BSN 206 Hallmark Exam Questions And Correct Answers With Complete Verified Solution.

BSN 206 Hallmark Exam Questions And Correct Answers With Complete Verified Solution. Which of the following patients would require follow-up? A child with a respiratory rate of 20 breaths per minute. An adolescent with a respiratory rate of 16 breaths per minute. A newborn with a respiratory rate of 40 breaths per minute. An adult with a respiratory rate of 10 breaths per minute. An adult with a respiratory rate of 10 breaths per minute Which of the following vital signs recorded for an older adult would be considered acceptable (within normal limits)? Temp 96.8° F (36 °C), P-60, R-18, BP 160/90, O2 sat 93%. Temp 97.0° F (36.1 °C), P-60, R-16, BP 116/78, O2 sat 95%. Temp 98.6 °F (37 °C), P-56, R-20, BP 120/80, O2 sat 91%. Temp 98.0 °F (36.7 °C), P-76, R-22, BP 110/70, O2 sat 88% Temp 97.0° F (36.1 °C), P-60, R-16, BP 116/78, O2 sat 95%. 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. The patient's age. The frequency for taking or monitoring the temperature. The patient's diagnosis. What changes to report immediately to the nurse. What changes to report immediately to the nurse The frequency for taking or monitoring the temperature The type of temperature required Which of the following situations may affect a patient's vital signs? (Select all that apply.) Moving from lying to standing position. Time of day. Occupation. Isolation precautions. Pain rated as a 7 on 0-10 pain scale. Moving from lying to standing position Time of Day Pain rated as a 7 on a 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 the patient with reassurance that he or she is being cared for by a competent staff. To provide a set of vital signs to use for comparison during and after surgery. You Answered To ensure the equipment is appropriately calibrated and functional. To verify the patient is not experiencing any complications that may contraindicate surgery or require intervention. You Answered To determine whether the patient is "feeling funny" or &quotdifferent&quot. 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 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? Document this as a normal finding in an elderly adult. Ask the NAP if the patient is nauseous. Instruct the NAP to obtain a full set of vital signs. Assess the patient s blood pressure. Assess the patient's blood pressure Which patient would it be appropriate for the nurse to delegate vital signs? Patient transferred from ICU. Elderly nursing home resident. New admission to the hospital. Patient with recent complaint of headache. Elderly nursing home resident Which person would be expected to have the lowest body temperature? An 80-year-old who walked half a mile. A child playing softball. A 16-year-old who ran 1 mile. A toddler who is febrile. An 80 year old who walked half a mile 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? "Change to the red thermometer probe and take the patient's temperature rectally." "Take the patient's temperature using the axillary route and when you record the reading, add 1°F." "Since the soup was not hot, go ahead and take the patient's temperature." "Ask the patient not to eat, drink, or smoke for 20 minutes and then assess the patient's oral temperature." Ask the patient to not eat, drink, or smoke for 20 minutes then assess the patient's oral temperature For which patient would a tympanic thermometer be the preferred thermometer to use? A marathon runner who developed weakness during the race. A tachypneic patient who is receiving oxygen by nasal cannula. A pediatric patient who had tubes surgically placed in the ears. A newborn that requires continuous temperature monitoring. A tachypneic patient who is receiving oxygen by nasal cannula Which of the following patients would require frequent assessment of their temperature? (Select all that apply.) A young adult with a white blood count of 15,000/mm3. An adult female in the recovery room following a hysterectomy. A patient receiving a blood transfusion for chronic anemia. A child who is below the normal height and weight for his age. An elderly patient who needs assistance with feeding and dressing. A young adult with a white blood count of 15,000/mm3 An adult female in the recovery room following a hysterectomy A patient receiving a blood transfusion for chronic anemia 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.) Remove the patient's blankets. Limit the patient's fluid intake. Apply a hyperthermia blanket as ordered. Administer an antipyretic to the patient as ordered. Place the patient's feet in a tub of cool water with ice. Remove the patient's blankets Administer an antipyretic to the patient as ordered 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 uses a blue-tipped electronic probe for assessing a patient's axillary temperature. 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. The NAP pulls the pinna up, back, and out in an adult when inserting the tympanic thermometer. The NAP waits un 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 Identify the factors that may have an effect on an elderly patient's temperature: (Select all that apply.) Participation in physical therapy exercises. Room temperature. Drinking a cold glass of water. Patient's height. Infection. Participation in physical therapy exercises room temperature drinking a cold glass of water infection If a 52-year-old patient has a normal temperature, what range should the patient's temperature fall within? 96.8-98.6 °F (36-37 °C) Correct! 96.8-100.4 °F (36-38 °C) 37-39 °C (98.6-102.2 °F) 35-36 °C (95-96.8 °F) 96.8-100.4F (36-38C) A 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? Chemical dot Tympanic Temporal artery Rectal electronic Temporal Artery The task of pulse assessment could be delegated to the NAP for which of the following patients? (Select all that apply.) An apical pulse of a patient who is to receive a cardiac drug. A femoral pulse following a lower leg amputation. A radial pulse of a patient in the emergency room with chest pain. The temporal pulse of a child. A radial pulse on a patient with a 1200 mL fluid restriction. The temporal pulse of a child A radial pulse on a patient with a 1200mL fluid restriction Which of the following patients would be at risk for having an alteration in peripheral pulse? (Select all that apply.) The patient who was just informed of a diagnosis of cancer. An elderly patient with Type 1 diabetes who is otherwise healthy. A patient who is receiving bolus IV fluids. A patient with Alzheimer's disease. A patient with peripheral vascular disease. The patient who was just informed of a diagnosis of cancer A patient who is receiving bolus IV fluids A patient with peripheral vascular disease Whenever there is an alteration in the radial pulse rate, rhythm, or amplitude, the nurse should initially do which of the following? Reassess the radial pulse for 30 seconds. Auscultate the apical pulse for quality and rate. Check the carotid pulses one side at a time. Check the radial pulse on the opposite side. Auscultate the apical pulse for quality and rate What is the normal pulse range for an adult? 90 to 140 beats per minute. 50 to 80 beats per minute. 120 to 160 beats per minute. 60 to 100 beats per minute. 60 to 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. True. False In which of the following patients would the nurse expect to find a decrease in pulse rate? (Select all that apply.) A patient who received morphine for pain. A student who is getting ready to take an exam. A patient returning from the operating room. A patient who experienced a bleeding episode. A newborn following a heelstick. A patient who received morphine for pain A patient returning from the operating room The new NAP is unable to palpate a patient's radial pulse. What could be a possible explanation for this difficulty? (Select all that apply.) The NAP assessed the patient's BP before taking the patient's pulse. The NAP is assessing for a pulse on the thumb side of the wrist. The NAP is assessing for a pulse on the ulnar side of the wrist. The patient was previously reported to have a full, bounding pulse. The NAP is pressing down too hard on the patient's radial site. The NAP failed to auscultate the patient's wrist with a stethoscope. The NAP is assessing for a pulse on the ulnar side of the wrist The NAP is pressing down too hard on the patient's radial site What is an appropriate nursing intervention for an adult patient with a respiratory rate of 30 breaths per minute? (Select all that apply.) Tell the patient their breaths are being counted so the patient will breathe slower. Count the respiratory rate again for a full 60 seconds (1 minute). Assess physiologic factors that may be causing the patient to breathe so fast. Administer a bronchodilator that will decrease the respiratory rate. Record this normal respiratory rate in the patient's medical record. Count the respiratory rate again for a full 60 seconds (1 minute) 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? (Select all that apply.) Smoking a cigarette. You Answered Having a pain level rating at 7 on a scale of 0-10. Using a bronchodilator prior to exercise. Correct! Feeling anxious when taking a test. Correct! Walking 1 mile briskly. Incurring a head injury from a motor vehicle accident. Taking an opioid to relieve pain. Correct! Having an addiction problem with amphetamines/cocaine. Feeling anxious when taking a test Walking 1 mile briskly Having an addiction problem with amphetemines/cocaine When assessing the respiratory rate, the nurse has difficulty seeing the patient's chest rise and fall with inspiration and expiration. What is the nurse's best action? Move the patient's arm over their chest and feel the rise and fall of the chest. Remove the patient's gown for better visualization of the patient's chest. Document the inability to visualize inspiration and expiration. Have another nurse assess the patient's respiratory rate. Move the patient's arm over their chest and feel the rise and fall of the chest How can the nurse best obtain an accurate measurement of a patient's respiratory rate? Inform the patient when monitoring his or her respirations. Correct! Continue to act as though taking the patient's pulse while discretely observing the rise and fall of the patient's chest. Assess the respirations while the patient is talking. Auscultate the lung sounds, asking the patient to take a deep breath in through the nose and exhale slowly through the mouth. 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? After taking the patient's pulse, the NAP continues to hold the patient's wrist, moving the arm across the patient's chest, and focuses on the patient's breathing. When the patient's respiratory rate is irregular, the NAP counts the patient's respirations for 1 full minute. When a patient inhales a breath, the NAP counts that as one, and when the patient exhales the breath, the NAP counts that as two. When the patient's respiratory rate is less than 12 or greater than 20, the NAP counts the patient's respirations for 1 full minute. When a patient inhales a breath, the NAP counts that as one, and when the patients exhales a 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 practice the technique of blood pressure measurement. To determine if there is a difference in the readings between the two arms. To verify the BP reading is 10 mm Hg higher in the dominant arm. To assess for a pulse deficit and record this as a baseline measurement. 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? An African-American patient with a systolic BP of 100. A football player with a diastolic BP of 94. An elderly patient with a systolic BP of 88. A pregnant woman with a diastolic BP of 67. 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 who is a double arm amputee following a motor vehicle accident. A patient with a deep vein thrombosis (blood clot, usually in the lower extremities). A patient with a history of a right-sided cerebrovascular accident (stroke). A patient with an arteriovenous shunt located in the forearm for hemodialysis. 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? Wait 30 seconds and repeat the measurement on the same arm. Assess the BP in the other arm. Get the nurse to assess the BP. Determine if the patient received an antihypertensive medication. Assess the BP in the other arm Using the image below, please choose the correct BP combination:<IM src=" Link (Links to an external may need to right click this link for it to open). Image A = 126/76, Image B = 140/90, Image C = 138/84, Image D = 120/80 Image A = 140/90, Image B = 138/84, Image C = 120/80, Image D = 126/76 Image A = 138/84, Image B = 120/80, Image C = 126/76, Image D = 140/90 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 has a temperature of 99.0°F when assessed rectally. The patient has been NPO since midnight before the surgery. The patient complains of pain at a 9 on a 0-10 pain scale. The body is compensating for the cool environment of the surgical suite. 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 In the left arm In the right leg In the left leg 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? Reattempt using a different electronic BP machine. Notify the health care provider of this change in patient condition. Increase the patient's rate of intravenous (IV) fluids. Take the patient's BP manually using a sphygmomanometer. 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 action by the nurse at this time? Request the NAP obtain the patient's pulse oximetry and report back. Ask the NAP to obtain and document a full set of vital signs. Assess the patient, including the pulse oximetry reading. Notify the health care provider of this change in condition. Assess the patient, including the pulse oximetry reading Which patient is at high risk for for the pulse oximetry alarm to sound? A patient with a continuous pulse oximetry reading of 84%. A patient who is receiving oxygen via face mask. A patient who has an intermittent pulse oximetry reading of 95%. A patient with a heart rate of 64 beats per minute. A patient with a continuous pulse oximetry reading of 84% A patient complains of feeling excessively tired. Which statement, if made by the NAP, indicates further instruction is necessary? "I will turn the continuous pulse oximetry alarms off at night so you can sleep." "I can give you a back massage to help you relax before bedtime." "If the finger clip is bothering you, I can attach a probe to your ear." "I will notify the nurse that you need your sleeping medication tonight." I will turn the continuous pulse oximetry alarms off at night so you can sleep. The NAP tells the nurse the patient's pulse oximetry is 85% on room air. What nursing action(s) should the nurse take? (Select all that apply.) Start oxygen at 2 liters per minute by nasal cannula. Reassess the patient's pulse oximetry. Place the patient in the high-Fowler's position. Have the NAP take the patient's vital signs. Assess the patient's respiratory and cardiac status. Reassess the patient's pulse oximetry Place the patient in the high-Fowler's position Assess the patient's respiratory and cardiac status The nurse reads the following entry in a patient's health record. The patient has an order for SpO2 every 4 hours. Based on this information, what would be the nurse's best action?01/25/17 0800 Unable to obtain pulse oximetry reading. Attempted X2 fingers of each hand. Patient's fingers cool to touch. Patient states has artificial nails. Patient on 2 L oxygen per nasal cannula. Respirations nonlabored. C. Smith, N.A.P.__ Remove one of the patient's acrylic nails and reattempt obtaining the SpO2. Place the patient's hands under warm running water and reattempt the reading. Have the NAP use a different site, such as the ear lobe, to obtain the SpO2 reading. Nothing further, as the NAP has provided sufficient data regarding patient condition. Have the NAP use a different site, such as the ear lobe, to obtain the SpO2 reading. Which of the following vital signs are expected for the adult patient who has problems in oxygenation? Temp 97.5° F (36.4 °C), P-76, R-20, BP 110/70, O2 sat 95%. Temp 98.2° F (36.8 °C), P-64, R-16, BP 120/80, O2 sat 96%. Temp 98.6° F (37 °C), P-102, R-28, BP 98/50, O2 sat 85%. Temp 97.9° F (36.6 °C), P-80, R-18, BP 140/90, O2 sat 95%. Temp 98.6° F (37 °C), P-102, R-28, BP 98/50, O2 sat 85%. 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 NAP? (Select all that apply.) Respiration. BP. Pulse. Temperature. Pulse oximetry. Respiration BP Pulse Temperature Pulse Oximetry The nurse decides to collect the patient's temperature orally using an electronic thermometer. Choose the equipment to be used. (Select all that apply.) Red probe electronic thermometer. Chemical oral thermometer. Blue probe electronic thermometer. Tympanic thermometer. Patient data recording sheet and a pen. Thermometer cover. Lubricant. Watch with second hand. Tissue. Chemical external thermometer. Blue probe electronic thermometer Patient data recording sheet and a pen Thermometer cover The patient's BP reading is 150/80 mmHg. For this patient, 80 is representative of: (Select all that apply.) The ventricles during contraction. The pulse pressure. The ventricles during relaxation. The systolic pressure. The diastolic pressure. The pulse deficit. The ventricles during relaxation The diastolic pressure The nurse is having great difficulty hearing any sound when taking a patient's BP. What can the nurse do to increase the ability to auscultate the reading? (Select all that apply.) Ensure the bladder of the cuff is centered 1 inch (2.5 cm) above the brachial artery.