Class 11 General Nursing — Exercise Solutions
Key Concepts Quick Recap
| Vital Sign | Normal Adult Range | Instrument |
|---|
| Temperature | 36.5°C – 37.5°C | Thermometer |
| Pulse | 60–100 bpm | Watch + fingers on radial artery |
| Respiration | 12–20 breaths/min | Observation (count chest rise) |
| Blood Pressure | 120/80 mmHg | Sphygmomanometer + stethoscope |
| SpO₂ | 95–100% | Pulse oximeter |
I. Choose the Best Answer (MCQs)
1. The normal oral temperature of an adult is: (a) 35°C – 36°C (b) 36.5°C – 37.5°C (c) 38°C – 39°C (d) 34°C – 35°C
Answer(b) 36.5°C – 37.5°C Oral temperature average: 37°C (98.6°F). Axillary (armpit): 0.5°C lower (~36.5°C). Rectal: 0.5°C higher (~37.5°C). Tympanic (ear): similar to rectal. Fever: >38°C. Hyperthermia: >40°C. Hypothermia: <35°C.
2. The most common site for measuring pulse in adults is: (a) Femoral artery (b) Carotid artery (c) Radial artery (d) Brachial artery
Answer(c) Radial artery Radial pulse: felt at wrist (lateral side, below thumb). Most convenient for routine monitoring. Other sites: carotid (neck — used in CPR), brachial (used with BP cuff), femoral, pedal (dorsalis pedis — for peripheral circulation). Apical pulse: stethoscope over left chest — most accurate for infants.
3. The first aid acronym RICE is used for: (a) Respiratory, Infection, Circulation, Evaluation (b) Rest, Ice, Compression, Elevation — for sprains and soft tissue injuries (c) Resuscitate, Immobilise, Check, Elevate (d) Respiration, Ice, Contamination, Exercise
Answer(b) Rest, Ice, Compression, Elevation — for sprains and soft tissue injuries RICE method: Rest (stop activity, rest injured area), Ice (apply ice pack 15-20 min to reduce swelling), Compression (bandage to reduce swelling), Elevation (raise injured limb above heart level to reduce swelling). Used for: ankle sprains, muscle strains, minor soft tissue injuries in first 48-72 hours.
4. Which position is used for a patient in shock? (a) Prone position (b) Fowler's position (c) Supine with legs elevated (Trendelenburg-like) (d) Lateral position
Answer(c) Supine with legs elevated (Trendelenburg-like) Shock position: patient flat (supine) with legs elevated 30-45° (unless spinal injury, breathing difficulty, or head injury). Increases venous return to heart and brain. Classic Trendelenburg (whole bed tilted) is no longer routinely recommended; modified (legs elevated, body flat) is preferred.
5. The most effective way to prevent the spread of infection is: (a) Wearing gloves at all times (b) Isolation of all patients (c) Hand hygiene (handwashing or alcohol rub) (d) Wearing a mask always
Answer(c) Hand hygiene (handwashing or alcohol rub) Hand hygiene: single most effective measure to prevent healthcare-associated infections (HAIs). WHO "5 Moments for Hand Hygiene": 1. Before patient contact. 2. Before aseptic procedure. 3. After body fluid exposure. 4. After patient contact. 5. After contact with patient surroundings.
6. The normal blood pressure reading for a healthy adult is: (a) 80/50 mmHg (b) 120/80 mmHg (c) 160/100 mmHg (d) 90/60 mmHg
Answer(b) 120/80 mmHg Blood pressure: systolic (heart contracting) / diastolic (heart relaxing). Classification: Normal: <120/80. Elevated: 120-129/<80. Stage 1 HTN: 130-139/80-89. Stage 2 HTN: ≥140/≥90. Hypotension: systolic <90. Measure with sphygmomanometer; report in mmHg.
7. Sterilisation differs from disinfection because: (a) Sterilisation uses chemicals only (b) Sterilisation destroys ALL microorganisms including spores; disinfection kills most but not spores (c) Disinfection is more effective than sterilisation (d) Sterilisation is only for surfaces
Answer(b) Sterilisation destroys ALL microorganisms including spores; disinfection kills most but not spores Sterilisation: complete destruction of all microorganisms including bacterial spores. Methods: autoclave (121°C/15psi/15min), dry heat, gamma radiation, ethylene oxide gas. Disinfection: destroys most pathogens but not all spores. Methods: chemical (bleach, glutaraldehyde), boiling, pasteurisation. Used for: instruments touching mucous membranes (not sterile sites).
II. Short Answer Questions
Q1. Describe the procedure for measuring blood pressure.
Answer
Equipment: sphygmomanometer (BP apparatus), stethoscope.
Procedure: 1. Allow patient to rest for 5 minutes; seated (preferred) or lying down. 2. Expose upper arm; position at heart level. 3. Apply cuff snugly 2-3 cm above antecubital fossa (bend of elbow); ensure cuff is appropriate size. 4. Locate brachial artery pulse; place stethoscope bell/diaphragm over it. 5. Close valve on bulb; inflate cuff rapidly to ~30 mmHg above expected systolic (or until pulse disappears). 6. Open valve slowly (2-3 mmHg/second); listen through stethoscope. 7. First Korotkoff sound heard = systolic pressure. 8. Sound disappears (Korotkoff phase 5) = diastolic pressure. 9. Record: systolic/diastolic mmHg (e.g., 120/80 mmHg); note arm and position. 10. Wait 1-2 minutes before remeasuring.
Q2. Explain the principles of aseptic technique in nursing.
Answer
Aseptic technique: set of practices designed to prevent contamination of wounds, sterile equipment, and other areas by ensuring only sterile objects touch sterile areas.
Principles: 1. Know what is sterile and what is not: sterile = free of all microorganisms. Once contaminated, must be re-sterilised or discarded. 2. Sterile objects become unsterile when touched by non-sterile objects: never reach across a sterile field; open packaging below waist level = unsterile. 3. Sterile fields must be constantly monitored: never leave sterile field unattended. 4. Air is a source of contamination: keep doors closed; minimise conversation and movement near sterile field; wear mask. 5. Edges of a sterile container are considered unsterile: 2.5 cm (1 inch) from edge = border zone. 6. Moisture contamination: wet sterile fields = unsterile (microorganisms travel through moisture via capillary action).
Applications: wound dressing, surgical procedures, catheter insertion, IV line setup.
Exam Checklist
- Temperature: 36.5-37.5°C. Pulse: 60-100 bpm. RR: 12-20/min. BP: 120/80 mmHg.
- Radial pulse: standard site. Apical: most accurate (infants).
- RICE: Rest, Ice, Compression, Elevation (soft tissue injuries).
- Hand hygiene: most effective infection control; WHO 5 Moments.
- Chain of infection: 6 links; break it by handwashing, PPE, sterilisation, vaccination.
- Sterilisation: kills ALL microbes including spores (autoclave). Disinfection: kills most, not spores.
- BP measurement: Korotkoff sounds; first sound = systolic; disappears = diastolic.
- Shock position: supine with legs elevated.
