Nursing 100 WCU Assessment 1
Exam Questions with Correct
Detailed Answers
Contact precautions - Answer- precautions used when a client has an infectious agent
that can be transmitted by direct or indirect contact with body secretion; requires a min
of gown and gloves prior to client interactions
systolic blood pressure - Answer- the point on the manometer at which the nurse hears
the first Korotkoff sound is
diastolic pressure - Answer- The point on the nanometer at which the Koritkoff sounds
are no longer audible is the
Tachycardia - Answer- pulse greater than 100 bpm
Bradycardia - Answer- slow heart rate (less than 60 bpm)
- central line-associated bloodstream infections
- catheter-associated unitary tract infections
- surgical site infections
- ventilator-assisted pneumonias - Answer- What are the four major HAIs
nursing interventions for hypertension - Answer- - encourage the client to adopt lifestyle
interventions such as exercise, stress reduction, low-sodium diet, and weight loss if
needed
- provide the client with information about anti hypertension medications, if prescribed
by the provider, including expected adverse effects and when the provider should be
notified.
nursing interventions for hypotension - Answer- - Increase fluids
- Place in an upright position unless medically contraindicated
- Evaluate the medications the client is taking
- Instruct the client about the risk for dizziness and falling
- Encourage the client to change positions slowly
- Avoid extremes in temperature
- Stay well hydrated
60 to 100 beats - Answer- What is the Normal pulse rate?
Grading of pulses - Answer- 0: absent
, 1: weak and diminished (barely palpable)
2: normal (easily palpable)
3: full
4: strong and bounding
36 C and 38 c
96.8 F- 100.4 F - Answer- What is the expected body temp?
nursing interventions of hyperthermia - Answer- - give a tepid bath
- cool fluids
- cooler environment
- administer medications as ordered
Inspiration - Answer- Is the intake of air by the lungs in order to oxygenate body tissues
and support cellular function
Expiration - Answer- Excels carbon dioxide from the lungs
12-20 breaths per minute - Answer- What is the expected rage for the respiratory rate?
oxygen saturation - Answer- 95-100%
acute pain - Answer- pain that last seconds to less than 6 months
Chronic pain - Answer- pain continues for 6 months or longer and can be intermittent or
continuous
- bacteria invade an open wound
- histamine, kinins, and prostaglandins arrive at the site
- plasma from the blood enter the site
- phagocytes occurs
- pus develops - Answer- What is the step of the inflammatory response?
Droplet precautions - Answer- should be in a private room
can be in the same room with a client who has the same infection
Airborne precautions - Answer- private room with door remained closed
airborne precautions examples - Answer- - client suspected of having tuberculosis
Contact precautions example - Answer- - client with a draining wound infected with
MRSA
- client with frequent, large diarrheal stools and who is incontinent
droplet precautions - Answer- - client diagnosed with adenovirus
Exam Questions with Correct
Detailed Answers
Contact precautions - Answer- precautions used when a client has an infectious agent
that can be transmitted by direct or indirect contact with body secretion; requires a min
of gown and gloves prior to client interactions
systolic blood pressure - Answer- the point on the manometer at which the nurse hears
the first Korotkoff sound is
diastolic pressure - Answer- The point on the nanometer at which the Koritkoff sounds
are no longer audible is the
Tachycardia - Answer- pulse greater than 100 bpm
Bradycardia - Answer- slow heart rate (less than 60 bpm)
- central line-associated bloodstream infections
- catheter-associated unitary tract infections
- surgical site infections
- ventilator-assisted pneumonias - Answer- What are the four major HAIs
nursing interventions for hypertension - Answer- - encourage the client to adopt lifestyle
interventions such as exercise, stress reduction, low-sodium diet, and weight loss if
needed
- provide the client with information about anti hypertension medications, if prescribed
by the provider, including expected adverse effects and when the provider should be
notified.
nursing interventions for hypotension - Answer- - Increase fluids
- Place in an upright position unless medically contraindicated
- Evaluate the medications the client is taking
- Instruct the client about the risk for dizziness and falling
- Encourage the client to change positions slowly
- Avoid extremes in temperature
- Stay well hydrated
60 to 100 beats - Answer- What is the Normal pulse rate?
Grading of pulses - Answer- 0: absent
, 1: weak and diminished (barely palpable)
2: normal (easily palpable)
3: full
4: strong and bounding
36 C and 38 c
96.8 F- 100.4 F - Answer- What is the expected body temp?
nursing interventions of hyperthermia - Answer- - give a tepid bath
- cool fluids
- cooler environment
- administer medications as ordered
Inspiration - Answer- Is the intake of air by the lungs in order to oxygenate body tissues
and support cellular function
Expiration - Answer- Excels carbon dioxide from the lungs
12-20 breaths per minute - Answer- What is the expected rage for the respiratory rate?
oxygen saturation - Answer- 95-100%
acute pain - Answer- pain that last seconds to less than 6 months
Chronic pain - Answer- pain continues for 6 months or longer and can be intermittent or
continuous
- bacteria invade an open wound
- histamine, kinins, and prostaglandins arrive at the site
- plasma from the blood enter the site
- phagocytes occurs
- pus develops - Answer- What is the step of the inflammatory response?
Droplet precautions - Answer- should be in a private room
can be in the same room with a client who has the same infection
Airborne precautions - Answer- private room with door remained closed
airborne precautions examples - Answer- - client suspected of having tuberculosis
Contact precautions example - Answer- - client with a draining wound infected with
MRSA
- client with frequent, large diarrheal stools and who is incontinent
droplet precautions - Answer- - client diagnosed with adenovirus
