Core Module 2 Exam practice Questions
And All Correct Answers.
The nurse is performing a physical assessment on a client during her first prenatal visit to the clinic. The
nurse takes the client's temperature and notes that the temperature is 99.2° F. Based on this finding,
which nursing action is most appropriate?
1. Document the temperature.
2. Notify the health care provider.
3. Retake the temperature by the rectal route.
4. Inform the client that the temperature is elevated and antibiotics may be required. - Answer 1)
Document the temp. It is normal and there is no need to notify the provider
The nurse is developing a plan of care for an older client that addresses interventions to prevent cold
discomfort and the development of accidental hypothermia. The nurse should document which desired
outcome in the plan of care?
1. The client's body temperature is 98° F.
2. The client's fingers and toes are cool to touch.
3. The client remains in a fetal position when in bed.
4. The client complains of coolness in the hands and feet only. - Answer 1. The client's body
temperature is 98° F.
The nurse assisted with the delivery of a newborn. Which nursing action is most effective in preventing
heat loss by evaporation?
1. Warming the crib pad
2. Closing the doors to the room
3. Drying the infant with a warm blanket
4. Turning on the overhead radiant warmer - Answer 3. Drying the infant with a warm blanket
,The nurse is taking the vital signs of a client. The nurse notes that the client's temperature is 100.2° F.
What is the priority nursing intervention?
1. Document the findings.
2. Retake the temperature in 15 minutes.
3. Notify the health care provider (HCP).
4. Increase hydration by encouraging oral fluids. - Answer 4. Increase hydration by encouraging oral
fluids.
The nurse has just administered ibuprofen (Motrin) to a child with a temperature of 38.8° C (102° F). The
nurse should also take which action?
1. Withhold oral fluids for 8 hours.
2. Sponge the child with cold water.
3. Plan to administer salicylate (aspirin) in 4 hours.
4. Remove excess clothing and blankets from the child. - Answer 4. Remove excess clothing and
blankets from the child.
A client arrives on the unit after surgery. On performing an assessment, the nurse notes that the client is
shaking uncontrollably. Which nursing action would be appropriate?
1. Massage the surgical site.
2. Contact the health care provider.
3. Cover the client with a warm blanket.
4. Place the client in Trendelenburg's position. - Answer 3. Cover the client with a warm blanket.
A nurse is assigned to the care of a client hospitalized with a diagnosis of hypothermia. The nurse
anticipates that the client will exhibit which findings on assessment of vital signs?
1. Increased heart rate and increased blood pressure
2. Increased heart rate and decreased blood pressure
, 3. Decreased heart rate and increased blood pressure
4. Decreased heart rate and decreased blood pressure - Answer 4. Decreased heart rate and decreased
blood pressure
When obtaining a health history from a patient with a neurologic problem, which question by the nurse
will elicit the most useful response from the patient?
A. "Do you ever have any nausea or dizziness?"
B. "Does the pain radiate from your back into your legs?"
C. "Do you have any sensations of pins and needles in your feet?"
D. "Can you describe the sensations you are having in your chest?" - Answer Answer: D. "Can you
describe the sensations you are having in your chest?"
Rationale: The most useful and valid information is obtained through the use of open-ended questions
that allow the patient to describe symptoms. The other questions encourage the use of "yes" or "no"
responses and may cause the patient to omit useful additional data.
When admitting a patient with acute confusion to the hospital, the nurse will interview the patient about
health problems and health history primarily to
a. determine the patient's motivation for self-care.
b. include the patient in health care decisions.
c. use the information given by the patient to guide care.
d. assess the patient's baseline cognitive abilities. - Answer Answer: D
Rationale: Appropriateness of the patient's response and the patient's use of language will help the
nurse to assess the baseline cognitive abilities of the patient. A confused patient may not be able to
participate in self-care or make informed health care decisions. The health history given by a confused
patient should not be used to guide decisions about care unless it can be verified by another source.
To assess the functioning of the optic nerve (CN II), the nurse should
a. apply a cotton wisp strand to the cornea.
b. have the patient read a magazine.
c. shine a bright light into the patient's pupil.
d. check for equal opening of the eyelids. - Answer Answer: B
And All Correct Answers.
The nurse is performing a physical assessment on a client during her first prenatal visit to the clinic. The
nurse takes the client's temperature and notes that the temperature is 99.2° F. Based on this finding,
which nursing action is most appropriate?
1. Document the temperature.
2. Notify the health care provider.
3. Retake the temperature by the rectal route.
4. Inform the client that the temperature is elevated and antibiotics may be required. - Answer 1)
Document the temp. It is normal and there is no need to notify the provider
The nurse is developing a plan of care for an older client that addresses interventions to prevent cold
discomfort and the development of accidental hypothermia. The nurse should document which desired
outcome in the plan of care?
1. The client's body temperature is 98° F.
2. The client's fingers and toes are cool to touch.
3. The client remains in a fetal position when in bed.
4. The client complains of coolness in the hands and feet only. - Answer 1. The client's body
temperature is 98° F.
The nurse assisted with the delivery of a newborn. Which nursing action is most effective in preventing
heat loss by evaporation?
1. Warming the crib pad
2. Closing the doors to the room
3. Drying the infant with a warm blanket
4. Turning on the overhead radiant warmer - Answer 3. Drying the infant with a warm blanket
,The nurse is taking the vital signs of a client. The nurse notes that the client's temperature is 100.2° F.
What is the priority nursing intervention?
1. Document the findings.
2. Retake the temperature in 15 minutes.
3. Notify the health care provider (HCP).
4. Increase hydration by encouraging oral fluids. - Answer 4. Increase hydration by encouraging oral
fluids.
The nurse has just administered ibuprofen (Motrin) to a child with a temperature of 38.8° C (102° F). The
nurse should also take which action?
1. Withhold oral fluids for 8 hours.
2. Sponge the child with cold water.
3. Plan to administer salicylate (aspirin) in 4 hours.
4. Remove excess clothing and blankets from the child. - Answer 4. Remove excess clothing and
blankets from the child.
A client arrives on the unit after surgery. On performing an assessment, the nurse notes that the client is
shaking uncontrollably. Which nursing action would be appropriate?
1. Massage the surgical site.
2. Contact the health care provider.
3. Cover the client with a warm blanket.
4. Place the client in Trendelenburg's position. - Answer 3. Cover the client with a warm blanket.
A nurse is assigned to the care of a client hospitalized with a diagnosis of hypothermia. The nurse
anticipates that the client will exhibit which findings on assessment of vital signs?
1. Increased heart rate and increased blood pressure
2. Increased heart rate and decreased blood pressure
, 3. Decreased heart rate and increased blood pressure
4. Decreased heart rate and decreased blood pressure - Answer 4. Decreased heart rate and decreased
blood pressure
When obtaining a health history from a patient with a neurologic problem, which question by the nurse
will elicit the most useful response from the patient?
A. "Do you ever have any nausea or dizziness?"
B. "Does the pain radiate from your back into your legs?"
C. "Do you have any sensations of pins and needles in your feet?"
D. "Can you describe the sensations you are having in your chest?" - Answer Answer: D. "Can you
describe the sensations you are having in your chest?"
Rationale: The most useful and valid information is obtained through the use of open-ended questions
that allow the patient to describe symptoms. The other questions encourage the use of "yes" or "no"
responses and may cause the patient to omit useful additional data.
When admitting a patient with acute confusion to the hospital, the nurse will interview the patient about
health problems and health history primarily to
a. determine the patient's motivation for self-care.
b. include the patient in health care decisions.
c. use the information given by the patient to guide care.
d. assess the patient's baseline cognitive abilities. - Answer Answer: D
Rationale: Appropriateness of the patient's response and the patient's use of language will help the
nurse to assess the baseline cognitive abilities of the patient. A confused patient may not be able to
participate in self-care or make informed health care decisions. The health history given by a confused
patient should not be used to guide decisions about care unless it can be verified by another source.
To assess the functioning of the optic nerve (CN II), the nurse should
a. apply a cotton wisp strand to the cornea.
b. have the patient read a magazine.
c. shine a bright light into the patient's pupil.
d. check for equal opening of the eyelids. - Answer Answer: B
