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NUR 101 EXAM 1 ACTUAL HEALTH ASSESSMENT
EXAM || ACCURATE AND FREQUENTLY TESTED
QUESTIONS AND 100% CORRECT ANSWERS WITH
RATIONALES|| LATEST AND COMPLETE UPDATE
WITH EXPERT VERIFIED SOLUTIONS|| SURE PASS!!
1. 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?: - ANSWER:
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.
2. A clients vital signs at the beginning of the shift are as follows: oral temper-
ature 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
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3) 102
4) 122: - ANSWER: 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.
3. 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: - ANSWER: 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.
4. The nurse hears rhonchi when auscultating a clients lungs. Which nursing
intervention would be appropriate for the nurse to implement before reassess- ing
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.: - ANSWER: 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
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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.
5. 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: - ANSWER: 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 in-
fants 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.
6. 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
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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: - ANSWER:
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
7. The clients temperature is 101.1F. Which is the correct conversion to centi-
grade?
1) 38.0C
2) 38.4C
3) 38.8C
4) 39.2C: - ANSWER: 2) 38.4C
To convert Fahrenheit to centigrade, subtract 32 from the temperature, and
multiply by 5/9.
8. The client has had a fever, ranging from 99.8F orally to 103F orally, over the
last 24 hours. The clients fever would be classified as
1) Constant 2)Intermittent 3)Relapsing
4)Remittent: - ANSWER: 4) Remittent
Remittent fevers fluctuate widely over a 24-hour period. Constant fevers stay
above normal with only slight fluctuations. Intermittent fevers alternate between
normal or subnormal temperatures with periods of fever. Relapsing fevers alternate
NUR 101 EXAM 1 ACTUAL HEALTH ASSESSMENT
EXAM || ACCURATE AND FREQUENTLY TESTED
QUESTIONS AND 100% CORRECT ANSWERS WITH
RATIONALES|| LATEST AND COMPLETE UPDATE
WITH EXPERT VERIFIED SOLUTIONS|| SURE PASS!!
1. 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?: - ANSWER:
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.
2. A clients vital signs at the beginning of the shift are as follows: oral temper-
ature 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
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3) 102
4) 122: - ANSWER: 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.
3. 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: - ANSWER: 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.
4. The nurse hears rhonchi when auscultating a clients lungs. Which nursing
intervention would be appropriate for the nurse to implement before reassess- ing
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.: - ANSWER: 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
,3|Page
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.
5. 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: - ANSWER: 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 in-
fants 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.
6. 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
, 4|Page
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: - ANSWER:
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
7. The clients temperature is 101.1F. Which is the correct conversion to centi-
grade?
1) 38.0C
2) 38.4C
3) 38.8C
4) 39.2C: - ANSWER: 2) 38.4C
To convert Fahrenheit to centigrade, subtract 32 from the temperature, and
multiply by 5/9.
8. The client has had a fever, ranging from 99.8F orally to 103F orally, over the
last 24 hours. The clients fever would be classified as
1) Constant 2)Intermittent 3)Relapsing
4)Remittent: - ANSWER: 4) Remittent
Remittent fevers fluctuate widely over a 24-hour period. Constant fevers stay
above normal with only slight fluctuations. Intermittent fevers alternate between
normal or subnormal temperatures with periods of fever. Relapsing fevers alternate
