BSN 206 Hallmarks
The nurse is performing a dressing change on a client who is postoperative from a
laparotomy. The client coughs and the nurse sees a few loops of intestine uncoiling
from the wound. What is the nurse's best action at this time?
a. Instruct the client to avoid looking at the wound.
b. Apply sterile saline-soaked towels to the area.
c. Apply sterile gloves and push the intestines back into the wound.
d. Assess the wound to determine the extent of evisceration. - answerb. Apply sterile
saline-soaked towels to the area.
A healthy 30-year-old male arrives at the clinic for a physical. The nurse is responsible
for collecting his vital signs. Which of these can be delegated to UAP? (Select all that
apply.)
Temperature.
BP.
Pulse.
Pulse oximetry.
Respiration. - answerTemperature.
BP.
Pulse.
Pulse oximetry.
Respiration.
The nurse documents vital signs on a newly admitted patient as: "blood pressure is
148/94 mm Hg, the pulse is 80 beats/min, and the respirations are 16 breaths/min." The
nurse would record the pulse pressure as:
a. 14 mm Hg.
b. 54 mm Hg.
c. 64 mm Hg.
d. 80 mm Hg. - answerb. 54 mm Hg.
The nurse caring for a 30-year-old post-surgical client would assess that they are in
pain as indicated by:
A) a temperature of 102° F.
B) a pulse rate of 120 beats/min.
C) respirations of 16 breaths/min.
D) blood pressure of 128/86 mm Hg. - answerB) a pulse rate of 120 beats/min.
,The nurse is performing a morning assessment and notes the client to be experiencing
dyspnea. Which client assessment findings would most indicate this respiratory
condition? (Select all that apply.)
Occasional productive cough
Temperature 100.1 °F
Pulse oximetry 89%
Respirations 26 & shallow
Patient in orthopneic position - answerPulse oximetry 89%
Respirations 26 & shallow
Patient in orthopneic position
A nurse notes a client has abnormal vital signs. What action by the nurse is best?
A) Notify the provider.
B) Compare with prior readings.
C) Document the findings.
D) Retake the vital signs in 15 minutes. - answerB) Compare with prior readings.
A nurse assesses a client's radial pulse rate to be 110 beats/min and regular. What
action by the nurse is best?
A) Assess the client for causes of tachycardia.
B) Document the findings in the client's chart.
C) Take an apical heart rate and compare the two.
D) Notify the client's health care provider. - answerA) Assess the client for causes of
tachycardia.
Because the older adult's blood vessels are nonelastic, they are prone to orthostatic
hypotension. A priority intervention for a client with orthostatic hypotension is to:
A) instruct the client to use the wheelchair for all mobility activity.
B) help the client to rise quickly and support the client for a minute.
C) keep the client in bed in a high Fowler's position.
D) allow the client to sit on the side of the bed for a minute before standing. - answerD)
allow the client to sit on the side of the bed for a minute before standing.
The nursing student learns that the purpose of measuring a client's vital signs includes
which of the following rationale? (Select all that apply.)
Evaluate effectiveness of interventions.
Monitor body systems functioning.
Identify early signs of problems.
Determine if a cure has been obtained.
Provide a baseline to compare against. - answerEvaluate effectiveness of interventions.
Monitor body systems functioning.
Identify early signs of problems.
Provide a baseline to compare against.
, The nurse receives a hand-off report on four clients. Which client finding should the
nurse assess first?
A) Pulse oximetry 96%
B) Respiratory rate 18 breaths/min
C) Blood pressure 102/62 mm Hg
D) Pulse 42 beats/min - answerD) Pulse 42 beats/min
For the nurse to assess the most accurate respiration count, the nurse should:
A) inform the patient about his respirations and ask him to breathe normally.
B) continue to hold the patient's radial pulse, and count the respirations for 30 seconds
and multiply them by 2.
C) count each inhalation and expiration for 1 full minute.
D) watch the patient's chest rise and fall from a distance. - answerB) continue to hold
the patient's radial pulse, and count the respirations for 30 seconds and multiply them
by 2.
Which of the following should the nurse report to the health care provider?
A) An adult client with a heart rate of 55.
B) An elderly male with a temperature of 96.8°F (36°C).
C) A young adult with a blood pressure of 110/70.
D) A newborn with a respiratory rate of 40. - answerA) An adult client with a heart rate
of 55.
The nurse is having great difficulty hearing any sound when taking a client's blood
pressure. What can the nurse do to increase the ability to auscultate the reading?
(Select all that apply.)
Reduce environmental noise by turning off the TV or closing the door.
Use the bell side of the stethoscope to auscultate the blood pressure.
Use a different stethoscope with longer tubing for improved conduction of sound.
Make sure the stethoscope does not touch the client's clothing or BP cuff.
Keep the stethoscope tubing still to avoid extraneous sound.
Ensure the bladder of the cuff is centered 1 inch (2.5 cm) above the brachial artery.
Ensure the chest piece is rotated to the diaphragm side. - answerReduce environmental
noise by turning off the TV or closing the door.
Make sure the stethoscope does not touch the client's clothing or BP cuff.
Keep the stethoscope tubing still to avoid extraneous sound.
Ensure the bladder of the cuff is centered 1 inch (2.5 cm) above the brachial artery.
The nurse is performing a dressing change on a client who is postoperative from a
laparotomy. The client coughs and the nurse sees a few loops of intestine uncoiling
from the wound. What is the nurse's best action at this time?
a. Instruct the client to avoid looking at the wound.
b. Apply sterile saline-soaked towels to the area.
c. Apply sterile gloves and push the intestines back into the wound.
d. Assess the wound to determine the extent of evisceration. - answerb. Apply sterile
saline-soaked towels to the area.
A healthy 30-year-old male arrives at the clinic for a physical. The nurse is responsible
for collecting his vital signs. Which of these can be delegated to UAP? (Select all that
apply.)
Temperature.
BP.
Pulse.
Pulse oximetry.
Respiration. - answerTemperature.
BP.
Pulse.
Pulse oximetry.
Respiration.
The nurse documents vital signs on a newly admitted patient as: "blood pressure is
148/94 mm Hg, the pulse is 80 beats/min, and the respirations are 16 breaths/min." The
nurse would record the pulse pressure as:
a. 14 mm Hg.
b. 54 mm Hg.
c. 64 mm Hg.
d. 80 mm Hg. - answerb. 54 mm Hg.
The nurse caring for a 30-year-old post-surgical client would assess that they are in
pain as indicated by:
A) a temperature of 102° F.
B) a pulse rate of 120 beats/min.
C) respirations of 16 breaths/min.
D) blood pressure of 128/86 mm Hg. - answerB) a pulse rate of 120 beats/min.
,The nurse is performing a morning assessment and notes the client to be experiencing
dyspnea. Which client assessment findings would most indicate this respiratory
condition? (Select all that apply.)
Occasional productive cough
Temperature 100.1 °F
Pulse oximetry 89%
Respirations 26 & shallow
Patient in orthopneic position - answerPulse oximetry 89%
Respirations 26 & shallow
Patient in orthopneic position
A nurse notes a client has abnormal vital signs. What action by the nurse is best?
A) Notify the provider.
B) Compare with prior readings.
C) Document the findings.
D) Retake the vital signs in 15 minutes. - answerB) Compare with prior readings.
A nurse assesses a client's radial pulse rate to be 110 beats/min and regular. What
action by the nurse is best?
A) Assess the client for causes of tachycardia.
B) Document the findings in the client's chart.
C) Take an apical heart rate and compare the two.
D) Notify the client's health care provider. - answerA) Assess the client for causes of
tachycardia.
Because the older adult's blood vessels are nonelastic, they are prone to orthostatic
hypotension. A priority intervention for a client with orthostatic hypotension is to:
A) instruct the client to use the wheelchair for all mobility activity.
B) help the client to rise quickly and support the client for a minute.
C) keep the client in bed in a high Fowler's position.
D) allow the client to sit on the side of the bed for a minute before standing. - answerD)
allow the client to sit on the side of the bed for a minute before standing.
The nursing student learns that the purpose of measuring a client's vital signs includes
which of the following rationale? (Select all that apply.)
Evaluate effectiveness of interventions.
Monitor body systems functioning.
Identify early signs of problems.
Determine if a cure has been obtained.
Provide a baseline to compare against. - answerEvaluate effectiveness of interventions.
Monitor body systems functioning.
Identify early signs of problems.
Provide a baseline to compare against.
, The nurse receives a hand-off report on four clients. Which client finding should the
nurse assess first?
A) Pulse oximetry 96%
B) Respiratory rate 18 breaths/min
C) Blood pressure 102/62 mm Hg
D) Pulse 42 beats/min - answerD) Pulse 42 beats/min
For the nurse to assess the most accurate respiration count, the nurse should:
A) inform the patient about his respirations and ask him to breathe normally.
B) continue to hold the patient's radial pulse, and count the respirations for 30 seconds
and multiply them by 2.
C) count each inhalation and expiration for 1 full minute.
D) watch the patient's chest rise and fall from a distance. - answerB) continue to hold
the patient's radial pulse, and count the respirations for 30 seconds and multiply them
by 2.
Which of the following should the nurse report to the health care provider?
A) An adult client with a heart rate of 55.
B) An elderly male with a temperature of 96.8°F (36°C).
C) A young adult with a blood pressure of 110/70.
D) A newborn with a respiratory rate of 40. - answerA) An adult client with a heart rate
of 55.
The nurse is having great difficulty hearing any sound when taking a client's blood
pressure. What can the nurse do to increase the ability to auscultate the reading?
(Select all that apply.)
Reduce environmental noise by turning off the TV or closing the door.
Use the bell side of the stethoscope to auscultate the blood pressure.
Use a different stethoscope with longer tubing for improved conduction of sound.
Make sure the stethoscope does not touch the client's clothing or BP cuff.
Keep the stethoscope tubing still to avoid extraneous sound.
Ensure the bladder of the cuff is centered 1 inch (2.5 cm) above the brachial artery.
Ensure the chest piece is rotated to the diaphragm side. - answerReduce environmental
noise by turning off the TV or closing the door.
Make sure the stethoscope does not touch the client's clothing or BP cuff.
Keep the stethoscope tubing still to avoid extraneous sound.
Ensure the bladder of the cuff is centered 1 inch (2.5 cm) above the brachial artery.
