BSN206 Hallmark Exam Actual study
Questions and correct/verified Answers
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. - ANSW-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% - ANSW-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. - ANSW-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. - ANSW-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 "different". - ANSW-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. - ANSW-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. - ANSW-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. - ANSW-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." - ANSW-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. - ANSW-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. - ANSW-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. - ANSW-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 - ANSW-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. - ANSW-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) - ANSW-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 - ANSW-Temporal Artery
The task of pulse assessment could be delegated to the NAP for which of the following patients? (Select
all that apply.)
Questions and correct/verified Answers
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. - ANSW-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% - ANSW-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. - ANSW-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. - ANSW-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 "different". - ANSW-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. - ANSW-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. - ANSW-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. - ANSW-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." - ANSW-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. - ANSW-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. - ANSW-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. - ANSW-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 - ANSW-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. - ANSW-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) - ANSW-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 - ANSW-Temporal Artery
The task of pulse assessment could be delegated to the NAP for which of the following patients? (Select
all that apply.)
