NSG 3100 exam 2
1. A nurse is making a home visit to a family of five children. The youngest, aged 5, has a temperature of
101.1°F, is lethargic, and has a poor appetite. This assessment leads you to suspect influenza. Which
instruction by the nurse is inconsistent with knowledge about influenza?
a. Keep children home from day care and school while symptoms are present.
b. Remind family that they only need to wash their hands if they are visibly dirty.
c. Do not share tissues, dishes, or personal care items to reduce the risk of transmission.
d. Encourage the family to receive their annual influenza vaccine. - ANSWER-b
1. The nurse notes that the patient has an irregular pulse. What action does the nurse take first?
a. Obtain the patient's blood pressure.
b. Ask another nurse to take the pulse.
c. Assess the pulse for a full minute.
d. Finish the rest of the vital signs - ANSWER-c
2. Which assessment findings would require the nurse to assess the patient further?
a. A 20-year-old male with a pulse rate of 136 after running 2 miles
b. A 40 year old with a blood pressure of 110/70 when first awakened
c. A 72 year old with a respiratory rate of 10 breaths/min
d. A 50 year old with a pulse rate of 88 beats/min - ANSWER-c
3. The nurse is completing a postoperative assessment on a patient in the postanesthesia recovery unit.
Which vital sign requires further assessment by the nurse for possible hypovolemic (low blood volume)
shock?
a. An increase in heart rate
b. An increased temperature
c. A decrease in blood pressure
d. A decrease in respiratory rate - ANSWER-a
4. The nurse is caring for a patient with a temperature of 103°F (30.4°C), respirations of 30 per minute,
pulse rate of 50 beats/min, and blood pressure of 100/60 mmHg. The patient is cold and clammy. What
does the nurse conclude about these findings?
a. The temperature is causing a lowered pulse rate; it will improve if the temperature decreases.
b. The low pulse rate is causing a decreased cardiac output, which has caused a low blood pressure.
c. The pulse rate and blood pressure are compensatory mechanisms to decrease the increased
metabolic rate from the temperature.
, NSG 3100 exam 2
d. The cool, clammy skin will help to increase the blood pressure and pulse as the body tries to warm the
skin. - ANSWER-b
5. The nurse is caring for a patient who was burned in a house fire. The right arm is heavily bandaged
and there is an intravenous line that was placed in the left forearm after three attempts. Which action
does the nurse take related to obtaining VS?
a. Use a Doppler machine to listen over the bandages.
b. A smaller cuff should be used to cover less of the upper arm.
c. The blood pressure should be taken on the popliteal artery.
d. The systolic pressure should be palpated from the radial artery. - ANSWER-c
6. The nurse is working in a rural community hospital that serves patients of all ages. Which decision by
the nurse shows the best judgment?
a. Taking an oral temperature in a 6-month-old infant
b. Taking a rectal temperature in a confused 78-year-old patient
c. Taking an axillary temperature in a newborn
d. Taking an oral temperature in a 26-year-old patient with dental extractions - ANSWER-c
7. After obtaining vital signs, which patient would the nurse see as the priority?
a. 1 year old, blood pressure 75/55 mmHg
b. 15 year old, blood pressure 115/70 mmHg
c. 6 year old, pulse of 125 beats/min
d. Newborn, pulse of 150 beats/min - ANSWER-c
A new patient is admitted to a medical unit with Clostridium difficile. Which type of precautions or
isolation does the nurse know is appropriate for this patient?
a. Airborne precautions
b. Droplet precautions
c. Contact precautions
d. Protective isolation - ANSWER-c
A nurse is caring for an overweight 60-year old woman with a reddened area over her coccyx. The
priority Nursing diagnosis for this patient is:
a. Impaired Nutritional Intake related to immobility
b. Impaired Mobility related to pain and discomfort.
c. Chronic Pain related to overweight.
1. A nurse is making a home visit to a family of five children. The youngest, aged 5, has a temperature of
101.1°F, is lethargic, and has a poor appetite. This assessment leads you to suspect influenza. Which
instruction by the nurse is inconsistent with knowledge about influenza?
a. Keep children home from day care and school while symptoms are present.
b. Remind family that they only need to wash their hands if they are visibly dirty.
c. Do not share tissues, dishes, or personal care items to reduce the risk of transmission.
d. Encourage the family to receive their annual influenza vaccine. - ANSWER-b
1. The nurse notes that the patient has an irregular pulse. What action does the nurse take first?
a. Obtain the patient's blood pressure.
b. Ask another nurse to take the pulse.
c. Assess the pulse for a full minute.
d. Finish the rest of the vital signs - ANSWER-c
2. Which assessment findings would require the nurse to assess the patient further?
a. A 20-year-old male with a pulse rate of 136 after running 2 miles
b. A 40 year old with a blood pressure of 110/70 when first awakened
c. A 72 year old with a respiratory rate of 10 breaths/min
d. A 50 year old with a pulse rate of 88 beats/min - ANSWER-c
3. The nurse is completing a postoperative assessment on a patient in the postanesthesia recovery unit.
Which vital sign requires further assessment by the nurse for possible hypovolemic (low blood volume)
shock?
a. An increase in heart rate
b. An increased temperature
c. A decrease in blood pressure
d. A decrease in respiratory rate - ANSWER-a
4. The nurse is caring for a patient with a temperature of 103°F (30.4°C), respirations of 30 per minute,
pulse rate of 50 beats/min, and blood pressure of 100/60 mmHg. The patient is cold and clammy. What
does the nurse conclude about these findings?
a. The temperature is causing a lowered pulse rate; it will improve if the temperature decreases.
b. The low pulse rate is causing a decreased cardiac output, which has caused a low blood pressure.
c. The pulse rate and blood pressure are compensatory mechanisms to decrease the increased
metabolic rate from the temperature.
, NSG 3100 exam 2
d. The cool, clammy skin will help to increase the blood pressure and pulse as the body tries to warm the
skin. - ANSWER-b
5. The nurse is caring for a patient who was burned in a house fire. The right arm is heavily bandaged
and there is an intravenous line that was placed in the left forearm after three attempts. Which action
does the nurse take related to obtaining VS?
a. Use a Doppler machine to listen over the bandages.
b. A smaller cuff should be used to cover less of the upper arm.
c. The blood pressure should be taken on the popliteal artery.
d. The systolic pressure should be palpated from the radial artery. - ANSWER-c
6. The nurse is working in a rural community hospital that serves patients of all ages. Which decision by
the nurse shows the best judgment?
a. Taking an oral temperature in a 6-month-old infant
b. Taking a rectal temperature in a confused 78-year-old patient
c. Taking an axillary temperature in a newborn
d. Taking an oral temperature in a 26-year-old patient with dental extractions - ANSWER-c
7. After obtaining vital signs, which patient would the nurse see as the priority?
a. 1 year old, blood pressure 75/55 mmHg
b. 15 year old, blood pressure 115/70 mmHg
c. 6 year old, pulse of 125 beats/min
d. Newborn, pulse of 150 beats/min - ANSWER-c
A new patient is admitted to a medical unit with Clostridium difficile. Which type of precautions or
isolation does the nurse know is appropriate for this patient?
a. Airborne precautions
b. Droplet precautions
c. Contact precautions
d. Protective isolation - ANSWER-c
A nurse is caring for an overweight 60-year old woman with a reddened area over her coccyx. The
priority Nursing diagnosis for this patient is:
a. Impaired Nutritional Intake related to immobility
b. Impaired Mobility related to pain and discomfort.
c. Chronic Pain related to overweight.
