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NUR 1175 ( LATEST 2024 / 2025 ) UNIT 1 | QUESTIONS & ANSWERS (SOLVED)
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NUR 1175 ( LATEST 2024 / 2025 ) UNIT 1 | QUESTIONS & ANSWERS (SOLVED)
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NUR 1175 UNIT 11. A nurse receives information during shift report that a patient is afebrile. What action will
the nurse take in response?
A. Checking the MAR for prescribed antipyretic medication
B. Reporting the finding to the primary care provider
C. Taking the patient's temperature using a different method
D. No action is necessary; this is a normal reading
Answer
d. Afebrile means without fever, or a temperature is within the normal range. No additional
actions are needed.
2. A nurse is assessing the vital signs of a group of patients in the emergency department. Which
patients require follow-up by the nurse? Select all that apply.
A. Infant whose temperature is 100.5°F (38.1°C)
B. Toddler whose blood pressure is 118/80
C. School-age child whose temperature is 102.2°F (39°C)
D. Adolescent whose pulse rate is 70 beats/min
E. Adult whose respiratory rate is 20 breaths/min
F. Older adult whose pulse rate is 42 beats/min
Answer
a, d, e, f.The normal temperature range for infants is 98.7° to 100.5°F (37.1° to 38.1°C). The
normal pulse rate for an adolescent is 55 to 105. The normal respiratory rate for an adult is 12 to
20 breaths/min and the normal pulse for an older adult is 40 to 100 beats/min. The normal blood
pressure for a toddler is 89/46, and the normal temperature for a child is 98.2° to 100°F (36.8° to
37.8°C; referto Table 26-1).
3. A nurse is caring for a newborn with hypothermia. What action does the nurse take to
prevent heat loss from convection?
,A. Wrapping the newborn in a blanket
B. Placing the newborn on a warmed surface
C. Reducing the temperature in the room
D. Increasing the temperature in the room
Answer
a. Convection refers to heat disseminated by motion between areas of unequal density, for
example, a fan blowing cool air over the body or an uncovered body. Placing the baby on a warmed
surface would prevent heat loss via conduction. Reducing the temperature may decrease heat loss
via perspiration (evaporation); increasing the temperature in the room may increase heat loss via
evaporation.
4. While taking an adult patient's pulse, a nurse obtains a heart rate of 140 beats/min. What
should the nurse do next?
A. Reassess the pulse in 1 hour
B. Measure the blood pressure
C. Document the information, noting tachycardia
D. Report the rate to the health care provider
Answer
d. A pulse rate of 140 beats/min in an adult, tachycardia, is abnormally fast, and should be reported
to the primary nurse or health care provider immediately. Tachycardia at rest often reflects an
underlying issue and can lead to decreased tissue perfusion; additional assessments are needed.
5. During assessment of vital signs, a patient reports severe abdominal pain. Which pain-
related changes in vital signs may be present? Select all that apply.
A. Pulse rate of 102
B. Body temperature 98.8°F
C. Blood pressure 154/86
D. Increased respiratory depth
E. Respiratory rate of 24
,F. Body temperature 100.8°F
Answer
a, c, e. The pulse, blood pressure, and respiratory rate often increase when a person is
experiencing pain; respiratory depth decreases. Pain does not affect body temperature.
6. A nurse is caring for a group of patients on a cardiac unit. Which finding will prompt the
nurseto assess the apical-radial pulse?
A. Bounding radial pulse
B. Immediately postoperative
C. Rapid, irregular pulse
D. Fluid volume deficit
Answer
a. The nurse assesses the apical-radial pulse when dysrhythmia exists or is suspected,
manifested by tachycardia or irregular pulse. The difference between the apical and radial pulse
rates, called the pulse deficit, captures heart beats not reaching the peripheral arteries.
7. A nurse is assessing the blood pressure of a patient with traumatic injuries using a Doppler
device. Which information does the nurse expect to obtain?
A. Amplitude of the brachial pulse
B. Mean arterial blood pressure
C. Estimation of the systolic blood pressure
D. Apical-radial pulse rate
Answer
b. A Doppler provides an estimation of the systolic blood pressure when the pulse is inaudible.
Diastolic pressure cannot be calculated because oscillations of the pulse will be audible during
the entire BP assessment; recall the nurse can auscultate a pulse with the Doppler. The pulse
amplitude
, obtained with palpation, the mean arterial pressure reflects the average blood pressure during a
cardiac cycle, and the apical-radial pulse is assessed to detect a pulse deficit, often present with
a dysrhythmia.
8. A nurse enters a room and finds a patient who is unable to catch their breath, has a respiratory
rate of 28, and is using accessory muscles to breathe. What intervention will the nurse use to
relieve dyspnea?
A. Remove pillows from under the head
B. Raise the head of the bed
C. Elevate the foot of the bed
D. Reassess the respiratory rate
Answer
b. Elevating the head of the bed facilitates lung expansion by allowing the abdominal contents
to descend, which facilitates lung expansion and oxygenation. Elevated respiratory may occur
due to distress or hypoxemia;assessing the respiratory rate does not resolve the problem of
dyspnea.
9. A nurse has assessed an older adult for orthostatic hypotension as shown in the electronic
health record (EHR). What action will the nurse take? Exhibit
Electronic health record (EHR)
Graphic sheet
800 AM BP
lying 124/76
BP sitting
118/74
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