NUR 225 Quizzes
As you are obtaining the oxygen saturation on a 19 year-old college student with severe
asthma, you note that she has black nail polish on her nails. You remove the polish from
one nail, and she asks you why her nail polish had to be removed. What is the best
response? - Answer Nail polish interferes with sensor function
A nurse is palpating a patient's radial pulse and identifies that it can be obliterated with
slight pressure. Which words accurately reflect this assessment when documenting the
information in the patient's clinical record? Select all that apply. - Answer Weak
Thready (palpable)
When taking an adult blood pressure, the onset of the sound the nurse hears is at 138,
the muffled sound the nurse hears is at 70, and the disappearance of the sound the
nurse hears is at 62. How should the nurse record this finding? - Answer 138/62
A nurse obtains the blood pressure of several patients. Which blood pressure reading is
considered the most hypertensive? - Answer 140/90 is hypertension 120/80-140/90 is
pre-hypertension
A nurse is assessing the vital signs of several patients. Which signs of respiratory
distress should the nurse report to the primary health-care provider? - Answer Dyspnea
(audible, labored breathing, shortness of breath)
Tachypnea
Severe hypoxaemia
Cyanosis
The patient requires routine temperature assessment but is confused, easily agitated,
and has a history of seizures. Which route will the nurse use to obtain the patient's
temperature? - Answer Tympanic
The nurse is working the night shift on a surgical unit and is making 4:00 AM rounds.
The nurse notices that the patient's temperature is 96.8° F (36° C), whereas at 4:00 PM
the preceding day, it was 98.6° F (37° C). What should the nurse do? - Answer Realize
this is a normal temperature variation
The nurse is caring for an infant and is obtaining the patient's vital signs. Which artery
will the nurse use to best obtain the infant's pulse? - Answer Brachial
The nurse needs to obtain a radial pulse from a patient. What must the nurse do to
obtain a correct measurement? - Answer Place the tips of the first two fingers over the
groove along the thumb side of the patient's wrist.
When assessing the heart rate of a patient, the nurse identifies a change in rate from 88
to 56 beats per minute. Which should the nurse do first? - Answer Obtain the other vital
signs
, NUR 225 Quizzes
The nurse is assessing a patient who she suspects has the nursing diagnosis of
hyperthermia related to vigorous exercise in hot weather. In reviewing the data, the
nurse knows that the most important sign of heatstroke is: - Answer Hot, dry skin
When a nurse goes into a room to take a patient's temperature, the patient is drinking a
cup of coffee. How long should the nurse wait to take the patient's oral temperature? -
Answer 30 min
The patient with heart failure is restless with a temperature of 102.2° F (39° C). Which
action will the nurse take? - Answer Place the patient on oxygen
A patient has a head injury and damages the hypothalamus. Which vital sign will the
nurse monitor most closely? - Answer Temperature
What is the removal of devitalized tissue from a wound called? - Answer Debridement
On assessing your patient's sacral pressure ulcer, you note that the tissue over the
sacrum is dark, hard, and adherent to the wound edge. What is the correct
category/stage for this patient's pressure ulcer? - Answer Unstageable
The nurse is caring for a patient who was involved in an automobile accident 2 weeks
ago. The patient sustained a head injury and is unconscious. Which priority element will
the nurse consider when planning care to decrease the development of a decubitus
ulcer? - Answer Pressure, turn this guy
Which nursing observation will indicate the patient is at risk for pressure ulcer
formation? - Answer The patient has fecal incontinence
The patient is immobile
The nurse is caring for a patient who is experiencing a full-thickness repair. Which type
of tissue will the nurse expect to observe when the wound is healing? - Answer
Granulation
The nurse is caring for a patient who is at risk for skin impairment. The patient is able to
sit up in a chair. The nurse includes this intervention in the plan of care. How long
should the nurse schedule the patient to sit in the chair? - Answer Less than 2 hours
The nurse is caring for a patient with a wound. The patient appears anxious as the
nurse is preparing to change the dressing. Which action should the nurse take? -
Answer Explain the procedure
Your post operative patient calls you to the room stating that after sneezing, he felt like
something pulled at his abdominal wound. You go in to assess the wound and find the
wound has eviscerated. Your first reaction is to: - Answer Evisceration is when
intestines come out Dehiscence is separation of suture
As you are obtaining the oxygen saturation on a 19 year-old college student with severe
asthma, you note that she has black nail polish on her nails. You remove the polish from
one nail, and she asks you why her nail polish had to be removed. What is the best
response? - Answer Nail polish interferes with sensor function
A nurse is palpating a patient's radial pulse and identifies that it can be obliterated with
slight pressure. Which words accurately reflect this assessment when documenting the
information in the patient's clinical record? Select all that apply. - Answer Weak
Thready (palpable)
When taking an adult blood pressure, the onset of the sound the nurse hears is at 138,
the muffled sound the nurse hears is at 70, and the disappearance of the sound the
nurse hears is at 62. How should the nurse record this finding? - Answer 138/62
A nurse obtains the blood pressure of several patients. Which blood pressure reading is
considered the most hypertensive? - Answer 140/90 is hypertension 120/80-140/90 is
pre-hypertension
A nurse is assessing the vital signs of several patients. Which signs of respiratory
distress should the nurse report to the primary health-care provider? - Answer Dyspnea
(audible, labored breathing, shortness of breath)
Tachypnea
Severe hypoxaemia
Cyanosis
The patient requires routine temperature assessment but is confused, easily agitated,
and has a history of seizures. Which route will the nurse use to obtain the patient's
temperature? - Answer Tympanic
The nurse is working the night shift on a surgical unit and is making 4:00 AM rounds.
The nurse notices that the patient's temperature is 96.8° F (36° C), whereas at 4:00 PM
the preceding day, it was 98.6° F (37° C). What should the nurse do? - Answer Realize
this is a normal temperature variation
The nurse is caring for an infant and is obtaining the patient's vital signs. Which artery
will the nurse use to best obtain the infant's pulse? - Answer Brachial
The nurse needs to obtain a radial pulse from a patient. What must the nurse do to
obtain a correct measurement? - Answer Place the tips of the first two fingers over the
groove along the thumb side of the patient's wrist.
When assessing the heart rate of a patient, the nurse identifies a change in rate from 88
to 56 beats per minute. Which should the nurse do first? - Answer Obtain the other vital
signs
, NUR 225 Quizzes
The nurse is assessing a patient who she suspects has the nursing diagnosis of
hyperthermia related to vigorous exercise in hot weather. In reviewing the data, the
nurse knows that the most important sign of heatstroke is: - Answer Hot, dry skin
When a nurse goes into a room to take a patient's temperature, the patient is drinking a
cup of coffee. How long should the nurse wait to take the patient's oral temperature? -
Answer 30 min
The patient with heart failure is restless with a temperature of 102.2° F (39° C). Which
action will the nurse take? - Answer Place the patient on oxygen
A patient has a head injury and damages the hypothalamus. Which vital sign will the
nurse monitor most closely? - Answer Temperature
What is the removal of devitalized tissue from a wound called? - Answer Debridement
On assessing your patient's sacral pressure ulcer, you note that the tissue over the
sacrum is dark, hard, and adherent to the wound edge. What is the correct
category/stage for this patient's pressure ulcer? - Answer Unstageable
The nurse is caring for a patient who was involved in an automobile accident 2 weeks
ago. The patient sustained a head injury and is unconscious. Which priority element will
the nurse consider when planning care to decrease the development of a decubitus
ulcer? - Answer Pressure, turn this guy
Which nursing observation will indicate the patient is at risk for pressure ulcer
formation? - Answer The patient has fecal incontinence
The patient is immobile
The nurse is caring for a patient who is experiencing a full-thickness repair. Which type
of tissue will the nurse expect to observe when the wound is healing? - Answer
Granulation
The nurse is caring for a patient who is at risk for skin impairment. The patient is able to
sit up in a chair. The nurse includes this intervention in the plan of care. How long
should the nurse schedule the patient to sit in the chair? - Answer Less than 2 hours
The nurse is caring for a patient with a wound. The patient appears anxious as the
nurse is preparing to change the dressing. Which action should the nurse take? -
Answer Explain the procedure
Your post operative patient calls you to the room stating that after sneezing, he felt like
something pulled at his abdominal wound. You go in to assess the wound and find the
wound has eviscerated. Your first reaction is to: - Answer Evisceration is when
intestines come out Dehiscence is separation of suture
