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BSN 206 Foundations of Nursing Fundamentals Hallmark Exam (Latest Update) Questions with Verified Answers | 100% Correct | Grade A – Nightingale
Question 1: The nurse is performing a dressing change on a
client who is postoperative from a laparotomy. The client coughs and the nurse sees a few loops of intestine uncoiling from the wound. What is the nurse's best action at this time?
Choices:
a) Instruct the client to avoid looking at the wound
b) Apply sterile saline-soaked towels to the area
c) Apply sterile gloves and push the intestines back into the
wound
d) Assess the wound to determine the extent of evisceration
Correct answer: b) Apply sterile saline-soaked towels to the area
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Question 2: A healthy 30-year-old male arrives at the clinic for a
physical. The nurse is responsible for collecting his vital signs.Which of these can be delegated to UAP? (Select all that apply)
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Choices:
a) Temperature
b) BP
c) Pulse
d) Pulse oximetry
e) Respiration
Correct answer:
a) Temperature
b) BP
c) Pulse
d) Pulse oximetry
e) Respiration
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Question 3: The nurse documents vital signs on a newly
admitted patient as: "blood pressure is 148/94 mm Hg, the pulse
is 80 beats/min, and the respirations are 16 breaths/min." The
nurse would record the pulse pressure as:
Choices:
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- 14 mm Hg
- 54 mm Hg
- 64 mm Hg
- 80 mm Hg
Correct answer: b) 54 mm Hg
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Question 4: The nurse caring for a 30-year-old post-surgical
client would assess that they are in pain as indicated by:
Choices:
a) A temperature of 102° F
b) A pulse rate of 120 beats/min
c) Respirations of 16 breaths/min
d) Blood pressure of 128/86 mm Hg
Correct answer: b) A pulse rate of 120 beats/min
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Question 5: The nurse is performing a morning assessment and
notes the client to be experiencing dyspnea. Which client assessment findings would most indicate this respiratory condition? (Select all that apply)
Choices:
a) Occasional productive cough
b) Temperature 100.1 °F
c) Pulse oximetry 89%
d) Respirations 26 & shallow
e) Patient in orthopneic position
Correct answer:
c) Pulse oximetry 89%
d) Respirations 26 & shallow
e) Patient in orthopneic position
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Question 6: A nurse notes a client has abnormal vital signs.
What action by the nurse is best?