NSG 3100 Exam 2 Practice Questions

1. A nurse is assessing a client’s bilateral pulses for symmetry. Which pulse site should not be assessed on both sides of the body at the same time? a. Radial b. Carotid c. Femoral d. Brachial 2. Which patient requires the nurse to assess further? a. 18-year-old woman with pulse rate of 140 after riding two miles on an exercise bike b. 50-year-old man with a BP 112/60 mm Hg on awakening in the morning c. 65-year-old man with a respiratory rate of 10 d. 40-year-old woman with a pulse of 88 3. Which vital sign will change first when a postoperative client has an internal bleed? a. Body temperature b. Blood pressure c. Pulse pressure d. Heart rate 4. A nurse obtains the blood pressure of several adults. Which blood pressure results should cause the most concern? a. 102/70 mm Hg b. 140/92 mm Hg c. 125/78 mm Hg d. 135/85 mm Hg 5. A nurse is taking care of a patient in isolation and needs to take a rectal temperature with a plastic thermometer. Which should the nurse do? a. Take the temperature for 5 minutes b. Wear gloves throughout the procedure c. Place the patient in the right lateral position d. Insert the thermometer 2 inches into the client’s anus 6. A nurse in the emergency department is caring for a client who is diagnosed with hypothermia. Which factor present in the client’s history may have precipitated this condition? a. Heatstroke b. Inability to sweat c. Excessive exercise d. High alcohol intake 7. The adult’s vital signs are: T: 99.0 (oral), pulse 88 beats per minute, respirations 16 breaths per minute and blood pressure of 182/100 mm Hg. Which sign should cause concern? a. Pulse 1 This study source was downloaded by from CourseH on :54:22 GMT -05:00 b. Respirations c. Temperature d. Blood Pressure 8. A client is admitted to the emergency department with difficulty breathing. Which client response identified by the nurse causes the most concern? a. Low pulse oximetry b. Wheezes on expiration c. Shortness of breath on exertion d. Use of accessory muscles of respiration 9. A nurse concluded that a client is experiencing pyrexia. Which client assessment precipitated this conclusion? a. Mental confusion b. Increased appetite c. Rectal temperature of 101.0 F d. Heart rate of 50 beats per minute 10. The nurse is obtaining the patient’s blood pressure. Which information is most5 important for the nurse to document? a. Staff member who took the blood pressure b. Client’s tolerance to having the blood pressure taken c. Client’s body position of the client is not in a sitting position d. Which head of a dual-head stethoscope was used to obtain the reading 11. A nurse is assessing a client who states “I feel cold” Which mechanism that helps regulate body temperature will increase body heat? a. Vasodilation b. Evaporation c. Shivering d. Radiation 12. Which characteristics indicates the need to take a rectal temperature rather than oral a. Mouth Breather b. History of vomiting c. Presence of confusion d. Intolerance of the semi-Fowler position e. Intelligence at the level of a seven-year-old child 13. The nurse is evaluating a family member taking the patient’s blood pressure as part of the discharge teaching plan. Which behavior indicates that the family member needs additional teaching? a. Positions the arm higher than the level of the heart b. Places the diaphragm of the stethoscope over the brachial artery 2 This study source was downloaded by from CourseH on :54:22 GMT -05:00 c. Applies the center of the bladder of the cuff on the lateral aspect of ted arm d. Releases the valve on the manometer so that the gauge drops 10mmm Hg per heartbeat e. Insert the earpieces of the stethoscope into the ears so that they tilt slightly backward 14. The patient gets out of bed to go to the bathroom and tells the nurse that he ‘’feels dizzy.”What should the nurse do first? a. Go for help b. Take the blood pressure c. Help the patient to sit down d. Have the patient take deep breaths 15. A patient with active tuberculosis is admitted to the hospital. The nurse recognizes that admission of this patient will require what type of PPE. a. Droplet precautions b. Airborne precautions c. Contact precautions d. Protective isolation 16. A patient is found to have MRSA. What type of implementation is used when working with this patient? a. Leave the linen in the patient’s room b. Use PPE for contact precautions c. Wipe the stethoscope before removing it from the room d. Identify on the patient’s door that the droplet precautions are in place 17. Which of these patients play the highest risk for infection? a. Surgical creation of a colostomy b. First degree burns on the back c. Puncture of the foot by a nail d. Papercut on the finger 18. A client’s stool is positive for Clostridium difficile. Which isolation precautions should the nurse institute? a. Droplet b. Contact c. Reverse d. Airborne 19. What are the signs or wound infection? 3 This study source was downloaded by from CourseH on :54:22 GMT -05:00 a. Leukocytes b. Malaise c. Edema d. Fever e. Pain 20. Pressure ulcers primarily form as a result of which of the following? a. Nitrogen buildup in the underlying tissue b. Prolonged illness or disease c. Tissue ischemia d. Poor hygiene 21. The nurse notes a patient’s skin is reddened with a pink wound bed and serous fluids present. Which stage of wound is this? a. Stage I b. Stage II c. Stage III d. Stage IV 22. Which cleansing agent should it be used on a wound with granulation? a. Sterile saline b. Hydrogen Peroxide c. Povidone Iodine (Betadine) d. Sodium Hydrochlorite 23. Describe a thick, yellow drainage a. Milky b. Serous c. Purulent d. Serosanguineous