NURS 311 EXAM QUESTIONS AND
ANSWERS
What will the nurse instruct nursing assistive personnel (NAP) to do when measuring
a patient's rectal temperature using an electronic thermometer? - ANSWER-Use the
probe with the red tip.
what contraindicates taking a rectal temperature measurement - ANSWER-Patient
has painful and swollen hemorrhoids.
Which nursing action best evaluates the effectiveness of an antipyretic medication in
a patient with an oral temperature of 101.6°F? - ANSWER-Assess oral temperature
30 minutes after the agent is administered.
Which instruction might the nurse give to nursing assistive personal (NAP) that is
applicable only to tympanic temperature assessment? - ANSWER-Gently tug the
pinna backward, up, and out before inserting the probe.
Which instruction might the nurse give to nursing assistive personnel (NAP) that is
applicable only to temporal artery temperature assessment? - ANSWER-Place the
sensor flush on the patient's forehead.
During the admissions process, the nurse initially assesses the patient's radial pulse
primarily for what purpose? - ANSWER-Establishment of a baseline as part of the
patient's vital signs
What will the nurse instruct nursing assistive personal (NAP) to do when measuring
an adult patient's radial pulse? - ANSWER-Palpate the patient's inner wrist on the
thumb side with the fingertips of your two middle fingers.
What is the nurse's priority action if a patient's radial pulse has an irregular rhythm? -
ANSWER-Assess the patient for a pulse deficit.
Inadequate oxygenation to the body will cause the radial pulse to become: -
ANSWER-Tachycardic
Which action would best assess the effect of exercise on a patient's radial pulse
measurement? - ANSWER-Measuring the patient's radial pulse before and after
exercise
Which action can the nurse take to keep a patient from consciously controlling his or
her breathing during an assessment? - ANSWER-Assess respiration after measuring
the pulse.
On the last assessment of a patient's respiration, her respiratory rate was 10 breaths
per minute. What should the nurse do when conducting the next assessment of this
patient's respiratory rate? - ANSWER-Count breaths for 60 seconds.
, When measuring a patient's respiratory rate, the nurse will count the number of
completed respiratory cycles per minute. What is the definition of a respiratory cycle?
- ANSWER-The number of inspirations and expirations per minute.
During the assessment of a patient's respiratory rate, when the second hand reaches
the 15-second mark, the respiratory count is 8. What should the nurse do at this
time? - ANSWER-Continue to count the patient's breaths for a full 60 seconds.
The nurse plans to assess a patient's respiratory rate; however, the patient has just
returned from ambulating to the bathroom. What should the nurse do to minimize the
effect of exercise on the patient's respiratory rate? - ANSWER-Encourage the patient
to rest for 10 minutes before assessing respiration.
The nurse is preparing to assess a patient's blood pressure. What would cause the
blood pressure reading to be inaccurately high? - ANSWER-Blood pressure cuff is
too loose around the arm
What would cause the nurse to delay the assessment of a patient's blood pressure?
- ANSWER-Patient has just finished having a cigarette
The nurse has just measured a patient's blood pressure and is waiting 2 minutes to
measure the pressure again. What is the purpose of taking two measurements? -
ANSWER-Minimize the effect of anxiety
The nurse is teaching a patient about ways to reduce blood pressure. What will the
nurse include in these instructions? - ANSWER-Ensure that your diet has an
adequate daily intake of calcium.
Where should the nurse measure the blood pressure of a patient recovering from a
left-sided mastectomy? - ANSWER-Use the right arm to take the blood pressure.
The nurse is planning to measure a patient's blood pressure. What does the systolic
measurement represent? - ANSWER-The pressure exerted against the arterial wall.
You have assigned a new nursing assistive personnel (NAP) to take routine vital
signs. You notice that the NAP's last three patients have had unusually low blood
pressure that you have had to confirm. What is the most likely reason the NAP is
obtaining falsely low blood pressure readings? - ANSWER-The blood pressure cuff
is too wide for arm circumference.
What should the nurse do if the patient's blood pressure is not within normal limits? -
ANSWER-This is the correct response, because the patient must be assessed for
possible cardiovascular problems.
What would the nurse do to prevent the spread of infection when assessing a
patient's blood pressure? - ANSWER-Clean the stethoscope with alcohol before and
after using it.
ANSWERS
What will the nurse instruct nursing assistive personnel (NAP) to do when measuring
a patient's rectal temperature using an electronic thermometer? - ANSWER-Use the
probe with the red tip.
what contraindicates taking a rectal temperature measurement - ANSWER-Patient
has painful and swollen hemorrhoids.
Which nursing action best evaluates the effectiveness of an antipyretic medication in
a patient with an oral temperature of 101.6°F? - ANSWER-Assess oral temperature
30 minutes after the agent is administered.
Which instruction might the nurse give to nursing assistive personal (NAP) that is
applicable only to tympanic temperature assessment? - ANSWER-Gently tug the
pinna backward, up, and out before inserting the probe.
Which instruction might the nurse give to nursing assistive personnel (NAP) that is
applicable only to temporal artery temperature assessment? - ANSWER-Place the
sensor flush on the patient's forehead.
During the admissions process, the nurse initially assesses the patient's radial pulse
primarily for what purpose? - ANSWER-Establishment of a baseline as part of the
patient's vital signs
What will the nurse instruct nursing assistive personal (NAP) to do when measuring
an adult patient's radial pulse? - ANSWER-Palpate the patient's inner wrist on the
thumb side with the fingertips of your two middle fingers.
What is the nurse's priority action if a patient's radial pulse has an irregular rhythm? -
ANSWER-Assess the patient for a pulse deficit.
Inadequate oxygenation to the body will cause the radial pulse to become: -
ANSWER-Tachycardic
Which action would best assess the effect of exercise on a patient's radial pulse
measurement? - ANSWER-Measuring the patient's radial pulse before and after
exercise
Which action can the nurse take to keep a patient from consciously controlling his or
her breathing during an assessment? - ANSWER-Assess respiration after measuring
the pulse.
On the last assessment of a patient's respiration, her respiratory rate was 10 breaths
per minute. What should the nurse do when conducting the next assessment of this
patient's respiratory rate? - ANSWER-Count breaths for 60 seconds.
, When measuring a patient's respiratory rate, the nurse will count the number of
completed respiratory cycles per minute. What is the definition of a respiratory cycle?
- ANSWER-The number of inspirations and expirations per minute.
During the assessment of a patient's respiratory rate, when the second hand reaches
the 15-second mark, the respiratory count is 8. What should the nurse do at this
time? - ANSWER-Continue to count the patient's breaths for a full 60 seconds.
The nurse plans to assess a patient's respiratory rate; however, the patient has just
returned from ambulating to the bathroom. What should the nurse do to minimize the
effect of exercise on the patient's respiratory rate? - ANSWER-Encourage the patient
to rest for 10 minutes before assessing respiration.
The nurse is preparing to assess a patient's blood pressure. What would cause the
blood pressure reading to be inaccurately high? - ANSWER-Blood pressure cuff is
too loose around the arm
What would cause the nurse to delay the assessment of a patient's blood pressure?
- ANSWER-Patient has just finished having a cigarette
The nurse has just measured a patient's blood pressure and is waiting 2 minutes to
measure the pressure again. What is the purpose of taking two measurements? -
ANSWER-Minimize the effect of anxiety
The nurse is teaching a patient about ways to reduce blood pressure. What will the
nurse include in these instructions? - ANSWER-Ensure that your diet has an
adequate daily intake of calcium.
Where should the nurse measure the blood pressure of a patient recovering from a
left-sided mastectomy? - ANSWER-Use the right arm to take the blood pressure.
The nurse is planning to measure a patient's blood pressure. What does the systolic
measurement represent? - ANSWER-The pressure exerted against the arterial wall.
You have assigned a new nursing assistive personnel (NAP) to take routine vital
signs. You notice that the NAP's last three patients have had unusually low blood
pressure that you have had to confirm. What is the most likely reason the NAP is
obtaining falsely low blood pressure readings? - ANSWER-The blood pressure cuff
is too wide for arm circumference.
What should the nurse do if the patient's blood pressure is not within normal limits? -
ANSWER-This is the correct response, because the patient must be assessed for
possible cardiovascular problems.
What would the nurse do to prevent the spread of infection when assessing a
patient's blood pressure? - ANSWER-Clean the stethoscope with alcohol before and
after using it.
