Hallmark final exam BSN-205|Verified Q’s and
A’s
Which of the follow would require a follow up? - -An adult with respirtations
of 10 breaths per minute
- Which of the following vital signs recorded for an older adult would be
considered acceptable (within normal limits)? - -Temp 97.0° F, P-60, R-16, BP
116/78, O2 sat 95%.
- Which of the following situations may affect a patients vital signs? - -Time
of day
Moving from lying to a standing postion
Pain rated as a 7 on a scale of 1-10
- Why is it necessay to take a patients vital signs preoperatively? - -To verify
the patients not experiencing any complications
To provide a set of vital signs for comparison during and after surgery.
- The NAP reports to the nurse a 65 year old patient's BP is 160/98. What is
the appropriate initial response of the nurse? - -Assess the patient's BP
- Which patient would it be appropriate for the nurse to delegate vital signs?
- -Elderly nursing home resident
- The nurse has delegated the task of temperature assessment to the NAP.
Which information should be provided to the NAP? - --The type of
temperature required
-The frequency for taking or monitoring the temperature
-What changes to report immediately to the nurse
- Who would you expect to have the lowest body temperature?
A) A 16 year old who ran 1 mile
B) An 80 year old who walked 1/2 mile
C) A toddler who is febrile
D) A child playing softball - -B. 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?
A) "Ask the patient not to eat, drink, or smoke for 15 minutes and then
assess the patient's oral temperature"
B) "Since the soup was not hot, go ahead and take the patient's
temperature."
,C) "Change to the red thermometer probe and take the patient's
temperature rectally."
D) "Take the patient's temperature using the axillary route and when you
record the reading, add 1°F." - -A) "Ask the patient not to eat, drink, or
smoke for 15 minutes and then assess the patient's oral temperature
- For which patient would a tympanic thermometer be the preferred
thermometer to use?
A) A marathon runner who developed weakness during the race.
B) A newborn in the intensive care unit that requires continuous temperature
monitoring.
C) A child who had tubes surgically placed in the ears.
D) A tachypneic patient who is receiving oxygen by nasal cannula. - -D) A
tachypneic patient who is receiving oxygen by nasal cannula.
- Which of the following patients would need frequent assessment of their
temperature? (Select all that apply.)
A) A patient receiving a blood transfusion for chronic anemia
B) An elderly patient who needs assistance with feeding and dressing
C) A 43 year old female who has undergone a hysterectomy
D) A child who is small for his age
E) A 19 year old with a while blood cell count of 15,000/mm - -A) A patient
receiving a blood transfusion for chronic anemia
A 43-year-old female who has undergone a hysterectomy. Correct
E) A 19 year old with a while blood cell count of 15,000/mm
- 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.)
A) Place the patient's feet in a tub of cool water with ice.
B) Apply a hyperthermia blanket as ordered.
C) Remove the patient's blankets.
D) Limit the patient's fluid intakeE) Administer an antipyretic to the patient
as ordered - -C) Remove the patient's blankets.
E) 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.)
A) The NAP inserts the red-tipped electronic thermometer probe into the
patient's mouth after applying a probe cover.
B) The NAP wipes the single-use chemical dot thermometer and places it
back in the patient's drawer for future use.
C) The NAP waits until a tone sounds to read the tympanic thermometer.
, D) The NAP uses a blue-tipped electronic probe for assessing a patient's
axillary temperature.E) The NAP pulls the pinna up, back, and out in an adult
when inserting the tympanic thermometer. - -A) The NAP inserts the red-
tipped electronic thermometer probe into the patient's mouth after applying
a probe cover. Correct
B) The NAP wipes the single-use chemical dot thermometer and places it
back in the patient's drawer for future use. Correct
- Identify the factors that may have an effect on an 82-year-old patient's
temperature: (Select all that apply.)
A) Drinking a cold glass of water
B) Participation in strenuous physical therapy exercises
C) Infection
D) Room Temperature
E) Patient's height - -A) Drinking a cold glass of water
B) Participation in strenuous physical therapy exercises
C) Infection
D) Room Temperature
- 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
A’s
Which of the follow would require a follow up? - -An adult with respirtations
of 10 breaths per minute
- Which of the following vital signs recorded for an older adult would be
considered acceptable (within normal limits)? - -Temp 97.0° F, P-60, R-16, BP
116/78, O2 sat 95%.
- Which of the following situations may affect a patients vital signs? - -Time
of day
Moving from lying to a standing postion
Pain rated as a 7 on a scale of 1-10
- Why is it necessay to take a patients vital signs preoperatively? - -To verify
the patients not experiencing any complications
To provide a set of vital signs for comparison during and after surgery.
- The NAP reports to the nurse a 65 year old patient's BP is 160/98. What is
the appropriate initial response of the nurse? - -Assess the patient's BP
- Which patient would it be appropriate for the nurse to delegate vital signs?
- -Elderly nursing home resident
- The nurse has delegated the task of temperature assessment to the NAP.
Which information should be provided to the NAP? - --The type of
temperature required
-The frequency for taking or monitoring the temperature
-What changes to report immediately to the nurse
- Who would you expect to have the lowest body temperature?
A) A 16 year old who ran 1 mile
B) An 80 year old who walked 1/2 mile
C) A toddler who is febrile
D) A child playing softball - -B. 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?
A) "Ask the patient not to eat, drink, or smoke for 15 minutes and then
assess the patient's oral temperature"
B) "Since the soup was not hot, go ahead and take the patient's
temperature."
,C) "Change to the red thermometer probe and take the patient's
temperature rectally."
D) "Take the patient's temperature using the axillary route and when you
record the reading, add 1°F." - -A) "Ask the patient not to eat, drink, or
smoke for 15 minutes and then assess the patient's oral temperature
- For which patient would a tympanic thermometer be the preferred
thermometer to use?
A) A marathon runner who developed weakness during the race.
B) A newborn in the intensive care unit that requires continuous temperature
monitoring.
C) A child who had tubes surgically placed in the ears.
D) A tachypneic patient who is receiving oxygen by nasal cannula. - -D) A
tachypneic patient who is receiving oxygen by nasal cannula.
- Which of the following patients would need frequent assessment of their
temperature? (Select all that apply.)
A) A patient receiving a blood transfusion for chronic anemia
B) An elderly patient who needs assistance with feeding and dressing
C) A 43 year old female who has undergone a hysterectomy
D) A child who is small for his age
E) A 19 year old with a while blood cell count of 15,000/mm - -A) A patient
receiving a blood transfusion for chronic anemia
A 43-year-old female who has undergone a hysterectomy. Correct
E) A 19 year old with a while blood cell count of 15,000/mm
- 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.)
A) Place the patient's feet in a tub of cool water with ice.
B) Apply a hyperthermia blanket as ordered.
C) Remove the patient's blankets.
D) Limit the patient's fluid intakeE) Administer an antipyretic to the patient
as ordered - -C) Remove the patient's blankets.
E) 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.)
A) The NAP inserts the red-tipped electronic thermometer probe into the
patient's mouth after applying a probe cover.
B) The NAP wipes the single-use chemical dot thermometer and places it
back in the patient's drawer for future use.
C) The NAP waits until a tone sounds to read the tympanic thermometer.
, D) The NAP uses a blue-tipped electronic probe for assessing a patient's
axillary temperature.E) The NAP pulls the pinna up, back, and out in an adult
when inserting the tympanic thermometer. - -A) The NAP inserts the red-
tipped electronic thermometer probe into the patient's mouth after applying
a probe cover. Correct
B) The NAP wipes the single-use chemical dot thermometer and places it
back in the patient's drawer for future use. Correct
- Identify the factors that may have an effect on an 82-year-old patient's
temperature: (Select all that apply.)
A) Drinking a cold glass of water
B) Participation in strenuous physical therapy exercises
C) Infection
D) Room Temperature
E) Patient's height - -A) Drinking a cold glass of water
B) Participation in strenuous physical therapy exercises
C) Infection
D) Room Temperature
- 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
