Exam (elaborations)
HALLMARK EXAM BSN206 WITH CORRECT QUESTIONS AN
HALLMARK EXAM BSN206 WITH CORRECT
QUESTIONS AND ANSWERS.
Whichyofytheyfollowingypatientsywouldyrequireyfollow-up? Aychildywithyayrespiratoryyrateyofy20ybreathsyperyminute. Anyadolescentywithyayrespiratoryyrateyofy16ybreathsyperyminute. Aynewbornywithyayrespiratoryyrateyofy40ybreathsyperyminute...
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HALLMARK EXAM BSN206 WITH CORRECT
QUESTIONS AND ANSWERS.
Whichyofytheyfollowingypatientsywouldyrequireyfollow-up?
Aychildywithyayrespiratoryyrateyofy20ybreathsyperyminute.
Anyadolescentywithyayrespiratoryyrateyofy16ybreathsyperyminute.
Aynewbornywithyayrespiratoryyrateyofy40ybreathsyperyminute.
Anyadultywithyayrespiratoryyrateyofy10ybreathsyperyminute.y-yCORRECTyANSWER-
Anyadultywithyayrespiratoryyrateyofy10ybreathsyperyminute
Whichyofytheyfollowingyvitalysignsyrecordedyforyanyolderyadultywouldybeyconsideredy
acceptabley(withinynormalylimits)?
Tempy96.8°yFy(36y°C),yP-60,yR-18,yBPy160/90,yO2ysaty93%.
Tempy97.0°yFy(36.1y°C),yP-60,yR-16,yBPy116/78,yO2ysaty95%.
Tempy98.6y°Fy(37y°C),yP-56,yR-20,yBPy120/80,yO2ysaty91%.
Tempy98.0y°Fy(36.7y°C),yP-76,yR-22,yBPy110/70,yO2ysaty88%y-yCORRECTyANSWER-
Tempy97.0°yFy(36.1y°C),yP-60,yR-16,yBPy116/78,yO2ysaty95%.
TheynurseyhasydelegatedytheytaskyofytemperatureyassessmentytoytheyNAP.yWhichyinf
ormationyshouldybeyprovidedytoytheyNAP?y(Selectyallythatyapply.)
Theytypeyofytemperatureyrequired.
Theypatient'syage.
Theyfrequencyyforytakingyorymonitoringytheytemperature.
Theypatient'sydiagnosis.
Whatychangesytoyreportyimmediatelyytoytheynurse.y-yCORRECTyANSWER-
Whatychangesytoyreportyimmediatelyytoytheynurse
Theyfrequencyyforytakingyorymonitoringytheytemperature
Theytypeyofytemperatureyrequired
Whichyofytheyfollowingysituationsymayyaffectyaypatient'syvitalysigns?y(Selectyallythatya
pply.)
Movingyfromylyingytoystandingyposition.
Timeyofyday.
Occupation.
Isolationyprecautions.
Painyratedyasyay7yony0-10ypainyscale.y-yCORRECTyANSWER-
Movingyfromylyingytoystandingyposition
TimeyofyDay
Painyratedyasyay7yonyay0-10ypainyscale
Theynurseywillytakeytheypatient'syvitalysignsypreoperativelyyandyrecordythemyasyparty
ofytheypatient'sypreparationyforysurgery.yWhyyisyitynecessaryytoytakeyvitalysignsypreo
peratively?y(Selectyallythatyapply.)
,Toyprovideytheypatientywithyreassuranceythatyheyorysheyisybeingycaredyforybyyaycomp
etentystaff.
Toyprovideyaysetyofyvitalysignsytoyuseyforycomparisonyduringyandyafterysurgery.
YouyAnsweredyToyensureytheyequipmentyisyappropriatelyycalibratedyandyfunctional.
Toyverifyytheypatientyisynotyexperiencingyanyycomplicationsythatymayycontraindicatey
surgeryyoryrequireyintervention.
YouyAnsweredyToydetermineywhetherytheypatientyisy"feelingyfunny"yory"differe
nt".y-yCORRECTyANSWER-
Toyprovideyaysetyofyvitalysignsytoyuseyforycomparisonyduringyandyafterysurgery
Toyverifyytheypatientyisynotyexperiencingyanyycomplicationsythatymayycontraindicatey
surgeryyoryrequireyintervention
TheyNAPyreportsytoytheynurseyay65-year-
oldypatientysybloodypressureyisy160/98.yWhatyisytheyappropriateyinitialyresponseyofyt
heynurse?
Documentythisyasyaynormalyfindingyinyanyelderlyyadult.
AskytheyNAPyifytheypatientyisynauseous.
InstructytheyNAPytoyobtainyayfullysetyofyvitalysigns.
Assessytheypatientysybloodypressure.y-yCORRECTyANSWER-
Assessytheypatient'sybloodypressure
Whichypatientywouldyitybeyappropriateyforytheynurseytoydelegateyvitalysigns?
PatientytransferredyfromyICU.
Elderlyynursingyhomeyresident.
Newyadmissionytoytheyhospital.
Patientywithyrecentycomplaintyofyheadache.y-yCORRECTyANSWER-
Elderlyynursingyhomeyresident
Whichypersonywouldybeyexpectedytoyhaveytheylowestybodyytemperature?
Any80-year-oldywhoywalkedyhalfyaymile.
Aychildyplayingysoftball.
Ay16-year-oldywhoyrany1ymile.
Aytoddlerywhoyisyfebrile.y-yCORRECTyANSWER-
Any80yyearyoldywhoywalkedyhalfyaymile
TheyNAPyisypreparingytoymeasureyaypatient'syvitalysigns.yTheypatientyreportsyhavingy
eatenyaybowlyofywarmysoup.yTheyNAPyasksytheyRNywhatyheyshouldydo.yWhatyisytheybe
styresponse?
"Changeytoytheyredythermometeryprobeyandytakeytheypatient'sytemperatureyrectally."
"Takeytheypatient'sytemperatureyusingytheyaxillaryyrouteyandywhenyyouyrecordytheyr
eading,yaddy1°F."
"Sinceytheysoupywasynotyhot,ygoyaheadyandytakeytheypatient'sytemperature."
"Askytheypatientynotytoyeat,ydrink,yorysmokeyfory20yminutesyandythenyassessytheypati
ent'syoralytemperature."y-yCORRECTyANSWER-
Askytheypatientytoynotyeat,ydrink,yorysmokeyfory20yminutesythenyassessytheypatient'sy
oralytemperature
,Forywhichypatientywouldyaytympanicythermometerybeytheypreferredythermometeryto
yuse?
Aymarathonyrunnerywhoydevelopedyweaknessyduringytheyrace.
Aytachypneicypatientywhoyisyreceivingyoxygenybyynasalycannula.
Aypediatricypatientywhoyhadytubesysurgicallyyplacedyinytheyears.
Aynewbornythatyrequiresycontinuousytemperatureymonitoring.y-
yCORRECTyANSWER-Aytachypneicypatientywhoyisyreceivingyoxygenybyynasalycannula
Whichyofytheyfollowingypatientsywouldyrequireyfrequentyassessmentyofytheirytemper
ature?y(Selectyallythatyapply.)
Ayyoungyadultywithyaywhiteybloodycountyofy15,000/mm3.
Anyadultyfemaleyinytheyrecoveryyroomyfollowingyayhysterectomy.
Aypatientyreceivingyaybloodytransfusionyforychronicyanemia.
Aychildywhoyisybelowytheynormalyheightyandyweightyforyhisyage.
Anyelderlyypatientywhoyneedsyassistanceywithyfeedingyandydressing.y-
yCORRECTyANSWER-Ayyoungyadultywithyaywhiteybloodycountyofy15,000/mm3
Anyadultyfemaleyinytheyrecoveryyroomyfollowingyayhysterectomy
Aypatientyreceivingyaybloodytransfusionyforychronicyanemia
TheyNAPyreportsythatytheypatient'sytemperatureyisy39°yCy(102.2y°F).yWhichyofytheyfol
lowingyareyappropriateynursingyactions?y(Selectyallythatyapply.)
Removeytheypatient'syblankets.
Limitytheypatient'syfluidyintake.
Applyyayhyperthermiayblanketyasyordered.
Administeryanyantipyreticytoytheypatientyasyordered.
Placeytheypatient'syfeetyinyaytubyofycoolywaterywithyice.y-yCORRECTyANSWER-
Removeytheypatient'syblankets
Administeryanyantipyreticytoytheypatientyasyordered
Whichyofytheyfollowingyactions,yifymadeybyytheyNAP,ywouldyrequireyinterventionyand
yfurtheryinstructionybyytheynurse?y(Selectyallythatyapply.)
TheyNAPyusesyayblue-
tippedyelectronicyprobeyforyassessingyaypatient'syaxillaryytemperature.
TheyNAPywipesytheysingle-
useychemicalydotythermometeryandyplacesyitybackyinytheypatient'sydraweryforyfuturey
use.
TheyNAPyinsertsytheyred-
tippedyelectronicythermometeryprobeyintoytheypatient'symouthyafteryapplyingyayprob
eycover.
TheyNAPypullsytheypinnayup,yback,yandyoutyinyanyadultywhenyinsertingytheytympanicyt
hermometer.
TheyNAPywaitsyuny-yCORRECTyANSWER-TheyNAPywipesytheysingle-
useychemicalydotythermometeryandyplacesyitybackyinytheypatient'sydraweryforyfuturey
use
, TheyNAPyinsertsytheyred=tippedyelectronicythermometeryprobeyintoytheypatient'sym
outhyafteryapplyingyayprobeycover
Identifyytheyfactorsythatymayyhaveyanyeffectyonyanyelderlyypatient'sytemperature:y(Se
lectyallythatyapply.)
Participationyinyphysicalytherapyyexercises.
Roomytemperature.
Drinkingyaycoldyglassyofywater.
Patient'syheight.
Infection.y-yCORRECTyANSWER-Participationyinyphysicalytherapyyexercises
roomytemperature
drinkingyaycoldyglassyofywater
infection
Ifyay52-year-
oldypatientyhasyaynormalytemperature,ywhatyrangeyshouldytheypatient'sytemperature
yfallywithin?
96.8-98.6y°Fy(36-37y°C)
Correct!y96.8-100.4y°Fy(36-38y°C)
37-39y°Cy(98.6-102.2y°F)
35-36y°Cy(95-96.8y°F)y-yCORRECTyANSWER-96.8-100.4Fy(36-38C)
Aynewbornypatient'sytemperatureyhasybeenyrisingyrapidlyyandytheybabyyhasybeenycry
ing.yWhichyofytheyfollowingythermometersywouldybeytheybestytoyuseyinymeasuringythi
sypatient'sytemperature?
Chemicalydot
Tympanic
Temporalyartery
Rectalyelectronicy-yCORRECTyANSWER-TemporalyArtery
TheytaskyofypulseyassessmentycouldybeydelegatedytoytheyNAPyforywhichyofytheyfollowi
ngypatients?y(Selectyallythatyapply.)
Anyapicalypulseyofyaypatientywhoyisytoyreceiveyaycardiacydrug.
Ayfemoralypulseyfollowingyaylowerylegyamputation.
Ayradialypulseyofyaypatientyinytheyemergencyyroomywithychestypain.
Theytemporalypulseyofyaychild.
Ayradialypulseyonyaypatientywithyay1200ymLyfluidyrestriction.y-yCORRECTyANSWER-
Theytemporalypulseyofyaychild
Ayradialypulseyonyaypatientywithyay1200mLyfluidyrestriction
Whichyofytheyfollowingypatientsywouldybeyatyriskyforyhavingyanyalterationyinyperiphe
ralypulse?y(Selectyallythatyapply.)
Theypatientywhoywasyjustyinformedyofyaydiagnosisyofycancer.
AnyelderlyypatientywithyTypey1ydiabetesywhoyisyotherwiseyhealthy.
AypatientywhoyisyreceivingybolusyIVyfluids.
AypatientywithyAlzheimer'sydisease.