BSN-205 Hallmark final exam Questions And
Correct Answers, With Complete Verified Solution.
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
-and a patient who's receiving bolus IV fluids
Whenever there's an alteration in the radial pulse rate, rhythm, or amplitude, the
nurse should initially do which of the following?
Auscultate the apical pulse for quality and rate
What's the normal pulse range for an adult?
60-100 beats per minute
The nurse should routinely auscultate the apical pulse with the bell side of the
stethoscope, and use the diaphragm side to identify heart murmurs
False
Correct Answers, With Complete Verified Solution.
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
-and a patient who's receiving bolus IV fluids
Whenever there's an alteration in the radial pulse rate, rhythm, or amplitude, the
nurse should initially do which of the following?
Auscultate the apical pulse for quality and rate
What's the normal pulse range for an adult?
60-100 beats per minute
The nurse should routinely auscultate the apical pulse with the bell side of the
stethoscope, and use the diaphragm side to identify heart murmurs
False
