Chapter 07: Vital Signs

Question 1

The patient’s oral temperature is 39 C (102.2 F). Which conclusion can the nurse make
about the patient on the basis of this information?
a. The patient is febrile.
b. The patient is afebrile.
c. An infection is present.
d. Inflammation is present

Answer 1

a. The patient is febrile

Question 2

The nurse is preparing to obtain a set of vital signs. Which is the most important factor for the
nurse to consider when measuring patient vital signs?
a. Documentation of vital signs requires timely and accurate recording.
b. Normal limits are very narrow and are generally the same for all patients.
c. Measuring equipment must be used correctly and appropriately.
d. Environmental factors play a minor role on patient vital signs.

Answer 2

c. Measuring equipment must be used correctly and appropriately.

Question 3

A patient has a severe upper respiratory and ear infection and has been experiencing diarrhea.
Assessment of the temperature would be most accurate if the nurse checked the temperature
using which site?
a. The rectum
b. The axilla

c. Under the tongue
d. The tympanic membrane

Answer 3

b. The axilla

Question 4

The nurse is validating the measurement of an infant’s pulse by a nursing student. Which
method should the nurse use to obtain the most accurate count?
a. Compress the bell of the stethoscope over the apex of the heart.
b. Locate the pulsations in the antecubital space.
c. Palpate the superficial artery on the medial side of the wrist.
d. Place the thumb and forefinger along the ridge on the outer side of the wrist

Answer 4

b. Locate the pulsations in the antecubital space.

Question 5

A patient born without arms needs to have a blood pressure assessment. Which artery should
the nurse use to most accurately obtain this measurement?
a. Femoral
b. Carotid
c. Brachial
d. Popliteal

Answer 5

d. Popliteal

Question 6

The nurse is running a blood pressure screening clinic at the community health center. Which
action should the nurse implement to obtain an accurate measurement of a patient’s blood
pressure on an upper extremity?
a. Use a cuff with a cuff width that is 40% wider than the circumference of the arm.

b. Limit the cuff deflation rate to 10 mm Hg per second or heartbeat.
c. Record the second Korotkoff sound as the systolic pressure.
d. Apply the diaphragm of the stethoscope lightly over the brachial artery.

Answer 6

a. Use a cuff with a cuff width that is 40% wider than the circumference of the arm.

Question 7

The patient is unstable, so the nurse is using an electronic blood pressure device to measure
blood pressures every 15 minutes. What should the nurse do to verify the accuracy of the
electronic blood pressure measurements?
a. Check when the device was last calibrated.
b. Know that the device adheres to current medical industry standards.
c. Take a manual blood pressure within several minutes of the electronic reading.
d. Verify that the systolic pressure is within 20% of patient baseline.

Answer 7

c. Take a manual blood pressure within several minutes of the electronic reading.

Question 8

A patient has an electronic blood pressure cuff that inflates every 15 minutes for a reading.
Which activity by the nursing student would require the nurse to intervene?
a. The cuff is positioned carefully on the gown sleeve for comfort.
b. The cuff is removed every 2 hours for a skin assessment.
c. The alarm limits on the electronic device are checked frequently.
d. The cuff is rotated to the other extremity every few hours as possible.

Answer 8

a. The cuff is positioned carefully on the gown sleeve for comfort.

Question 9

The nurse delegates temperature measurement to nursing assistive personnel (NAP). For
which patient should the nurse instruct the NAP to use the tympanic thermometer?
a. 10-year-old patient with a left leg fracture
b. 12-hour-old infant in the newborn nursery

c. 5-year-old patient with bilateral otitis media
d. 15-year-old patient who had bilateral tympanoplasties today

Answer 9

a. 10-year-old patient with a left leg fracture

Question 10

The nurse needs to measure the adult patient’s temperature, but the patient has just finished a
cup of coffee. Which is the best type of temperature for the nurse to obtain accurate results
efficiently?
a. Rectal
b. Axillary
c. Tympanic
d. Disposable

Answer 10

c. Tympanic

Question 11

The nurse is preparing to obtain a rectal temperature. Nursing care is correct if the nurse
inserts the thermometer how far into the rectum of an adult?
a. 1.3 cm (1/2 inch)
b. 3.5 cm (1 1/2 inches)
c. 5.1 cm (2 inches)
d. 6.4 cm (2 1/2 inches)

Answer 11

b. 3.5 cm (1 1/2 inches)

Question 12

While inserting a rectal thermometer, the nurse encounters resistance. What action should the
nurse take?
a. Remove the thermometer immediately.
b. Ask the patient to take a few deep breaths.
c. Apply mild pressure to advance the thermometer.
d. Remove the thermometer and reinsert gentle

Answer 12

a. Remove the thermometer immediately.

Question 13

The nurse notes that the patient’s tympanic temperature is 37.88 C (100.2 F) at 4 PM on the
patient’s second postoperative day. What should the nurse do initially?
a. Check the leukocyte count.
b. Collaborate for cultures.
c. Ask the patient to drink some fluid.
d. Offer the patient another blanket.

Answer 13

c. Ask the patient to drink some fluid.

Question 14

The nurse is teaching a family member how to check a teenager’s temperature using a
tympanic thermometer. Which step is most important for the nurse to include in order to
obtain an accurate reading?
a. Pull the pinna down and back.
b. Pull the pinna up and back.
c. Place the probe loosely into the ear canal.
d. Point the probe toward the eye

Answer 14

b. Pull the pinna up and back.

Question 15

A patient taking a new cardiac medication suddenly develops an irregular pulse. The nurse
plans to obtain an apical-radial pulse. What action by the nurse is best?
a. One nurse counts the apical pulse while another counts the radial pulse at the same
time.
b. The nurse delegates the task to two experienced nursing assistants.
c. The nurse feels the radial pulse while watching the cardiac monitor.
d. The nurse takes the apical pulse first, followed by the radial pulse.

Answer 15

a. One nurse counts the apical pulse while another counts the radial pulse at the same
time.

Question 16

The nurse is preparing to measure the patient’s blood pressure with an electronic blood
pressure device. Which concept is most important for the nurse to consider?
a. Use the extremity closest to the nurse.
b. The cuff size must match the extremity being used.
c. The brachial artery is always the best one to use.
d. The temporal artery is used if neither arm is available.

Answer 16

b. The cuff size must match the extremity being used.

Question 17

The nurse is preparing to assess the apical pulse. At which location should the nurse listen to
obtain an accurate apical pulse on an adult patient?
a. At the fifth intercostal space at the left sternal border
b. At the fifth left intercostal space at the midclavicular line
c. At the second intercostal space at the left midclavicular line
d. At the second right intercostal space at the midclavicular line

Answer 17

b. At the fifth left intercostal space at the midclavicular line

Question 18

The nursing assistant reports the following vital signs for four patients just evaluated. Which
patient should the nurse see first?
a. 25 respirations per minute for a toddler
b. 38 respirations per minute for a newborn
c. 12 respirations per minute for an 8-year-old child
d. 14 respirations per minute for an adult patien

Answer 18

c. 12 respirations per minute for an 8-year-old child

Question 19

At what distance above the antecubital fossa does the nurse position a blood pressure (BP)
cuff when using the brachial artery to measure BP?
a. 2.5 cm (1 inch)
b. 0.6 cm (1/4 inch)
c. 1.3 cm (1/2 inch)
d. 5.1 cm (2 inches)

Answer 19

a. 2.5 cm (1 inch)

Question 20

The nurse uses a blood pressure (BP) cuff that is too narrow for the arm of a patient with
morbid obesity. What problem will the nurse encounter because of the cuff used?
a. The Korotkoff sounds will not be heard.
b. Only a palpable BP can be obtained.
c. The stethoscope cannot be positioned correctly.
d. A false high BP reading will occur.

Answer 20

d. A false high BP reading will occur.

Question 21

The nurse is assessing a new orientee’s knowledge of when to take vital signs. The following
statement indicates a need for more education.
a. “I should take vital signs upon admission.”
b. “I should take vital signs when there is any change in condition.”
c. “I should take vital signs at the beginning and end of a blood transfusion.”
d. “I should take vital signs if a patient reports feeling different.”

Answer 21

c. “I should take vital signs at the beginning and end of a blood transfusion.”

Question 22

While positioning the patient for a routine blood pressure check, the patient asks the nurse
why a support was placed under the arm before the BP cuff was applied. Which response by
the nurse is most accurate?
a. “This method prevents any problems in obtaining an accurate reading.”
b. “This method helps the arm relax so the reading will be correct.”
c. “I want you to be as comfortable as possible during this time.”
d. “Just sit back and relax and let me get this reading right now.”

Answer 22

b. “This method helps the arm relax so the reading will be correct.”

Question 23

The nurse assesses the patient’s respirations and notes the patient routinely takes two to three
breaths followed by an irregular period of apnea. How does the nurse document this finding?
a. Biot’s respirations
b. Cheyne-Stokes respirations

c. Kussmaul’s respirations
d. Hyperpneic respirations

Answer 23

a. Biot’s respirations

Question 24

The nurse is caring for a lethargic, 18-year-old patient with a respiratory rate of 32 breaths per

minute. What is the first action the nurse should take?
a. Place the patient in high-Fowler’s position.
b. Assess the remaining vital signs.
c. Reassess the respiratory rate.
d. Notify the health care provider

Answer 24

a. Place the patient in high-Fowler’s position.

Question 25

The nurse has delegated the task of obtaining a pulse oximetry reading to the NAP. Which of
the following statements by the NAP indicates a need for further education?
a. “The pulse oximetry reading was 95%.”
b. “The patient’s pulse rate was 78 according to the readout.”
c. “I made sure the patient did not have nail polish on.”
d. “I made sure the patient was not receiving a respiratory treatment.”

Answer 25

b. “The patient’s pulse rate was 78 according to the readout.”

Question 26

The nurse is going to measure the patient’s oxygen saturation. The nurse knows pulse 
oximetry readings can be influenced by which of the following factors. (Select all that apply.)
a. Nail polish
b. Respiratory treatments
c. Poor circulation to the site
d. Tremors
e. Hemoglobin levels
f. Latex allergy

Answer 26

a. Nail polish
b. Respiratory treatments
c. Poor circulation to the site
d. Tremors
e. Hemoglobin level

Question 27

The patient’s oral temperature is 37.1 C (98.78 F) at 1 PM. Which of the following actions
should the nurse take next?
a. Administer acetaminophen 650 mg by mouth now.
b. Offer the patient an additional blanket.
c. Document that the patient is afebrile.
d. Compare this with the patient’s prior readings

Answer 27

c. Document that the patient is afebrile.