NMNC 1135 Exam (with
Rationales) Questions and
Answers 100% Correct
Match the abbreviation to the definition.
ADL
CBG
DOE
H&P
SpO2 - ANSWER - activities of daily living
capillary blood glucose
dyspnea on exertion
history and physical
oxygen saturation (pulse ox)
When taking an adult blood pressure, the onset of the sound the nurse hears is at
138, the muffled sound the nurse hears is at 70, and the disappearance of the
sound the nurse hears is at 62. How should the nurse record this finding?
A. 68
B. 76
C. 138/62
D. 138/70 - ANSWER - C. 138/62
Rationale: 138/62 is the correct reading. The fifth sound marks the disappearance of
sound. In adolescents and adults the fifth sound corresponds with the diastolic
pressure. The fourth sound becomes muffled and low pitched as the cuff is further
deflated. At this point the cuff pressure has fallen below the pressure within the
vessel walls; this sound is the diastolic pressure in infants and children. 68 is the
pulse pressure of 138/70; 76 is the pulse pressure for 138/62
,A nurse is caring for a patient who smokes and drinks caffeine-containing
beverages. What should the nurse understand before assessing the patient's blood
pressure (BP)?
A.Smoking results in vasodilation, decreasing BP for up to 3 hours.
B.Caffeine increases BP for up to 15 minutes.
C.Smoking result in vasoconstriction, temporarily increasing BP.
D.Caffeine intake should be avoided 3 hours before BP measurement. - ANSWER -
C.Smoking result in vasoconstriction, temporarily increasing BP.
Rationale: Smoking results in vasoconstriction, a narrowing of blood vessels. BP
rises when a person smokes and returns to baseline about 15 to 20 minutes after
stopping smoking. Caffeine increases BP for up to 3 hours. Be sure that patient has
not ingested caffeine or smoked 20 to 30 minutes before BP measurement.
The nurse is assessing the patient's respirations. Which action by the nurse is most
appropriate?
A.Inform the patient of counting respirations.
B.Do not touch the patient until completed.
C.Obtain without the patient knowing.
D.Estimate respirations. - ANSWER - C.Obtain without the patient knowing.
Rationale: Do not let a patient know that you are assessing respirations. A patient
aware of the assessment can alter the rate and depth of breathing. Assess
respirations immediately after measuring pulse rate, with your hand still on the
patient's wrist as it rests over the chest or abdomen. Respirations are the easiest of
all vital signs to assess, but they are often the most haphazardly measured. Do not
estimate respirations.
The nurse needs to obtain a radial pulse from a patient. What should the nurse do
to obtain a correct measurement?
A. Place the tips of the first two fingers over the groove along the thumb side of the
patient's wrist.
B. Place the tips of the first two fingers over the groove along the little finger side of
the patient's wrist.
C. Place the thumb over the groove along the little finger side of the patient's wrist.
, D. Place the thumb over the groove along the thumb side of the patient's wrist. -
ANSWER - A. Place the tips of the first two fingers over the groove along the thumb
side of the patient's wrist.
Rationale: Place the tips of the first two or middle three fingers of the hand over the
groove along the radial or thumb side of the patient's inner wrist. Fingertips are the
most sensitive parts of the hand to palpate arterial pulsation. The thumb has a
pulsation that interferes with accuracy. The groove along the little finger is the ulnar
pulse.
When interviewing a client, the nurse wants to use an open-ended question. Which
of the following questions should the nurse use?
A. Do you have any concerns right now?
B. How many times do you get up to go to the bathroom at night?
C. Is your family worried about you being in the hospital?
D. What do you mean when you say, "I don't feel quite right?" - ANSWER - D. What
do you mean when you say, "I don't feel quite right?"
Rationale: Open-ended questions will encourage the client to give more information
about their situation. The other questions can be answered with a "yes" or "no"
(closed ended) and will not provide further information unless more detail is
requested by the nurse.
A patient is found to be unresponsive and not breathing. Which site should the
nurse use to check the patient's pulse rate?
A. Radial
B. Apical
C. Carotid
D. Brachial - ANSWER - C. Carotid
Rationale: The heart continues to deliver blood through the carotid artery to the
brain as long as possible. The carotid pulse is easily accessible during physiological
shock or cardiac arrest. The radial pulse is used to assess peripheral circulation or to
assess the status of circulation to the hand. The brachial site is used to assess the
status of circulation to the lower arm. The apical pulse is used to auscultate the
apical area.
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