BSN 205 Exam With 100% Correct Answers
2023
The NAP reports to the nurse the pts RR is 32 and the pt is complaining of SOB. What is the
best action by the nurse at this time? - Correct Answer-Assess the pt, including the pulse
oximetry reading.
Which pt is at high risk for the pulse oximetry alarm to sound? - Correct Answer-A pt with a
continuous pulse oximetry reading of 84%
The nurse is ambulating the patient for the first time following the patient's lengthy time of
being on bed rest. Which of the following would be an appropriate action by the nurse to
determine the patient's activity tolerance? - Correct Answer-Assess vital signs before and after
ambulating the patient.
You take a patient's vital signs on admission to the hospital. Why is it important to take vital
signs at this time? - Correct Answer-To obtain a baseline measurement for comparison with
subsequent vital sign measurements
You are preparing to take a patient's temperature. Which of the following factors may affect
the patient's oral temperature reading? - Correct Answer-If the patient has recently consumed
a hot or cold beverage,
If the patient has recently exercised,
Warmth of the room, If the patient has recently smoked
The NAP reports to you that a patient is "feeling different" and appears less alert. Your first
action should be to: - Correct Answer-Obtain the vital signs yourself.
Which of the following patients is exhibiting abnormal vital sign values for their age?
1. Newborn: Temperature 98.6º F, pulse 130, respiration 35, mean BP 65/41, pulse oximetry
99%
2. Adolescent: Temperature 37º C, pulse 84, respiration 16, BP 110/65, pulse oximetry 100%
3. Adult: Temperature 96.7º F, pulse 55, respiration 24, BP 160/90, pulse oximetry 84%
4. Older adult: Temperature 96.8º F, pulse 98, respiration 12, BP 116/76, pulse oximetry 95%
- Correct Answer-Adult: Temperature 96.7º F, pulse 55, respiration 24, BP 160/90, pulse
oximetry 84%
You check the patient's baseline temperature reading and note that it was recorded as 98.6° F
(37 °C). What would you expect the temperature reading to be if it was obtained using the
rectal route? - Correct Answer-99.5° F (37.5 °C)
You check the patient's temperature using the axillary route, and the thermometer reads 97.9°
F (36.6 °C). Which of the following would be the most accurate documentation of the reading?
- Correct Answer-97.9° F (36.6 °C) Ax
,Easy to read thermometer and provides results in 4 to 15 seconds - Correct Answer-Electric
thermometer
Good thermometer for patients in isolation - Correct Answer-Chemical thermometer
Disposable thermometer - Correct Answer-chemical thermometer
Provides core temperature measurement in a patient with tachypnea - Correct Answer-
tympanic thermometer
Sensor thermometer cover not required - Correct Answer-temporal artery thermometer
Often underestimates temperature - Correct Answer-chemical thermometer
Risk of transferring nosocomial Clostridium infections rectally; also expensive thermometer -
Correct Answer-Electronic thermometer
Otitis media and cerumen can lead to false readings with this thermometer - Correct Answer-
tympanic thermometer
Affected by skin moisture such as diaphoresis or sweating - Correct Answer-Temporal artery
thermometer
what is likely to result in a higher temperature reading? - Correct Answer-The temperature of a
teenager who just ran a mile.
The temperature of a college student taking an exam
A temperature taken in the evening
Which of the following patients may require more frequent temperature measurement and
nursing assessment because they are at risk for an alteration in temperature? (Select all that
apply.)
1. A patient who is in the recovery room after having his gallbladder removed
2. A patient with pneumonia
3. A patient receiving a blood transfusion
4. A patient who is receiving physical therapy
5. A patient with cancer whose white blood cell (WBC) count is 2500 per mm³ - Correct
Answer-A patient who is in the recovery room after having his gallbladder removed
A patient with pneumonia
A patient receiving a blood transfusion
A patient with cancer whose white blood cell (WBC) count is 2500 per mm³
thermometers (and corresponding route) would be most accurate for monitoring rapid changes
in core body temperature? - Correct Answer-Oral electronic thermometer
Temporal artery thermometer
How far should a rectal thermometer be inserted in an adult? - Correct Answer-1.5 in (3.8 cm)
How far should a rectal thermometer be inserted in a child? - Correct Answer-0.5 in (1.3 cm)
, In what direction should the nurse pull the pinna of the adult when taking a tympanic
temperature? - Correct Answer-Backward, up, and out
At the end of the clinical day, the nursing instructor notices that a student nurse has
documented a resident having a temperature of 99.8° F (37.7° C) and that the student
administered a flu shot. What should the student nurse have done? - Correct Answer-Held the
flu vaccine; notify supervisor or instructor of increase in temperature.
A temperature reading obtained at noon will likely be ________ the 6 PM reading. - Correct
Answer-lower than
Because older adults often maintain a ________ body temperature, a temperature within an
acceptable range in an adult may reflect a fever in an older adult. - Correct Answer-lower
A young adult has been admitted to the hospital with a fever of unknown origin. Intravenous
(IV) fluids have been started, and the patient is feeling much better. You are going to take the
patient's temperature. Which of the following would be the best thermometer selection? -
Correct Answer-An electronic thermometer with a blue probe end
The patient's temperature is 102.2 ºF (39 ºC). What action should you take? - Correct Answer-
Administer an antipyretic as ordered.
Before taking the patient's temperature, the patient tells you they just drank some ice water.
What is your best action? - Correct Answer-Request that the patient refrain from eating or
drinking until you return in 20 minutes to assess their oral temperature
The skill of radial pulse measurement can or can not be delegated to NAP. - Correct Answer-
can
If the patient is to receive a medication that requires an apical pulse before administration, it
should or should not be delegated to NAP. - Correct Answer-should not
NAP should be instructed to report any abnormalities that should be ________ by the nurse. -
Correct Answer-confirmed
You enter the patient's room to take routine vital signs. You see that the patient has just
finished exercising with physical therapy. What is your best action? - Correct Answer-Wait 5 to
10 minutes before assessing the pulse.
When measuring an irregular radial pulse, you must: - Correct Answer-Consider reassessing
the patient using the apical site.
Count the rate over 60 seconds/1 full minute.
2nd right ICS - Correct Answer-aortic valve area
2nd left ICS - Correct Answer-pulmonic valve area
3rd left ICS - Correct Answer-Erb's point
Left lower sternal border - Correct Answer-tricuspid valve area
2023
The NAP reports to the nurse the pts RR is 32 and the pt is complaining of SOB. What is the
best action by the nurse at this time? - Correct Answer-Assess the pt, including the pulse
oximetry reading.
Which pt is at high risk for the pulse oximetry alarm to sound? - Correct Answer-A pt with a
continuous pulse oximetry reading of 84%
The nurse is ambulating the patient for the first time following the patient's lengthy time of
being on bed rest. Which of the following would be an appropriate action by the nurse to
determine the patient's activity tolerance? - Correct Answer-Assess vital signs before and after
ambulating the patient.
You take a patient's vital signs on admission to the hospital. Why is it important to take vital
signs at this time? - Correct Answer-To obtain a baseline measurement for comparison with
subsequent vital sign measurements
You are preparing to take a patient's temperature. Which of the following factors may affect
the patient's oral temperature reading? - Correct Answer-If the patient has recently consumed
a hot or cold beverage,
If the patient has recently exercised,
Warmth of the room, If the patient has recently smoked
The NAP reports to you that a patient is "feeling different" and appears less alert. Your first
action should be to: - Correct Answer-Obtain the vital signs yourself.
Which of the following patients is exhibiting abnormal vital sign values for their age?
1. Newborn: Temperature 98.6º F, pulse 130, respiration 35, mean BP 65/41, pulse oximetry
99%
2. Adolescent: Temperature 37º C, pulse 84, respiration 16, BP 110/65, pulse oximetry 100%
3. Adult: Temperature 96.7º F, pulse 55, respiration 24, BP 160/90, pulse oximetry 84%
4. Older adult: Temperature 96.8º F, pulse 98, respiration 12, BP 116/76, pulse oximetry 95%
- Correct Answer-Adult: Temperature 96.7º F, pulse 55, respiration 24, BP 160/90, pulse
oximetry 84%
You check the patient's baseline temperature reading and note that it was recorded as 98.6° F
(37 °C). What would you expect the temperature reading to be if it was obtained using the
rectal route? - Correct Answer-99.5° F (37.5 °C)
You check the patient's temperature using the axillary route, and the thermometer reads 97.9°
F (36.6 °C). Which of the following would be the most accurate documentation of the reading?
- Correct Answer-97.9° F (36.6 °C) Ax
,Easy to read thermometer and provides results in 4 to 15 seconds - Correct Answer-Electric
thermometer
Good thermometer for patients in isolation - Correct Answer-Chemical thermometer
Disposable thermometer - Correct Answer-chemical thermometer
Provides core temperature measurement in a patient with tachypnea - Correct Answer-
tympanic thermometer
Sensor thermometer cover not required - Correct Answer-temporal artery thermometer
Often underestimates temperature - Correct Answer-chemical thermometer
Risk of transferring nosocomial Clostridium infections rectally; also expensive thermometer -
Correct Answer-Electronic thermometer
Otitis media and cerumen can lead to false readings with this thermometer - Correct Answer-
tympanic thermometer
Affected by skin moisture such as diaphoresis or sweating - Correct Answer-Temporal artery
thermometer
what is likely to result in a higher temperature reading? - Correct Answer-The temperature of a
teenager who just ran a mile.
The temperature of a college student taking an exam
A temperature taken in the evening
Which of the following patients may require more frequent temperature measurement and
nursing assessment because they are at risk for an alteration in temperature? (Select all that
apply.)
1. A patient who is in the recovery room after having his gallbladder removed
2. A patient with pneumonia
3. A patient receiving a blood transfusion
4. A patient who is receiving physical therapy
5. A patient with cancer whose white blood cell (WBC) count is 2500 per mm³ - Correct
Answer-A patient who is in the recovery room after having his gallbladder removed
A patient with pneumonia
A patient receiving a blood transfusion
A patient with cancer whose white blood cell (WBC) count is 2500 per mm³
thermometers (and corresponding route) would be most accurate for monitoring rapid changes
in core body temperature? - Correct Answer-Oral electronic thermometer
Temporal artery thermometer
How far should a rectal thermometer be inserted in an adult? - Correct Answer-1.5 in (3.8 cm)
How far should a rectal thermometer be inserted in a child? - Correct Answer-0.5 in (1.3 cm)
, In what direction should the nurse pull the pinna of the adult when taking a tympanic
temperature? - Correct Answer-Backward, up, and out
At the end of the clinical day, the nursing instructor notices that a student nurse has
documented a resident having a temperature of 99.8° F (37.7° C) and that the student
administered a flu shot. What should the student nurse have done? - Correct Answer-Held the
flu vaccine; notify supervisor or instructor of increase in temperature.
A temperature reading obtained at noon will likely be ________ the 6 PM reading. - Correct
Answer-lower than
Because older adults often maintain a ________ body temperature, a temperature within an
acceptable range in an adult may reflect a fever in an older adult. - Correct Answer-lower
A young adult has been admitted to the hospital with a fever of unknown origin. Intravenous
(IV) fluids have been started, and the patient is feeling much better. You are going to take the
patient's temperature. Which of the following would be the best thermometer selection? -
Correct Answer-An electronic thermometer with a blue probe end
The patient's temperature is 102.2 ºF (39 ºC). What action should you take? - Correct Answer-
Administer an antipyretic as ordered.
Before taking the patient's temperature, the patient tells you they just drank some ice water.
What is your best action? - Correct Answer-Request that the patient refrain from eating or
drinking until you return in 20 minutes to assess their oral temperature
The skill of radial pulse measurement can or can not be delegated to NAP. - Correct Answer-
can
If the patient is to receive a medication that requires an apical pulse before administration, it
should or should not be delegated to NAP. - Correct Answer-should not
NAP should be instructed to report any abnormalities that should be ________ by the nurse. -
Correct Answer-confirmed
You enter the patient's room to take routine vital signs. You see that the patient has just
finished exercising with physical therapy. What is your best action? - Correct Answer-Wait 5 to
10 minutes before assessing the pulse.
When measuring an irregular radial pulse, you must: - Correct Answer-Consider reassessing
the patient using the apical site.
Count the rate over 60 seconds/1 full minute.
2nd right ICS - Correct Answer-aortic valve area
2nd left ICS - Correct Answer-pulmonic valve area
3rd left ICS - Correct Answer-Erb's point
Left lower sternal border - Correct Answer-tricuspid valve area
