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NUR 101 ( LATEST 2024 / 2025 ) EXAM 5 | A++ EXAM WITH ALL NEW QS & AS - GUARANTEED PASS!
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NUR 101 ( LATEST 2024 / 2025 ) EXAM 5 | A++ EXAM WITH ALL NEW QS & AS - GUARANTEED PASS!
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NUR 101 Exam 51. 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
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.
2. 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
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.
3. 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
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.
4. 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
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.
5. 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
,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.
6. 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 walkingdown the hall
4)Increased respiratory rate when the heart rate increases:
ANSWER
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
7. The clients temperature is 101.1F. Which is the correct conversion to centi- grade?
1) 38.0C
2) 38.4C
3) 38.8C
4) 39.2C:
ANSWER
2) 38.4C
To convert Fahrenheit to centigrade, subtract 32 from the temperature, and multiply by 5/9.
, 8. 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
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.
9. 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
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.
10. 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:
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