BSN 205 HALLMARK UPDATED QUESTIONS AND
SOLUTIONS GRADED A+
✔✔The nurse is performing a dressing change on a patient who is postoperative from a
laparotomy. The patient coughs and the nurse sees a few loops of intestine uncoiling
from the wound. What is the nurse's best action at this time? - ✔✔Apply sterile saline-
soaked towels to the area
✔✔Which of the following may indicate an increased risk for wound dehiscence? -
✔✔There is an increase in serosanguineous drainage from the wound
✔✔Which of the following patients is at greatest risk for developing a wound infection? -
✔✔A diabetic obese patient who smokes.
✔✔The nurse is caring for a patient with a Jackson-Pratt drain. Which of the following
indicates correct understanding? - ✔✔-The nurse instructs the NAP to empty the drain
every 8-12 hours or when it is 2/3 full and document the amount as output on the intake
and output record
-The nurse ensures the drainage device appears deflated after it is emptied.
✔✔A nurse is applying a wound V.A.C. dressing independently for the first time. What
action, if made by the nurse, indicates that further instruction is needed in performing
this procedure? - ✔✔The nurse cuts the foam approximately one-half inch smaller than
the size of the wound and gently places the foam in the wound, avoiding any tunneled
and undermined areas.
✔✔ou are reviewing the signs, symptoms, and prevention of hypoxia with the family of a
patient who requires frequent suctioning at home. Choose the information that you
should cover. (Select all that apply.)
A.Restlessness and anxiety are indications of hypoxia.
B.Confusion, disorientation, and altered consciousness are indications of hypoxia.
C.Increases in pulse, respiration, and blood pressure are indications of hypoxia.
d.Having difficulty breathing and looking blue are indications of hypoxia.
e.Infection and fever are indications of hypoxia.
f.Bronchitis and chronic obstructive pulmonary disease are indications of hypoxia. -
✔✔abcdf
✔✔An elderly woman is hospitalized with pneumonia and anemia and has a history of
heart failure. She is weak and has a poor cough effort. Her current vital signs are
temperature 100.2 °F (37.9 °C), pulse 114, respiration 26, blood pressure 106/58. She
has oxygen ordered at 2 liters by nasal cannula. Her oxygen saturation measures 88%
when on room air, 93% with supplemental oxygen. She develops shortness of breath on
any activity and eats little because it is difficult for her to eat and breathe at the same
, time. Which of the following are risk factors for this patient developing hypoxia? (Select
all that apply.)Group of answer choices
a.Anemia.
b.Tachycardia.
c.Increased secretions with weak cough.
d.Impaired cardiac function.
e.Shortness of breath.
f.Pneumonia. - ✔✔acdf
✔✔Which of the following patients would have the greatest potential for an alteration in
respiration?Group of answer choices
A 15-year-old boy with a migraine headache.
A 44-year-old woman with anemia.
A 19-year-old woman with diarrhea.
A 32-year-old man with an earache. - ✔✔A 44-year-old woman with anemia.
✔✔Which of the following, if exhibited by the patient, is a late sign of hypoxia?Group of
answer choices
Restlessness.
Anxiety.
Eupnea.
Cyanosis. - ✔✔cyanosis
✔✔Which of the following would lead to an increase in oxygen demand?Group of
answer choices
A fever.
Sleep.
Taking a narcotic.
Postural drainage. - ✔✔a fever
✔✔What nursing intervention is appropriate for the patient with a large amount of
sputum?Group of answer choices
Perform nasotracheal suctioning every hour.
Encourage the patient to cough every hour while awake.
Place the patient on fluid restriction.
Avoid all milk products. - ✔✔Encourage the patient to cough every hour while awake.
✔✔The nurse is caring for a patient who underwent major abdominal surgery 24 hours
ago. The 72-year-old male patient is weak and lethargic because of large doses of
medication for pain control. After noting audible gurgling on inspiration and expiration,
the nurse completes a respiratory assessment. Which assessment parameters indicate
the need for oral suction? (Select all that apply.)
Group of answer choicesa.
SOLUTIONS GRADED A+
✔✔The nurse is performing a dressing change on a patient who is postoperative from a
laparotomy. The patient coughs and the nurse sees a few loops of intestine uncoiling
from the wound. What is the nurse's best action at this time? - ✔✔Apply sterile saline-
soaked towels to the area
✔✔Which of the following may indicate an increased risk for wound dehiscence? -
✔✔There is an increase in serosanguineous drainage from the wound
✔✔Which of the following patients is at greatest risk for developing a wound infection? -
✔✔A diabetic obese patient who smokes.
✔✔The nurse is caring for a patient with a Jackson-Pratt drain. Which of the following
indicates correct understanding? - ✔✔-The nurse instructs the NAP to empty the drain
every 8-12 hours or when it is 2/3 full and document the amount as output on the intake
and output record
-The nurse ensures the drainage device appears deflated after it is emptied.
✔✔A nurse is applying a wound V.A.C. dressing independently for the first time. What
action, if made by the nurse, indicates that further instruction is needed in performing
this procedure? - ✔✔The nurse cuts the foam approximately one-half inch smaller than
the size of the wound and gently places the foam in the wound, avoiding any tunneled
and undermined areas.
✔✔ou are reviewing the signs, symptoms, and prevention of hypoxia with the family of a
patient who requires frequent suctioning at home. Choose the information that you
should cover. (Select all that apply.)
A.Restlessness and anxiety are indications of hypoxia.
B.Confusion, disorientation, and altered consciousness are indications of hypoxia.
C.Increases in pulse, respiration, and blood pressure are indications of hypoxia.
d.Having difficulty breathing and looking blue are indications of hypoxia.
e.Infection and fever are indications of hypoxia.
f.Bronchitis and chronic obstructive pulmonary disease are indications of hypoxia. -
✔✔abcdf
✔✔An elderly woman is hospitalized with pneumonia and anemia and has a history of
heart failure. She is weak and has a poor cough effort. Her current vital signs are
temperature 100.2 °F (37.9 °C), pulse 114, respiration 26, blood pressure 106/58. She
has oxygen ordered at 2 liters by nasal cannula. Her oxygen saturation measures 88%
when on room air, 93% with supplemental oxygen. She develops shortness of breath on
any activity and eats little because it is difficult for her to eat and breathe at the same
, time. Which of the following are risk factors for this patient developing hypoxia? (Select
all that apply.)Group of answer choices
a.Anemia.
b.Tachycardia.
c.Increased secretions with weak cough.
d.Impaired cardiac function.
e.Shortness of breath.
f.Pneumonia. - ✔✔acdf
✔✔Which of the following patients would have the greatest potential for an alteration in
respiration?Group of answer choices
A 15-year-old boy with a migraine headache.
A 44-year-old woman with anemia.
A 19-year-old woman with diarrhea.
A 32-year-old man with an earache. - ✔✔A 44-year-old woman with anemia.
✔✔Which of the following, if exhibited by the patient, is a late sign of hypoxia?Group of
answer choices
Restlessness.
Anxiety.
Eupnea.
Cyanosis. - ✔✔cyanosis
✔✔Which of the following would lead to an increase in oxygen demand?Group of
answer choices
A fever.
Sleep.
Taking a narcotic.
Postural drainage. - ✔✔a fever
✔✔What nursing intervention is appropriate for the patient with a large amount of
sputum?Group of answer choices
Perform nasotracheal suctioning every hour.
Encourage the patient to cough every hour while awake.
Place the patient on fluid restriction.
Avoid all milk products. - ✔✔Encourage the patient to cough every hour while awake.
✔✔The nurse is caring for a patient who underwent major abdominal surgery 24 hours
ago. The 72-year-old male patient is weak and lethargic because of large doses of
medication for pain control. After noting audible gurgling on inspiration and expiration,
the nurse completes a respiratory assessment. Which assessment parameters indicate
the need for oral suction? (Select all that apply.)
Group of answer choicesa.
