NUR401 Midterm Exam Questions with
Answers
A student nurse is assessing the blood pressure of a client with the client's arm unsupported.
What are the expected errors in the obtained readings? - ✔✔False High
Rationale: If the client's arm is unsupported, or if the arm is below the heart level, the resulting
outcome is a false high reading. Application of the stethoscope too firmly against antecubital
fossa will result in a false low diastolic reading. Repeated assessments of blood pressure too
often result in a false high systolic reading. Deflating the cuff too slowly results in a false high
diastolic reading.
The nurse is caring for a surgical client who develops a wound infection during hospitalization.
How is this type of infection classified? - ✔✔Nosocomial
Rationale: A nosocomial infection is acquired in a health care setting. This is also referred to as a
hospital-acquired infection. It is a result of poor infection control procedures such as a failure to
wash hands between clients. A primary infection is synonymous with initial infection. A
secondary infection is made possible by a primary infection that lowers the host's resistance
and causes an infection by another kind of organism. A superinfection is a new infection caused
by an organism different from that which caused the initial infection. The microbe responsible
is usually resistant to the treatment given for the initial infection.
When to measure vital signs - ✔✔-On admission to a healthcare facility
-When assessing pts during home care visit
-In hospital during routine schedule according to health care provider order or standard of
practice
-Before, during, & after surgical procedure/invasive diagnostic procedure
-Before/during/after blood transfusion products
-Before/during/after admin of med or therapies that affect cardiovascular, respiratory, or temp
control function
-When pt condition changes (ex. loss of consciousness)
-Before/during/after interventions influencing VS (ex. ambulation, before/after ROM exercises -
When pt reports nonspecific symptoms of physical distress (ex. feeling 'funny' or 'different')
, Normal Temperature Ranges - ✔✔36C- 38C (96.8F - 100.4F)
-Average oral temp = 37C (98.6F)
-Temp controlled by hypothalamus
Patterns of Fever - ✔✔Sustained- constant body temp continuously above 100.4F- little
fluctuation
Intermittent- Fever spikes mixed with reg temp levels-returns to acceptable value at least once
in 24 hrs
Remittent- Spikes and falls w/o return to acceptable level
Relapsing- Periods of febrile episodes mixed with acceptable values sometimes longer than 24
hrs
Classifications of Hypothermia - ✔✔Mild- 34-36C // 93.2 - 96.8F
Moderate- 30-40C // 86-93.2F
Severe- >30C // >86F
Heatstroke - ✔✔a dangerous condition in which the body loses its ability to cool itself through
perspiration (40.2C // 104.4f)
Na+ and K+ depletion, elevated pulse, low BP
--mgmt = fluid/electrolyte support, cooling, rest
Oral Temp Site Advantages & Limitation - ✔✔Advantages: easy access/no position change req,
comfortable for pt, provides accurate surface reading, reflects rapid change in core temp,
reliable for intubated patients
Answers
A student nurse is assessing the blood pressure of a client with the client's arm unsupported.
What are the expected errors in the obtained readings? - ✔✔False High
Rationale: If the client's arm is unsupported, or if the arm is below the heart level, the resulting
outcome is a false high reading. Application of the stethoscope too firmly against antecubital
fossa will result in a false low diastolic reading. Repeated assessments of blood pressure too
often result in a false high systolic reading. Deflating the cuff too slowly results in a false high
diastolic reading.
The nurse is caring for a surgical client who develops a wound infection during hospitalization.
How is this type of infection classified? - ✔✔Nosocomial
Rationale: A nosocomial infection is acquired in a health care setting. This is also referred to as a
hospital-acquired infection. It is a result of poor infection control procedures such as a failure to
wash hands between clients. A primary infection is synonymous with initial infection. A
secondary infection is made possible by a primary infection that lowers the host's resistance
and causes an infection by another kind of organism. A superinfection is a new infection caused
by an organism different from that which caused the initial infection. The microbe responsible
is usually resistant to the treatment given for the initial infection.
When to measure vital signs - ✔✔-On admission to a healthcare facility
-When assessing pts during home care visit
-In hospital during routine schedule according to health care provider order or standard of
practice
-Before, during, & after surgical procedure/invasive diagnostic procedure
-Before/during/after blood transfusion products
-Before/during/after admin of med or therapies that affect cardiovascular, respiratory, or temp
control function
-When pt condition changes (ex. loss of consciousness)
-Before/during/after interventions influencing VS (ex. ambulation, before/after ROM exercises -
When pt reports nonspecific symptoms of physical distress (ex. feeling 'funny' or 'different')
, Normal Temperature Ranges - ✔✔36C- 38C (96.8F - 100.4F)
-Average oral temp = 37C (98.6F)
-Temp controlled by hypothalamus
Patterns of Fever - ✔✔Sustained- constant body temp continuously above 100.4F- little
fluctuation
Intermittent- Fever spikes mixed with reg temp levels-returns to acceptable value at least once
in 24 hrs
Remittent- Spikes and falls w/o return to acceptable level
Relapsing- Periods of febrile episodes mixed with acceptable values sometimes longer than 24
hrs
Classifications of Hypothermia - ✔✔Mild- 34-36C // 93.2 - 96.8F
Moderate- 30-40C // 86-93.2F
Severe- >30C // >86F
Heatstroke - ✔✔a dangerous condition in which the body loses its ability to cool itself through
perspiration (40.2C // 104.4f)
Na+ and K+ depletion, elevated pulse, low BP
--mgmt = fluid/electrolyte support, cooling, rest
Oral Temp Site Advantages & Limitation - ✔✔Advantages: easy access/no position change req,
comfortable for pt, provides accurate surface reading, reflects rapid change in core temp,
reliable for intubated patients
