NUR 120 EXAM 1 LATEST VERSION 2024 -

NUR 120 EXAM 1 LATEST VERSION 2024 -

2025 WITH QUESTIONS AND WELL

VERIFIED CORRECT ANSWERS [ALREADY

GRADED A+] ||NUR 120 2024 NEW EXAM!!

The nurse is caring for a patient with a temp of 103 F, respirations of 30 per min., pulse rate of 50 beats per minute, and BP of 100/60. The patient is cold and clammy. What does the nurse conclude about these findings?

• The temp is causing a lowered pulse rate; it will improve if the temp. decreases.
• The low pulse rate is causing a decreased cardiac output, which has caused a low

BP

• The pulse rate and BP are compensatory mechanisms to decrease the increased

metabolic rate from the temp.

• The cool, clammy skin will help to increase the BP and pulse as the body tries to

warm the skin - ANSWER-B

"Creating a risk of harm to others by failing to do something a reasonable person would ordinarily do, or do something that a reasonable person would ordinarily not do." Which assessment findings would require the nurse to further assess the pt?

• A young adult male with a pulse rate of 136 after running 2 miles
• A 40 yr old female with a BP of 110/70 when 1st awakened
• A 72 yr old female with a respiratory rate of 10 breaths per min. 1 / 4

• A 50 yr old male with a pulse rate of 88 beats per min. - ANSWER-C

The nurse is caring for a pt who was burned in a house fire. The right arm is heavily bandaged and there is an intravenous line that was placed in the left forearm after 3 attempts. Which action does the nurse take related to obtaining VS?

• A BP is not needed because the pt is awake, alert, and talking to the nurse.
• A smaller cuff should be used to cover less of the upper arm
• The BP should be taken on the popliteal artery
• The systolic pressure should be palpated from the radial artery - ANSWER-C.

The nurse is completing a postoperative assessment on a pt in the post-anesthesia recovery unit. Which VS requires further assessment by the nurse for the possible hypovolemic (low blood volume) shock?

• An increase in HR
• An increased temp. reading
• A decrease in BP
• A decrease in RR - ANSWER-A

Which actions by the nurse could result in a BP measurement error? SELECT ALL

THAT APPLY

• Placing the diaphragm of the stethoscope over the brachial artery
• Using the same cuff for all pts
• Wrapping the bottom edge of the cuff over the antecubital space 2 / 4

• Releasing the valve quickly to prevent pt discomfort
• Taking a measurement after the pt rests quietly for 5 mins. - ANSWER-B, C, D

A nurse goes to another unit to see a friend who has been admitted. The nurse goes

to look at a friend's medical record. This is an example of:

• Invasion of privacy
• Breach of confidentiality
• Liability
• Malpractice - ANSWER-A

Prior to identifying accurate nursing diagnosis, which action MUST be taken by the nurse?

• Reading the patients history
• Setting realistic, measurable goals
• Comparing evidence- based practices
• Clustering related patient data - ANSWER-D

Patient advocacy is best demonstrated by the nurse:

• Learning how to do a new procedure
• Returning with the client at the agreed-upon time.
• Preparing the client's room for comfort and privacy.
• Supporting the client's right to refuse treatment. - ANSWER-D 3 / 4

What phrase BEST describes the essence of critical thinking?

• Understanding without conscious reasoning
• Providing care based on nursing experience
• Consulting with a primary care provider
• Seeking solutions to problems - ANSWER-D

The nurse is caring for a pt who experienced a major trauma and has lost approx. 2 units of blood. Which intial compensatory mechanisms would the nurse expect the pt to exhibit. SELECT ALL THAT APPLY

• Increased BP
• Increased urinary output
• Increased pulse rate
• Decreased temp.
• Decreased respirations - ANSWER-A, C

Nurses may be held liable for actions that are considered unintentional torts. Which of the following actions is an example of this type of tort?

• Restraining a client who refuses care and wants to leave the hospital.
• Taking photos of a client surgical wound to post to a website.
• Leaving the side rails down, leading to the pt falling and becoming injured.
• Discussing the clients sexually transmitted disease while riding the elevator with

visitors. - ANSWER-C

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