NUR 204 Exam 1 Study Guide Questions With Complete Solutions.
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Course
NUR 204
Institution
NUR 204
The nurse is measuring blood pressures as part of a community health fair. Which blood pressure reading would cause the nurse to refer the patient for follow-up regarding hypertension?
a. 108/70
b. 116/78
c. 128/80
d. 138/88 - Answer D
A reading of 138/88 mm Hg has both systolic and diast...
NUR 204 Exam 1 Study Guide Questions
With Complete Solutions.
The nurse is measuring blood pressures as part of a community health fair. Which blood pressure
reading would cause the nurse to refer the patient for follow-up regarding hypertension?
a. 108/70
b. 116/78
c. 128/80
d. 138/88 - Answer D
A reading of 138/88 mm Hg has both systolic and diastolic pressures that are considered high and
classified as hypertension stage 1. This patient should be referred for additional readings. The other
readings are within normal limits, although all patients should be considered for health promotion
teaching regarding cardiac health, especially the patient with a blood pressure of 128/80 mm Hg, which
is in the elevated category.
The nurse is admitting a stable patient for a minor outpatient procedure. What site would the nurse
most commonly use to assess pulse rate?
a. Radial site
b. Apical site
c. Brachial site
d. Carotid site - Answer A
The radial site is the most easily accessible and most commonly used site for routine monitoring of pulse
rate for a stable patient. The apical site is a very accurate site but requires a stethoscope and access to
the chest of the patient. It is used when the pulse is irregular or when certain medication effects are
being monitored. The brachial artery can be used for infants and young children in emergency situations
and is used to palpate and auscultate blood pressure. A carotid pulse is used when a peripheral pulse
cannot be felt.
The unlicensed assistive personnel reports vital signs for a patient to the nurse: temperature of 99.2° F
(37.3° C) oral, pulse of 88 bpm and regular, respirations of 18 BPM and regular, blood pressure of
,178/112 mm Hg, and oxygen saturation of 96%. Which vital sign should the nurse be most concerned
about?
a. Temperature
b. Pulse
c. Respirations
d. Blood pressure - Answer D
The blood pressure is well above the expected normal of less than120/80 mm Hg and requires
immediate follow-up evaluation by the nurse. The temperature is within the normal range of 95.9° to
99.5° F for an oral reading. The pulse rate is within the normal range of 60 to 100 bpm. Respirations are
within the normal range of 12 to 20 BPM. The oxygen saturation is within the normal range of 95% to
100%.
From the nurse's understanding, which statements regarding temperature and heat production in the
body are accurate? (Select all that apply.)
a. Heat generates energy for cellular functions.
b. Hormones, such as thyroid hormones, decrease metabolism and heat production.
c. Exercise decreases heat production through muscular activity.
d. Expected temperature readings vary by the route selected for measurement.
e.Women tend to have more fluctuations in temperature than do men. - Answer a, d, e
Heat is a by-product of metabolism that supplies energy for cellular functions; there are expected
alterations in temperature readings depending on the route used—for example, the rectal temperature
is higher than the oral temperature; because of hormonal influences, women tend to have more
temperature fluctuations than men. Thyroid hormone increases metabolism and temperature. Muscular
activity from exercise increases temperature
The nurse is performing an initial assessment of a patient with a severe infection at hospital admission.
Vital signs for the patient indicate hypotension and tachycardia. Which data would support this
evaluation?
a. Pulse 78, blood pressure 140/88
b. Pulse 86, blood pressure 120/76
c. Pulse 100, blood pressure 118/68
, d. Pulse 114, blood pressure 88/56 - Answer D
A pulse over 100 is tachycardia; a blood pressure less than or equal to 88/56 is hypotension. All of the
other measurements of pulse are within normal limits for an adult, and the blood pressures are within
normal limits, except 140/88 mm Hg, which is hypertensive
The nurse places a patient with a high fever on a cooling blanket. How is heat loss achieved with this
treatment?
a. Radiation
b. Convection
c. Conduction
d. Evaporation - Answer C
Conduction is the transfer of heat from a warm object (the patient) to a cooler object (the cooling
blanket) during direct contact. Radiation is heat loss from one surface to another without direct contact.
Convection is the loss of heat from cool air flowing over a warm body. Evaporation is the conversion of a
liquid to a vapor, such as when perspiration evaporates.
Which clinical patient scenario is associated with the most critical need for the nurse to obtain vital
signs?
a. Ambulating for the first time after surgery
b. Complaining of pressure in the chest
c. Completing ambulating 100 feet after a stroke
d. Complaining of hunger while NPO (nothing by mouth) - Answer B
Chest pressure is a classic sign of a heart attack, and vital signs should be checked immediately. Vital
signs may be monitored before, during, or after activity, but this is not the most critical need. Unless the
vital signs have changed drastically, not having baseline values before ambulation makes it hard to
interpret vital signs after activity. Hunger is not a critical indicator for the need for obtaining vital signs.
The nurse understands that which statement is correct regarding respiratory rates?
a. Infants have a lower respiratory rate than adults.
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