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NUR 101 Exam 1fully solved & updated(GUARANTEED SUCCESS).
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NUR 101 : Exam 1fully solved& updated(GUARANTEED
SUCCESS)
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
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
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