NUR 101 : Exam 1 p p p p
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1. A patient tells the nurse, Im having a lot of pain in my hip. Which response by th
p p p p p p p p p p p p p p p p p
e nurse is open-
p p p
ended and would stimulate the patient to provide the most complete data? Ch
p p p p p p p p p p p p
oose all that are correct.
p p p p
1) Is your pain severe?
p p p
2) Tell me about your pain. p p p p
3) When did you first notice this pain? p p p p p p
4) How would you describe your pain?: ANS:
p p p p p p
2) Tell me about your pain. p p p p
4) How would you describe your pain?
p p p p p p
The responses Tell me about your pain and How would you describe your pain? are o
p p p p p p p p p p p p p p p
pen-
ended responses that stimulate conversation. Although it is important information, th
p p p p p p p p p p
e question Is your pain severe? prompts a yes or no response. When did you first notic
p p p p p p p p p p p p p p p p
e this pain?also important informationis likely to stimulate a brief, factual answer. Suc
p p p p p p p p p p p p
h questions allow the nurse to control the patients response.
p p p p p p p p p
Limiting the response might lead to an incomplete assessment.
p p p p p p p p
2. A clients vital signs at the beginning of the shift are as follows: oral temper-
p p p p p p p p p p p p p p
pature 99.3F (37C), heart rate 82 beats/min, respiratory rate 14 breaths/min, and b
p p p p p p p p p p p p
lood pressure 118/76 mm Hg. Four hours later the clients oral temperature is 10
p p p p p p p p p p p p p
2.2F (39C). Based on the temperature change, the nurse should anticipate the
p p p p p p p p p p p p
clients heart rate would be how many beats/min?
p p p p p p p
1) 62 p
2) 82 p
3) 102
4) 122: ANS: 3) 102 p p p
Heart rate increases about 10 beats per minute for each degree of temperature to mee
p p p p p p p p p p p p p p
increased metabolic needs and compensate for peripheral dilation.
p p p p p p p
3. The nurse is assessing vital signs for a client after surgical procedure on th
p p p p p p p p p p p p p
e left leg. IV fluids are infusing. It would be most important for the nurse to
p p p p p p p p p p p p p p p
1) Compare the left pedal pulse with the right pedal pulse p p p p p p p p p
2) Count the clients respiratory rate for 1 full minute
p p p p p p p p
3) Take the blood pressure in the arm without an IV
p p p p p p p p p
4) Take an oral temperature with an electronic thermometer: ANS: 1) Compare th
p p p p p p p p p p p
e left pedal pulse with the right pedal pulse
p p p p p p p p
1p/p84
, NUR 101 : Exam 1
p p p p
Studyponlinepatphttps://quizlet.com/_8mgkel
For a client having surgery on the leg, the most important data would be whether the
p p p p p p p p p p p p p p p
2p/p84
, NUR 101 : Exam 1 p p p p
Studyponlinepatphttps://quizlet.com/_8mgkel
circulation has been compromised because of the surgery.This can be done only by co
p p p p p p p p p p p p p p
mparing one leg with the other. The nurse would, of course, count the respiratory rate f
p p p p p p p p p p p p p p p
or 1 full minute and take the BP in the arm without the IV. Oral temperatures are com
p p p p p p p p p p p p p p p p p
monly obtained using electronic thermometers.
p p p p
4. The nurse hears rhonchi when auscultating a clients lungs. Which nursing i
p p p p p p p p p p p
ntervention would be appropriate for the nurse to implement before reassess-p p p p p p p p p p
ing lung sounds?
p p p
1) Have the client take several deep breaths. p p p p p p
2) Request the client take a deep breath and cough. p p p p p p p p
3) Take the clients blood pressure and apical pulse.
p p p p p p p
4) Count the clients respiratory rate for 1 minute.: ANS: 2) Request the client ta
p p p p p p p p p p p p p
ke a deep breath and cough.
p p p p p
Rhonchi are caused by secretions in the large airways and may clear with coughing. Th
p p p p p p p p p p p p p p
is how you differentiate between rhonchi and other adventitious sounds. Deep breathi
p p p p p p p p p p p
g will not help to clear rhonchi. Taking the blood pressure and apical pulse and countin
p p p p p p p p p p p p p p p
the respiratory rate are not effective for clearing rhonchi and would not be sufficient for t
p p p p p p p p p p p p p p p
e nurse to identify whether the sounds were, indeed, rhonchi.
p p p p p p p p p
5. Which of the following sets of vital signs are all within normal limits for p
p p p p p p p p p p p p p p
atients at rest? p p
1) Infant: T 98.8F (rectal), HR 160, RR 16, BP 120/54 p p p p p p p p p
2) Adolescent: T 98.2F (oral), HR 80, RR 18, BP 108/68 p p p p p p p p p
3) Adult: T 99.6F (oral), HR 48, RR 22, BP 130/84 p p p p p p p p p
4) Older adult: T 98.6F (oral), HR 110, RR 28, BP 170/95: ANS: 2) Adolescent: T
p p p p p p p p p p p p p p
98.2F (oral), HR 80, RR 18, BP 108/68
p p p p p p p
All of the adolescents vital signs are within normal parameters for the age. The in-
p p p p p p p p p p p p p p
pfants temperature is below normal for a rectal reading because the core temperature is
p p p p p p p p p p p p p p
approximately 1 degree higher than readings from other sites.The heart rate (HR) for a p p p p p p p p p p p p p p
n infant is high, the respiratory rate (RR) is low, and the blood pressure (BP) is high for
p p p p p p p p p p p p p p p p p p
the age. For the typical adult, the temperature is high, the HR is low, the RR is high, and
p p p p p p p p p p p p p p p p p p
pthe BP is elevated for the age. For the older adult, the temperature is high-
p p p p p p p p p p p p p p
end normal, the HR is high, the RR is high, and the BP is high for the age.
p p p p p p p p p p p p p p p p p
6. The nurse assesses the following changes in a clients vital signs. Which cl
p p p p p p p p p p p p
ient situation should be reported to the primary care provider?
p p p p p p p p p
1) Decreased blood pressure (BP) after standing up p p p p p p
3p/p84
, NUR 101 : Exam 1 p p p p
Studyponlinepatphttps://quizlet.com/_8mgkel
2) Decreased temperature after a period of diaphoresis p p p p p p p
3)Increased heart rate after walking down the hall p p p p p p p
4)Increased respiratory rate when the heart rate increases: ANS: 1)Decreased blp p p p p p p p p p
od pressure (BP) after standing up
p p p p p
A drop in the clients blood pressure when standing indicates orthostatic hypotension, an
p p p p p p p p p p p p
the cause should be investigated. The changes in vital signs indicated in the other opt
p p p p p p p p p p p p p p
ns are normal changes for the situations.
p p p p p p
PTS:1DIF:ModerateREF:p. 439 for hypotension information but should read content ab p p p p p p p p p
out all of the vital signs p p p p p
7. The clients temperature is 101.1F. Which is the correct conversion to centi-
p p p p p p p p p p p
pgrade?
1) 38.0C
2) 38.4C
3) 38.8C
4) 39.2C: ANS: 2) 38.4C p p p
To convert Fahrenheit to centigrade, subtract 32 from the temperature, and multiply by
p p p p p p p p p p p p
5/9.
p
8. The client has had a fever, ranging from 99.8F orally to 103F orally, over the la
p p p p p p p p p p p p p p p
st 24 hours. The clients fever would be classified as
p p p p p p p p p
1) Constant 2) p
Intermittent 3 p
)Relapsing
4)Remittent: ANS: 4) Remittent p p p
Remittent fevers fluctuate widely over a 24- p p p p p p
hour period. Constant fevers stay above normal with only slight fluctuations. Intermitte
p p p p p p p p p p p
fevers alternate between normal or subnormal temperatures with periods of fever. Re
p p p p p p p p p p p p
apsing fevers alternate between periods of fever and periods of normal temperature, e
p p p p p p p p p p p p
ch phase lasting 1 to 2 days.
p p p p p p
9. A clients vital signs 4 hours ago were temperature (oral) 101.4F (38.6C), hear
p p p p p p p p p p p p
t rate 110 beats/min, respiratory rate 26 breaths/min, and blood pressure 124/7
p p p p p p p p p p p
8 mm Hg. The temperature is now 99.4F (37.4C). Based only on the expected rel
p p p p p p p p p p p p p p
ationship between temperature and respiratory rate, the nurse might best anti
p p p p p p p p p p
cipate the clients respiratory rate to be p p p p p p
1)16
4p/p84
Studyponlinepatphttps://quizlet.com/_8mgkel
1. A patient tells the nurse, Im having a lot of pain in my hip. Which response by th
p p p p p p p p p p p p p p p p p
e nurse is open-
p p p
ended and would stimulate the patient to provide the most complete data? Ch
p p p p p p p p p p p p
oose all that are correct.
p p p p
1) Is your pain severe?
p p p
2) Tell me about your pain. p p p p
3) When did you first notice this pain? p p p p p p
4) How would you describe your pain?: ANS:
p p p p p p
2) Tell me about your pain. p p p p
4) How would you describe your pain?
p p p p p p
The responses Tell me about your pain and How would you describe your pain? are o
p p p p p p p p p p p p p p p
pen-
ended responses that stimulate conversation. Although it is important information, th
p p p p p p p p p p
e question Is your pain severe? prompts a yes or no response. When did you first notic
p p p p p p p p p p p p p p p p
e this pain?also important informationis likely to stimulate a brief, factual answer. Suc
p p p p p p p p p p p p
h questions allow the nurse to control the patients response.
p p p p p p p p p
Limiting the response might lead to an incomplete assessment.
p p p p p p p p
2. A clients vital signs at the beginning of the shift are as follows: oral temper-
p p p p p p p p p p p p p p
pature 99.3F (37C), heart rate 82 beats/min, respiratory rate 14 breaths/min, and b
p p p p p p p p p p p p
lood pressure 118/76 mm Hg. Four hours later the clients oral temperature is 10
p p p p p p p p p p p p p
2.2F (39C). Based on the temperature change, the nurse should anticipate the
p p p p p p p p p p p p
clients heart rate would be how many beats/min?
p p p p p p p
1) 62 p
2) 82 p
3) 102
4) 122: ANS: 3) 102 p p p
Heart rate increases about 10 beats per minute for each degree of temperature to mee
p p p p p p p p p p p p p p
increased metabolic needs and compensate for peripheral dilation.
p p p p p p p
3. The nurse is assessing vital signs for a client after surgical procedure on th
p p p p p p p p p p p p p
e left leg. IV fluids are infusing. It would be most important for the nurse to
p p p p p p p p p p p p p p p
1) Compare the left pedal pulse with the right pedal pulse p p p p p p p p p
2) Count the clients respiratory rate for 1 full minute
p p p p p p p p
3) Take the blood pressure in the arm without an IV
p p p p p p p p p
4) Take an oral temperature with an electronic thermometer: ANS: 1) Compare th
p p p p p p p p p p p
e left pedal pulse with the right pedal pulse
p p p p p p p p
1p/p84
, NUR 101 : Exam 1
p p p p
Studyponlinepatphttps://quizlet.com/_8mgkel
For a client having surgery on the leg, the most important data would be whether the
p p p p p p p p p p p p p p p
2p/p84
, NUR 101 : Exam 1 p p p p
Studyponlinepatphttps://quizlet.com/_8mgkel
circulation has been compromised because of the surgery.This can be done only by co
p p p p p p p p p p p p p p
mparing one leg with the other. The nurse would, of course, count the respiratory rate f
p p p p p p p p p p p p p p p
or 1 full minute and take the BP in the arm without the IV. Oral temperatures are com
p p p p p p p p p p p p p p p p p
monly obtained using electronic thermometers.
p p p p
4. The nurse hears rhonchi when auscultating a clients lungs. Which nursing i
p p p p p p p p p p p
ntervention would be appropriate for the nurse to implement before reassess-p p p p p p p p p p
ing lung sounds?
p p p
1) Have the client take several deep breaths. p p p p p p
2) Request the client take a deep breath and cough. p p p p p p p p
3) Take the clients blood pressure and apical pulse.
p p p p p p p
4) Count the clients respiratory rate for 1 minute.: ANS: 2) Request the client ta
p p p p p p p p p p p p p
ke a deep breath and cough.
p p p p p
Rhonchi are caused by secretions in the large airways and may clear with coughing. Th
p p p p p p p p p p p p p p
is how you differentiate between rhonchi and other adventitious sounds. Deep breathi
p p p p p p p p p p p
g will not help to clear rhonchi. Taking the blood pressure and apical pulse and countin
p p p p p p p p p p p p p p p
the respiratory rate are not effective for clearing rhonchi and would not be sufficient for t
p p p p p p p p p p p p p p p
e nurse to identify whether the sounds were, indeed, rhonchi.
p p p p p p p p p
5. Which of the following sets of vital signs are all within normal limits for p
p p p p p p p p p p p p p p
atients at rest? p p
1) Infant: T 98.8F (rectal), HR 160, RR 16, BP 120/54 p p p p p p p p p
2) Adolescent: T 98.2F (oral), HR 80, RR 18, BP 108/68 p p p p p p p p p
3) Adult: T 99.6F (oral), HR 48, RR 22, BP 130/84 p p p p p p p p p
4) Older adult: T 98.6F (oral), HR 110, RR 28, BP 170/95: ANS: 2) Adolescent: T
p p p p p p p p p p p p p p
98.2F (oral), HR 80, RR 18, BP 108/68
p p p p p p p
All of the adolescents vital signs are within normal parameters for the age. The in-
p p p p p p p p p p p p p p
pfants temperature is below normal for a rectal reading because the core temperature is
p p p p p p p p p p p p p p
approximately 1 degree higher than readings from other sites.The heart rate (HR) for a p p p p p p p p p p p p p p
n infant is high, the respiratory rate (RR) is low, and the blood pressure (BP) is high for
p p p p p p p p p p p p p p p p p p
the age. For the typical adult, the temperature is high, the HR is low, the RR is high, and
p p p p p p p p p p p p p p p p p p
pthe BP is elevated for the age. For the older adult, the temperature is high-
p p p p p p p p p p p p p p
end normal, the HR is high, the RR is high, and the BP is high for the age.
p p p p p p p p p p p p p p p p p
6. The nurse assesses the following changes in a clients vital signs. Which cl
p p p p p p p p p p p p
ient situation should be reported to the primary care provider?
p p p p p p p p p
1) Decreased blood pressure (BP) after standing up p p p p p p
3p/p84
, NUR 101 : Exam 1 p p p p
Studyponlinepatphttps://quizlet.com/_8mgkel
2) Decreased temperature after a period of diaphoresis p p p p p p p
3)Increased heart rate after walking down the hall p p p p p p p
4)Increased respiratory rate when the heart rate increases: ANS: 1)Decreased blp p p p p p p p p p
od pressure (BP) after standing up
p p p p p
A drop in the clients blood pressure when standing indicates orthostatic hypotension, an
p p p p p p p p p p p p
the cause should be investigated. The changes in vital signs indicated in the other opt
p p p p p p p p p p p p p p
ns are normal changes for the situations.
p p p p p p
PTS:1DIF:ModerateREF:p. 439 for hypotension information but should read content ab p p p p p p p p p
out all of the vital signs p p p p p
7. The clients temperature is 101.1F. Which is the correct conversion to centi-
p p p p p p p p p p p
pgrade?
1) 38.0C
2) 38.4C
3) 38.8C
4) 39.2C: ANS: 2) 38.4C p p p
To convert Fahrenheit to centigrade, subtract 32 from the temperature, and multiply by
p p p p p p p p p p p p
5/9.
p
8. The client has had a fever, ranging from 99.8F orally to 103F orally, over the la
p p p p p p p p p p p p p p p
st 24 hours. The clients fever would be classified as
p p p p p p p p p
1) Constant 2) p
Intermittent 3 p
)Relapsing
4)Remittent: ANS: 4) Remittent p p p
Remittent fevers fluctuate widely over a 24- p p p p p p
hour period. Constant fevers stay above normal with only slight fluctuations. Intermitte
p p p p p p p p p p p
fevers alternate between normal or subnormal temperatures with periods of fever. Re
p p p p p p p p p p p p
apsing fevers alternate between periods of fever and periods of normal temperature, e
p p p p p p p p p p p p
ch phase lasting 1 to 2 days.
p p p p p p
9. A clients vital signs 4 hours ago were temperature (oral) 101.4F (38.6C), hear
p p p p p p p p p p p p
t rate 110 beats/min, respiratory rate 26 breaths/min, and blood pressure 124/7
p p p p p p p p p p p
8 mm Hg. The temperature is now 99.4F (37.4C). Based only on the expected rel
p p p p p p p p p p p p p p
ationship between temperature and respiratory rate, the nurse might best anti
p p p p p p p p p p
cipate the clients respiratory rate to be p p p p p p
1)16
4p/p84
