NUR 101 ACTUAL Exam 1 WITH QUESTIONS AND CORRECT VERIFIED AND DETAILED
ANSWERS WITH RATIONAL GRADED A+ [ BRAND NEW!!!!!
A patient tells the nurse, Im having a lot of pain in my hip. Which response by the nurse is open-ended
and would stimulate the patient to provide the most complete data? Choose all that are correct.
1) Is your pain severe?
2) Tell me about your pain.
3) When did you first notice this pain?
4) How would you describe your pain? - (answer)ANS:
2) Tell me about your pain.
4) How would you describe your pain?
The responses Tell me about your pain and How would you describe your pain? are open-ended
responses that stimulate conversation. Although it is important information, the question Is your pain
severe? prompts a yes or no response. When did you first notice this pain?also important informationis
likely to stimulate a brief, factual answer. Such questions allow the nurse to control the patients
response. Limiting the response might lead to an incomplete assessment.
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 - (answer)ANS: 3) 102
Heart rate increases about 10 beats per minute for each degree of temperature to meet increased
metabolic needs and compensate for peripheral dilation.
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
,NUR 101 ACTUAL Exam 1 WITH QUESTIONS AND CORRECT VERIFIED AND DETAILED
ANSWERS WITH RATIONAL GRADED A+ [ BRAND NEW!!!!!
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 - (answer)ANS: 1) Compare the left pedal
pulse with the right pedal pulse
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.
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. - (answer)ANS: 2) Request the client take a deep
breath and cough.
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.
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
,NUR 101 ACTUAL Exam 1 WITH QUESTIONS AND CORRECT VERIFIED AND DETAILED
ANSWERS WITH RATIONAL GRADED A+ [ BRAND NEW!!!!!
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 - (answer)ANS: 2) Adolescent: T 98.2F (oral), HR
80, RR 18, BP 108/68
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.
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 - (answer)ANS: 1)Decreased blood pressure
(BP) after standing up
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.
PTS:1DIF:ModerateREF:p. 439 for hypotension information but should read content about all of the vital
signs
The clients temperature is 101.1F. Which is the correct conversion to centigrade?
1)38.0C
, NUR 101 ACTUAL Exam 1 WITH QUESTIONS AND CORRECT VERIFIED AND DETAILED
ANSWERS WITH RATIONAL GRADED A+ [ BRAND NEW!!!!!
2)38.4C
3)38.8C
4)39.2C - (answer)ANS: 2) 38.4C
To convert Fahrenheit to centigrade, subtract 32 from the temperature, and multiply by 5/9.
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 - (answer)ANS: 4) Remittent
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.
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 - (answer)ANS: 2) 18
ANSWERS WITH RATIONAL GRADED A+ [ BRAND NEW!!!!!
A patient tells the nurse, Im having a lot of pain in my hip. Which response by the nurse is open-ended
and would stimulate the patient to provide the most complete data? Choose all that are correct.
1) Is your pain severe?
2) Tell me about your pain.
3) When did you first notice this pain?
4) How would you describe your pain? - (answer)ANS:
2) Tell me about your pain.
4) How would you describe your pain?
The responses Tell me about your pain and How would you describe your pain? are open-ended
responses that stimulate conversation. Although it is important information, the question Is your pain
severe? prompts a yes or no response. When did you first notice this pain?also important informationis
likely to stimulate a brief, factual answer. Such questions allow the nurse to control the patients
response. Limiting the response might lead to an incomplete assessment.
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 - (answer)ANS: 3) 102
Heart rate increases about 10 beats per minute for each degree of temperature to meet increased
metabolic needs and compensate for peripheral dilation.
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
,NUR 101 ACTUAL Exam 1 WITH QUESTIONS AND CORRECT VERIFIED AND DETAILED
ANSWERS WITH RATIONAL GRADED A+ [ BRAND NEW!!!!!
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 - (answer)ANS: 1) Compare the left pedal
pulse with the right pedal pulse
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.
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. - (answer)ANS: 2) Request the client take a deep
breath and cough.
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.
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
,NUR 101 ACTUAL Exam 1 WITH QUESTIONS AND CORRECT VERIFIED AND DETAILED
ANSWERS WITH RATIONAL GRADED A+ [ BRAND NEW!!!!!
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 - (answer)ANS: 2) Adolescent: T 98.2F (oral), HR
80, RR 18, BP 108/68
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.
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 - (answer)ANS: 1)Decreased blood pressure
(BP) after standing up
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.
PTS:1DIF:ModerateREF:p. 439 for hypotension information but should read content about all of the vital
signs
The clients temperature is 101.1F. Which is the correct conversion to centigrade?
1)38.0C
, NUR 101 ACTUAL Exam 1 WITH QUESTIONS AND CORRECT VERIFIED AND DETAILED
ANSWERS WITH RATIONAL GRADED A+ [ BRAND NEW!!!!!
2)38.4C
3)38.8C
4)39.2C - (answer)ANS: 2) 38.4C
To convert Fahrenheit to centigrade, subtract 32 from the temperature, and multiply by 5/9.
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 - (answer)ANS: 4) Remittent
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.
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 - (answer)ANS: 2) 18
