BSN 205 Hallmark Exam (Nightin gale College ) | 60 Actual Questions and Answers 100% Correct | New Update 2024 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. - Answer 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. - Answer 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/minut e - Answer 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 ra te 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 - Answer 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 - Answer 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 - Answer 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 - Answer 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 - Answer 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 - Answer 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 - Answer 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.
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