RNRS 117 EXAM 2 QUESTIONS AND ANSWERS WITH
COMPLETE SOLUTIONS GRADED A++
Which range is acceptable for an adult diastolic pressure?
Less than 80 mm Hg
At what age in years does the respiratory system begin to decline in healthy
people?
25
While assessing the oral temperature of a patient using an electronic
thermometer, why would the nurse ask the pt to close their lips?
To maintain proper position of the probe
The nurse locates different anatomical landmarks to identify the point of the
apical impulse. What is the rationale behind this nursing action?
To hear heart sounds clearly
When taking a rectal temperature, why would the nurse angle the probe up
towards the umbilicus?
Ensuring exposure to blood vessels
How would the nurse determine the ventilatory rhythm of a patient?
Observing the pattern of breathing
While assessing axillary temperature, for which reason would the nurse raise the
patient's arm away from the torso?
To inspect for the presence of lesions
,The nurse has difficulty hearing the heart sounds of a patient who is 80 years old.
Which factor explains the muffled heart sounds?
Increased air space in the lungs
What is kyphosis?
Exaggerated thoracic curvature
Which consequence may occur in an older patient due to kyphosis?
Restricted chest expansion
Why would the nurse inflate the blood pressure cuff 30 mm Hg over the point in
which the distal pulse disappears?
To prevent a false low reading
Which assessment would the nurse perform before obtaining body temperature?
Identify medications and treatments, determine pertinent laboratory values, collect
previous baseline body temperature
Which intervention would the nurse perform after determining that the pt's BP is
inadequate for perfusion?
Placing the pt in supine position., which enhances circulation
Which statements are true regarding the factors affecting the vital signs of older
adults?
Pay attention to subtle temperature changes, decrease in sweat gland activity can lead
to hyperthermia
What BP finding would be abnormal for an 80-year-old pt?
Decreased systolic blood pressure
, What is a normal reference range for carbon dioxide concentration from exhaled
air (ETCO2)?
35-45 mm Hg
What factor in older adults would cause the nurse to have trouble identifying a
pulse oximeter probe site?
Anemia, decreased cardiac output, cold-induced vasoconstriction
What position would promote comfort for a patient receiving a rectal
temperature?
Side-lying
Which vital sign can be altered due to decreased sweat gland activity in an older
adult?
Temperature
What is the reference range for oral temperatures for an older adult?
96.8-100F
What is the reference range for rectal temperatures for an older adult?
96.8-99.5F
What is the average tympanic body temperature for an adult?
98.6F
Why would the nurse raise the HOB to 60 degrees when assessing a pt's
respiration?
To promote ventilatory movement
What does cerumen do to a temperature reading?
Distorts them
COMPLETE SOLUTIONS GRADED A++
Which range is acceptable for an adult diastolic pressure?
Less than 80 mm Hg
At what age in years does the respiratory system begin to decline in healthy
people?
25
While assessing the oral temperature of a patient using an electronic
thermometer, why would the nurse ask the pt to close their lips?
To maintain proper position of the probe
The nurse locates different anatomical landmarks to identify the point of the
apical impulse. What is the rationale behind this nursing action?
To hear heart sounds clearly
When taking a rectal temperature, why would the nurse angle the probe up
towards the umbilicus?
Ensuring exposure to blood vessels
How would the nurse determine the ventilatory rhythm of a patient?
Observing the pattern of breathing
While assessing axillary temperature, for which reason would the nurse raise the
patient's arm away from the torso?
To inspect for the presence of lesions
,The nurse has difficulty hearing the heart sounds of a patient who is 80 years old.
Which factor explains the muffled heart sounds?
Increased air space in the lungs
What is kyphosis?
Exaggerated thoracic curvature
Which consequence may occur in an older patient due to kyphosis?
Restricted chest expansion
Why would the nurse inflate the blood pressure cuff 30 mm Hg over the point in
which the distal pulse disappears?
To prevent a false low reading
Which assessment would the nurse perform before obtaining body temperature?
Identify medications and treatments, determine pertinent laboratory values, collect
previous baseline body temperature
Which intervention would the nurse perform after determining that the pt's BP is
inadequate for perfusion?
Placing the pt in supine position., which enhances circulation
Which statements are true regarding the factors affecting the vital signs of older
adults?
Pay attention to subtle temperature changes, decrease in sweat gland activity can lead
to hyperthermia
What BP finding would be abnormal for an 80-year-old pt?
Decreased systolic blood pressure
, What is a normal reference range for carbon dioxide concentration from exhaled
air (ETCO2)?
35-45 mm Hg
What factor in older adults would cause the nurse to have trouble identifying a
pulse oximeter probe site?
Anemia, decreased cardiac output, cold-induced vasoconstriction
What position would promote comfort for a patient receiving a rectal
temperature?
Side-lying
Which vital sign can be altered due to decreased sweat gland activity in an older
adult?
Temperature
What is the reference range for oral temperatures for an older adult?
96.8-100F
What is the reference range for rectal temperatures for an older adult?
96.8-99.5F
What is the average tympanic body temperature for an adult?
98.6F
Why would the nurse raise the HOB to 60 degrees when assessing a pt's
respiration?
To promote ventilatory movement
What does cerumen do to a temperature reading?
Distorts them
