BSN 205 HALLMARK FINAL EXAM ACTUAL QUESTIONS
AND SOLUTIONS GRADED A+
✔✔If a 52-year-old patient has a normal temperature, what range should the patient's
temperature fall within?
A) 37-39 °C (98.6-102.2 °F)
B) 96.8-100.4 °F (36-38 °C)
C) 35-36 °C (95-96.8 °F)
D) 96.8-98.6 °F (36-37 °C) - ✔✔B) 96.8-100.4 °F (36-38 °C)
✔✔Your newborn patient's temperature has been rising rapidly and the baby has been
crying. Which of the following thermometers would be the best to use in measuring this
patient's temperature?
A) Temporal Artery
B) Tympanic
C) Chemical dot
D) Rectal Electronic - ✔✔A) Temporal Artery
✔✔The task of pulse assessment could be delegated to the NAP for which of the
following patients? - ✔✔-A radial pulse on a patient with a 1200 ml fluid restriction
-The temporal pulse of a child
✔✔Which of the following patients would be at risk for having an alteration in peripheral
pulse? - ✔✔-The patient who was just informed of a diagnosis of cancer
-a patient with peripheral vascular disease
-and a patient who's receiving bolus IV fluids
✔✔Whenever there's an alteration in the radial pulse rate, rhythm, or amplitude, the
nurse should initially do which of the following? - ✔✔Auscultate the apical pulse for
quality and rate
✔✔What's the normal pulse range for an adult? - ✔✔60-100 beats per minute
✔✔The nurse should routinely auscultate the apical pulse with the bell side of the
stethoscope, and use the diaphragm side to identify heart murmurs - ✔✔False
✔✔In which of the following patients would the nurse expect to find a decrease in pulse
rate/ - ✔✔A patient returning from the operating room and a patient who received
morphine for pain
,✔✔The new NAP is unable to palpate a patient's radial pulse. What could be a possible
explanation for this difficulty? - ✔✔The NAP is assessing for a pulse on the ulnar side of
the wrist and the NAP is pressing down too hard on the patient's radial site
✔✔What's an appropriate nursing intervention for an adult patient with a respiratory rate
of 30 breaths per minute? - ✔✔-Count the respiratory rate again for a full 60secs
- assess physiologic factors that may be causing the patient to breathe so fast
✔✔Which of the following may increase both rate and depth of respiration? - ✔✔-
Walking a mile briskly
-feeling anxious when taking a test
-having an addiction problem with amphetamines/cocaine.
✔✔When assessing the respiratory rate, then nurse has difficulty seeing the patient's
chest rise and fall with inspiration and expiration. What's the nurse's best action? -
✔✔Move the patient's arm over their chest and feel the rise an fall of the chest
✔✔How can the nurse best obtain an accurate measurement of a patient's respiratory
rate? - ✔✔Continue to act as though taking the patient's pulse while discretely
observing the rise and fall of the patient's chest
✔✔The nurse is validating the NAP's skill with respiratory rate assessment. Which of
the following actions, if made by the NAP, indicates that further instruction is needed? -
✔✔When a patient inhales a breath, the NAP counts that as one when the patient
exhales the breath, the NAP counts that as two
✔✔The nurse assesses the BP in both arms of a newly admitted patient. Why would the
nurse do this? - ✔✔To determine if there is a difference in the readings between the two
arms.
✔✔Which of the following patients would be considered hypertensive after having two
or more consistent readings of these values? - ✔✔A football player with a diastolic BP
of 94.
✔✔For which patient should you avoid using a leg pressure cuff (thigh cuff) to assess
BP? - ✔✔A patient with a deep vein thrombosis (blood clot, usually in the lower
extremities).
✔✔The student nurse is unsure of the BP measurement. What should the student nurse
do first? - ✔✔Assess the BP in the other arm.
✔✔Using the image below, please choose the correct BP combination: - ✔✔Image A =
120/80, Image B = 128/76, Image C = 140/90, Image D = 138/84
, ✔✔It is 7 a.m. and the nurse takes the vital signs of a postoperative patient and finds
his blood pressure is elevated. Which of the following could explain the cause for this
alteration in BP? - ✔✔The patient complains of pain at a 9 on a 0-10 pain scale.
✔✔The patient has a history of a left mastectomy. Where should the nurse take the
patient's blood pressure? - ✔✔In the right arm
✔✔The nurse is unable to obtain a BP reading using an electronic BP machine on a
post-operative patient. The machine reads "Error." What priority action should the nurse
take? - ✔✔Take the patient's BP manually using a sphygmomanometer.
✔✔The NAP reports to the nurse the patient's respirations are 32 and the patient is
complaining of shortness of breath. What is the best nursing action at this time?
A) Request the NAP obtain the patient's pulse oximetry and report the reading to the
nurse.
B) Ask the NAP to obtain a full set of vital signs
C) Assess the patient yourself, including the pulse oximetry reading
D) Notify the health care provider - ✔✔C) Assess the patient yourself, including the
pulse oximetry reading
✔✔Which patient is at high risk for for the pulse oximetry alarm to sound?
A) A patient with a continuous pulse oximetry reading of 84%. Correct
B) A patient who is receiving oxygen via face mask.
C) A patient who has an intermittent pulse oximetry reading of 95%
D) A patient with a HR of 64 beats per minute - ✔✔A) A patient with a continuous pulse
oximetry reading of 84%. Correct
✔✔A patient complains of feeling excessively tired. Which statement, if made by the
NAP, indicates further instruction is necessary?
A) "I will turn the continuous pulse oximetry alarms off at night so you can sleep without
interruption."
B) "I can give you a back massage to help you relax."
C) "What kind of nighttime ritual helps you go to sleep?"
D) "If the finger clip is bothering you, I can attach a probe to your ear."
E) "I will notify the nurse and the two of you can determine whether you need your
sleeping medication." - ✔✔A) "I will turn the continuous pulse oximetry alarms off at
night so you can sleep without interruption."
✔✔The NAP tells you that the patient's pulse oximetry is 85% on room air. What nursing
action(s) should you take? (Select all that apply.)
AND SOLUTIONS GRADED A+
✔✔If a 52-year-old patient has a normal temperature, what range should the patient's
temperature fall within?
A) 37-39 °C (98.6-102.2 °F)
B) 96.8-100.4 °F (36-38 °C)
C) 35-36 °C (95-96.8 °F)
D) 96.8-98.6 °F (36-37 °C) - ✔✔B) 96.8-100.4 °F (36-38 °C)
✔✔Your newborn patient's temperature has been rising rapidly and the baby has been
crying. Which of the following thermometers would be the best to use in measuring this
patient's temperature?
A) Temporal Artery
B) Tympanic
C) Chemical dot
D) Rectal Electronic - ✔✔A) Temporal Artery
✔✔The task of pulse assessment could be delegated to the NAP for which of the
following patients? - ✔✔-A radial pulse on a patient with a 1200 ml fluid restriction
-The temporal pulse of a child
✔✔Which of the following patients would be at risk for having an alteration in peripheral
pulse? - ✔✔-The patient who was just informed of a diagnosis of cancer
-a patient with peripheral vascular disease
-and a patient who's receiving bolus IV fluids
✔✔Whenever there's an alteration in the radial pulse rate, rhythm, or amplitude, the
nurse should initially do which of the following? - ✔✔Auscultate the apical pulse for
quality and rate
✔✔What's the normal pulse range for an adult? - ✔✔60-100 beats per minute
✔✔The nurse should routinely auscultate the apical pulse with the bell side of the
stethoscope, and use the diaphragm side to identify heart murmurs - ✔✔False
✔✔In which of the following patients would the nurse expect to find a decrease in pulse
rate/ - ✔✔A patient returning from the operating room and a patient who received
morphine for pain
,✔✔The new NAP is unable to palpate a patient's radial pulse. What could be a possible
explanation for this difficulty? - ✔✔The NAP is assessing for a pulse on the ulnar side of
the wrist and the NAP is pressing down too hard on the patient's radial site
✔✔What's an appropriate nursing intervention for an adult patient with a respiratory rate
of 30 breaths per minute? - ✔✔-Count the respiratory rate again for a full 60secs
- assess physiologic factors that may be causing the patient to breathe so fast
✔✔Which of the following may increase both rate and depth of respiration? - ✔✔-
Walking a mile briskly
-feeling anxious when taking a test
-having an addiction problem with amphetamines/cocaine.
✔✔When assessing the respiratory rate, then nurse has difficulty seeing the patient's
chest rise and fall with inspiration and expiration. What's the nurse's best action? -
✔✔Move the patient's arm over their chest and feel the rise an fall of the chest
✔✔How can the nurse best obtain an accurate measurement of a patient's respiratory
rate? - ✔✔Continue to act as though taking the patient's pulse while discretely
observing the rise and fall of the patient's chest
✔✔The nurse is validating the NAP's skill with respiratory rate assessment. Which of
the following actions, if made by the NAP, indicates that further instruction is needed? -
✔✔When a patient inhales a breath, the NAP counts that as one when the patient
exhales the breath, the NAP counts that as two
✔✔The nurse assesses the BP in both arms of a newly admitted patient. Why would the
nurse do this? - ✔✔To determine if there is a difference in the readings between the two
arms.
✔✔Which of the following patients would be considered hypertensive after having two
or more consistent readings of these values? - ✔✔A football player with a diastolic BP
of 94.
✔✔For which patient should you avoid using a leg pressure cuff (thigh cuff) to assess
BP? - ✔✔A patient with a deep vein thrombosis (blood clot, usually in the lower
extremities).
✔✔The student nurse is unsure of the BP measurement. What should the student nurse
do first? - ✔✔Assess the BP in the other arm.
✔✔Using the image below, please choose the correct BP combination: - ✔✔Image A =
120/80, Image B = 128/76, Image C = 140/90, Image D = 138/84
, ✔✔It is 7 a.m. and the nurse takes the vital signs of a postoperative patient and finds
his blood pressure is elevated. Which of the following could explain the cause for this
alteration in BP? - ✔✔The patient complains of pain at a 9 on a 0-10 pain scale.
✔✔The patient has a history of a left mastectomy. Where should the nurse take the
patient's blood pressure? - ✔✔In the right arm
✔✔The nurse is unable to obtain a BP reading using an electronic BP machine on a
post-operative patient. The machine reads "Error." What priority action should the nurse
take? - ✔✔Take the patient's BP manually using a sphygmomanometer.
✔✔The NAP reports to the nurse the patient's respirations are 32 and the patient is
complaining of shortness of breath. What is the best nursing action at this time?
A) Request the NAP obtain the patient's pulse oximetry and report the reading to the
nurse.
B) Ask the NAP to obtain a full set of vital signs
C) Assess the patient yourself, including the pulse oximetry reading
D) Notify the health care provider - ✔✔C) Assess the patient yourself, including the
pulse oximetry reading
✔✔Which patient is at high risk for for the pulse oximetry alarm to sound?
A) A patient with a continuous pulse oximetry reading of 84%. Correct
B) A patient who is receiving oxygen via face mask.
C) A patient who has an intermittent pulse oximetry reading of 95%
D) A patient with a HR of 64 beats per minute - ✔✔A) A patient with a continuous pulse
oximetry reading of 84%. Correct
✔✔A patient complains of feeling excessively tired. Which statement, if made by the
NAP, indicates further instruction is necessary?
A) "I will turn the continuous pulse oximetry alarms off at night so you can sleep without
interruption."
B) "I can give you a back massage to help you relax."
C) "What kind of nighttime ritual helps you go to sleep?"
D) "If the finger clip is bothering you, I can attach a probe to your ear."
E) "I will notify the nurse and the two of you can determine whether you need your
sleeping medication." - ✔✔A) "I will turn the continuous pulse oximetry alarms off at
night so you can sleep without interruption."
✔✔The NAP tells you that the patient's pulse oximetry is 85% on room air. What nursing
action(s) should you take? (Select all that apply.)
