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NUR 101 Exam 1 Questions and Answers Latest Update
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NUR 101 Exam 1 Questions andAnswers Latest Update
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 information is 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
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
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
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
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.
, 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 - Answer-ANS: 2) Had surgery and
lost a unit of blood intraoperatively
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.
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 - Answer-
ANS: 1) Resting morning blood pressure is 136/86 while the afternoon BP is 128/84 mm
Hg
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.
A client who has been hospitalized for an infection states, The nursing assistant told me
my vital signs are all within normal limits; that means Im cured. The nurses best
response would be which of the following?
1) Your vital signs confirm that your infection is resolved; how do you feel?
2) Ill let your healthcare provider know so you can be discharged.
3) Your vital signs are stable, but there are other things to assess.
4) We still need to keep monitoring your temperature for a while. - Answer-ANS: 3) Your
vital signs are stable, but there are other things to assess.
Vital signs are one indicator of a clients physiological status, but they are not an
absolute indicator of well-being from every aspect. It may be inaccurate to state that the
vital signs indicate the infection is resolved; vital signs could stabilize even if the
infection remains active. The healthcare providers decision regarding the clients
readiness for discharge is not based exclusively on the vital signs but rather is based on
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