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HALLMARK EXAM BSN 206 EXAM | ALL QUESTIONS
AND CORRECT ANSWERS | GRADED A+ | VERIFIED
ANSWERS | LATEST EXAM 2025 | JUST RELEASED
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 The nurse can carry out this move without assistance A minimum of two None, since the device does all the lifting during the move --------- CORRECT ANSWER-----------------At least 3 In which position will the nurse place the patient to move him or her up in bed? Sitting in the bed Supine with the head of the bed flat Prone with the head of the bed flat Supine with the head of the bed at a 30-degree angle ---------CORRECT ANSWER-----------------Supine with the head of the bed flat 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? Lift the patient to place the device directly under him or her. Sit the patient up in the bed, and place the device behind the shoulders. Roll the patient from side to side, and place the device under the draw sheet. Remove the draw sheet, and replace it with the device. ---------CORRECT ANSWER-----------------Roll the patient from side to side, and place the device under the draw sheet Which patient is most at risk of developing permanently impaired mobility?
An 11-year-old boy who sustained a fractured pelvis during a fall from his tree house A 79-year-old man recovering from surgery to release a contracture of the connective tissue in his hand A 72-year-old woman hospitalized for anemia associated with diabetic nephropathy (kidney disease) A 55-year-old woman with mental illness who had become malnourished --- ------CORRECT ANSWER-----------------A 72-year-old woman hospitalized for anemia associated with diabetic nephropathy (kidney disease) The nurse notes that a patient's left elbow is resistant to extension and flexion while performing range of motion exercises. What is the appropriate nursing action? Move the joint through the full range of motion exercises. Omit all the range of motion exercises until the health care provider is notified. Inform the health care provider that the patient is uncooperative with exercising. Perform range of motion to the left elbow until resistance is met. --------- CORRECT ANSWER-----------------Perform range of motion to the left elbow until resistance is met The nurse is performing passive shoulder and elbow exercises for a patient who is recovering from surgery to remove a soft-tissue tumor in her upper arm. Why does the nurse cup one hand around the patient's elbow and support the forearm and wrist during the ROM exercises? To keep the arm above the level of the heart To listen for crepitus in the joint To ensure stability while exercising the joint To assess the patient's muscle tension ---------CORRECT ANSWER---------- -------To ensure stability while exercising the joint Which of the following are basic guidelines when assisting a patient with passive range of motion?
A patient lying supine in bed is being transferred to a wheelchair using a transfer belt. Which action would the nurse perform just before moving the patient to the side of the bed? Position the chair so that the patient will move toward his or her stronger side. Raise the head of the bed 30 degrees. Help the patient put on skid-resistant footwear. Place the transfer belt over the patient's clothing. ---------CORRECT ANSWER-----------------Raise the head of the bed 30 degrees. The nurse is preparing to transfer a patient with left-sided weakness from the bed to a wheelchair using a transfer belt. Which position would the nurse instruct the patient to assume? Place both feet together on the floor. Place your weaker foot forward and your stronger leg toward the back. Extend both of your legs and feet. Place your stronger leg forward and your weaker leg toward the back. ------- --CORRECT ANSWER-----------------Place your stronger leg forward and your weaker leg toward the back A patient has been transferred to a wheelchair with a transfer belt. What is one action the nurse would take to position the patient safely in the chair? Lower the foot rests, and place the patient's feet on them. Remove the transfer belt. Remove the wheelchair leg rests. Ask the patient to rate his or her pain level. ---------CORRECT ANSWER---- -------------Lower the foot rests, and place the patient's feet on them What does the nurse do after attaching the hooks to the holes in the sling on a hydraulic lift? Lower the head of the bed.
Have the patient cross the arms over the chest. Elevate the head of the bed. Remove the patient's eyeglasses. ---------CORRECT ANSWER----------------
- Have the patient cross the arms over the chest When preparing for safe patient transfer using a hydraulic lift, the nurse performs which action first? Arranges for at least three healthcare personnel to assist in the transfer Applies clean gloves Makes sure the patient agrees to the intervention Assesses the patient for weakness, dizziness, or postural hypotension ------ ---CORRECT ANSWER-----------------Assess the patient for weakness, dizziness, or postural hypotension Which position is used when applying the sling to transfer a patient from the bed to a chair with a hydraulic lift? Side-lying Supine Prone Sims ---------CORRECT ANSWER-----------------Supine Which action would decrease a patient's pain before a transfer with a hydraulic lift? Explain the procedure to the patient before beginning the transfer. Postpone the transfer if the patient reports having physical pain or anxiety before the transfer. Administer a prescribed analgesic 30 to 60 minutes before the transfer. Stop the transfer if the patient expresses or displays physical signs of pain. ---------CORRECT ANSWER-----------------Administer a prescribed analgesic 30 to 60 minutes before the transfer
Why might the nurse choose not to apply a pair of prescribed elastic stockings to a patient's legs? The patient has become fully ambulatory. The patient's skin is irritated. The patient says they are too tight. The patient will have a scheduled bath in a few hours. ---------CORRECT ANSWER-----------------The patient's skin is irritated After determining the proper size stocking and assessing the patient's circulatory status, a nurse delegates the application of elastic stockings to nursing assistive personnel (NAP). The nurse discovers that the NAP has been using moisturizer on the patient's legs before applying the stockings. What is the best action by the nurse? Explain that moisturizer may cause excessive skin softening, which can lead to skin breakdown. Inspect the patient's skin for color variations. Instruct NAP to use a small amount of cornstarch or powder. Ask the patient if he or she is allergic to the moisturizer. ---------CORRECT ANSWER-----------------Instruct NAP to use a small amount of cornstarch or powder A patient was diagnosed with a urinary tract infection. The patient has been drinking fruit juice and has increased his intake of fluids but has failed to take his antibiotic as prescribed because it caused gastric upset. Three days later, the patient presents to the clinic with fever, malaise, nausea, and vomiting. What might you suspect? The patient probably has the flu. The patient may now have a systemic infection. The patient is displaying signs of a localized infection. The patient is experiencing an allergic response to his medication. --------- CORRECT ANSWER-----------------The patient may now have a systemic infection
The nurse is preparing to insert a urinary catheter. To perform this procedure, the nurse will use: Surgical asepsis (sterile technique). Medical asepsis (clean technique). Droplet precautions. Standard precautions. ---------CORRECT ANSWER-----------------Surgical asepsis (sterile technique) The nurse is working in a busy emergency room. On entering station 1, the nurse dons a pair of clean disposable gloves. The nurse sees that the patient has a gunshot wound to the chest and is concerned there may be splattering of infectious materials. The nurse applies goggles, a mask, and a gown. What is this called? Following standard precautions. Using medical asepsis. Using surgical asepsis. Infection control to prevent a health care-acquired infection. --------- CORRECT ANSWER-----------------Following Standard Precautions A nurse assists a patient with a Foley catheter to ambulate down the hall. The nurse holds the catheter bag below the level of the patient s bladder. What link in the chain of infection is the nurse breaking by doing so? Portal of exit. Portal of entry. Reservoir. Host susceptibility. ---------CORRECT ANSWER-----------------Portal of entry The nurse manager is reviewing the use of standard precautions with the staff. Which of the following should be included in the review? (Select all that apply.) Standard precautions are used to protect you from potential contact with blood and body fluids. Standard precautions should be observed in every patient encounter.
The type of temperature required Which of the following situations may affect a patient's vital signs? (Select all that apply.) Moving from lying to standing position. Time of day. Occupation. Isolation precautions. Pain rated as a 7 on 0-10 pain scale. ---------CORRECT ANSWER------------ -----Moving from lying to standing position Time of Day Pain rated as a 7 on a 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 the patient with reassurance that he or she is being cared for by a competent staff. To provide a set of vital signs to use for comparison during and after surgery. You Answered To ensure the equipment is appropriately calibrated and functional. To verify the patient is not experiencing any complications that may contraindicate surgery or require intervention. You Answered To determine whether the patient is "feeling funny" or "different". ---------CORRECT ANSWER-----------------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 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? Document this as a normal finding in an elderly adult. Ask the NAP if the patient is nauseous.
Instruct the NAP to obtain a full set of vital signs. Assess the patient s blood pressure. ---------CORRECT ANSWER------------- ----Assess the patient's blood pressure Which patient would it be appropriate for the nurse to delegate vital signs? Patient transferred from ICU. Elderly nursing home resident. New admission to the hospital. Patient with recent complaint of headache. ---------CORRECT ANSWER----- ------------Elderly nursing home resident Which person would be expected to have the lowest body temperature? An 80-year-old who walked half a mile. A child playing softball. A 16-year-old who ran 1 mile. A toddler who is febrile. ---------CORRECT ANSWER-----------------An 80 year old who walked half a mile The NAP is preparing to measure a patient's vital signs. The patient reports having eaten a bowl of warm soup. The NAP asks the RN what he should do. What is the best response? "Change to the red thermometer probe and take the patient's temperature rectally." "Take the patient's temperature using the axillary route and when you record the reading, add 1°F." "Since the soup was not hot, go ahead and take the patient's temperature." "Ask the patient not to eat, drink, or smoke for 20 minutes and then assess the patient's oral temperature." ---------CORRECT ANSWER----------------- Ask the patient to not eat, drink, or smoke for 20 minutes then assess the patient's oral temperature
The NAP uses a blue-tipped electronic probe for assessing a patient's axillary temperature. 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. The NAP pulls the pinna up, back, and out in an adult when inserting the tympanic thermometer. The NAP waits un ---------CORRECT ANSWER-----------------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 Identify the factors that may have an effect on an elderly patient's temperature: (Select all that apply.) Participation in physical therapy exercises. Room temperature. Drinking a cold glass of water. Patient's height. Infection. ---------CORRECT ANSWER-----------------Participation in physical therapy exercises room temperature drinking a cold glass of water infection If a 52-year-old patient has a normal temperature, what range should the patient's temperature fall within? 96.8-98.6 °F (36-37 °C) Correct! 96.8-100.4 °F (36-38 °C) 37 - 39 °C (98.6-102.2 °F) 35 - 36 °C (95-96.8 °F) ---------CORRECT ANSWER-----------------96.8- 100.4F (36-38C)
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? Chemical dot Tympanic Temporal artery Rectal electronic ---------CORRECT ANSWER-----------------Temporal Artery The task of pulse assessment could be delegated to the NAP for which of the following patients? (Select all that apply.) An apical pulse of a patient who is to receive a cardiac drug. A femoral pulse following a lower leg amputation. A radial pulse of a patient in the emergency room with chest pain. The temporal pulse of a child. A radial pulse on a patient with a 1200 mL fluid restriction. --------- CORRECT ANSWER-----------------The temporal pulse of a child A radial pulse on a patient with a 1200mL fluid restriction Which of the following patients would be at risk for having an alteration in peripheral pulse? (Select all that apply.) The patient who was just informed of a diagnosis of cancer. An elderly patient with Type 1 diabetes who is otherwise healthy. A patient who is receiving bolus IV fluids. A patient with Alzheimer's disease. A patient with peripheral vascular disease. ---------CORRECT ANSWER----- ------------The patient who was just informed of a diagnosis of cancer A patient who is receiving bolus IV fluids A patient with peripheral vascular disease Whenever there is an alteration in the radial pulse rate, rhythm, or amplitude, the nurse should initially do which of the following? Reassess the radial pulse for 30 seconds. Auscultate the apical pulse for quality and rate. Check the carotid pulses one side at a time.
The NAP failed to auscultate the patient's wrist with a stethoscope. --------- CORRECT ANSWER-----------------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 What is an appropriate nursing intervention for an adult patient with a respiratory rate of 30 breaths per minute? (Select all that apply.) Tell the patient their breaths are being counted so the patient will breathe slower. 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. Administer a bronchodilator that will decrease the respiratory rate. Record this normal respiratory rate in the patient's medical record. --------- CORRECT ANSWER-----------------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 Which of the following may increase both rate and depth of respiration? (Select all that apply.) Smoking a cigarette. You Answered Having a pain level rating at 7 on a scale of 0-10. Using a bronchodilator prior to exercise. Correct! Feeling anxious when taking a test. Correct! Walking 1 mile briskly. Incurring a head injury from a motor vehicle accident. Taking an opioid to relieve pain. Correct! Having an addiction problem with amphetamines/cocaine. --------- CORRECT ANSWER-----------------Feeling anxious when taking a test Walking 1 mile briskly Having an addiction problem with amphetemines/cocaine
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. Remove the patient's gown for better visualization of the patient's chest. Document the inability to visualize inspiration and expiration. Have another nurse assess the patient's respiratory rate. ---------CORRECT ANSWER-----------------Move the patient's arm over their chest and feel the rise and fall of the chest How can the nurse best obtain an accurate measurement of a patient's respiratory rate? Inform the patient when monitoring his or her respirations. Correct! Continue to act as though taking the patient's pulse while discretely observing the rise and fall of the patient's chest. Assess the respirations while the patient is talking. Auscultate the lung sounds, asking the patient to take a deep breath in through the nose and exhale slowly through the mouth. ---------CORRECT ANSWER-----------------Continue to act as though taking the patient's pulse while discretely observing the rise and fall of the patient's chest The nurse is validating the NAP's skill with respiratory rate assessment. Which of the following actions, if made by the NAP, indicates that further instruction is needed? After taking the patient's pulse, the NAP continues to hold the patient's wrist, moving the arm across the patient's chest, and focuses on the patient's breathing. When the patient's respiratory rate is irregular, the NAP counts the patient's respirations for 1 full minute. When a patient inhales a breath, the NAP counts that as one, and when the patient exhales the breath, the NAP counts that as two. When the patient's respiratory rate is less than 12 or greater than 20, the NAP counts the patient's respirations for 1 full minute. ---------CORRECT ANSWER-----------------When a patient inhales a breath, the NAP counts
Wait 30 seconds and repeat the measurement on the same arm. Assess the BP in the other arm. Get the nurse to assess the BP. Determine if the patient received an antihypertensive medication. --------- CORRECT ANSWER-----------------Assess the BP in the other arm Using the image below, please choose the correct BP combination:<IM src="http://www.coursewareobjects.com/objects/nso3e_v1/images/assess ment_images/mod1l5q5.gif" Link (Links to an external site.you may need to right click this link for it to open). Image A = 126/76, Image B = 140/90, Image C = 138/84, Image D = 120/ Image A = 140/90, Image B = 138/84, Image C = 120/80, Image D = 126/ Image A = 138/84, Image B = 120/80, Image C = 126/76, Image D = 140/90 ---------CORRECT ANSWER-----------------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 has a temperature of 99.0°F when assessed rectally. The patient has been NPO since midnight before the surgery. The patient complains of pain at a 9 on a 0-10 pain scale. The body is compensating for the cool environment of the surgical suite. --- ------CORRECT ANSWER-----------------The patient complains of pain at a 9 on a 0-10 pain scale The patient has a history of a left mastectomy. Where should the nurse take the patient's blood pressure? In the right arm In the left arm In the right leg
In the left leg ---------CORRECT ANSWER-----------------In the right arm 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? Reattempt using a different electronic BP machine. Notify the health care provider of this change in patient condition. Increase the patient's rate of intravenous (IV) fluids. Take the patient's BP manually using a sphygmomanometer. --------- CORRECT ANSWER-----------------Take the patient's BP manually using a sphygmomanometer 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? Request the NAP obtain the patient's pulse oximetry and report back. Ask the NAP to obtain and document a full set of vital signs. Assess the patient, including the pulse oximetry reading. Notify the health care provider of this change in condition. --------- CORRECT ANSWER-----------------Assess the patient, including the pulse oximetry reading Which patient is at high risk for for the pulse oximetry alarm to sound? A patient with a continuous pulse oximetry reading of 84%. A patient who is receiving oxygen via face mask. A patient who has an intermittent pulse oximetry reading of 95%. A patient with a heart rate of 64 beats per minute. ---------CORRECT ANSWER-----------------A patient with a continuous pulse oximetry reading of 84% A patient complains of feeling excessively tired. Which statement, if made by the NAP, indicates further instruction is necessary?
