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NUR101 / NUR 101 (Latest 2024 / 2025 Update) Health Assessment | Guide
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NUR101 / NUR 101 (Latest 2024 / 2025 Update) Health Assessment | Guide
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: NUR101 / NUR 101 (Latest Update) HealthAssessment | Guide
Which of the following actions by the nurse is the MOST appropriate means of
preventing infection?
A. Washing hands after client contact
B. Washing hands after removing gloves
C. Hand hygiene between clients
D. Hand hygiene before entry to a client's room and upon exit of a client's room -
ANSWER D. Hand hygiene before entry to a client's room and upon exit of a
client's room
The nurse witnesses another nurse, wearing a gown and gloves, enter a client room
labeled "Airborne Precautions". Which of the following actions by the witnessing
nurse is MOST appropriate?
A. Notify the nurse manager to discuss policies with the other nurse.
B. Ask a physician to give a presentation on which precautions require which types
of personal protective equipment (PPE).
C. Remind the other nurse that she needs a mask in addition to a gown and gloves
for airborne-type precautions.
D. Ask the other nurse to look up the policy about precautions. - ANSWER C.
Remind the other nurse that she needs a mask in addition to a gown and gloves for
airborne-type precautions.
The client who has a fever experienced significant diaphoresis during the night. The
client stated, "I am tired and I just want to sleep." What is the most appropriate action
for the nurse to do regarding bathing the client?
A. Consult with the physician before providing care
B. Give a complete bed bath
C. Postpone bathing until the afternoon
D. Wait until the client feels better - ANSWER B. Give a complete bed bath
The nurse is working with a middle-aged female after knee surgery. Ambulation is
still difficult for the client, and the physical therapist has suggested the client use a
cane. The nurse states which of the following with respect to using a cane rather
than a walker for this injury?
A. "The cane is just a reminder to use good posture."
B. "The cane can be more dangerous than helpful, and another type of assistive
device should be considered for this client."
C. "The cane will help with fatigue while assisting the client with balance and
support.
D. "A cane does not offer any relief on weight-bearing joints." - ANSWER C. "The
cane will help with fatigue while assisting the client with balance and support.
,An elderly client, who is not oriented to time, place or person, had a total hip
replacement. The client is attempting to get out of bed and pull out the IV line that is
infusing antibiotics. The client has bilateral soft wrist restraints and a vest restraint.
Which of the following interventions by the nurse are appropriate? Select all that
apply.
A. Ask the client if he needs to use the bathroom, and provide range-of-motion
exercises every 2 hours.
B. Document the type of restraint used and assess the need for continued use.
C. Tie the restraints to the side rail of the bed.
D. Obtain a new physician order for the restraint every 12 hours. - ANSWER A. Ask
the client if he needs to use the bathroom, and provide range-of-motion exercises
every 2 hours.
B. Document the type of restraint used and assess the need for continued use.
Which principle of body mechanics should the nurse implement when providing
nursing care?
A. Hold an object away from the body.
B. Extend the arms when lifting objects
C. Squat when lifting objects off the floor
D. Keep feet together when moving an object - ANSWER C. Squat when lifting
objects off the floor
A nurse needs to document a patients intake for the shift. Which of the following
items would be included in the total? Select all that apply.
A. 4 ounces of orange juice
B. 6 ounces of broth
C. 8 ounces of applesauce
D. 8 ounces of ice cream - ANSWER A. 4 ounces of orange juice
B. 6 ounces of broth
D. 8 ounces of ice cream
Which of the following procedure techniques has the most effect on the accuracy of
an apical pulse count?
A. Counting the rate for one full minute
B. Exposing only the left side of the chest
C. Determining why assessment of apical pulse is indicated
D. Using your ring finger to palpate the intercostal spaces - ANSWER A. Counting
the rate for one full minute
The nurse obtains the following vital signs on an adult patient: T: 100.6 F, BP:
100/60, HR 110, respirations:36. What is the first action by the nurse?
A. Offer oral fluids
B. Begin an IV infusion
C. Obtain a pulse oximetry
, D. Administer oxygen - ANSWER C. Obtain a pulse oximetry
Which of these steps in taking a blood pressure are correct? Select all that apply.
A. Use a bladder that encircles 25% of the arm
B. Wrap the cuff snugly around the client's arm
C. As the client to hold their arm at heart level
D. Have the client sit with feet flat on the floor - ANSWER B. Wrap the cuff snugly
around the client's arm
D. Have the client sit with feet flat on the floor
A nurse is measuring a client's vital signs and uses a pulse oximeter to obtain which
of the following types of information?
A. respiratory rate
B. amount of oxygen in the blood
C. percentage of hemoglobin-carrying oxygen
D. amount of carbon dioxide in the blood - ANSWER C. percentage of hemoglobin-
carrying oxygen
A nurse assesses the vital signs of a 50 year old female client and documents the
results. Which of the following are considered within normal range for this client?
Select all that apply.
A. Oral temperature 98.2 degree F
B. Apical pulse 88 beats/minute and regular
C. Respiratory rate of 30 breaths/minute
D. Blood pressure 114/78 mm Hg while in a sitting position
E. Oxygen saturation of 90% - ANSWER A. Oral temperature 98.2 degree F
B. Apical pulse 88 beats/minute and regular
D. Blood pressure 114/78 mm Hg while in a sitting position
Which question by the nurse best assesses a client's pain tolerance?
A. "At what point on the scale of 1 to 10 do you feel that you must have pain
medication?"
B. "What activities help distract you so that you don't feel the need for pain
medication?"
C. "How intense on a scale of 1 to 10 is the pain that you feel right now?"
D. "Do you take pain medication frequently?" - ANSWER A. "At what point on the
scale of 1 to 10 do you feel that you must have pain medication?"
Which assessment result would require the nurse to assess the client further?
A. A 21 year old male with a pulse rate of 140 after riding 2 miles on an exercise
bike.
B. A 50 year old man with a blood pressure of 118/64 upon awakening in the
morning
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