF:p. 439 for hypotension information but should read content about
all of the vital signs
The clients temperature is 101.1F. Which is the correct conversion to centigrade?
1)38.0C
2)38.4C
