NURS 224 EXAM 3 QUESTIONS WITH CORRECT
ANSWERS
An older client has an oral temperature reading of 97.2 degrees F. The nurse
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realizes that this client's low temperature could be due to which observation?
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1. The anxiety level of the client has increased.
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2. Hormones have fluctuated in this client.
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3. Muscle activity has increased during the client's therapy session.
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4. Loss of subcutaneous fat is noted. - CORRECT ANSWER✔✔-4. Loss of
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subcutaneous fat is noted. | | |
The nurse is preparing to measure a client's temperature. What is the first thing
| | | | | | | | | | | | | |
that the nurse should do to ensure an accurate temperature reading?
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1. Assess that the equipment used is working properly.
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2. Place the client in a position that is most comfortable for the health care
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provider.
3. Take the temperature with a chemical disposable thermometer when the client
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is perspiring.
| |
4. Wait at least 10 minutes before taking the temperature after a client has been
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smoking. - CORRECT ANSWER✔✔-1. Assess that the equipment used is working
| | | | | | | | | | |
properly.
,The nurse needs to measure the temperature of a client who has a history of
| | | | | | | | | | | | | | |
heart disease and has eaten a bowl of vegetable soup 45 minutes ago. Which site
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should the nurse use?
| | |
1. Axilla
|
2. Oral
|
3. Popliteal
|
4. Rectal - CORRECT ANSWER✔✔-2. Oral
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While waiting for the physician to respond regarding a client's elevated
| | | | | | | | | | |
temperature, what can the nurse do to assist the client?| | | | | | | | |
1. Bathe the client with ice water.
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2. Give the client an antipyretic.
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3. Increase fluid intake.
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4. Lower the room temperature. - CORRECT ANSWER✔✔-3. Increase fluid intake.
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While assessing the dorsalis pedis pulse of a client, the nurse determines that the
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pulse is absent. However, the extremity is warm and pink with nail beds
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blanching at 2 to 3 seconds of capillary refilling time. How would the nurse
| | | | | | | | | | | | | |
explain these findings? | |
1. A change in the client's health status has occurred.
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2. The client has thrown a blood clot in that extremity.
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3. The RN's watch has stopped working.
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,4. Too much pressure was applied over the pulse site. - CORRECT ANSWER✔✔-4.
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Too much pressure was applied over the pulse site.
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The RN assesses a client who is recovering from femoral popliteal bypass surgery
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and discovers that it is difficult to assess the dorsalis pedis pulses. Which nursing
| | | | | | | | | | | | | |
intervention would be most appropriate for the nurse to use?
| | | | | | | | |
1. Ask another nurse to assess the pulses.
| | | | | | |
2. Document the findings.
| | |
3. Obtain a Doppler ultrasound stethoscope.
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4. Wait and try again later. - CORRECT ANSWER✔✔-3. Obtain a Doppler
| | | | | | | | | | | |
ultrasound stethoscope. |
When assessing a client's peripheral pulse, the health care provider is also
| | | | | | | | | | | |
assessing which of the following?
| | | |
1. Depth
|
2. Rhythm
|
3. Sound
|
4. Stress - CORRECT ANSWER✔✔-2. Rhythm
| | | | |
The nurse is going to assess the apical-radial pulse of a client with a
| | | | | | | | | | | | | |
cardiovascular disorder. Which rationale did the RN use to make this decision?
| | | | | | | | | | |
1. A forceful radial pulse is much too difficult to count correctly.
| | | | | | | | | | |
, 2. Both arteriole and venous sounds were heard simultaneously.
| | | | | | | |
3. The pulse was bounding and easily obliterated.
| | | | | | |
4. The thrust of blood from the heart is too feeble for the wave to be felt at the
| | | | | | | | | | | | | | | | | | |
peripheral pulse site. - CORRECT ANSWER✔✔-4. The thrust of blood from the
| | | | | | | | | | | |
heart is too feeble for the wave to be felt at the peripheral pulse site.
| | | | | | | | | | | | | |
A client is unconscious and in respiratory distress after being in a motor vehicle
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crash. Which should the nurse realize as being a factor that caused a change in
| | | | | | | | | | | | | | |
this client's respiratory rate?
| | |
1. Exercise
|
2. Increased intracranial pressure
| | |
3. Increased environmental temperature
| | |
4. Stress - CORRECT ANSWER✔✔-2. Increased intracranial pressure
| | | | | | |
The nurse needs to assess a client's respiratory status. Which client position
| | | | | | | | | | | |
would be the best for this assessment?
| | | | | |
1. Prone|
2. Semi-Fowler's
|
3. Side-lying
|
4. Supine - CORRECT ANSWER✔✔-2. Semi-Fowler's
| | | | |
A client is being treated for congestive heart failure. Which physical finding would
| | | | | | | | | | | |
lead the RN to believe the client's condition has not improved?
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ANSWERS
An older client has an oral temperature reading of 97.2 degrees F. The nurse
| | | | | | | | | | | | | |
realizes that this client's low temperature could be due to which observation?
| | | | | | | | | | |
1. The anxiety level of the client has increased.
| | | | | | | |
2. Hormones have fluctuated in this client.
| | | | | |
3. Muscle activity has increased during the client's therapy session.
| | | | | | | | |
4. Loss of subcutaneous fat is noted. - CORRECT ANSWER✔✔-4. Loss of
| | | | | | | | | | | |
subcutaneous fat is noted. | | |
The nurse is preparing to measure a client's temperature. What is the first thing
| | | | | | | | | | | | | |
that the nurse should do to ensure an accurate temperature reading?
| | | | | | | | | |
1. Assess that the equipment used is working properly.
| | | | | | | |
2. Place the client in a position that is most comfortable for the health care
| | | | | | | | | | | | | | |
provider.
3. Take the temperature with a chemical disposable thermometer when the client
| | | | | | | | | | |
is perspiring.
| |
4. Wait at least 10 minutes before taking the temperature after a client has been
| | | | | | | | | | | | | | |
smoking. - CORRECT ANSWER✔✔-1. Assess that the equipment used is working
| | | | | | | | | | |
properly.
,The nurse needs to measure the temperature of a client who has a history of
| | | | | | | | | | | | | | |
heart disease and has eaten a bowl of vegetable soup 45 minutes ago. Which site
| | | | | | | | | | | | | | |
should the nurse use?
| | |
1. Axilla
|
2. Oral
|
3. Popliteal
|
4. Rectal - CORRECT ANSWER✔✔-2. Oral
| | | | |
While waiting for the physician to respond regarding a client's elevated
| | | | | | | | | | |
temperature, what can the nurse do to assist the client?| | | | | | | | |
1. Bathe the client with ice water.
| | | | | |
2. Give the client an antipyretic.
| | | | |
3. Increase fluid intake.
| | |
4. Lower the room temperature. - CORRECT ANSWER✔✔-3. Increase fluid intake.
| | | | | | | | | |
While assessing the dorsalis pedis pulse of a client, the nurse determines that the
| | | | | | | | | | | | |
pulse is absent. However, the extremity is warm and pink with nail beds
| | | | | | | | | | | | | |
blanching at 2 to 3 seconds of capillary refilling time. How would the nurse
| | | | | | | | | | | | | |
explain these findings? | |
1. A change in the client's health status has occurred.
| | | | | | | | |
2. The client has thrown a blood clot in that extremity.
| | | | | | | | | |
3. The RN's watch has stopped working.
| | | | | |
,4. Too much pressure was applied over the pulse site. - CORRECT ANSWER✔✔-4.
| | | | | | | | | | | | |
Too much pressure was applied over the pulse site.
| | | | | | | |
The RN assesses a client who is recovering from femoral popliteal bypass surgery
| | | | | | | | | | | | |
and discovers that it is difficult to assess the dorsalis pedis pulses. Which nursing
| | | | | | | | | | | | | |
intervention would be most appropriate for the nurse to use?
| | | | | | | | |
1. Ask another nurse to assess the pulses.
| | | | | | |
2. Document the findings.
| | |
3. Obtain a Doppler ultrasound stethoscope.
| | | | |
4. Wait and try again later. - CORRECT ANSWER✔✔-3. Obtain a Doppler
| | | | | | | | | | | |
ultrasound stethoscope. |
When assessing a client's peripheral pulse, the health care provider is also
| | | | | | | | | | | |
assessing which of the following?
| | | |
1. Depth
|
2. Rhythm
|
3. Sound
|
4. Stress - CORRECT ANSWER✔✔-2. Rhythm
| | | | |
The nurse is going to assess the apical-radial pulse of a client with a
| | | | | | | | | | | | | |
cardiovascular disorder. Which rationale did the RN use to make this decision?
| | | | | | | | | | |
1. A forceful radial pulse is much too difficult to count correctly.
| | | | | | | | | | |
, 2. Both arteriole and venous sounds were heard simultaneously.
| | | | | | | |
3. The pulse was bounding and easily obliterated.
| | | | | | |
4. The thrust of blood from the heart is too feeble for the wave to be felt at the
| | | | | | | | | | | | | | | | | | |
peripheral pulse site. - CORRECT ANSWER✔✔-4. The thrust of blood from the
| | | | | | | | | | | |
heart is too feeble for the wave to be felt at the peripheral pulse site.
| | | | | | | | | | | | | |
A client is unconscious and in respiratory distress after being in a motor vehicle
| | | | | | | | | | | | | |
crash. Which should the nurse realize as being a factor that caused a change in
| | | | | | | | | | | | | | |
this client's respiratory rate?
| | |
1. Exercise
|
2. Increased intracranial pressure
| | |
3. Increased environmental temperature
| | |
4. Stress - CORRECT ANSWER✔✔-2. Increased intracranial pressure
| | | | | | |
The nurse needs to assess a client's respiratory status. Which client position
| | | | | | | | | | | |
would be the best for this assessment?
| | | | | |
1. Prone|
2. Semi-Fowler's
|
3. Side-lying
|
4. Supine - CORRECT ANSWER✔✔-2. Semi-Fowler's
| | | | |
A client is being treated for congestive heart failure. Which physical finding would
| | | | | | | | | | | |
lead the RN to believe the client's condition has not improved?
| | | | | | | | | | |
