Hallmark BSN 206 (Latest Update 2025 /
2026) Questions with Verified Answers |
100% Correct | Grade A - Nightingale
Which of the following patients would require follow-up?
An adult with a respiratory rate of 10 breaths per minute.
Rational: The normal respiratory rate for a newborn is 30 to 60 breaths per minute.
The normal respiratory rate of a child is 20 breaths per minute. The normal
respiratory rate for a teenager is 16 to 20 breaths per minute. The normal
respiratory rate for an adult is 12 to 20 breaths per minute. A rate of 10 would
require follow-up.
Which of the following vital signs recorded for an older adult would be considered
acceptable (within normal limits)?
Temp 97.0° F (36.1 °C), P-60, R-16, BP 116/78, O2 sat 95%.
Rational: Normal values for an older adult are: average body temperature
approximately 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, and pulse
oximetry 95% to 100%. A BP greater than 140 over 90 may be an indication of
hypertension.
The nurse has delegated the task of temperature assessment to the NAP. Which
information should be provided to the NAP? (Select all that apply.)
-The type of temperature required.
-What changes to report immediately to the nurse.
-The frequency for taking or monitoring the temperature.
Rational: It is more important that the temperature be done on time by the correct
route, with the correct equipment, and that identified changes be reported as
requested.
,Which of the following situations may affect a patient's vital signs? (Select all that
apply.)
-Time of day.
-Moving from lying to standing position.
-Pain rated as a 7 on 0-10 pain scale.
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? (Select all that apply.)
To provide a set of vital signs to use for comparison during and after surgery.
To verify the patient is not experiencing any complications that may contraindicate
surgery or require intervention.
Rational: 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?
Assess the patient s blood pressure.
Rational: 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?
Elderly nursing home resident.
Rational: 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?
An 80-year-old who walked half a mile.
Rational: The 80-year-old would have a lower starting temperature and therefore,
would most likely have the lowest body temperature although it may take longer to
return to baseline after exercise. To be febrile means to have a fever. The toddler
would fail to have the lowest body temperature. A 16-year-old will have a higher
starting body temperature, and exercise will increase the body temperature further.
A child will have a higher starting temperature and exercise will increase the body
temperature further.
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?
"Ask the patient not to eat, drink, or smoke for 20 minutes and then assess the
patient's oral temperature."
Rational: 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?
A tachypneic patient who is receiving oxygen by nasal cannula.
Rational:An advantage to the tympanic thermometer is that it can be used for
tachypneic patients. The tympanic thermometer is contraindicated in patients who
have had surgery of the ear or tympanic membrane and does not accurately
measure core temperature after exercise. A continuous measurement cannot be
obtained with the tympanic thermometer.
.
Which of the following patients would require frequent assessment of their
temperature? (Select all that apply.)
, -An adult female in the recovery room following a hysterectomy.
-A young adult with a white blood count of 15,000/mm3.
-A patient receiving a blood transfusion for chronic anemia.
Rational: Certain conditions place patients at risk for temperature alterations and
may require more frequent assessment. Patients at risk may include those receiving
a blood product infusion, those who are of a postoperative status, and those with a
white blood cell count below 5,000 or above 12,000/mm3.
The NAP reports that the patient's temperature is 39° C (102.2 °F). Which of the
following are appropriate nursing actions? (Select all that apply.)
-Administer an antipyretic to the patient as ordered.
-Remove the patient's blankets.
Rational: Although the task of temperature assessment may be delegated, it is the
nurse's responsibility to determine the accuracy of the measurement and to assess
for further indication of infection. Fluids should be increased to 3 L daily (unless
contraindicated). The nurse should administer an antipyretic as ordered and
reassess the temperature in 30 minutes and every 4 hours until the temperature has
stabilized within normal limits. A cool wet wash cloth may be provided, but the
patient should not be excessively chilled, such as with ice. Cooling the temperature
in the room will aid in reducing the temperature, and reducing the amount of
external covering will promote heat loss. A hyperthermia blanket is used to raise
body temperature.
Which of the following actions, if made by the NAP, would require intervention
and further instruction by the nurse? (Select all that apply.)
-The NAP wipes the single-use chemical dot thermometer and places it back in the
patient's drawer for future use.
-The NAP inserts the red-tipped electronic thermometer probe into the patient's
mouth after applying a probe cover.
Rational:The electronic thermometers are differentiated by the probe cover tips:
blue for oral or axillary, red for rectal. Even though a probe cover is applied, a red-
tipped probe should not be placed into a patient's mouth. The single-use chemical
dot thermometer is plastic and can only be used once. All electronic thermometers
(oral, axillary, rectal) and the tympanic thermometer have a tone that sounds when
2026) Questions with Verified Answers |
100% Correct | Grade A - Nightingale
Which of the following patients would require follow-up?
An adult with a respiratory rate of 10 breaths per minute.
Rational: The normal respiratory rate for a newborn is 30 to 60 breaths per minute.
The normal respiratory rate of a child is 20 breaths per minute. The normal
respiratory rate for a teenager is 16 to 20 breaths per minute. The normal
respiratory rate for an adult is 12 to 20 breaths per minute. A rate of 10 would
require follow-up.
Which of the following vital signs recorded for an older adult would be considered
acceptable (within normal limits)?
Temp 97.0° F (36.1 °C), P-60, R-16, BP 116/78, O2 sat 95%.
Rational: Normal values for an older adult are: average body temperature
approximately 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, and pulse
oximetry 95% to 100%. A BP greater than 140 over 90 may be an indication of
hypertension.
The nurse has delegated the task of temperature assessment to the NAP. Which
information should be provided to the NAP? (Select all that apply.)
-The type of temperature required.
-What changes to report immediately to the nurse.
-The frequency for taking or monitoring the temperature.
Rational: It is more important that the temperature be done on time by the correct
route, with the correct equipment, and that identified changes be reported as
requested.
,Which of the following situations may affect a patient's vital signs? (Select all that
apply.)
-Time of day.
-Moving from lying to standing position.
-Pain rated as a 7 on 0-10 pain scale.
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? (Select all that apply.)
To provide a set of vital signs to use for comparison during and after surgery.
To verify the patient is not experiencing any complications that may contraindicate
surgery or require intervention.
Rational: 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?
Assess the patient s blood pressure.
Rational: 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?
Elderly nursing home resident.
Rational: 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?
An 80-year-old who walked half a mile.
Rational: The 80-year-old would have a lower starting temperature and therefore,
would most likely have the lowest body temperature although it may take longer to
return to baseline after exercise. To be febrile means to have a fever. The toddler
would fail to have the lowest body temperature. A 16-year-old will have a higher
starting body temperature, and exercise will increase the body temperature further.
A child will have a higher starting temperature and exercise will increase the body
temperature further.
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?
"Ask the patient not to eat, drink, or smoke for 20 minutes and then assess the
patient's oral temperature."
Rational: 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?
A tachypneic patient who is receiving oxygen by nasal cannula.
Rational:An advantage to the tympanic thermometer is that it can be used for
tachypneic patients. The tympanic thermometer is contraindicated in patients who
have had surgery of the ear or tympanic membrane and does not accurately
measure core temperature after exercise. A continuous measurement cannot be
obtained with the tympanic thermometer.
.
Which of the following patients would require frequent assessment of their
temperature? (Select all that apply.)
, -An adult female in the recovery room following a hysterectomy.
-A young adult with a white blood count of 15,000/mm3.
-A patient receiving a blood transfusion for chronic anemia.
Rational: Certain conditions place patients at risk for temperature alterations and
may require more frequent assessment. Patients at risk may include those receiving
a blood product infusion, those who are of a postoperative status, and those with a
white blood cell count below 5,000 or above 12,000/mm3.
The NAP reports that the patient's temperature is 39° C (102.2 °F). Which of the
following are appropriate nursing actions? (Select all that apply.)
-Administer an antipyretic to the patient as ordered.
-Remove the patient's blankets.
Rational: Although the task of temperature assessment may be delegated, it is the
nurse's responsibility to determine the accuracy of the measurement and to assess
for further indication of infection. Fluids should be increased to 3 L daily (unless
contraindicated). The nurse should administer an antipyretic as ordered and
reassess the temperature in 30 minutes and every 4 hours until the temperature has
stabilized within normal limits. A cool wet wash cloth may be provided, but the
patient should not be excessively chilled, such as with ice. Cooling the temperature
in the room will aid in reducing the temperature, and reducing the amount of
external covering will promote heat loss. A hyperthermia blanket is used to raise
body temperature.
Which of the following actions, if made by the NAP, would require intervention
and further instruction by the nurse? (Select all that apply.)
-The NAP wipes the single-use chemical dot thermometer and places it back in the
patient's drawer for future use.
-The NAP inserts the red-tipped electronic thermometer probe into the patient's
mouth after applying a probe cover.
Rational:The electronic thermometers are differentiated by the probe cover tips:
blue for oral or axillary, red for rectal. Even though a probe cover is applied, a red-
tipped probe should not be placed into a patient's mouth. The single-use chemical
dot thermometer is plastic and can only be used once. All electronic thermometers
(oral, axillary, rectal) and the tympanic thermometer have a tone that sounds when
