Hallmark Exam BSN206
Which of the following patients would re-
quire follow-up?
A child with a respiratory rate of 20
breaths per minute.
An adolescent with a respiratory rate of An adult with a respiratory rate of 10
16 breaths per minute. breaths per minute
A newborn with a respiratory rate of 40
breaths per minute.
An adult with a respiratory rate of 10
breaths per minute.
Which of the following vital signs record-
ed for an older adult would be considered
acceptable (within normal limits)?
Temp 96.8° F (36 °C), P-60, R-18, BP
160/90, O2 sat 93%.
Temp 97.0° F (36.1 °C), P-60, R-16, BP
Temp 97.0° F (36.1 °C), P-60, R-16, BP
116/78, O2 sat 95%.
116/78, O2 sat 95%.
Temp 98.6 °F (37 °C), P-56, R-20, BP
120/80, O2 sat 91%.
Temp 98.0 °F (36.7 °C), P-76, R-22, BP
110/70, O2 sat 88%
The nurse has delegated the task of tem-
perature assessment to the NAP. Which
information should be provided to the
NAP? (Select all that apply.) What changes to report immediately to
The type of temperature required. the nurse
The patient's age. The frequency for taking or monitoring
The frequency for taking or monitoring the temperature
the temperature. The type of temperature required
The patient's diagnosis.
What changes to report immediately to
the nurse.
Which of the following situations may af-
fect a patient's vital signs? (Select all that
Moving from lying to standing position
apply.)
Time of Day
Moving from lying to standing position.
Pain rated as a 7 on a 0-10 pain scale
Time of day.
Occupation.
, Hallmark Exam BSN206
Isolation precautions.
Pain rated as a 7 on 0-10 pain scale.
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? (Select all that ap-
ply.)
To provide the patient with reassurance
To provide a set of vital signs to use for
that he or she is being cared for by a
comparison during and after surgery
competent staff.
To verify the patient is not experiencing
To provide a set of vital signs to use for
any complications that may contraindi-
comparison during and after surgery.
cate surgery or require intervention
To ensure the equipment is appropriately
calibrated and functional.
To verify the patient is not experiencing
any complications that may contraindi-
cate surgery or require intervention.
To determine whether the patient is "feel-
ing funny" or "different".
The NAP reports to the nurse a
65-year-old patient s blood pressure is
160/98. What is the appropriate initial re-
sponse of the nurse?
Document this as a normal finding in an
Assess the patient's blood pressure
elderly adult.
Ask the NAP if the patient is nauseous.
Instruct the NAP to obtain a full set of
vital signs.
Assess the patient s blood pressure.
Which patient would it be appropriate for
the nurse to delegate vital signs?
Patient transferred from ICU.
Elderly nursing home resident. Elderly nursing home resident
New admission to the hospital.
Patient with recent complaint of
headache.
, Hallmark Exam BSN206
Which person would be expected to have
the lowest body temperature?
An 80-year-old who walked half a mile.
An 80 year old who walked half a mile
A child playing softball.
A 16-year-old who ran 1 mile.
A toddler who is febrile.
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?
"Change to the red thermometer probe
and take the patient's temperature rec-
Ask the patient to not eat, drink, or smoke
tally."
for 20 minutes then assess the patient's
"Take the patient's temperature using the
oral temperature
axillary route and when you record the
reading, add 1°F."
"Since the soup was not hot, go ahead
and take the patient's temperature."
"Ask the patient not to eat, drink, or
smoke for 20 minutes and then assess
the patient's oral temperature."
For which patient would a tympanic ther-
mometer be the preferred thermometer
to use?
A marathon runner who developed
weakness during the race.
A tachypneic patient who is receiving
A tachypneic patient who is receiving
oxygen by nasal cannula
oxygen by nasal cannula.
A pediatric patient who had tubes surgi-
cally placed in the ears.
A newborn that requires continuous tem-
perature monitoring.
Which of the following patients would re-
quire frequent assessment of their tem-
A young adult with a white blood count of
perature? (Select all that apply.)
15,000/mm3
A young adult with a white blood count of
15,000/mm3.
, Hallmark Exam BSN206
An adult female in the recovery room
following a hysterectomy.
A patient receiving a blood transfusion An adult female in the recovery room
for chronic anemia. following a hysterectomy
A child who is below the normal height A patient receiving a blood transfusion
and weight for his age. for chronic anemia
An elderly patient who needs assistance
with feeding and dressing.
The NAP reports that the patient's tem-
perature is 39° C (102.2 °F). Which of
the following are appropriate nursing ac-
tions? (Select all that apply.)
Remove the patient's blankets.
Remove the patient's blankets
Limit the patient's fluid intake.
Administer an antipyretic to the patient
Apply a hyperthermia blanket as or-
as ordered
dered.
Administer an antipyretic to the patient
as ordered.
Place the patient's feet in a tub of cool
water with ice.
Which of the following actions, if made by
the NAP, would require intervention and
further instruction by the nurse? (Select
all that apply.)
The NAP uses a blue-tipped electronic
probe for assessing a patient's axillary
The NAP wipes the single-use chemical
temperature.
dot thermometer and places it back in the
The NAP wipes the single-use chemical
patient's drawer for future use
dot thermometer and places it back in
The NAP inserts the red=tipped electron-
the patient's drawer for future use.
ic thermometer probe into the patient's
The NAP inserts the red-tipped electron-
mouth after applying a probe cover
ic thermometer probe into the patient's
mouth after applying a probe cover.
The NAP pulls the pinna up, back, and
out in an adult when inserting the tym-
panic thermometer.
The NAP waits un
Which of the following patients would re-
quire follow-up?
A child with a respiratory rate of 20
breaths per minute.
An adolescent with a respiratory rate of An adult with a respiratory rate of 10
16 breaths per minute. breaths per minute
A newborn with a respiratory rate of 40
breaths per minute.
An adult with a respiratory rate of 10
breaths per minute.
Which of the following vital signs record-
ed for an older adult would be considered
acceptable (within normal limits)?
Temp 96.8° F (36 °C), P-60, R-18, BP
160/90, O2 sat 93%.
Temp 97.0° F (36.1 °C), P-60, R-16, BP
Temp 97.0° F (36.1 °C), P-60, R-16, BP
116/78, O2 sat 95%.
116/78, O2 sat 95%.
Temp 98.6 °F (37 °C), P-56, R-20, BP
120/80, O2 sat 91%.
Temp 98.0 °F (36.7 °C), P-76, R-22, BP
110/70, O2 sat 88%
The nurse has delegated the task of tem-
perature assessment to the NAP. Which
information should be provided to the
NAP? (Select all that apply.) What changes to report immediately to
The type of temperature required. the nurse
The patient's age. The frequency for taking or monitoring
The frequency for taking or monitoring the temperature
the temperature. The type of temperature required
The patient's diagnosis.
What changes to report immediately to
the nurse.
Which of the following situations may af-
fect a patient's vital signs? (Select all that
Moving from lying to standing position
apply.)
Time of Day
Moving from lying to standing position.
Pain rated as a 7 on a 0-10 pain scale
Time of day.
Occupation.
, Hallmark Exam BSN206
Isolation precautions.
Pain rated as a 7 on 0-10 pain scale.
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? (Select all that ap-
ply.)
To provide the patient with reassurance
To provide a set of vital signs to use for
that he or she is being cared for by a
comparison during and after surgery
competent staff.
To verify the patient is not experiencing
To provide a set of vital signs to use for
any complications that may contraindi-
comparison during and after surgery.
cate surgery or require intervention
To ensure the equipment is appropriately
calibrated and functional.
To verify the patient is not experiencing
any complications that may contraindi-
cate surgery or require intervention.
To determine whether the patient is "feel-
ing funny" or "different".
The NAP reports to the nurse a
65-year-old patient s blood pressure is
160/98. What is the appropriate initial re-
sponse of the nurse?
Document this as a normal finding in an
Assess the patient's blood pressure
elderly adult.
Ask the NAP if the patient is nauseous.
Instruct the NAP to obtain a full set of
vital signs.
Assess the patient s blood pressure.
Which patient would it be appropriate for
the nurse to delegate vital signs?
Patient transferred from ICU.
Elderly nursing home resident. Elderly nursing home resident
New admission to the hospital.
Patient with recent complaint of
headache.
, Hallmark Exam BSN206
Which person would be expected to have
the lowest body temperature?
An 80-year-old who walked half a mile.
An 80 year old who walked half a mile
A child playing softball.
A 16-year-old who ran 1 mile.
A toddler who is febrile.
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?
"Change to the red thermometer probe
and take the patient's temperature rec-
Ask the patient to not eat, drink, or smoke
tally."
for 20 minutes then assess the patient's
"Take the patient's temperature using the
oral temperature
axillary route and when you record the
reading, add 1°F."
"Since the soup was not hot, go ahead
and take the patient's temperature."
"Ask the patient not to eat, drink, or
smoke for 20 minutes and then assess
the patient's oral temperature."
For which patient would a tympanic ther-
mometer be the preferred thermometer
to use?
A marathon runner who developed
weakness during the race.
A tachypneic patient who is receiving
A tachypneic patient who is receiving
oxygen by nasal cannula
oxygen by nasal cannula.
A pediatric patient who had tubes surgi-
cally placed in the ears.
A newborn that requires continuous tem-
perature monitoring.
Which of the following patients would re-
quire frequent assessment of their tem-
A young adult with a white blood count of
perature? (Select all that apply.)
15,000/mm3
A young adult with a white blood count of
15,000/mm3.
, Hallmark Exam BSN206
An adult female in the recovery room
following a hysterectomy.
A patient receiving a blood transfusion An adult female in the recovery room
for chronic anemia. following a hysterectomy
A child who is below the normal height A patient receiving a blood transfusion
and weight for his age. for chronic anemia
An elderly patient who needs assistance
with feeding and dressing.
The NAP reports that the patient's tem-
perature is 39° C (102.2 °F). Which of
the following are appropriate nursing ac-
tions? (Select all that apply.)
Remove the patient's blankets.
Remove the patient's blankets
Limit the patient's fluid intake.
Administer an antipyretic to the patient
Apply a hyperthermia blanket as or-
as ordered
dered.
Administer an antipyretic to the patient
as ordered.
Place the patient's feet in a tub of cool
water with ice.
Which of the following actions, if made by
the NAP, would require intervention and
further instruction by the nurse? (Select
all that apply.)
The NAP uses a blue-tipped electronic
probe for assessing a patient's axillary
The NAP wipes the single-use chemical
temperature.
dot thermometer and places it back in the
The NAP wipes the single-use chemical
patient's drawer for future use
dot thermometer and places it back in
The NAP inserts the red=tipped electron-
the patient's drawer for future use.
ic thermometer probe into the patient's
The NAP inserts the red-tipped electron-
mouth after applying a probe cover
ic thermometer probe into the patient's
mouth after applying a probe cover.
The NAP pulls the pinna up, back, and
out in an adult when inserting the tym-
panic thermometer.
The NAP waits un
