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PRELIM EXAMINATION NCM 100 SKILLS LAB Zhallene Michelle E.

Sanchez, RN CRN Name: ____________________________________ Score: __________________ Section: ____________ Date: __________________ GENERAL INSTRUCTIONS: Write all the answers in the test booklet provided for you, you can write anything on the test questionnaires, but any erasures on the test booklet or answer sheets would be considered as a wrong answer. Write clearly and legibly and the uses of correction fluid, erasers or bal pens to strike out any wrong answers are not allowed. Test I. Select the correct answer for each item of the following questions.

1.
a.

Absence of Fever (without fever; body temperature is normal) a. Fever b. Cerumen c. Febrile d. Afebrile

1.
a. b. c. d. 2.

Force exerted by blood in the arteries Pulse Pressure Diastolic Pressure Blood Pressure Piloerection

The nurse listens to Mrs. Sullens lungs and notes a hissing sound or musical sound. The nurse documents this as:

a. Wheezes

b. Rhonchi

c. Gurgles

d. Vesicular

2.

The Primary factor responsible for body heat production is: a. b. c. d. Metabolism Release of thyroxine Thyroxine output Muscle activity

3.

The heat-regulating center is found in the: a. b. c. d. Medulla oblongata Thalamus Hypothalamus Pons

4.

A process of heat loss which involves the transfer of heat from one surface to another is: a. b. c. d. Radiation Conduction Convection Evaporation

Nurses dispense comfort, compassion, and caring without even a prescription. ~Val Saintsbury

5.

The following statements are true about body temperature EXCEPT: a. b. c. d. Core body temperature measures the temperature of deep tissues. Highest body temperature is usually reached between 8:00PM to 12:00 M.N. Elderly people are at risk of hypothermia due to decreased thermoregulatory controls and decreased subcutaneous body heat production. Sympathetic response stimulation decreases body heat production.

6.

The client with fever had been observed to experience elevated temperature for few days, followed by 1 to 2 days of normal range of temperature. The type of fever he is experiencing is: a. b. c. d. Intermittent fever Relapsing fever Remittent fever Constant fever

7.

Which of the following is not an appropriate nursing action when taking oral temperature: a. b. c. d. Wash the thermometer from the bulb to the stem before use. Place the thermometer under the tongue directed towards the side Take oral temperature for 2-3 minutes Take oral temperature using a thermometer with pear-shaped bulb.

8.

The following are contraindications to oral temperature taking EXCEPT: a. b. c. d. Dyspnea Diarrhea Nasal-packing Nausea and vomiting

9.

Which of the following nursing actions is inappropriate when taking the rectal temperature? a. b. c. d. Assist client to assume lateral position Lubricate thermometer with water-soluble lubricant before use Hold the thermometer in place for 2 minutes Instruct client to strain during insertion of the thermometer.

10. The following are correct nursing actions when taking the radial pulse EXCEPT: a. b. c. d. Put the palms downward Use the thumb to palpate the artery Use two to three fingertips to palpate the pulse at the inner wrist Assess the pulse rate, rhythm, volume, and bilateral equality

11. The difference between the systolic pressure and the diastolic pressure is: a. b. c. d. Apical rate Cardiac rate Pulse deficit Pulse pressure

Nurses dispense comfort, compassion, and caring without even a prescription. ~Val Saintsbury

12. When measuring the blood pressure, the following are nursing considerations EXCEPT: a. b. c. d. Ensure that the client is rested Use appropriate size of BP cuff Inflate and deflate BP cuff 2-3 mmHg/sec Read upper meniscus of mercury

13. The process involved in the exchange of gases in the lungs is:
a. b. c. d. Diffusion Osmosis Hydrostatic pressure Oncotic pressure

14. The primary respiratory center is: a. Medulla oblongata Carotid and aortic bodies proprioceptors

b. Pons
c. d.

15. Which of the following factors primarily affects BP? a. b. c. d. Age Stress Gender Obesity

16. During assessment, the nurse palpates the clients pulse. It is rapid, weak and irregular. An irregular pulse is characteristic of: a. b. c. d. Bradycardia Tachycardia Asystole Dysrhythmia

17. Using a blood pressure cuff that is too small for the patients arm can result in:
a. b. c. d. False high measurement False low measurement No significant difference in measurement The inability to obtain a measurement

18. A 38 y/o clients vital signs at 8 a.m. are axillary temperature 99.6 F (37.6 C); pulse rate 88 bpm; respiratory rate 30 cpm. Which findings should be reported? a. b. c. d. Respiratory rate only Temperature only Pulse rate and temperature Temperature and respiratory

19. The centigrade (Celsius) reading for a Fahrenheit reading of 102 is:

Nurses dispense comfort, compassion, and caring without even a prescription. ~Val Saintsbury

a. b. c. d.

39 47 38.9 40.1

20. The respiratory control center is located in the: a. b. c. d. Medulla oblongata Hypothalamus Cerebellum pituitary

21. A normal respiratory rate for the average adult: a. b. c. d. 8 to 14 per minute 12 to 18 per minute 20-40 per minute 30 to 80 per minute

22. A client has very shallow breathing pattern that is interrupted by periods of apnea. The nurse should chart this as: a. b. c. d. Cheyne-stokes respirations Kussmauls respirations Biots breathing Apneustic breathing

23. The thumb is not used in palpating because a. b. c. d. The index finger is more sensitive to touch Thumb pressure may obliterate the pulse It is more awkward The nurse might feel his/her own thumb pulse

24. During the past 24 hours, a clients temperature has fluctuated widely above the normal range. The nurse should record this as: a. b. c. d. Intermittent fever Remittent fever Relapsing fever Constant fever

27-31. The location of the different pulse rates are as follows: ______27. Carotid pulse ______28. Popliteal pulse ______29. Dorsalis pedis ______30. Posterior tibial pulse ______31. Apical pulse A. Left, mid-clavicular, fifth ICS B. Medial aspect of the ankle C. Dorsum of the foot D. Lateral aspect of the neck E. Back of knee

32-37. The following conditions are characterized by which of the following assessment findings in an adult client?

Nurses dispense comfort, compassion, and caring without even a prescription. ~Val Saintsbury

_____32. Pyrexia _____33. Normotension _____34. Hypothermia _____35.hypertension _____36. Tachycardia _____37. Tachypnea Test II. MATCHING TYPE:

A. BP is 120/80mmHg B. RR=25/min C. Temperature=37.9 C D. 125bpm E. Temperature= 36 C F. BP=150/90 mmHg

COLUMN A _______1. A shrill, harsh sound heard during inspiration with laryngeal obstruction _______2. Snoring or sonorous respirations, usually due to a partial obstructions of the upper airway _______3. Continuous, high pitched musical squeak or whistling sound occuring on expiration and sometimes on inspiration when air moves through narrowed or partially obstructed airway. _______4. Gurgling sounds heard as air passes through moist secretions in t he respiratory tract _______5. Sound you hear when taking BP. _______6. Pressure of the blood as a result of contraction of the ventricle; the pressure of height of blood wave. _______7. The pressure when the ventricles are at rest. _______8. The difference between the diastolic and the systolic pressure _______9. Blood pressure is measured as? _______10. Is wave of blood created by contraction of left ventricle of the heart. _______11. Pulse located away from the heart. Example foot, wrist, or neck. _______12. Central pulse located at the apex of the heart. _______13. Normal PR for Newborns _______14. Normal PR for 1 year old _______15. Normal PR for 10 years old ________16. Normal PR Adult ________17. Normal RR for infants ________18. Normal RR for Pre-schoolers

Nurses dispense comfort, compassion, and caring without even a prescription. ~Val Saintsbury

________19. Normal RR for School Age ________20. Normal RR Adult

COLUMN B.
A. B. C. D. E. F. G. H. I. J. K. L. M. N. O. P. Q. R. S. T. U. V. W. X. Y. Z. Stridor Bubbling Wheeze Stertor Apical Pulse Peripheral Pulse Pulse mmHg pulse pressure diastolic pressure systolic pressure korotkoff pulse rhythm respiration 60-100 beats per minute 60-90 beats per minute 80-140 beats per minute 120-160 beats per minute 30-660 cycles per minute 20-40 cycles per minute 15-25 cycles per minute 12-20 cycles per minute Eupnea Orthopnea Cardiac output Blood viscosity

Test III. Enumeration Assessment of Respiration: 1._____________________ 2._________________ 3.________________ 4.____________________

Nurses dispense comfort, compassion, and caring without even a prescription. ~Val Saintsbury