BSN206-05: Hallmark Final QUESTIONS & CORRECT ANSWERS

BSN206-05: Hallmark Final QUESTIONS & CORRECT 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 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 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. 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. 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. 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.