BSN 205 Hallmark Exam Questions And Correct Answers, With Complete Verified Solution

BSN 205 Hallmark Exam Questions And Correct Answers, With Complete Verified Solution Question 1 of 5 Which instruction to nursing assistive personnel (NAP) reflects the nurse's correct understanding of the NAP's role in caring for a patient receiving intravenous (IV) fluids by gravity drip? Assess the IV site frequently for signs of inflammation. Be sure not to obscure the insertion site with the dressing. Let me know when you notice that the IV bag contains less than 100 mL. Tell the patient to notify me if the IV site is painful, swollen, or red. Let me know when you notice that the IV bag contains less than 100 mL. Question 2 of 5 The provider has ordered that a patient be 1000 mL of IV normal saline to run over 12 hours. What is the first step in the calculation of the rate of infusion? Calculate the hourly volume of normal saline the patient should receive. Determine the drop factor of the tubing that will be used for the infusion. Calculate the drops per minute at which the tubing will be regulated. Determine the drops per mL that the tubing will deliver. Calculate the hourly volume of normal saline the patient should receive. Question 3 of 5 The provider orders that a patient be given 1000 mL of IV normal saline to run over 10 hours. The drop factor of the selected tubing is 15. What is the correct rate of infusion in drops per minute?25 drops/minute30 drops/minute35 drops/minute40 drops/minute 25 drops/minute Question 4 of 5 The nurse receives an order to infuse 1000 mL of D5W at 125 mL continuously. Which of the following actions by the nurse indicates correct interpretation of this order?Infusing D5W 1000 mL for 8 hours and then discontinuing the infusionInfusing D5W at a rate of 125 mL/hr for 24 hours and then discontinuing the infusionInfusing D5W at a rate of 125 mL/hr until the health care provider changes the orderCalling the health care provider to clarify the order Infusing D5W at a rate of 125 mL/hr until the health care provider changes the order Question 5 of 5 Which action by the nurse helps to ensure patient safety when administering IV fluids by gravity to very young children? Using microdrip tubing for the infusion Using macrodrip tubing for the infusion Using a volume-control device for the infusion Not infusing more than 25 mL/hour of IV fluids Using a volume-control device for the infusion Question 1 of 4 The nurse is completing a patient's shift assessment and notes that the patient is lethargic, but restless and agitated. Which nursing diagnosis should the nurse include to the plan of care based on this data? Acute Confusion Decreased Cardiac Output Impaired Gas Exchange Fatigue Acute Confusion Lethargy, agitation, and restlessness are characteristic of this nursing diagnosis. Question 2 of 4 Mr. Abdul states, "I can't catch my breath." The nurse observes that his breathing is labored, his respirations are slow and deep, and his oxygen saturation level is 90%. Based on these assessment findings, which nursing diagnosis does the nurse include in Mr. Abdul's plan of care? Impaired Gas Exchange Decreased Cardiac Output Acute Confusion Imbalanced Nutrition Impaired Gas Exchange The patient's presentation and the nurse's observation are evidence for including this nursing diagnosis into Mr. Abdul's plan of care. Question 3 of 4 Match each nursing diagnosis with the appropriate cluster of assessment data about Mr. Abdul. Dyspnea, labored breathing, PaCO2 = 60 Impaired Gas Exchange Restless, anxiety, unsure about current events Acute Confusion Unable to fix meals and take medication Self-Care Deficit Question 4 of 4 Order the nursing diagnoses for Mr. Abdul's plan of care from highest priority to lowest priority. Impaired Gas Exchange Risk for Injury Acute Confusion Self-Care Deficit Question 1 of 4 Which NOC outcome is appropriate for Mr. Abdul's nursing diagnosis of Acute Confusion? Select all that apply. Cognition Distorted Thought Self-Control Information Processing Memory Adherence Behavior Cognition Distorted Thought Self-Control Information Processing Memory Question 2 of 4 The patient's ABG analysis is as follows: pH - 7.2; PaCO2 - 60 mm Hg; PaO2 - 73 mm Hg; HCO3− - 25 mEq/L. The nurse identifies the nursing diagnostic statement of Impaired Gas Exchange r/t COPD AEB ABG results. Which goal statement should the nurse include in the plan of care? Patient's pH value will return to a level between 7.35 and 7.45 within 12 hours. Patient's oxygen saturation will be 97% within 12 hours. Patient will be able to walk 100 feet down the hall with a respiratory rate less than 22 breaths per minute by Day 3 of hospital stay. The patient will require decreased supplemental oxygen based on assessment data. Patient's pH value will return to a level between 7.35 and 7.45 within 12 hours. This goal is specific and realistic and is appropriate for the nurse to include in the plan of care. Question 3 of 4 Match each nursing diagnosis with its corresponding goal statement for Mr. Abdul. Patient's blood pressure will return to baseline within 24 hours. Decreased Cardiac Output Patient is able to perform usual ADLs during hospitalization. Self-Care Deficit Patient's ABG results will return to baseline/WNL within 24 hours. Impaired Gas Exchange Patient will be alert and oriented x3 within 24 hours. Acute Confusion Correct Answer Exactly! Previous Question 4 of 4 Which NOC outcome is appropriate when planning care based on Mr. Abdul's nursing diagnosis of Decreased Cardiac Output? Fluid Balance Tissue Perfusion: Vital Signs Hydration Respiratory Status: Gas Exchange Tissue Perfusion: Vital Signs Tissue Perfusion: Vital Signs is an NOC outcome appropriate for Decreased Cardiac Output. Question 1 of 4 Which interventions should the nurse implement for a patient who is experiencing respiratory acidosis? Select all that apply. Encourage deep breathing exercises Monitor breath sounds Provide emotional support Question 2 of 4 Which nursing intervention is appropriate for all patients who are experiencing an acid-base imbalance?Encouraging deep breathing exercisesMonitoring the ABG analysisPreparing for mechanical ventilationAdministering oxygen, per order Monitoring the ABG analysis Monitoring the ABG analysis is a nursing intervention that is appropriate for all acid-base imbalances. Question 3 of 4 Which collaborative nursing intervention is appropriate for a patient who is experiencing respiratory alkalosis? Encouraging the patient to increase the depth and rate of respirations Asking the patient to breathe slowly into a paper bag Increasing the patient's oral fluid intake Administering sodium bicarbonate to the patient, per order Asking the patient to breathe slowly into a paper bag Breathing exhaled air from the paper bag that contains a higher amount of carbon dioxide may help increase the PaCO2 level and restore the pH to normal levels. This is an appropriate collaborative nursing intervention for this patient. Question 4 of 4 Which intervention is appropriate for a patient who is experiencing metabolic acidosis? Oxygen Potassium Seizure precautions Sodium bicarbonate Sodium bicarbonate Sodium bicarbonate is commonly required in the treatment of metabolic acidosis in order to assist with restoring low pH levels to WNL. Question 1 of 12 A patient is admitted with an acid-base imbalance. The patient's current assessment data includes hypotension and dysrhythmia. Which is the priority nursing diagnosis that the nurse should include in the plan of care? Decreased Cardiac Output Acute Confusion Impaired Gas Exchange Fatigue Decreased Cardiac Output Acid-base imbalance, coupled with hypotension and dysrhythmia, indicates a priority nursing diagnosis of Decreased Cardiac Output. Question 2 of 12 Which nursing diagnoses should the nurse include in the plan of care for a patient who is experiencing acid-base imbalance, hypoxemia, hypotension, restlessness, anxiety, and decreased oxygen saturation? Select all that apply. Acute Confusion Decreased Cardiac Output Impaired Gas Exchange Fatigue Electrolyte Imbalance Acute Confusion Decreased Cardiac Output Impaired Gas Exchange Question 3 of 12 A patient, who is postoperative for abdominal surgery, presents to the medical-surgical unit from the post-anesthesia care unit (PACU). The nurse's admission assessment reveals the following: shallow and irregular respirations with a rate of 12 breaths per minute. Lung sounds clear but decreased bilaterally. ABG result post-extubation: pH 7.29, PCO2 46 mm Hg, O2 sat 88%. Which nursing diagnosis is a priority for this patient? Impaired Gas Exchange Ineffective Airway Clearance Ineffective Breathing Pattern Acute Pain Ineffective Breathing Pattern Decreased respiratory rate, shallow and irregular respirations, and the current ABG values are all characteristic of Ineffective Breathing Pattern; therefore, this is the priority nursing diagnosis. Question 4 of 12 The nurse is completing a patient's shift assessment and notes that the patient is lethargic, but restless and agitated. Which nursing diagnosis should the nurse include to the plan of care based on this data? Acute Confusion Decreased Cardiac Output Impaired Gas Exchange Fatigue Acute Confusion Lethargy, agitation, and restlessness are characteristic of this nursing diagnosis. Question 5 of 12 The nurse formulates a nursing diagnosis of Decreased Cardiac Output for a patient admitted with metabolic acidosis. The goal statement is: the patient's blood pressure will return to baseline or WNL within 24 hours of admission. Which NOC outcome should the nurse include in the plan of care? Hydration Tissue Perfusion: Vital Signs Fluid Balance Respiratory Status: Gas Exchange