BSN-205 Hallmark final exam Questions And Correct Answers, With Complete Verified Solution.

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 In which of the following patients would the nurse expect to find a decrease in pulse rate/ A patient returning from the operating room and a patient who received morphine for pain The new NAP is unable to palpate a patient's radial pulse. What could be a possible explanation for this difficulty? The NAP is assessing for a pulse on the ulnar side of the wrist and the NAP is pressing down too hard on the patient's radial site What's an appropriate nursing intervention for an adult patient with a respiratory rate of 30 breaths per minute? -Count the respiratory rate again for a full 60secs - assess physiologic factors that may be causing the patient to breathe so fast Which of the following may increase both rate and depth of respiration? -Walking a mile briskly -feeling anxious when taking a test -having an addiction problem with amphetamines/cocaine. When assessing the respiratory rate, then nurse has difficulty seeing the patient's chest rise and fall with inspiration and expiration. What's the nurse's best action? Move the patient's arm over their chest and feel the rise an fall of the chest How can the nurse best obtain an accurate measurement of a patient's respiratory rate? Continue to act as though taking the patient's pulse while discretely observing the rise and fall of the patient's chest The nurse is validating the NAP's skill with respiratory rate assessment. Which of the following actions, if made by the NAP, indicates that further instruction is needed? When a patient inhales a breath, the NAP counts that as one when the patient exhales the breath, the NAP counts that as two The nurse assesses the BP in both arms of a newly admitted patient. Why would the nurse do this? To determine if there is a difference in the readings between the two arms. Which of the following patients would be considered hypertensive after having two or more consistent readings of these values? A football player with a diastolic BP of 94. For which patient should you avoid using a leg pressure cuff (thigh cuff) to assess BP? A patient with a deep vein thrombosis (blood clot, usually in the lower extremities). The student nurse is unsure of the BP measurement. What should the student nurse do first? Assess the BP in the other arm. Using the image below, please choose the correct BP combination: Image A = 120/80, Image B = 128/76, Image C = 140/90, Image D = 138/84 It is 7 a.m. and the nurse takes the vital signs of a postoperative patient and finds his blood pressure is elevated. Which of the following could explain the cause for this alteration in BP? The patient complains of pain at a 9 on a 0-10 pain scale. The patient has a history of a left mastectomy. Where should the nurse take the patient's blood pressure? In the right arm The nurse is unable to obtain a BP reading using an electronic BP machine on a post-operative patient. The machine reads "Error." What priority action should the nurse take? Take the patient's BP manually using a sphygmomanometer. The NAP reports to the nurse the patient's respirations are 32 and the patient is complaining of shortness of breath. What is the best nursing action at this time? A) Request the NAP obtain the patient's pulse oximetry and report the reading to the nurse. B) Ask the NAP to obtain a full set of vital signs C) Assess the patient yourself, including the pulse oximetry reading D) Notify the health care provider C) Assess the patient yourself, including the pulse oximetry reading Which patient is at high risk for for the pulse oximetry alarm to sound? A) A patient with a continuous pulse oximetry reading of 84%. Correct B) A patient who is receiving oxygen via face mask. C) A patient who has an intermittent pulse oximetry reading of 95% D) A patient with a HR of 64 beats per minute A) A patient with a continuous pulse oximetry reading of 84%. Correct A patient complains of feeling excessively tired. Which statement, if made by the NAP, indicates further instruction is necessary? A) "I will turn the continuous pulse oximetry alarms off at night so you can sleep without interruption." B) "I can give you a back massage to help you relax." C) "What kind of nighttime ritual helps you go to sleep?" D) "If the finger clip is bothering you, I can attach a probe to your ear." E) "I will notify the nurse and the two of you can determine whether you need your sleeping medication." A) "I will turn the continuous pulse oximetry alarms off at night so you can sleep without interruption." The NAP tells you that the patient's pulse oximetry is 85% on room air. What nursing action(s) should you take? (Select all that apply.) A) Start oxygen at 2 liters per minute by nasal cannula B) Reassess pulse oximetry C) Place the patient in the high-Fowler's position D) Have the NAP take the patient's vital signs E) Assess the patient's respiratory and cardiac status B) Reassess pulse oximetry C) Place the patient in the high-Fowler's position E) Assess the patient's respiratory and cardiac status