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NSG 3100 EXAM 2 2026/2027 (2 LATEST
VERSIONS) WITH ACTUAL CORRECT
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what is the normal range for heart rate 60 - 100 bpm list out the 0-3 number scale assessing pulse intensity 0 - absent pulse 1 - weak/diminshed 2 - normal 3 - bounding what is the normal range for breathing 12 - 20 breaths per minute what is the term for difficulty breathing experienced in positions other than sitting or standing orthopnea what term is described as rhythmic respirations going from very deep to very shallow or apneic periods and is associated with heart failure, renal failure, drug overdose, increased intracranial pressure, or impending death cheyne-stokes respirations
what term is described as respirations abnormally deep, regular, and increased in rate and is associated with diabetic ketoacidosis kussmaul breathing what term is described as respirations abnormally shallow for two or three breaths, followed by irregular period of apnea and is associated with meningitis. severe brain injury Biot breathing what constitutes orthostatic blood pressure drop of 20 mmHg in systolic pressure and drop of 10 mmHg in diastolic pressure when changing positions what is the normal reading for oxygen saturation 95% or greater what is the normal range for blood pressure 90 - 120/60- 80 what systolic pressure is considered elevated blood pressure 120 - 129 what systolic and diastolic pressures are considered hypertension stage 1 systolic pressure of 130-39 and diastolic pressure of 80- 89 what systolic and diastolic pressures are considered hypertension stage 2 systolic pressure of 140 or greater and diastolic pressure of 90 or higher what are the 6 components of the chain of infection in order
- infectious agent
- source/reservoir
- portal of exit
- measles
- varicella
- TB
- covid 19 what PPE is required for contact precaution gown & gloves what PPE is required for droplet precaution mask (surgical) what PPE is required for airborne precaution N95 respirator what is the order of donning PPE
- gown
- mask
- eye wear
- gloves what is the order of doffing PPE
- gloves (wash hands)
- eyewear
- mask
- gown (wash hands again) what are the 3 classifications of wounds based on depth
- superficial wound
- partial thickness wound
- full thickness wound what are the 3 phases of wound healing
- inflammatory
- proliferative
- maturation which phase of healing is characterized by the body's initial response to wounding of the body which includes pain, redness, warmth, and swelling inflammatory phase which phase of healing is characterized by repair of the defect, filling in the wound bed with new tissue, and resurfacing the wound skin proliferative phase which phase of healing is known as the remodeling phase and is characterized by scar tissue maturation phase what is a stage 1 pressure injury non-blanchable erythema of intact skin what is a stage 2 pressure injury a partial thickness wound that involves the epidermis and dermis what is a stage 3 pressure injury full thickness skin wound that extends into the subcutaneous tissue what is a stage 4 pressure injury full thickness wound that involves exposure of muscle, bone, or connective tissue
what is the term for the transfer of heat by movement or circulation of warm matter such as air or water evaporation what are the 5 locations to measure temperature
- temporal
- tympanic (ear)
- oral
- axillary
- rectal what are the 9 locations to measure a pulse
- temporal
- carotid
- apical
- brachial
- radial
- femoral
- popliteal
- posterior tibial
- dorsalis pedis what is an unstageable pressure injury full thickness wound in which the amount of necrotic tissue makes it impossible to assess the depth of the wound what is a deep tissue injury purple or maroon area of intact skin that can progress rapidly, exposing deeper layers of tissue damage
what are the 6 categories in the Braden scale
- sensory perception
- moisture
- activity
- mobility
- nutrition
- friction and shear what are the 4 categories for sensory perception in the Braden scale
- completely limited
- very limited
- slightly limited
- no impairment what are the 4 categories for moisture in the Braden scale
- constantly moist
- very moist
- occasionally moist
- rarely moist what are the 4 categories for activity in the Braden scale
- bedfast
- chairfast
- walks occasionally
- walks frequently what are the 4 categories for mobility in the Braden scale
- completely immobile
- very limited
- alginates
- gels which dressing is used for packing all kinds of wounds and absorbing exudate from heavily draining wounds gauze dressing which dressing is made of adhesive-backed polyurethane and used for autolytic debridement of minimally draining wounds that have no sign of infection transparent dressing which dressing is occlusive, provide a moist environment and used for clean, uninfected wounds with small to moderate amounts of drainage hydrocolloid dressing which dressing is able to pull fluid away from the wound bed yet maintain a moist wound environment and used for wounds with moderate to heavy amounts of exudate foam dressing which dressing is made from seawood fibers, highly absorbent, and used for highly exudative wounds alginate dressing which dressing adds moisture to wounds and shouldn't be used with highly exudative wounds gel dressing what term is described as respirations abnormally shallow for two or three breaths, followed by irregular period of apnea and is associated with meningitis. severe brain injury Biot breathing
VERSION 2
the nurse is measuring blood pressure as a part of community health fair. which blood pressure reading would cause the nurse to refer the patient for follow-up regarding hypertension? a- 108/ b- 116/ c- 128/ d- 138/ d the nurse is admitting a stable patient for a minor outpatient procedure. what site would the nurse most commonly use to assess pulse rate? a- radial site b- apical site c- brachial site d- carotid site a the UAP reports vital signs for a patient to the nurse: temp of 99.2 oral, pulse of 88bpm and regular respirations of 18bpm, BP 178/112mmHg, O2 sat of 96%. which vital sign should the nurse be most concerned about? a- temp b- pulse
The nurse places a patient with a high fever on a cooling blanket. How is heat loss achieved with this treatment? a. Radiation b. Convection c. Conduction d. Evaporation c which clinical patient scenario is associated with the most critical need for the nurse to obtain vital signs? a- ambulating for the first time after surgery b- complaining of pressure in the chest c- completing ambulating 100ft after a stroke d- complaining of hunger while NPO (nothing by mouth) b the nurse understands that which statement is correct regarding respiratory rates? a- infants have a lower respiratory rate b- healthy adults breathe between 12-20 times a minute c- a compensatory response to a fever is to breathe at a slower rate d- an increase in intracranial pressure results in an increase rate b
the nurse is caring for a patient who has a blood pressure of 184/110. an hour after administering an antihypertensive med, the nurse returns to recheck the BP, only to find the patient in the chair pale, sweaty, feeling faint. which is the expected explanation for the nurse's observation? a- the BP is 184/110; medication has no effect b- the BP is 118/76; the sudden drop has caused the signs c- the BP is 174/96; the medication has made the patient sick d- the BP is 13-/82; the symptoms are from another cause b it is 6am and the UAP reports to the nurse that the patient has a temp of 96.7F tympanic. Which factor explains the reading? a- the pts room is cold b- the pt was drinking cold water c- the pt is exhibiting a normal circadian rhythm d- the patient just completed a warm shower c The nurse is caring for a patient who has been diagnosed with MRSA located in her incision. what transmission based precautions will the nurse implement for the patient? a- private room b- private, negative airflow room
a- an illness resulting from living in an unclean environment b- a result of lack of knowledge about food preparation c- a disease resulting from pathogens in or on the body d- an acute or chronic illness resulting from traumatic injury c the nurse is caring for a patient who had abdominal surgery and has developed an infection in the wound while hospitalized. which agent is most likely the cause of the infection? a- virus b- bacterium c- fungus d- spore b a nurse is preparing to change a sterile dressing and has donned a pair of sterile gloves. to maintain surgical asepsis, what else must the nurse do? a- keep the amount of splashes on the sterile field to a minimum b- if a sneeze is imminent, cover the nose and mouth with a gloved hand c- with a moist saline sponge, use the dominant hand to clean the wound and then apply a dry dressing d- regard the outer 1 inch of the sterile field as contaminated d
what is the proper order of removal of soiled personal protective equipment when the nurse leaves the patient's room? a- gown, goggles, mask, gloves, and exit the room b- gloves, wash hands, remove gown, mask, and wash hands c- gloves, goggles, gown, mask and wash hands d- goggles, mask, gloves, gown, and wash hands c Of the following hospitalized patients, who is most at risk for acquiring a health-care-associated infection? a. 60-year-old who smokes two packs of cigarettes per day b. 40-year-old who has an indwelling urinary catheter in place c. 65-year-old who is a vegetarian and slightly underweight d. 60-year-old who has a white blood cell count of 6000 b a patient develops food poisoning from contaminated food. what is the means of transmission for the infectious organism? a- direct contact b- vector c- vehicle d- airborn c
b- cover the wound with saline-moistened gauze c- apple a binder to pull the wound edges together and provide support to the edges d- notify the physician e- allow the area to be exposed to air until all the drainage has stopped b,d which features are characteristic of a closed drainage system, such as a jackson-pratt drain? SATA a- works by gravity b- provides for early discharge c- usually is inserted in surgery d- reduces the amount of antibiotics required e- allows for accurate measurement of wound drainage c,e which skin-care intervention should be initiated by the nurse caring for a patient with urinary or fecal incontinence? (SATA) a- changing the adult brief every 8 hours b- cleansing frequently with hot water and a strong soap c- using an incontinence cleanser d- frequent position changes e- applying a moisture barrier ointment c,d,e
based on the knowledge of areas at greatest risk for development of a pressure injury in the bedridden patient, the nurse identifies which position to minimize the risk? a- 30 degree side lying b- sitting with the head of the bed elevated 75 degrees c- 90 degree side lying d- lying supine with the bed flat a a patient who has suffered a stroke is unable to maintain his position while seated in a chair without sliding down. his physician has ordered him up in a chair for part of the day. what does the nurse recognize as the patient's greatest risk for development of pressure injuries? a- moisture from incontinence b- nutritional deficiencies c- pressure and shear d- aging c a patient has a stage 3 pressure injury on the coccyx. which food will be most beneficial in improving the healing process? a- food high in vitamin D b- whole grain carbs c- high calorie, high protein drink d- food high in fat and water content
