BSN206-05: Hallmark Final Exam
Questions and Correct Detailed
Answers
A patient was brought to the emergency department following a motor vehicle accident. He appears
drowsy, but will arouse to his name being called. He is bleeding profusely from an injury to his leg.
What would the nurse expect his vital signs to be?
98.6°F (37°C), 84, 20, 120/80
97.8°F (36.5°C), 110, 24, 80/40
99.0°F (37.2°C), 88, 16, 130/80
100.4°F (38°C), 76, 24, 140/90 - Answer: 97.8°F (36.5°C), 110, 24, 80/40
The nurse would expect vital signs to be reflective of hypovolemic shock: tachycardic, tachypneic,
and hypotensive.
The nurse was assigned to care for five patients. Which of the following vital sign measurements
would be cause for concern? (Select all that apply.)
75-year-old with pulse oximetry of 88% on room air
65-year-old with blood pressure of 140/90
8-year-old with respiratory rate of 24 breaths/minute
88-year-old with temperature of 96.8° F (36° F)
22-year-old with heart rate of 90 beats/minute - Answer: 75-year-old with pulse oximetry of 88% on
room air
65-year-old with blood pressure of 140/90
The nurse reads the following nurse's note in the patient's health record. What is the priority nursing
intervention based on this information?9/21/17 1800 Patient complains of headaches, almost daily,
occurring more frequently in the evening. BP 164/98. P. Johnson N.A.P.
Inform the patient it is normal to have a higher BP reading in the evening.
Instruct the NAP to repeat the BP measurement using a manual cuff.
Obtain a complete set of vital signs and gather further assessment data.
Administer acetaminophen (Tylenol) to relieve the patient's headache. - Answer: Obtain a complete
set of vital signs and gather further assessment data.
,It is the responsibility of the nurse to verify abnormal vital signs. The nurse will want to gather a
complete set of vital signs and additional data, such as does the patient take antihypertensive
medications? if so, when was it last taken? is this a usual BP reading for the patient compared to
baseline? Once more information is gathered, the nurse may contact the health care provider for
follow-up.
A nursing student is assigned to take the vital signs on a patient and finds the radial pulse to be
irregular. What action should the nursing student take?
Ask a fellow student to assess the pulse.
Wait 15 minutes and reassess the pulse.
Auscultate the patient's apical pulse.
Check the patient's previous pulse reading. - Answer: Auscultate the patient's apical pulse.
The nursing student should auscultate the patient's apical pulse. Another nursing student may or
may not be able to obtain a radial pulse and it is the responsibility of the nursing student to
complete tasks assigned in order to become proficient and independent in nursing assessment. It is
unnecessary to wait 15 minutes to reassess the pulse. Checking a previous reading may be valuable
for comparison, but does not result in obtaining the pulse rate at this time.
An elderly patient was recently admitted to a medical unit with severe fluid and electrolyte
imbalance. His family states that he has periods of confusion. What are some practical precautions
the nurse can take to ensure the patient's safety without having to use restraints? (Select all that
apply.)
Use a security camera to monitor the patient while in bed.
Make staff assignments for patients in adjacent rooms.
Activate the bed alarm when the patient is in bed.
Perform nurse toilet and turn or comfort and safety rounds hourly.
Administer IV fluids to reverse fluid imbalance. - Answer: Make staff assignments for patients in
adjacent rooms.
Activate the bed alarm when the patient is in bed.
Perform nurse toilet and turn or comfort and safety rounds hourly.
You may use a bed alarm to alert staff of the patient getting up without assistance. Having assigned
patients in close proximity facilitates the ability of staff to monitor and respond quickly to their
assigned patients. Hourly rounding will enable the nurse to meet patient needs and avoid the patient
getting up without assistance. Although some health care agencies may have rooms equipped with
, security cameras and have the staff to monitor them, it is unlikely in most settings. The infusion of
fluids is determined by a health care provider and will not necessarily quickly reverse confusion.
A patient is admitted to a medical unit with pneumonia. She is able to ambulate on her own to the
bathroom. What safety precautions should be taken for this patient? (Select all that apply.)
Explain the use of the call light.
Keep the bed in the low, locked position.
Keep all side rails up when patient is in bed.
Place a bedside commode near bed with back to wall.
Ensure that the pathway to the bathroom is clear.
Keep patient's personal items on the overbed table. - Answer: Ensure that the pathway to the
bathroom is clear.
Keep patient's personal items on the overbed table.
Explain the use of the call light.
Keep the bed in the low, locked position.
To promote safety for a recently admitted patient who is able to ambulate, the nurse should explain
the use of the call light, keeping it in an accessible location for the patient. Keep the bed in a low,
locked position. Keep the pathway clear to reduce the likelihood of the patient falling over objects or
bumping into them. Side rails may be considered a restraint device when used to prevent the
ambulatory patient from getting out of bed. The nurse may ask the patient if she would like to have
one side rail up. The patient is ambulatory; therefore, offering a bedside commode would be
unnecessary. Necessary items such as eyeglasses should be placed within the patient's easy reach,
such as on the overbed table. This facilitates independence and self-care and prevents falls that
occur when a patient reaches too far.
The nurse walking down the hospital corridor glances into the patient's room and sees the patient's
feet and legs sticking out from the bathroom entrance. The nurse immediately goes into the room
and determines that the patient has fallen. What actions should be taken? (Select all that apply.)
Call for assistance.
Assess for injury.
Notify the health care provider.
Avoid moving the patient until the health care provider arrives.
Assess the situation for precipitous factors (e.g., hypotension, slippery footwear, etc.).
Apply a restraint after returning the patient to bed.
Fill out an agency occurrence or sentinel event report. - Answer: Call for assistance.
Questions and Correct Detailed
Answers
A patient was brought to the emergency department following a motor vehicle accident. He appears
drowsy, but will arouse to his name being called. He is bleeding profusely from an injury to his leg.
What would the nurse expect his vital signs to be?
98.6°F (37°C), 84, 20, 120/80
97.8°F (36.5°C), 110, 24, 80/40
99.0°F (37.2°C), 88, 16, 130/80
100.4°F (38°C), 76, 24, 140/90 - Answer: 97.8°F (36.5°C), 110, 24, 80/40
The nurse would expect vital signs to be reflective of hypovolemic shock: tachycardic, tachypneic,
and hypotensive.
The nurse was assigned to care for five patients. Which of the following vital sign measurements
would be cause for concern? (Select all that apply.)
75-year-old with pulse oximetry of 88% on room air
65-year-old with blood pressure of 140/90
8-year-old with respiratory rate of 24 breaths/minute
88-year-old with temperature of 96.8° F (36° F)
22-year-old with heart rate of 90 beats/minute - Answer: 75-year-old with pulse oximetry of 88% on
room air
65-year-old with blood pressure of 140/90
The nurse reads the following nurse's note in the patient's health record. What is the priority nursing
intervention based on this information?9/21/17 1800 Patient complains of headaches, almost daily,
occurring more frequently in the evening. BP 164/98. P. Johnson N.A.P.
Inform the patient it is normal to have a higher BP reading in the evening.
Instruct the NAP to repeat the BP measurement using a manual cuff.
Obtain a complete set of vital signs and gather further assessment data.
Administer acetaminophen (Tylenol) to relieve the patient's headache. - Answer: Obtain a complete
set of vital signs and gather further assessment data.
,It is the responsibility of the nurse to verify abnormal vital signs. The nurse will want to gather a
complete set of vital signs and additional data, such as does the patient take antihypertensive
medications? if so, when was it last taken? is this a usual BP reading for the patient compared to
baseline? Once more information is gathered, the nurse may contact the health care provider for
follow-up.
A nursing student is assigned to take the vital signs on a patient and finds the radial pulse to be
irregular. What action should the nursing student take?
Ask a fellow student to assess the pulse.
Wait 15 minutes and reassess the pulse.
Auscultate the patient's apical pulse.
Check the patient's previous pulse reading. - Answer: Auscultate the patient's apical pulse.
The nursing student should auscultate the patient's apical pulse. Another nursing student may or
may not be able to obtain a radial pulse and it is the responsibility of the nursing student to
complete tasks assigned in order to become proficient and independent in nursing assessment. It is
unnecessary to wait 15 minutes to reassess the pulse. Checking a previous reading may be valuable
for comparison, but does not result in obtaining the pulse rate at this time.
An elderly patient was recently admitted to a medical unit with severe fluid and electrolyte
imbalance. His family states that he has periods of confusion. What are some practical precautions
the nurse can take to ensure the patient's safety without having to use restraints? (Select all that
apply.)
Use a security camera to monitor the patient while in bed.
Make staff assignments for patients in adjacent rooms.
Activate the bed alarm when the patient is in bed.
Perform nurse toilet and turn or comfort and safety rounds hourly.
Administer IV fluids to reverse fluid imbalance. - Answer: Make staff assignments for patients in
adjacent rooms.
Activate the bed alarm when the patient is in bed.
Perform nurse toilet and turn or comfort and safety rounds hourly.
You may use a bed alarm to alert staff of the patient getting up without assistance. Having assigned
patients in close proximity facilitates the ability of staff to monitor and respond quickly to their
assigned patients. Hourly rounding will enable the nurse to meet patient needs and avoid the patient
getting up without assistance. Although some health care agencies may have rooms equipped with
, security cameras and have the staff to monitor them, it is unlikely in most settings. The infusion of
fluids is determined by a health care provider and will not necessarily quickly reverse confusion.
A patient is admitted to a medical unit with pneumonia. She is able to ambulate on her own to the
bathroom. What safety precautions should be taken for this patient? (Select all that apply.)
Explain the use of the call light.
Keep the bed in the low, locked position.
Keep all side rails up when patient is in bed.
Place a bedside commode near bed with back to wall.
Ensure that the pathway to the bathroom is clear.
Keep patient's personal items on the overbed table. - Answer: Ensure that the pathway to the
bathroom is clear.
Keep patient's personal items on the overbed table.
Explain the use of the call light.
Keep the bed in the low, locked position.
To promote safety for a recently admitted patient who is able to ambulate, the nurse should explain
the use of the call light, keeping it in an accessible location for the patient. Keep the bed in a low,
locked position. Keep the pathway clear to reduce the likelihood of the patient falling over objects or
bumping into them. Side rails may be considered a restraint device when used to prevent the
ambulatory patient from getting out of bed. The nurse may ask the patient if she would like to have
one side rail up. The patient is ambulatory; therefore, offering a bedside commode would be
unnecessary. Necessary items such as eyeglasses should be placed within the patient's easy reach,
such as on the overbed table. This facilitates independence and self-care and prevents falls that
occur when a patient reaches too far.
The nurse walking down the hospital corridor glances into the patient's room and sees the patient's
feet and legs sticking out from the bathroom entrance. The nurse immediately goes into the room
and determines that the patient has fallen. What actions should be taken? (Select all that apply.)
Call for assistance.
Assess for injury.
Notify the health care provider.
Avoid moving the patient until the health care provider arrives.
Assess the situation for precipitous factors (e.g., hypotension, slippery footwear, etc.).
Apply a restraint after returning the patient to bed.
Fill out an agency occurrence or sentinel event report. - Answer: Call for assistance.
