BSN 206 ISB -HALLMARK EXAM II (NIGHTINGALE
COLLEGE) |REAL EXAM QUESTIONS AND
CORRECT ANSWERS (100% VERIFIED) ||100%
GUARANTEED PASS!!!
MULTIPLE CHOICES
Which of the following would require follow-up?
a. an adult with a resp. rate of 10 breaths per minute
b. a child with resp. rate of 20 breaths per minute
c. an adolescent with a resp. rate of 16 breaths per minute
d. a newborn with a resp. rate of 40 breaths per minute
A newborn with a resp. rate of 40 breaths per minute
The normal Resp. rate for a newborn is 30-60 breaths per minute.
Normal resp rate for a teenager is 16-20 breaths per minute
Normal resp. rate for an adult is 12-20 breahts per minute
A rate of 10 would require a follow-up
Which of the following vital signs recorded for an older adult would be considered acceptable (within normal
limits)?
a. Temp. 98.0F (36.7 C), P-76, BP 110/70, O2 sat 88%
b. Temp. 96.8F (36.0 C), P-60, R-18, BP 160/90, O2 sat 93%
c. Temp. 97.0F (36.1 C), P-60, R-16, BP 116/78, O2 sat 95%
d. Temp. 98.6F (37.0 C), P-56, R-20, BP 120/80, O2 sat 91%
Temp. 97.0F (36.1 C), P-60, BP 116/78, O2 sat 95%
Normal values for an aoolder adult are: average body temp. approx. 36 C (96.8F), heart rate 60 to 100 beats per
minute, resp. rate 16-25 breaths per minute, average BP less than 120/80, and pulse oximetry 95% to 100%.
A BP greater than 140/90 may be an indication of hypertension
1
,The nurse has delegated the task of temp. assessment to the NAP. Which information should be provided to the
NAP?
a. The patient's diagnosis
b. What changes to report immediately to the nurse.
c. The type of temp. required
d. The frequency for taking or monitoring the temp.
e. The patient's age.
What changes to report immediately to the nurse
The type of temperature required
The frequency for taking or monitoring the temperature
Which of the following situations may affect a patient's vital signs?
a. Isolation precautions
b. Pain rated as a 7 on a 0-10 scale
c. Occupation
d. Time of day
e. Moving from lying to standing position
Pain rated as a 7 on a 0-10 scale
Time of day
Moving from lying to standing position
Factors that may alter vital signs include time of day, stress (emotional/physical), temp alterations/weather
conditions, exercise/activity, emotions, medication, postural changes, acute pain, smoking, disease/injury status,
noise, food/liquid consumption, and odors.
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?
- 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 intiial
response of the nurse?
Assess the patient's BP
2
,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, teh 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?
a. Patient with a recent complaint of headache
b. New admission to the hospital
c. Patient transferred from ICU
d. Elderly nursing home resident
Elderly nursing home resident
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 aheadache 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?
a. A toddler who is febrile
b. An 80-year-old who walked half a mile
c. A child playing softball
d. A 16-year-old who ran 1 mile
An 80 year old who walked half a mile.
The 80 year old would have a lower standing temp. and therefore, would most likely have the lowest body temp.
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 temp.
* a 16 year old will have. ahigher starting body temp. and exercise will increase the body temp. further.
* A child will have a higher starting temp. and exercise will increase the bodytemp. further
The NAP is preparing to measure a patient's vital signs. The patient reports having eating 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 orla temperature
* The temp. of food or liquid could impair the accuracy of the reading. The NAP should ask teh patient not to eat,
drink or smoke for 20 minutes and then assess teh oral temp.
* Option of taking a rectal temp. at this time can be needlessly embarrassing and uncomfortabe for the patient.
3
, * Although axillary route could be used, it is less accurate than the oral route. Furthermore, when recording an
axillary temp. reading, teh site is documeted but the reading itself is unchanged.
For which patient would a tympanic thermometer be the preferred thermometer to use?
a. A newborn that requires continuous temperature monitoring
b. A tachypneic patient who is receiving oxygen by nasal cannula
c. A pediatric patient who had tubes surgically placed in the ears
d. A marathon runner who developed weakness during the race
A tachypneic patient who is receiving oxygen by nasal cannula
* An advantageto 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 temp. after exercise.
* A continuous measurement cannot be obtained with the tympanic thermometer
Which of the following patients would require frequent assessment of their temperature?
- A patient receiving a blood transfusion for chronic anemia
- A young adult with a white blood count of 15,000/mm^3
- An adult female in the recovery room following a hysterectomy
* Certain conditions place patinets 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 at ostoperative status, and those
with a white blood cell count below 5,000 or above 12,000/mm^3
The NAP reports that the patient's temperature is 39C (102.2 F) Which of the following are appropriate nursing
actions? (select all that apply)
- Apply a hyperthermia blanket as ordered
- Administer an antipyretic to the patient as ordered
- Remove the patient's blankets
- Limit the patient's fluid intake
- Place the patient's feet in a tub of cool water with ice
- Administer an atipyretic to the patient as ordered
- Remove the patient's blankets
4
COLLEGE) |REAL EXAM QUESTIONS AND
CORRECT ANSWERS (100% VERIFIED) ||100%
GUARANTEED PASS!!!
MULTIPLE CHOICES
Which of the following would require follow-up?
a. an adult with a resp. rate of 10 breaths per minute
b. a child with resp. rate of 20 breaths per minute
c. an adolescent with a resp. rate of 16 breaths per minute
d. a newborn with a resp. rate of 40 breaths per minute
A newborn with a resp. rate of 40 breaths per minute
The normal Resp. rate for a newborn is 30-60 breaths per minute.
Normal resp rate for a teenager is 16-20 breaths per minute
Normal resp. rate for an adult is 12-20 breahts per minute
A rate of 10 would require a follow-up
Which of the following vital signs recorded for an older adult would be considered acceptable (within normal
limits)?
a. Temp. 98.0F (36.7 C), P-76, BP 110/70, O2 sat 88%
b. Temp. 96.8F (36.0 C), P-60, R-18, BP 160/90, O2 sat 93%
c. Temp. 97.0F (36.1 C), P-60, R-16, BP 116/78, O2 sat 95%
d. Temp. 98.6F (37.0 C), P-56, R-20, BP 120/80, O2 sat 91%
Temp. 97.0F (36.1 C), P-60, BP 116/78, O2 sat 95%
Normal values for an aoolder adult are: average body temp. approx. 36 C (96.8F), heart rate 60 to 100 beats per
minute, resp. rate 16-25 breaths per minute, average BP less than 120/80, and pulse oximetry 95% to 100%.
A BP greater than 140/90 may be an indication of hypertension
1
,The nurse has delegated the task of temp. assessment to the NAP. Which information should be provided to the
NAP?
a. The patient's diagnosis
b. What changes to report immediately to the nurse.
c. The type of temp. required
d. The frequency for taking or monitoring the temp.
e. The patient's age.
What changes to report immediately to the nurse
The type of temperature required
The frequency for taking or monitoring the temperature
Which of the following situations may affect a patient's vital signs?
a. Isolation precautions
b. Pain rated as a 7 on a 0-10 scale
c. Occupation
d. Time of day
e. Moving from lying to standing position
Pain rated as a 7 on a 0-10 scale
Time of day
Moving from lying to standing position
Factors that may alter vital signs include time of day, stress (emotional/physical), temp alterations/weather
conditions, exercise/activity, emotions, medication, postural changes, acute pain, smoking, disease/injury status,
noise, food/liquid consumption, and odors.
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?
- 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 intiial
response of the nurse?
Assess the patient's BP
2
,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, teh 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?
a. Patient with a recent complaint of headache
b. New admission to the hospital
c. Patient transferred from ICU
d. Elderly nursing home resident
Elderly nursing home resident
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 aheadache 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?
a. A toddler who is febrile
b. An 80-year-old who walked half a mile
c. A child playing softball
d. A 16-year-old who ran 1 mile
An 80 year old who walked half a mile.
The 80 year old would have a lower standing temp. and therefore, would most likely have the lowest body temp.
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 temp.
* a 16 year old will have. ahigher starting body temp. and exercise will increase the body temp. further.
* A child will have a higher starting temp. and exercise will increase the bodytemp. further
The NAP is preparing to measure a patient's vital signs. The patient reports having eating 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 orla temperature
* The temp. of food or liquid could impair the accuracy of the reading. The NAP should ask teh patient not to eat,
drink or smoke for 20 minutes and then assess teh oral temp.
* Option of taking a rectal temp. at this time can be needlessly embarrassing and uncomfortabe for the patient.
3
, * Although axillary route could be used, it is less accurate than the oral route. Furthermore, when recording an
axillary temp. reading, teh site is documeted but the reading itself is unchanged.
For which patient would a tympanic thermometer be the preferred thermometer to use?
a. A newborn that requires continuous temperature monitoring
b. A tachypneic patient who is receiving oxygen by nasal cannula
c. A pediatric patient who had tubes surgically placed in the ears
d. A marathon runner who developed weakness during the race
A tachypneic patient who is receiving oxygen by nasal cannula
* An advantageto 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 temp. after exercise.
* A continuous measurement cannot be obtained with the tympanic thermometer
Which of the following patients would require frequent assessment of their temperature?
- A patient receiving a blood transfusion for chronic anemia
- A young adult with a white blood count of 15,000/mm^3
- An adult female in the recovery room following a hysterectomy
* Certain conditions place patinets 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 at ostoperative status, and those
with a white blood cell count below 5,000 or above 12,000/mm^3
The NAP reports that the patient's temperature is 39C (102.2 F) Which of the following are appropriate nursing
actions? (select all that apply)
- Apply a hyperthermia blanket as ordered
- Administer an antipyretic to the patient as ordered
- Remove the patient's blankets
- Limit the patient's fluid intake
- Place the patient's feet in a tub of cool water with ice
- Administer an atipyretic to the patient as ordered
- Remove the patient's blankets
4
