Online Practice Test 29

Your Results for: "NCLEX® Review"

Print this page

Site Title: Kozier & Erb's Fundamentals of Nursing Book Title: Kozier & Erb's Fundamentals of Nursing Location on Site: Chapter 29 > NCLEX® Review Date/Time Submitted: July 17, 2012 at 1:08 PM (UTC/GMT)

Summary of Results 40% Correct of 10 Scored items: 4 Correct:  40% 6 Incorrect:  60% More information about scoring

1.		Body heat that is lost when the nurse turns on the air conditioning at the client's request is what type of loss? Your Answer: Conduction Correct Answer: Convection
		Objective: Describe factors that affect the vital signs and accurate measurement of them. Rationale: Convection is heat lost by air currents. Radiation is transfer of heat from one object to another. Conduction is transfer from a warmer molecule to one of lower temperature. Vaporization is lost from respiratory tract and from skin. Nursing Process: Assessment Client Need: Physiologic Integrity Cognitive Level: Analysis Strategy: Use nursing knowledge and the process of elimination to make a selection.
2.		When should the nurse take a client's temperature if the nurse wants to assess at the point of highest body temperature? Your Answer: 1000 and 1400 (10 a.m. & 2 p.m.) Correct Answer: 2000 and 2400 (8 p.m. & midnight)
		Objective: Identify the variations in normal body temperature, pulse, respirations, and blood pressure that occur from infancy to old age. Rationale: Body temperatures change throughout the day, with the highest body temperature reached between 2000 and 2400 hours. Nursing Process: Assessment Client Need: Physiologic Integrity Cognitive Level: Application Strategy: Use nursing knowledge and the process of elimination to make a selection.
3.		What type of fever would the nurse document if the client had a wide range of temperature fluctuations over normal for a period of 24 hours? Your Answer: Intermittent Correct Answer: Remittent
		Objective: Identify the variations in normal body temperature, pulse, respirations, and blood pressure that occur from infancy to old age. Rationale: A remittent fever widely fluctuates above normal over a 24-hour period. An intermittent fever rises above normal between periods of normal or subnormal temperatures. A relapsing fever is short febrile periods of a few days interspersed with 1-2 days of normal temperature. A constant fever remains above normal. Nursing Process: Assessment Client Need: Physiologic Integrity Cognitive Level: Analysis Strategy: Use nursing knowledge and the process of elimination to make a selection.
4.		What intervention would be most appropriate for a client with mild hypothermia? Your Answer: Applying blankets
		Objective: Describe appropriate nursing care for alterations in body temperature. Rationale: For mild hypothermia, rewarming the body by applying blankets is most appropriate. The others would be interventions for severe hypothermia. Nursing Process: Implementation Client Need: Physiologic Integrity Cognitive Level: Application Strategy: Use nursing knowledge and the process of elimination to make a selection.
5.		When assessing the pulse of a client on digitalis, what rate would the nurse expect as compared with the pulse prior to starting digitalis? Your Answer: It would not change. Correct Answer: It would decrease.
		Objective: List the characteristics that should be included when assessing pulses. Rationale: Digitalis will decrease the heart rate, thereby decreasing the pulse. Nursing Process: Assessment Client Need: Physiologic Integrity Cognitive Level: Analysis Strategy: Use nursing knowledge and the process of elimination to make a selection.
6.		A nurse documents deep respirations on the client record. Which criteria were most likely assessed? Your Answer: A large amount of air inhaled and a large amount exhaled
		Objective: Describe the mechanics of breathing and the mechanisms that control respirations. Rationale: Deep respirations involve a large amount of inhaled and exhaled air. Shallow respirations involve a small amount of air exchange. Normal respirations entail easy effort, with about 500 ml of air on inhalation. Nursing Process: Assessment Client Need: Physiologic Integrity Cognitive Level: Analysis Strategy: Use nursing knowledge and the process of elimination to make a selection.
7.		A nurse needs to assess a client's pulse pressure. What is the correct procedure? Your Answer: Subtract the systolic from the diastolic blood pressure. Correct Answer: Subtract the diastolic from the systolic blood pressure.
		Objective: Differentiate systolic from diastolic blood pressure. Rationale: The difference between the diastolic and the systolic pressures is called the pulse pressure. Nursing Process: Assessment Client Need: Physiologic Integrity Cognitive Level: Application Strategy: Use nursing knowledge and the process of elimination to make a selection.
8.		What are the most common sites for measuring body temperature? (Select all that apply.) Your Answer: Oral Temporal Tympanic membrane Axillary Correct Answers: Oral Temporal Tympanic membrane Rectal Axillary
		Objective: Compare methods of measuring body temperature. Rationale: The most common sites for measuring body temperature are oral, rectal, axillary, tympanic membrane, and skin/temporal artery. Nursing Process: Assessment Client Need: Safe, Effective Care Environment Cognitive Level: Analysis Strategy: Use nursing knowledge to determine common measurement of body temperature. Objective: Compare methods of measuring body temperature. Rationale: The most common sites for measuring body temperature are oral, rectal, axillary, tympanic membrane, and skin/temporal artery. Nursing Process: Assessment Client Need: Safe, Effective Care Environment Cognitive Level: Analysis Strategy: Use nursing knowledge to determine common measurement of body temperature.
9.		If a client has a temperature of 100 degrees Fahrenheit, calculate the finding in Celsius. __________ Your Answer: 37.8
		Objective: Describe appropriate nursing care for alterations in body temperature. Rationale: To calculate Celsius from Fahrenheit, deduct 32 from Fahrenheit reading and then multiply by the fraction 5/9. Nursing Process: Assessment Client Need: Physiologic Integrity Cognitive Level: Application Strategy: Use calculator to determine conversion.
10.		Which technique is best for assessing the respirations of a 3-year-old? Your Answer: Observe the rise and fall of the abdomen.
		Objective: Identify the components of a respiratory assessment. Rationale: A child who knows respirations are being counted may alter the respiratory effort or become upset. Observing the rise and fall of the abdomen without telling the child is the most accurate method. Nursing Process: Assessment Client Need: Safe, Effective Care Environment Cognitive Level: Application Strategy: Use nursing knowledge and the process of elimination to make a selection.