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Hallmark BSN 206 (Latest Update 2025 /
2026) Questions with Verified Answers |
100% Correct | Grade A - Nightingale
Which of the following patients would require follow-up? An adult with a respiratory rate of 10 breaths per minute. Rational: The normal respiratory rate for a newborn is 30 to 60 breaths per minute. The normal respiratory rate of a child is 20 breaths per minute. The normal respiratory rate for a teenager is 16 to 20 breaths per minute. The normal respiratory rate for an adult is 12 to 20 breaths per minute. A rate of 10 would require follow-up. Which of the following vital signs recorded for an older adult would be considered acceptable (within normal limits)? Temp 97.0° F (36.1 °C), P-60, R-16, BP 116/78, O2 sat 95%. Rational: Normal values for an older adult are: average body temperature approximately 36° C (96.8° F), heart rate 60 to 100 beats per minute, respiratory rate 16 to 25 breaths per minute, average BP less than 120 over 80, and pulse oximetry 95% to 100%. A BP greater than 140 over 90 may be an indication of hypertension. The nurse has delegated the task of temperature assessment to the NAP. Which information should be provided to the NAP? (Select all that apply.) -The type of temperature required. -What changes to report immediately to the nurse. -The frequency for taking or monitoring the temperature. Rational: It is more important that the temperature be done on time by the correct route, with the correct equipment, and that identified changes be reported as requested.
Which of the following situations may affect a patient's vital signs? (Select all that apply.) -Time of day. -Moving from lying to standing position. -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 apply.) To provide a set of vital signs to use for comparison during and after surgery. To verify the patient is not experiencing any complications that may contraindicate surgery or require intervention. Rational: The patient who is going to surgery is going to experience a change in condition and an invasive procedure. Vital signs are necessary so that the operative team has a baseline for comparison as well as to rule out any complications before the beginning of the surgical event. Providing reassurance to the patient can be done verbally. If a patient reports feeling different, assessing vital signs is appropriate. There is no indication the patient is feeling different. Equipment should be maintained in a functional state at all times. The NAP reports to the nurse a 65-year-old patient s blood pressure is 160/98. What is the appropriate initial response of the nurse? Assess the patient s blood pressure. Rational: This is out of normal range. If there is a question regarding a patient's vital signs or a suspected change in the patient's condition that may require further assessment, the nurse should take the patient's vital signs rather than delegating the task. . Which patient would it be appropriate for the nurse to delegate vital signs? Elderly nursing home resident. Rational: The nurse may delegate routine vital signs of stable patients. Obtaining a baseline upon admission or transfer patient should be completed by the nurse. If a patient has a change in condition, such as a headache which could be reflective of hypertension, the nurse should assess the patient's vital signs.
-An adult female in the recovery room following a hysterectomy. -A young adult with a white blood count of 15,000/mm3. -A patient receiving a blood transfusion for chronic anemia. Rational: Certain conditions place patients at risk for temperature alterations and may require more frequent assessment. Patients at risk may include those receiving a blood product infusion, those who are of a postoperative status, and those with a white blood cell count below 5,000 or above 12,000/mm3. The NAP reports that the patient's temperature is 39° C (102.2 °F). Which of the following are appropriate nursing actions? (Select all that apply.) -Administer an antipyretic to the patient as ordered. -Remove the patient's blankets. Rational: Although the task of temperature assessment may be delegated, it is the nurse's responsibility to determine the accuracy of the measurement and to assess for further indication of infection. Fluids should be increased to 3 L daily (unless contraindicated). The nurse should administer an antipyretic as ordered and reassess the temperature in 30 minutes and every 4 hours until the temperature has stabilized within normal limits. A cool wet wash cloth may be provided, but the patient should not be excessively chilled, such as with ice. Cooling the temperature in the room will aid in reducing the temperature, and reducing the amount of external covering will promote heat loss. A hyperthermia blanket is used to raise body temperature. 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 wipes the single-use chemical dot thermometer and places it back in the patient's drawer for future use. -The NAP inserts the red-tipped electronic thermometer probe into the patient's mouth after applying a probe cover. Rational:The electronic thermometers are differentiated by the probe cover tips: blue for oral or axillary, red for rectal. Even though a probe cover is applied, a red- tipped probe should not be placed into a patient's mouth. The single-use chemical dot thermometer is plastic and can only be used once. All electronic thermometers (oral, axillary, rectal) and the tympanic thermometer have a tone that sounds when
the measurement is complete. Pull the pinna up, back, and out in an adult when inserting the tympanic thermometer. Identify the factors that may have an effect on an elderly patient's temperature: (Select all that apply.) -Participation in physical therapy exercises -Drinking a cold glass of water -Room temperature -Infection If a 52-year-old patient has a normal temperature, what range should the patient's temperature fall within? 96.8-100.4 °F (36-38 °C) Rational: The normal temperature range for an adult is 96.8° F to 100.4° F or 36° C to 38° C. The normal temperature range for a newborn is 95.9° F to 99.5° F. Nursing judgment should be used to determine whether further assessment is indicated regarding an individual patient s temperature, even if it is within the identified range of normal for most people. For example, a patient recovering from a stroke with a feeding tube and a temperature of 99.0° should be assessed further as this may be an initial indication of aspiration. A newborn patient's temperature has been rising rapidly and the baby has been crying. Which of the following thermometers would be the best to use in measuring this patient's temperature? Temporal artery Rational: The temporal artery thermometer reflects rapid change in core temperature and can be used on newborns. The tympanic membrane sensor is unable to accurately measure core temperature changes during and after exercise. Chemical dot thermometers are inappropriate for use when there is a sudden and/or variable rise in temperature. It would be unnecessary to use a rectal thermometer and could cause bowel perforation if inserted too far on a newborn. The task of pulse assessment could be delegated to the NAP for which of the following patients? (Select all that apply.) -A radial pulse on a patient with a 1200 mL fluid restriction. -The temporal pulse of a child. Rational: The skill of pulse measurement can be delegated to NAP unless the
In which of the following patients would the nurse expect to find a decrease in pulse rate? (Select all that apply.) -A patient returning from the operating room. -A patient who received morphine for pain. Rational: Having general anesthesia or receiving an opioid analgesic may decrease the pulse rate. A newborn has a higher pulse rate than an adult. Sympathetic stimulation such as anxiety will increase the pulse rate. Having a decreased fluid volume will increase the pulse rate as the heart attempts to compensate to maintain cardiac output. The new NAP is unable to palpate a patient’s radial pulse. What could be a possible explanation for this difficulty? (Select all that apply.) -The NAP is assessing for a pulse on the ulnar side of the wrist. -The NAP is pressing down too hard on the patient's radial site. Rational: The radial pulse is found on the radial (thumb) side of the wrist. Pressing too hard on the radial site may obliterate the pulse; light pressure should be used. A weak, thready pulse may be difficult to palpate, not a full, bounding pulse. The pulse is palpated, not auscultated, at the radial site. If a pulse is to be auscultated, it is done so at the PMI. The order of vital sign assessment should not affect the ability to obtain a patient's radial pulse.If not selected (incorrect). The radial pulse is found on the radial (thumb) side of the wrist. Pressing too hard on the radial site may obliterate the pulse; light pressure should be used. A weak, thready pulse may be difficult to palpate, not a full, bounding pulse. The pulse is palpated, not auscultated, at the radial site. If a pulse is to be auscultated, it is done so at the PMI. The order of vital sign assessment should not affect the ability to obtain a patient's radial pulse. What is an appropriate nursing intervention for an adult patient with a respiratory rate of 30 breaths per minute? (Select all that apply.) -Count the respiratory rate again for a full 60 seconds (1 minute). -Assess physiologic factors that may be causing the patient to breathe so fast. Rational:If the patient has a respiratory rate greater than 20 breaths per minute, you should count the respiratory rate again over a full minute and assess for factors causing the patient's elevated respiratory rate. Administering a bronchodilator
would require a physician's order and may not treat the cause (e.g., pain could be the cause of the increased rate). You should attempt to assess the patient's respiratory rate inconspicuously to prevent the patient from altering the rate of breathing. The normal respiratory rate for an adult is 12 to 20 breaths/minute. Which of the following may increase both rate and depth of respiration? (Select all that apply.) -Feeling anxious when taking a test -Having an addiction problem with amphetamines/cocaine. -Walking 1 mile briskly. Rational: Exercise, anxiety, and amphetamines/cocaine increase both respiratory rate and depth. Respiratory rate may increase when the patient is in pain, but breathing becomes shallow. Smoking also increases the respiratory rate, but depth is unaffected. Opioids may depress both respiratory rate and depth. It is clinically significant when both rate and depth are affected. Bronchodilators decrease the respiratory rate. Damage to the brain stem impairs the respiratory center and slows the rate and rhythm. When assessing the respiratory rate, the nurse has difficulty seeing the patient's chest rise and fall with inspiration and expiration. What is the nurse's best action? Move the patient's arm over their chest and feel the rise and fall of the chest. Rational: If unable to visualize respirations, the nurse should discreetly feel the patient's respirations. The nurse should first attempt to hold the patient's wrist and move it over the patient's chest or abdomen, feel the rise and fall of inspiration and expiration, and assess the rate. The nurse needs to obtain the patient's respiratory rate. Documenting inability to visualize respirations may imply the patient is deceased or that the nurse is incompetent. . How can the nurse best obtain an accurate measurement of a patient's respiratory rate? Continue to act as though taking the patient's pulse while discretely observing the rise and fall of the patient's chest. Rational: If the patient is aware that the nurse is monitoring his or her respirations, the patient will most likely alter the breathing pattern. It is best to discretely observe the rise and fall of the patient's chest. Assessing the patient's respirations
Rational: Leg pressure cuffs should be avoided on patients with deep vein thrombosis. The student nurse is unsure of the BP measurement. What should the student nurse do first? Assess the BP in the other arm. Rational: Repeating a BP too quickly will result in a false high diastolic reading. Wait 1 to 2 minutes to repeat a measurement, or measure the pressure in the opposite arm. Using the image below, please choose the correct BP combination: Image A = 120/80, Image B = 128/76, Image C = 140/90, Image D = 138/ It is 7 a.m. and the nurse takes the vital signs of a postoperative patient and finds his blood pressure is elevated. Which of the following could explain the cause for this alteration in BP? The patient complains of pain at a 9 on a 0-10 pain scale. Rational: Pain is the likely cause of the increase in the patient s blood pressure. Although dehydration can cause a decrease in blood pressure, the patient has only been restricted of oral fluids, and likely had an IV during surgery to maintain fluid balance. Furthermore, the patient has only been NPO for 7 hours. Environmental temperature may affect a patient s temperature and pulse. A rectal temperature of 99.0°F correlates with an oral temperature of 98.1°F, which is within normal limits. Body temperature can affect pulse and respiratory rate. . The patient has a history of a left mastectomy. Where should the nurse take the patient's blood pressure? In the right arm Rational: The nurse should take the patient's blood pressure in the opposite arm of the mastectomy, in this case, the right arm. If the patient had a shunt for dialysis, this should be avoided also. The nurse is unable to obtain a BP reading using an electronic BP machine on a post-operative patient. The machine reads "Error." What priority action should the nurse take? Take the patient's BP manually using a sphygmomanometer Rational: Electronic BP machines are less accurate in low flow conditions and valuable time could be lost attempting to find an electronic BP machine that will
record the patient's blood pressure. The nurse should retake the blood pressure manually. The nurse will need to obtain further assessment data, including complete vital sign measurements, prior to determining if the health care provider needs to be contacted, or when providing a report of patient condition to the health care provider. An order from the health care provider would be required before changing the rate of IV infusion. . The NAP reports to the nurse the patient's respirations are 32 and the patient is complaining of shortness of breath. What is the best action by the nurse at this time? Assess the patient, including the pulse oximetry reading. Rational: The nurse should assess the patient. The NAP can obtain a pulse oximetry reading if the patient is stable and after the NAP's skill with the oximeter is validated. Which patient is at high risk for for the pulse oximetry alarm to sound? A patient with a continuous pulse oximetry reading of 84%. Rational: Continuous pulse oximetry alarms activate if oxygen saturation falls below 85% and/or the probe falls off. A patient complains of feeling excessively tired. Which statement, if made by the NAP, indicates further instruction is necessary? "I will turn the continuous pulse oximetry alarms off at night so you can sleep." Rational: The oximeter alarms should remain on for continuous pulse oximetry. Further inquiry may assist the staff in meeting the patient's need for sleep. The NAP tells the nurse the patient's pulse oximetry is 85% on room air. What nursing action(s) should the nurse take? (Select all that apply.) -Reassess the patient's pulse oximetry. -Place the patient in the high-Fowler's position. -Assess the patient's respiratory and cardiac status. Rational: The first action the nurse should take is to reassess the patient's pulse oximetry, making sure the probe is intact and correctly positioned. The nurse may place the patient in the high-Fowler's position to promote optimal ventilation. The nurse should observe the patient for signs of decreased oxygenation such as
A nurse assesses a client's radial pulse rate to be 110 beats/min and regular. What action by the nurse is best? Assess the client for causes of tachycardia. Rational: Tachycardia (rapid heart rate) is often caused by factors such as pain, anxiety, fever, or fluid volume alterations. The nurse should assess the client thoroughly for possible causative factors. Since the pulse is regular, there is no reason to take an apical pulse. The findings should be documented, but the nurse needs to do more. The provider may or may not need to be notified, depending on the outcome of the nurse's assessment. A nursing student is assigned to take the vital signs on a client and finds the radial pulse to be irregular. What action should the nursing student take? Auscultate the client's apical pulse. Rational: The nursing student should auscultate the client's apical pulse. Another nursing student may or may not be able to obtain a radial pulse and it is the responsibility of the nursing student to complete tasks assigned in order to become proficient and independent in nursing assessment. It is unnecessary to wait 15 minutes to reassess the pulse. Checking a previous reading may be valuable for comparison, but does not result in obtaining the pulse rate at this time. . The nurse has applied a pulse oximeter to the finger of a client who is hypothermic. The pulse oximeter does not provide a good reading. What action by the nurse is best? Assess the fingers for good circulation. Rational: A patient who is hypothermic may not have good circulation to the extremities. The nurse should assess the patient's circulation, and if it is poor to the extremities, choose another spot at which to measure the oxygen saturation. Moving the probe to another finger or removing nail polish will not help if the problem is poor circulation. The nurse should document appropriately but needs to do more than just charting that the reading could not be obtained. Which of the following vital signs are expected for the adult client who has problems in oxygenation? Temp 98.6° F (37 °C), P-102, R-28, BP 98/50, O2 sat 85%. Rational: The client with cyanosis would most likely have an oxygen saturation below the normal limits of 95% to 100%. The respiratory rate and the heart rate
may also be elevated as the body attempts to compensate for a decrease in oxygen. A decreased blood pressure may be evident in the person who is experiencing hypovolemic shock. An elevated blood pressure reading is not an expected finding associated with cyanosis; rather, a decreased oxygen saturation reading would be expected. The nurse assesses that the 86-year-old client is experiencing orthostatic hypotension when assessments indicate: (Select all that apply.) -dizziness upon rising to a standing position. -blurred vision Rational: Assessment of dizziness, drop in up to 20 mm Hg from baseline BP, syncope, and blurred vision are all indicative of orthostatic hypotension. A nurse notes a client has abnormal vital signs. What action by the nurse is best? Compare with prior readings. Rational: Individual vital signs are not as important as the trends. For instance, a client may have a blood pressure higher than "normal" that is normal for the client. Trends give more useful information than a single reading. Documentation is important, but the nurse needs to do more. If the readings are significantly abnormal, the provider should be notified. The nurse may retake the vital signs if he/she is not confident of the first set of measurements, but should not wait for time to pass. The nurse is assessing the patient and family for probable familial causes of the patient’s hypertension. The nurse begins by analyzing the patient’s personal history, as well as family history and current lifestyle situation. Which findings will the nurse consider to be risk factors? (Select all that apply.) -heavy alcohol intake -cigarette smoking -obesity Rational: Obesity, cigarette smoking, and heavy alcohol consumption are risk factors linked to hypertension. Weight loss and regular exercise can decrease the risk for hypertension. A nurse is assessing results of vital signs for a group of client. Match the condition to the assessment findings the nurse is reviewing.
Rational: A client with a temperature above the normal range (100.2° F) is called febrile. The nursing faculty member is observing a student taking a client's carotid pulse. What action by the student requires intervention by the faculty member? Compares pulses in both carotid arteries at the same time. Rational: The carotid arteries are the main supply route of blood to the brain. Compressing both sides of the carotid arteries at the same time can lead to ischemia. The other actions are appropriate. An elderly patient was recently admitted to a medical unit with severe fluid and electrolyte imbalance. His family states that he has periods of confusion. What are some practical precautions the nurse can take to ensure the patient's safety without having to use restraints? (Select all that apply.) Make staff assignments for patients in adjacent rooms. Activate the bed alarm when the patient is in bed. Perform nurse toilet and turn or comfort and safety rounds hourly. A patient is admitted to a medical unit with pneumonia. She is able to ambulate on her own to the bathroom. What safety precautions should be taken for this patient? (Select all that apply.) Explain the use of the call light. Keep the bed in the low, locked position. Ensure that the pathway to the bathroom is clear. Keep patient's personal items on the overbed table. Rational: To promote safety for a recently admitted patient who is able to ambulate, the nurse should explain the use of the call light, keeping it in an accessible location for the patient. Keep the bed in a low, locked position. Keep the pathway clear to reduce the likelihood of the patient falling over objects or bumping into them. Side rails may be considered a restraint device when used to prevent the ambulatory patient from getting out of bed. The nurse may ask the patient if she would like to have one side rail up. The patient is ambulatory; therefore, offering a bedside commode would be unnecessary. Necessary items such as eyeglasses should be placed within the patient's easy reach, such as on the overbed table. This facilitates independence and self-care and prevents falls that occur when a patient reaches too far.
The nurse walking down the hospital corridor glances into the patient’s room and sees the patient's feet and legs sticking out from the bathroom entrance. The nurse immediately goes into the room and determines that the patient has fallen. What actions should be taken? (Select all that apply.) Call for assistance. Assess for injury. Notify the health care provider. Assess the situation for precipitous factors (e.g., hypotension, slippery footwear, etc.). Fill out an agency occurrence or sentinel event report. Rational:The nurse should first call for assistance and assess the patient for injury. The nurse should stay with the patient until assistance arrives to help lift the patient to the bed or to a wheelchair. The health care provider should be notified. The patient may be moved to a bed or wheelchair before the health care provider arrives. The nurse should note pertinent events related to the fall and resultant treatment in the patient's medical record. The agency's incident reporting policy should be followed. The nurse will reassess the patient and environment to determine if the fall could have been prevented. The nurse may then reinforce identified risks with the patient and review safety measures needed to prevent a fall. The use of restraints requires a health care provider's order. Which of the following are appropriate safety measures for the use of a wheelchair? (Select all that apply.) Brakes on both wheels are locked when the patient is being transferred into the wheelchair. Back the wheelchair into and out of an elevator. Seat patient in wheelchair with buttocks against back of seat. Rational: To keep the chair steady and secure, the brakes on both wheels must be locked securely when a patient is transferred into or out of a wheelchair. The footplates should be raised before the transfer so that they are not a trip hazard and should be lowered, placing the patient's feet on them, after the patient is seated so that the patient's feet will be supported with movement of the wheelchair. The wheelchair should be backed into and out of an elevator, with rear large wheels
Rational: In general, patients should be repositioned as needed and at least every 2 hours if they are in bed and every 20 to 30 minutes if they are sitting in a chair to prevent the development of pressure ulcers. A patient with paraplegia would not be able to feel discomfort from pressure. Which of the following patients should be allowed to lie back down? A patient who complains of feeling dizzy and slightly nauseous when sitting on the bedside. Rational: A drop in blood pressure of approximately 20 mm Hg in systolic pressure or 10 mm Hg in diastolic pressure with symptoms of dizziness, pallor, or fainting indicates orthostatic hypotension. This patient's blood pressure changed within a normal range. A patient with orders to be up in chair needs to be encouraged to stay up in the chair in order to improve endurance. When preparing to move a patient in bed, what will the nurse do first? Assess the patient's ability to help with moving. Rational: Assessing the patient's ability to help is the first thing the nurse must do, since the answer determines how much help is needed with the move. The patient's weight is important to know, but it is not the first action the nurse must take. The most effective means of moving the patient will be determined in part by whether the patient is able to help. When preparing to move a patient in bed with the help of an assistant, which posture will both caregivers use to ensure their own safety? Flex the hips and knees. Rational: Flexing the hips and knees is the safest posture for both caregivers to assume when moving a patient in bed. Standing with the knees locked could injure the legs or the back. Standing with the feet together could injure the legs or the back. The body weight should be shifted from the front leg to the back leg. A patient who weighs 200 lbs. needs to be moved up in bed with the aid of a friction-reducing device. The nurse will prepare for this move by assembling how many caregivers? At least three Rational: Since a friction-reducing device will be used and the client weighs more than 157 lbs., a minimum of three to four people are needed to move this patient safely. The device does not function independently, and the nurse cannot use it without the help of other caregivers. The nurse cannot carry out this move by himself or herself.
In which position will the nurse place the patient to move him or her up in bed? Supine with the head of the bed flat Rational: Placing the patient in the supine position with the head of the bed flat is the recommended position to use to move a patient up in bed. The patient should not be supine with the head of the bed at a 30-degree angle, sitting, or prone when being moved up in bed. A patient will be moved up in bed with the use of a friction-reducing device. How will the nurse place this device under the patient? Roll the patient from side to side, and place the device under the draw sheet. Rational: The patient will be rolled from side to side and the device placed under the draw sheet. The patient is not lifted in order to place the device under him or her. The device must be placed under the draw sheet. The device must be behind the entire length of the patient, and not just placed at the level of the shoulders. . When preparing to apply elastic stockings, why does the nurse assess for skin discoloration? To identify the potential risk for deep vein thrombosis (DVT) Rational: The nurse assesses for skin discoloration because it is one possible indicator of deep vein thrombosis (DVT). Improper patient positioning is not a rationale for why the nurse assesses for skin discoloration. The selection of proper stocking size would be done after the nurse assesses for skin discoloration. Determining whether the use of a sequential compression device is needed is not why the nurse assesses for skin discoloration. Which condition is not associated with venous stasis, part of Virchow's triad? Anxiety Rational: Pregnancy, obesity, and immobility can all cause pooling of blood in the lower extremities. Anxiety is not associated with blood stasis. Why does the nurse remove the patient's elastic stockings at least once per shift? To check the skin for irritation or breakdown Rational: The nurse removes the patient's elastic stockings at least once per shift to
