NUR 204 EXAM 1 QUESTIONS WITH CORRECT ANSWERS
1. A clients vital signs at the beginning of the shift are as follows: oral temperature
99.3F (37C), heart rate 82 beats/min, respiratory rate 14 breaths/min, and blood
pressure 118/76 mm Hg. Four hours later the clients oral temperature is 102.2F
(39C). Based on the temperature change, the nurse should anticipate the clients
heart rate would be how many beats/min?
1) 62
2) 82
3) 102
4) 122 -- Correct Answer ✔✔ 3
Heart rate increases about 10 beats per minute for each degree of temperature to
meet increased metabolic needs and compensate for peripheral dilation.
2. The nurse is assessing vital signs for a client after surgical procedure on the left leg.
IV fluids are infusing. It would be most important for the nurse to
1) Compare the left pedal pulse with the right pedal pulse
2) Count the clients respiratory rate for 1 full minute
3) Take the blood pressure in the arm without an IV
4) Take an oral temperature with an electronic thermometer -- Correct
Answer ✔✔ 1
For a client having surgery on the leg, the most important data would be whether
the circulation has been compromised because of the surgery. This can be done
only by comparing one leg with the other. The nurse would, of course, count the
respiratory rate for 1 full minute and take the BP in the arm without the IV. Oral
temperatures are commonly obtained using electronic thermometers.
3. The nurse hears rhonchi when auscultating a clients lungs. Which nursing
intervention would be appropriate for the nurse to implement before reassessing
lung sounds?
, 1) Have the client take several deep breaths.
2) Request the client take a deep breath and cough.
3) Take the clients blood pressure and apical pulse.
4) Count the clients respiratory rate for 1 minute. -- Correct Answer ✔✔ 2
Rhonchi are caused by secretions in the large airways and may clear with coughing.
This is how you differentiate between rhonchi and other adventitious sounds. Deep
breathing will not help to clear rhonchi. Taking the blood pressure and apical pulse
and counting the respiratory rate are not effective for clearing rhonchi and would
not be sufficient for the nurse to identify whether the sounds were, indeed,
rhonchi.
4. Which of the following sets of vital signs are all within normal limits for patients at
rest?
1) Infant: T 98.8F (rectal), HR 160, RR 16, BP 120/54
2) Adolescent: T 98.2F (oral), HR 80, RR 18, BP 108/68
3) Adult: T 99.6F (oral), HR 48, RR 22, BP 130/84
4) Older adult: T 98.6F (oral), HR 110, RR 28, BP 170/95 -- Correct Answer
✔✔ 2
All of the adolescents vital signs are within normal parameters for the age. The
infants temperature is below normal for a rectal reading because the core
temperature is approximately 1 degree higher than readings from other sites. The
heart rate (HR) for an infant is high, the respiratory rate (RR) is low, and the blood
pressure (BP) is high for the age. For the typical adult, the temperature is high, the
HR is low, the RR is high, and the BP is elevated for the age. For the older adult,
the temperature is high-end normal, the HR is high, the RR is high, and the BP is
high for the age.
5. The nurse assesses the following changes in a clients vital signs. Which client
situation should be reported to the primary care provider?
1) Decreased blood pressure (BP) after standing up
2) Decreased temperature after a period of diaphoresis
3) Increased heart rate after walking down the hall
4) Increased respiratory rate when the heart rate increases -- Correct Answer
✔✔ 1
, A drop in the clients blood pressure when standing indicates orthostatic
hypotension, and the cause should be investigated. The changes in vital signs
indicated in the other options are normal changes for the situations.
6. The clients temperature is 101.1F. Which is the correct conversion to centigrade?
1) 38.0C
2) 38.4C
3) 38.8C
4) 39.2C -- Correct Answer ✔✔ 2
To convert Fahrenheit to centigrade, subtract 32 from the temperature, and
multiply by 5/9.
7. The client has had a fever, ranging from 99.8F orally to 103F orally, over the last 24
hours. The clients fever would be classified as
1) Constant
2) Intermittent
3) Relapsing
4) Remittent -- Correct Answer ✔✔ 4
Remittent fevers fluctuate widely over a 24-hour period. Constant fevers stay
above normal with only slight fluctuations. Intermittent fevers alternate between
normal or subnormal temperatures with periods of fever. Relapsing fevers alternate
between periods of fever and periods of normal temperature, each phase lasting 1
to 2 days.
8. A clients vital signs 4 hours ago were temperature (oral) 101.4F (38.6C), heart rate
110 beats/min, respiratory rate 26 breaths/min, and blood pressure 124/78 mm Hg.
The temperature is now 99.4F (37.4C). Based only on the expected relationship
between temperature and respiratory rate, the nurse might best anticipate the
clients respiratory rate to be
1) 16
2) 18
3) 20
4) 22 -- Correct Answer ✔✔ 2
, For every degree Fahrenheit (0.6C) the temperature falls, the respiratory rate may
decrease up to 4 breaths per minute. The clients temperature has fallen 2 degrees;
multiplied by 4, this is 8. It was 26 breaths/min: 26 8 = 18 breaths/min. Keep in
mind, this is an estimate and would vary depending on the patients baseline health,
current condition, age, and other factors.
9. Which one of the following clients would probably have a higher than normal
respiratory rate? A client who has
1) Had surgery and is receiving a narcotic analgesic
2) Had surgery and lost a unit of blood intraoperatively
3) Lived at a high altitude and then moved to sea level
4) Been exposed to the cold and is now hypothermic -- Correct Answer ✔✔
2
A reduction in hemoglobin from blood loss would increase the respiratory rate.
Narcotics and hypothermia slow the respiratory rate. Going from lower altitudes
to higher altitudes inhibits oxygen binding, so going to a lower altitude would
decrease the respiratory rate or have no effect. Hypothermia decreases the
metabolic rate, so the respiratory rate would likely decrease.
10. For which of the following adult clients should the nurse make follow-up
observations and monitor the vital signs closely? A client whose
1) Resting morning blood pressure is 136/86 while the afternoon BP is 128/84
mm Hg
2) Oral temperature is 97.9F in the morning and 99.8F in the evening
3) Heart rate was 76 beats/min before eating and 88 beats/min after eating
4) Respiratory rate is 16 breaths/min when standing and 18 when lying down --
Correct Answer ✔✔ 1
Both the blood pressures would be classified as prehypertension according to the
JNC 7 Express guidelines. Body temperature normally increases during the course
of a day. Heart rate increases for several hours after eating. Respiratory depth
decreases when lying down, so it would be normal for the rate would increase;
both rates are within normal limits.
1. A clients vital signs at the beginning of the shift are as follows: oral temperature
99.3F (37C), heart rate 82 beats/min, respiratory rate 14 breaths/min, and blood
pressure 118/76 mm Hg. Four hours later the clients oral temperature is 102.2F
(39C). Based on the temperature change, the nurse should anticipate the clients
heart rate would be how many beats/min?
1) 62
2) 82
3) 102
4) 122 -- Correct Answer ✔✔ 3
Heart rate increases about 10 beats per minute for each degree of temperature to
meet increased metabolic needs and compensate for peripheral dilation.
2. The nurse is assessing vital signs for a client after surgical procedure on the left leg.
IV fluids are infusing. It would be most important for the nurse to
1) Compare the left pedal pulse with the right pedal pulse
2) Count the clients respiratory rate for 1 full minute
3) Take the blood pressure in the arm without an IV
4) Take an oral temperature with an electronic thermometer -- Correct
Answer ✔✔ 1
For a client having surgery on the leg, the most important data would be whether
the circulation has been compromised because of the surgery. This can be done
only by comparing one leg with the other. The nurse would, of course, count the
respiratory rate for 1 full minute and take the BP in the arm without the IV. Oral
temperatures are commonly obtained using electronic thermometers.
3. The nurse hears rhonchi when auscultating a clients lungs. Which nursing
intervention would be appropriate for the nurse to implement before reassessing
lung sounds?
, 1) Have the client take several deep breaths.
2) Request the client take a deep breath and cough.
3) Take the clients blood pressure and apical pulse.
4) Count the clients respiratory rate for 1 minute. -- Correct Answer ✔✔ 2
Rhonchi are caused by secretions in the large airways and may clear with coughing.
This is how you differentiate between rhonchi and other adventitious sounds. Deep
breathing will not help to clear rhonchi. Taking the blood pressure and apical pulse
and counting the respiratory rate are not effective for clearing rhonchi and would
not be sufficient for the nurse to identify whether the sounds were, indeed,
rhonchi.
4. Which of the following sets of vital signs are all within normal limits for patients at
rest?
1) Infant: T 98.8F (rectal), HR 160, RR 16, BP 120/54
2) Adolescent: T 98.2F (oral), HR 80, RR 18, BP 108/68
3) Adult: T 99.6F (oral), HR 48, RR 22, BP 130/84
4) Older adult: T 98.6F (oral), HR 110, RR 28, BP 170/95 -- Correct Answer
✔✔ 2
All of the adolescents vital signs are within normal parameters for the age. The
infants temperature is below normal for a rectal reading because the core
temperature is approximately 1 degree higher than readings from other sites. The
heart rate (HR) for an infant is high, the respiratory rate (RR) is low, and the blood
pressure (BP) is high for the age. For the typical adult, the temperature is high, the
HR is low, the RR is high, and the BP is elevated for the age. For the older adult,
the temperature is high-end normal, the HR is high, the RR is high, and the BP is
high for the age.
5. The nurse assesses the following changes in a clients vital signs. Which client
situation should be reported to the primary care provider?
1) Decreased blood pressure (BP) after standing up
2) Decreased temperature after a period of diaphoresis
3) Increased heart rate after walking down the hall
4) Increased respiratory rate when the heart rate increases -- Correct Answer
✔✔ 1
, A drop in the clients blood pressure when standing indicates orthostatic
hypotension, and the cause should be investigated. The changes in vital signs
indicated in the other options are normal changes for the situations.
6. The clients temperature is 101.1F. Which is the correct conversion to centigrade?
1) 38.0C
2) 38.4C
3) 38.8C
4) 39.2C -- Correct Answer ✔✔ 2
To convert Fahrenheit to centigrade, subtract 32 from the temperature, and
multiply by 5/9.
7. The client has had a fever, ranging from 99.8F orally to 103F orally, over the last 24
hours. The clients fever would be classified as
1) Constant
2) Intermittent
3) Relapsing
4) Remittent -- Correct Answer ✔✔ 4
Remittent fevers fluctuate widely over a 24-hour period. Constant fevers stay
above normal with only slight fluctuations. Intermittent fevers alternate between
normal or subnormal temperatures with periods of fever. Relapsing fevers alternate
between periods of fever and periods of normal temperature, each phase lasting 1
to 2 days.
8. A clients vital signs 4 hours ago were temperature (oral) 101.4F (38.6C), heart rate
110 beats/min, respiratory rate 26 breaths/min, and blood pressure 124/78 mm Hg.
The temperature is now 99.4F (37.4C). Based only on the expected relationship
between temperature and respiratory rate, the nurse might best anticipate the
clients respiratory rate to be
1) 16
2) 18
3) 20
4) 22 -- Correct Answer ✔✔ 2
, For every degree Fahrenheit (0.6C) the temperature falls, the respiratory rate may
decrease up to 4 breaths per minute. The clients temperature has fallen 2 degrees;
multiplied by 4, this is 8. It was 26 breaths/min: 26 8 = 18 breaths/min. Keep in
mind, this is an estimate and would vary depending on the patients baseline health,
current condition, age, and other factors.
9. Which one of the following clients would probably have a higher than normal
respiratory rate? A client who has
1) Had surgery and is receiving a narcotic analgesic
2) Had surgery and lost a unit of blood intraoperatively
3) Lived at a high altitude and then moved to sea level
4) Been exposed to the cold and is now hypothermic -- Correct Answer ✔✔
2
A reduction in hemoglobin from blood loss would increase the respiratory rate.
Narcotics and hypothermia slow the respiratory rate. Going from lower altitudes
to higher altitudes inhibits oxygen binding, so going to a lower altitude would
decrease the respiratory rate or have no effect. Hypothermia decreases the
metabolic rate, so the respiratory rate would likely decrease.
10. For which of the following adult clients should the nurse make follow-up
observations and monitor the vital signs closely? A client whose
1) Resting morning blood pressure is 136/86 while the afternoon BP is 128/84
mm Hg
2) Oral temperature is 97.9F in the morning and 99.8F in the evening
3) Heart rate was 76 beats/min before eating and 88 beats/min after eating
4) Respiratory rate is 16 breaths/min when standing and 18 when lying down --
Correct Answer ✔✔ 1
Both the blood pressures would be classified as prehypertension according to the
JNC 7 Express guidelines. Body temperature normally increases during the course
of a day. Heart rate increases for several hours after eating. Respiratory depth
decreases when lying down, so it would be normal for the rate would increase;
both rates are within normal limits.
