NURS 125 Final Exam 2022. Review
Questions and answers.
A patient on a medical- surgical floor reports having shortness of breath. The nurse needs to conduct
which type of assessment? - Ans-A problem-based/focused assessment
For which patient is a shift assessment indicated? - Ans-The person who had abdominal surgery
yesterday
Which of the following examples represents a secondary prevention level of health promotion? - Ans-
Blood pressure screenings
Which of the following is an example of objective data? - Ans-Vomiting
A nurse suspects a patient is a victim of physical abuse. Which response by the nurse will most likely
encourage the patient to confide in the nurse? - Ans-"I've seen people who have been hurt by their
significant others. Do you feel safe in your home?"
A patient answers questions quietly and appears sad. While answering questions about her marriage,
she begins to cry. Which response by the nurse is appropriate in this situation? - Ans-"I see that you are
upset. Is there something you'd like to discuss?"
A nurse is interviewing a patient. Which of the following questions is an open-ended question? - Ans-
Can you tell me how you have been feeling?
When interviewing a patient to obtain a health history, asking if the patient has "dypsnea" can fall into
which of the following systems? - Ans-Respiratory and Cardiovascular
A nurse asks a patient to rate their pain on a scale of "0-10". This is which part of the mnemonic for
symptom analysis of "OLD CARTS"? - Ans-Severity

When examining a patient, the nurse remembers to follow which principle of Standard Precautions? -
Ans-Wear gloves when in contact with the patient's blood or other body fluids.
Which of the following is a correct statement regarding the technique LIGHT palpation? Light palpation
is - Ans-Used to assess tenderness
The nurse is unable to hear the patient's breath sounds. To determine the cause of this problem the
nurse needs to ensure that the - Ans-valve is open to the diaphragm on the head of the stethoscope.
A nurse is preparing to take a patient's blood pressure. The blood pressure cuff is too narrow (small).
How accurate will this patient's blood pressure be using this blood pressure cuff? - Ans-Higher than the
actual value
Where does the nurse attach the sensor probe of the pulse oximeter to measure a patient's oxygen
saturation? - Ans-Around the patient's index fingernail
During a physical assessment of an elderly adult, the nurse has difficulty palpating the patient's dorsalis
pedis pulses. Which piece of equipment would be helpful during this assessment? - Ans-Doppler
A patient on a cardiac floor is complaining of chest pain. The nurse needs to conduct which type of
assessment? - Ans-A problem-based focused assessment
An example of Primary prevention of Health Promotion is: - Ans-Immunizations
Which of the following is an example of subjective (symptoms) data? - Ans-Headache
Which of the following is one of the goals of Healthy People 2020? - Ans-To promote quality of life &
healthy behaviors across all life stages
During a mental health assessment, a women begins to cry when the nurse asks about her marriage.
Which action by the nurse is most therapeutic? - Ans-" I see that you're upset. Can you discuss why
you're feeling this way?"

While collecting data on a patient, the nurse obtains vital signs. This is done PRIMARILY to - Ans-obtain
baseline indicators of the patient's health status.
A nurse is about to take a patient's temperature. The patient has just finished a cup of hot coffee. The
nurse should : - Ans-wait 10 minutes, then take the temperature.
To position an adult's ear correctly for a tympanic membrane temperature, the nurse should - Ans-tug
the ear's helix in an upward direction.
A nurse assesses an irregular pulse while counting for 15 seconds. What is the most appropriate action
for the nurse to take at this time? - Ans-Count the patient's pulse for a full minute.
A nurse takes a patient's pulse. The nurse documents "80 beats per minute and regular"-
What does the "regular" refer to? - Ans-Rhythm
A nurse is taking vital signs of an adult patient whose oxygen saturation is 96%. The patient's
temperature is 102 F, blood pressure is 120/77 pulse is 90 beats/min, and respiratory rate is 26
breaths/min. Which factor may be contributing to the elevated respiratory rate? - Ans-Temperature
Which actions by the nurse results in the patient's blood pressure measurement being falsely high?
1. Deflating the blood pressure cuff too rapidly
2. Positioning the patient's arm above the level of the heart
3. Using a blood pressure cuff that is too narrow for the upper arm
4. Wrapping the blood pressure cuff too loosely
5. Reinflating the blood pressure cuff before it is completely deflated - Ans-2,3,4
The difference between the systolic pressure and the diastolic pressure is known as the - Ans-Pulse
pressure
A patient who is obese and has a fractured leg is reporting pain at 8/10. The patient is also craving a
cigarette. Vital signs are temperature 38.1 C, respirations 18 breaths/min, pulse 77 beats/min and blood

pressure 170/95mm Hg. Which of the following could be contributing to the increase in blood pressure?
- Ans-Pain, obesity, smoking
A patient's vital signs are temperature 37.1 C, respirations 18-20 breaths/minutes, blood pressure
120/70mm Hg, oxygen saturation 79%. Which vital sign is considered abnormal and in need of further
evaluation? - Ans-Oxygen saturation
Which set of vital signs should the nurse recognize as within the expected range for that age group? -
Ans-NEWBORN BP 84/60: pulse, 128 beats/min; respirations, 42 breaths/min
True or False:
Nurses are responsible for knowing about the health beliefs, practices and values of ALL cultural and
racial groups. - Ans-False
An older man who is near death has been admitted to the hospital and family members are at his
bedside. During the admission assessment the nurse uses which question or statement to appropriately
address spiritual needs? - Ans-"Are there any special needs that you and your family request at this
time?"
Which of the following would indicate that the nurse needs additional education about pain
management?Select all that apply. - Ans-A patient's report of pain is probably inaccurate when the
patient looks comfortable.
A patient is only in pain if their vital signs reflect it with increase heart rate and inspirations.
Trying to determine the "drug seeking" patients.
During an admission history a patient reports having lower back pain for about a year. How would the
nurse categorize this pain? - Ans-persistent (chronic)
Which of the following statements is TRUE about pain tolerance? - Ans-Pain tolerance increases after
alcohol consumption
Pain tolerance decreases with repeated exposure to boredom

2022 NURS125 Medical Surgical Final Exam With Answers (139 Solved Questions)

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