BSN 206 Foundations of Nursing
Fundamentals Hallmark Exam (Latest
Update ) Questions & Answers
100% Correct {Grade A} - Nightingale
Ensure the chest piece is rotated to the diaphragm side. - correct answer Reduce
environmental noise by turning off the TV or closing the door.
Make sure the stethoscope does not touch the client's clothing or BP cuff.
Keep the stethoscope tubing still to avoid extraneous sound.
Ensure the bladder of the cuff is centered 1 inch (2.5 cm) above the brachial artery.
Ensure the chest piece is rotated to the diaphragm side.
A nurse performs orthostatic blood pressure readings on a client with the following
results: lying 148/76 mm Hg, standing 110/60 mm Hg. What action by the nurse is
best?
A) Reassess the blood pressures in 1 hour.
B) Reassure the client that these findings are normal.
C) Instruct the client not to get up without help.
D) Document the findings and continue to monitor. - correct answer C) Instruct the
client not to get up without help.
, BSN 206 Foundations of Nursing
Fundamentals Hallmark Exam (Latest
Update ) Questions & Answers
100% Correct {Grade A} - Nightingale
The nurse is performing a dressing change on a client who is postoperative from a
laparotomy. The client coughs and the nurse sees a few loops of intestine uncoiling
from the wound. What is the nurse's best action at this time?
a. Instruct the client to avoid looking at the wound.
b. Apply sterile saline-soaked towels to the area.
c. Apply sterile gloves and push the intestines back into the wound.
d. Assess the wound to determine the extent of evisceration. - correct answer b.
Apply sterile saline-soaked towels to the area.
A healthy 30-year-old male arrives at the clinic for a physical. The nurse is responsible
for collecting his vital signs. Which of these can be delegated to UAP? (Select all that
apply.)
Temperature.
BP.
Pulse.
Pulse oximetry.
Respiration. - correct answer Temperature.
BP.
Pulse.
, BSN 206 Foundations of Nursing
Fundamentals Hallmark Exam (Latest
Update ) Questions & Answers
100% Correct {Grade A} - Nightingale
Pulse oximetry.
Respiration.
The nurse documents vital signs on a newly admitted patient as: "blood pressure is
148/94 mm Hg, the pulse is 80 beats/min, and the respirations are 16 breaths/min."
The nurse would record the pulse pressure as:
a. 14 mm Hg.
b. 54 mm Hg.
c. 64 mm Hg.
d. 80 mm Hg. - correct answer b. 54 mm Hg.
The nursing student learns that the purpose of measuring a client's vital signs
includes which of the following rationale? (Select all that apply.)
Evaluate effectiveness of interventions.
Monitor body systems functioning.
Identify early signs of problems.
Determine if a cure has been obtained.
Provide a baseline to compare against. - correct answer Evaluate effectiveness of
interventions.
Monitor body systems functioning.
Identify early signs of problems.
, BSN 206 Foundations of Nursing
Fundamentals Hallmark Exam (Latest
Update ) Questions & Answers
100% Correct {Grade A} - Nightingale
Provide a baseline to compare against.
The nurse receives a hand-off report on four clients. Which client finding should the
nurse assess first?
A) Pulse oximetry 96%
B) Respiratory rate 18 breaths/min
C) Blood pressure 102/62 mm Hg
D) Pulse 42 beats/min - correct answer D) Pulse 42 beats/min
For the nurse to assess the most accurate respiration count, the nurse should:
A) inform the patient about his respirations and ask him to breathe normally.
B) continue to hold the patient's radial pulse, and count the respirations for 30
seconds and multiply them by 2.
C) count each inhalation and expiration for 1 full minute.
D) watch the patient's chest rise and fall from a distance. - correct answer B) continue
to hold the patient's radial pulse, and count the respirations for 30 seconds and
multiply them by 2.
Which of the following should the nurse report to the health care provider?
A) An adult client with a heart rate of 55.
B) An elderly male with a temperature of 96.8°F (36°C).
Fundamentals Hallmark Exam (Latest
Update ) Questions & Answers
100% Correct {Grade A} - Nightingale
Ensure the chest piece is rotated to the diaphragm side. - correct answer Reduce
environmental noise by turning off the TV or closing the door.
Make sure the stethoscope does not touch the client's clothing or BP cuff.
Keep the stethoscope tubing still to avoid extraneous sound.
Ensure the bladder of the cuff is centered 1 inch (2.5 cm) above the brachial artery.
Ensure the chest piece is rotated to the diaphragm side.
A nurse performs orthostatic blood pressure readings on a client with the following
results: lying 148/76 mm Hg, standing 110/60 mm Hg. What action by the nurse is
best?
A) Reassess the blood pressures in 1 hour.
B) Reassure the client that these findings are normal.
C) Instruct the client not to get up without help.
D) Document the findings and continue to monitor. - correct answer C) Instruct the
client not to get up without help.
, BSN 206 Foundations of Nursing
Fundamentals Hallmark Exam (Latest
Update ) Questions & Answers
100% Correct {Grade A} - Nightingale
The nurse is performing a dressing change on a client who is postoperative from a
laparotomy. The client coughs and the nurse sees a few loops of intestine uncoiling
from the wound. What is the nurse's best action at this time?
a. Instruct the client to avoid looking at the wound.
b. Apply sterile saline-soaked towels to the area.
c. Apply sterile gloves and push the intestines back into the wound.
d. Assess the wound to determine the extent of evisceration. - correct answer b.
Apply sterile saline-soaked towels to the area.
A healthy 30-year-old male arrives at the clinic for a physical. The nurse is responsible
for collecting his vital signs. Which of these can be delegated to UAP? (Select all that
apply.)
Temperature.
BP.
Pulse.
Pulse oximetry.
Respiration. - correct answer Temperature.
BP.
Pulse.
, BSN 206 Foundations of Nursing
Fundamentals Hallmark Exam (Latest
Update ) Questions & Answers
100% Correct {Grade A} - Nightingale
Pulse oximetry.
Respiration.
The nurse documents vital signs on a newly admitted patient as: "blood pressure is
148/94 mm Hg, the pulse is 80 beats/min, and the respirations are 16 breaths/min."
The nurse would record the pulse pressure as:
a. 14 mm Hg.
b. 54 mm Hg.
c. 64 mm Hg.
d. 80 mm Hg. - correct answer b. 54 mm Hg.
The nursing student learns that the purpose of measuring a client's vital signs
includes which of the following rationale? (Select all that apply.)
Evaluate effectiveness of interventions.
Monitor body systems functioning.
Identify early signs of problems.
Determine if a cure has been obtained.
Provide a baseline to compare against. - correct answer Evaluate effectiveness of
interventions.
Monitor body systems functioning.
Identify early signs of problems.
, BSN 206 Foundations of Nursing
Fundamentals Hallmark Exam (Latest
Update ) Questions & Answers
100% Correct {Grade A} - Nightingale
Provide a baseline to compare against.
The nurse receives a hand-off report on four clients. Which client finding should the
nurse assess first?
A) Pulse oximetry 96%
B) Respiratory rate 18 breaths/min
C) Blood pressure 102/62 mm Hg
D) Pulse 42 beats/min - correct answer D) Pulse 42 beats/min
For the nurse to assess the most accurate respiration count, the nurse should:
A) inform the patient about his respirations and ask him to breathe normally.
B) continue to hold the patient's radial pulse, and count the respirations for 30
seconds and multiply them by 2.
C) count each inhalation and expiration for 1 full minute.
D) watch the patient's chest rise and fall from a distance. - correct answer B) continue
to hold the patient's radial pulse, and count the respirations for 30 seconds and
multiply them by 2.
Which of the following should the nurse report to the health care provider?
A) An adult client with a heart rate of 55.
B) An elderly male with a temperature of 96.8°F (36°C).
