BSN205 Hallmark- Vital Signs ISB
UPDATED ACTUAL Exam Questions and
CORECT Answers
Normal respiratory rates - CORRECT ANSWER -newborn is 30 to 60 breaths per minute.
child is 20 breaths per minute.
teenager is 16 to 20 breaths per minute.
adult is 12 to 20 breaths per minute.
A rate of 10 would require follow-up.
Normal adult vital signs - CORRECT ANSWER -temperature 36° C (96.8° F)
heart rate 60 to 100 beats per minute
respiratory rate 16 to 25 breaths per minute
average BP less than 120 over 80
pulse oximetry 95% to 100%.
The nurse has delegated the task of temperature assessment to the NAP. Which information
should be provided to the NAP? - CORRECT ANSWER -The type of temperature
required.
The frequency for taking or monitoring the temperature.
What changes to report immediately to the nurse.
Which of the following situations may affect a patient's vital signs? - CORRECT
ANSWER -time of day, stress (emotional and physical), temperature alterations/weather
conditions, exercise/activity, emotions, medication, postural changes, acute pain, smoking,
disease/injury status, noise, food/liquid consumption, and odors.
The nurse will take the patient's vital signs preoperatively and record them as part of the patient's
preparation for surgery. Why is it necessary to take vital signs preoperatively? - CORRECT
ANSWER -The patient who is going to surgery is going to experience a change in
, condition and an invasive procedure. Vital signs are necessary so that the operative team has a
baseline for comparison as well as to rule out any complications before the beginning of the
surgical event. Providing reassurance to the patient can be done verbally. If a patient reports
feeling different, assessing vital signs is appropriate. There is no indication the patient is feeling
different. Equipment should be maintained in a functional state at all times.
The NAP reports to the nurse a 65-year-old patient s blood pressure is 160/98. What is the
appropriate initial response of the nurse? - CORRECT ANSWER -This is out of normal
range. If there is a question regarding a patient's vital signs or a suspected change in the patient's
condition that may require further assessment, the nurse should take the patient's vital signs
rather than delegating the task.
Which patient would it be appropriate for the nurse to delegate vital signs? - CORRECT
ANSWER -The nurse may delegate routine vital signs of stable patients. Obtaining a
baseline upon admission or transfer patient should be completed by the nurse. If a patient has a
change in condition, such as a headache which could be reflective of hypertension, the nurse
should assess the patient's vital signs.
Which person would be expected to have the lowest body temperature? - CORRECT
ANSWER -The 80 year old would have the lower starting body temp.
The NAP is preparing to measure a patient's vital signs. The patient reports having eaten a bowl
of warm soup. The NAP asks the RN what he should do. What is the best response? - CORRECT
ANSWER -The temperature of food or liquid could impair the accuracy of the reading.
The NAP should ask the patient not to eat, drink, or smoke for 20 minutes and then assess the
oral temperature.
Taking a rectal temperature can be needlessly embarrassing and uncomfortable for the patient.
Although the axillary route could be used, it is less accurate than the oral route. Furthermore,
when recording an axillary temperature reading, the site is documented, but the reading itself is
unchanged.
For which patient would a tympanic thermometer be the preferred thermometer to use? -
CORRECT ANSWER -An advantage to the tympanic thermometer is that it can be used
for tachypneic patients.
UPDATED ACTUAL Exam Questions and
CORECT Answers
Normal respiratory rates - CORRECT ANSWER -newborn is 30 to 60 breaths per minute.
child is 20 breaths per minute.
teenager is 16 to 20 breaths per minute.
adult is 12 to 20 breaths per minute.
A rate of 10 would require follow-up.
Normal adult vital signs - CORRECT ANSWER -temperature 36° C (96.8° F)
heart rate 60 to 100 beats per minute
respiratory rate 16 to 25 breaths per minute
average BP less than 120 over 80
pulse oximetry 95% to 100%.
The nurse has delegated the task of temperature assessment to the NAP. Which information
should be provided to the NAP? - CORRECT ANSWER -The type of temperature
required.
The frequency for taking or monitoring the temperature.
What changes to report immediately to the nurse.
Which of the following situations may affect a patient's vital signs? - CORRECT
ANSWER -time of day, stress (emotional and physical), temperature alterations/weather
conditions, exercise/activity, emotions, medication, postural changes, acute pain, smoking,
disease/injury status, noise, food/liquid consumption, and odors.
The nurse will take the patient's vital signs preoperatively and record them as part of the patient's
preparation for surgery. Why is it necessary to take vital signs preoperatively? - CORRECT
ANSWER -The patient who is going to surgery is going to experience a change in
, condition and an invasive procedure. Vital signs are necessary so that the operative team has a
baseline for comparison as well as to rule out any complications before the beginning of the
surgical event. Providing reassurance to the patient can be done verbally. If a patient reports
feeling different, assessing vital signs is appropriate. There is no indication the patient is feeling
different. Equipment should be maintained in a functional state at all times.
The NAP reports to the nurse a 65-year-old patient s blood pressure is 160/98. What is the
appropriate initial response of the nurse? - CORRECT ANSWER -This is out of normal
range. If there is a question regarding a patient's vital signs or a suspected change in the patient's
condition that may require further assessment, the nurse should take the patient's vital signs
rather than delegating the task.
Which patient would it be appropriate for the nurse to delegate vital signs? - CORRECT
ANSWER -The nurse may delegate routine vital signs of stable patients. Obtaining a
baseline upon admission or transfer patient should be completed by the nurse. If a patient has a
change in condition, such as a headache which could be reflective of hypertension, the nurse
should assess the patient's vital signs.
Which person would be expected to have the lowest body temperature? - CORRECT
ANSWER -The 80 year old would have the lower starting body temp.
The NAP is preparing to measure a patient's vital signs. The patient reports having eaten a bowl
of warm soup. The NAP asks the RN what he should do. What is the best response? - CORRECT
ANSWER -The temperature of food or liquid could impair the accuracy of the reading.
The NAP should ask the patient not to eat, drink, or smoke for 20 minutes and then assess the
oral temperature.
Taking a rectal temperature can be needlessly embarrassing and uncomfortable for the patient.
Although the axillary route could be used, it is less accurate than the oral route. Furthermore,
when recording an axillary temperature reading, the site is documented, but the reading itself is
unchanged.
For which patient would a tympanic thermometer be the preferred thermometer to use? -
CORRECT ANSWER -An advantage to the tympanic thermometer is that it can be used
for tachypneic patients.
