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NUR 258 ACUTE CARE NURSING FINAL EXAM
2025/2026 ACTUAL QUESTIONS AND ANSWERS
GRADED A+
What are the 4 physical exam techniques?
inspection, palpation, percussion, auscultation
What is done the moment you first see the patient?
- First physical exam technique used
Inspection
What are the 6 things needed for the Setting of an Assessment?
Privacy
Adequate lighting
Warmth
Necessary equipment to prevent interruption
Physical and psychological preparation
Third person if indicated or needed to maintain safety
phase of the nursing process during which data are gathered for the purpose of identifying actual or potential health problems
Physical assessment
What are the 5 types of data collection?
Complete (total health) database
Episodic (problem) Centered database
Follow-Up database
Emergency database
Lifespan Considerations
- initial assessment on admission
Complete (total health) database
Data collection of health history + complete exam
Data collection that is a focused assessment for a specific problem
Episodic (problem) centered database
Data collection that is a time-lapsed re-assessment or a re-progress check
Follow-up database
Data collection that is done when there is a serious or life-threatening situations or an emergency
Emergency database
What is the Position, Preparation, and Sequence when assessing an aging adult?
Position: Sit of bed or chair and monitor comfort
Preparation: Don't assume hearing difficulty, be aware of changes in senses, and encourage rest periods
Sequence: Head to toe minimizing position changes
*ANSWERS ARE BEFORE THE QUESTIONS FROM THIS POINT
Palpation
What physical exam technique often confirms inspection?
Percussion
Physical exam technique that involves tapping on skin
Auscultation
Physical exam technique that uses a stethoscope and directs sound to ears
Bell
Used when listening to soft or low pitched sounds
Diaphragm
Used when listening to high pitched sounds
Vital signs
Indicate some of the bodies basic functions and reflect many things about health
- several sets form a baseline
After surgery, during a blood transfusion, or changes in patient status
When do we take vital signs more frequently?
96.4-99.1 F (35.8-37.3 C)
Normal adult range of Body Temperature
Age
Environment
Time of day
Exercise
Stress
Hormones
Temperature route which gives good core temperature, used as last resort, with no rectal problems?
Tympanic (ear)
Temperature route that is used for children but some question accuracy?
Axillary
Temperature route that is not as accurate, and must be deep in armpit and held tightly to body
Core
Temperature route used when using urinary catheters and central lines
Pulse
Contraction of ventricles pumps blood into arteries through aorta
Apical and Radial
What are the two main pulse sites?
apical
Most accurate pulse site
- taken when patient is on cardiac medication and pediatrics
radial
Most common pulse site
- thumb side of wrist, easy to access
rate, rhythm, quality
What are the 3 characteristics of the pulse to look for?
0 = absent
2+ = normal
3+ to 4+ = bounding
What is the scale for quality of heart rate?
120-160 bpm
Exercise/activity
Temperature
Medications
What are 3 major influences that impact the pulse?
30-60 breaths per minute
Acceptable Respiratory rate of a newborn?
30-50 breaths per minute
Acceptable Respiratory rate of an infant (6 months)?
25-32 breaths per minute
Acceptable Respiratory rate of a Toddler (2 y/o)?
20-30 breaths per minute
Acceptable Respiratory rate of a Child?
Acceptable Respiratory rate of an Adolescent?
Acceptable Respiratory rate of an Adult?
Stress, Pain, Anxiety
Medications
Exercise
3 major influences of respiration
Blood pressure
the force blood exerts against the walls of blood vessels
systolic
pressure when heart beats
diastolic
pressure when heart rests
Optimal BP for a 6 year old?
Optimal BP for 10-13 y/o?
Optimal BP for 14-17 y/o?
Less than 120/
Optimal BP for an adult?
referred pain
pain that is felt in a location other than where the pain originates
radiating pain
starts at the origin but extends to other locations
Intensity (0-10 scale)
Quality (feel like?)
Onset and Duration (Start, how long?)
Alleviating Factors
Aggravating Factors
Timing
Effect of pain of quality of life
Pain level goal
What questions should a Nurse ask when doing a pain assessment?
Numerical rating scale (0-10)
Wong-Baker Faces
FLACC
What are the Pain Assessment scales/tools?
Face, Legs, Activity, Cry, Consolability
Meaning of FLACC pain scale?
a, an, appears, seems, apparently, good, normal, big, large, small judgments or personal opinions
Words to avoid when charting
story-paragraph form
All patient information is documented in what form?
Data, Action, Response (DAR)
What should the focus be when charting on a patient?
Problem, Intervention, Evaluation
PIE
Subjective, Objective, Assessment, Plan
SOAP
Nurse's Notes
short narrative formation for deviation/changes
incident report
Not in patient chart, but used per facility to track patient problems
Biographical/demographical data
Source (who is giving info)
Reason for seeking care (chief complaint)
Past health (chronic illnesses, immunizations, allergies, meds)
Family history
What is documented for a patients health history?
Medical Reconciliation
Process of comparing the patients medications listed in records to the medications the patient is currently taking
Tobacco use
Alcohol use
Street drug use
Inches x 2.54 = cm
How do you convert inches to centimeters?
Pounds / 2.2 = kilograms
How do you convert pounds to kilograms?
Health history from parent, Pregnancy history, Developmental and Nutritional history
What other things should a nurse ask about when assessing the health of child?
primary prevention
Preventing infection before it even occurs
- handwashing, masks, immunizations
secondary prevention
Works to reduce the infections impact
- treating infection with antibiotics, patient education
tertiary prevention
Works to minimize long lasting effects of infection
incubation period
Time of entrance of infection to first symptoms
Prodromal stage
From nonspecific symptoms to more specific symptoms and infection may be transmittable to others
Illness stage
Specific symptoms of infection/illness evident
Convalesnce
Acute symptoms of infection/illness disappear
Direct contact
Mode of transmission when there is infection by a health care workers hands
