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BSN205 Hallmark Exam
| Question | Answer |
|---|---|
| Which of the following patients would require follow up? A. A new born with a RR of 40bpm B. A child with a RR of 20 bpm C. An adult with a RR of 10 bpm D. An adolescent with a RR of 16 BPM | C Rationale: The normal RR for a NB is 30-60 bpm. The normal RR for a child is 20 bpm. The normal RR for a teenager is 16-20 bmp. The normal RR for an adult is 12-20bpm. |
| Which vital signs recorded for an older adult wiuld be considered WNL? A. T-98.6, P-56, R-20, BP-120/80, O2sat 91% B. T- 98.0, P-76, R-33, BP-110/70, O2sat 88% C. T- 96.9, P-60, R-18, BP-160/90, O2sat 93% D. T- 97, P60, R-16, BP-116/78, O2sat 95% | D Rationale: Normal values for older adults are: 96.0 T, P-60-100 BPM, RR-16-25BPM, average BP less than 120/80, and SpO2 of 95%-100%. A BP greater than 140/90 may be an indication of hypertension |
| What info should be provided to the NAP for temp assessment? A. The type of temperature needed B. The patients dx C. What changed to report immediately to the nurse D. The frequency for taking or monitoring the temp E. The patients age | A, C, D Rationale: It is more important that the temperatbe be done on time by the correct route, with the correct equipment, and that identified changes be reported. |
| Which of the following may affect a patients vital signs? A. Pain rated as a 7 on a 0-10 pain scale B. Time of day C. Moving from lying to standing D. Isolation precautions E. Occupation | A, B, C Rationale: Time of day, stress, temperature alterations or weather conditions, exercise/activity, emotions, medications, postural changes, smoking, disease, noise, liquid/food consumption, and orors can all affect vital signs. |
| The nurse takes patients VS properatively and records them as part of patient prep for surgery. Why is this important? | It verifies the patient is not experiencing any complications that may contraindicate surgery or require intervention, and it provides. set of vital signs to use for comparison during and after surgery |
| The NAP reports to the nurse a 65 year old patients BP is 160/98, what is an appropriate inital response of the nurse? | Assess the patients BP. Rationale: This is out of the normal range, if there is a question regarding the patients vital signs or a suspectied change in the patients condidtion that may require further assessment, the RN is responsible. |
| Which patient would is be appropriate to delegate VS? A. Patient with a recent complaint of headache B. Patient transferred from the ICU C. Elderly nursing home resident D. New admit to the hospital | C. Rationale: The nurse may delegate routine vital signs of stable patients. Baseline vitals should be obtained by the nurse, and nurse should obtain VS for change in condition. |
| Which person would be expected to have the lowest body temperature? A. A 16 year old who ran 1 mile B. A toddler who is febrile C. An 80 year old who walked 1/2 mile D. A child playing softball | C. Rationale: The 80yrold would have a lower starting temperature, therefore would most likely have the lowest body temperature, although it may take longer to return to baseline after the exercise. |
| The NAP is prepping to take patient VS. The NAP reports having eaten a bowl of warm soup. What should the RN have the NAP do? | Ask the patient not to eat, drink, or smoke for 20 minutes and then assess the patient's oral temperature. Rationale: The temp of food or liquid for impair the accuracy of the reading. Oral is the most accurate and least invasive route. |
| For which patient for a tympanic thermometer be the preferred method? A. A tachypneic patient who is receiving O2 by nasal cannula B. A NB who requires continuous temp monitoring C. A pediatric patient who had tubes surgically placed in the ears | A Rationale: An advantage to the tympanic thermometer is that it can be used for tachypneic patients. Contraindicated in patients who have had ear surgery. |
| What patients would require frequent temperature assessments? | An adult female in the recovery room after a hysterectomy A patient receiving a blood transfusion for chronic anemia A young adult man with a WBC of 15,000/mm3 |
| The NAP reports that the patients temp is 102.2 F. What are the appropriate nursing actions? | Remove the patients blankets, administer an antipyretic to the patient as ordered. |
| What actions by an NAP would require nursing intervention? |
Created by:
hfullmer
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