vital signs

Question 1

A patient has a head injury and damages the hypothalamus. Which vital sign will the nurse
monitor most closely?
a. Pulse
b. Respirations
c. Temperature
d. Blood pressure

Answer 1

temperature

Question 2

A patient presents with heatstroke. The nurse uses cool packs, cooling blanket, and a fan.
Which technique is the nurse using when the fan produces heat loss?
a. Radiation
b. Conduction
c. Convection
d. Evaporation

Answer 2

convection

Question 3

The patient has a temperature of 105.2F. The nurse is attempting to lower temperature by
providing tepid sponge baths and placing cool compresses in strategic body locations. Which
technique is the nurse using to lower the patient’s temperature?
a. Radiation
b. Conduction
c. Convection
d. Evaporation

Answer 3

conduction

Question 4

A nurse is focusing on temperature regulation of newborns and infants. Which action will the
nurse take?
a. Apply just a diaper.
b. Double the clothing.
c. Place a cap on their heads.
d. Increase room temperature to 90 degrees.

Answer 4

C

Question 5

The nurse is working the night shift on a surgical unit and is making 4:00 AM rounds. The
nurse notices that the patient’s temperature is 96.8F (36C), whereas at 4:00 PM the
preceding day, it was 98.6F (37C). What should the nurse do?
a. Call the health care provider immediately to report a possible infection.
b. Administer medication to lower the temperature further.
c. Provide another blanket to conserve body temperature.
d. Realize that this is a normal temperature variation.

Answer 5

D

Question 6

The nurse is caring for a patient who has a temperature reading of 100.4F (38C). The
patient’s last two temperature readings were 98.6F (37C) and 96.8F (36C). Which action
will the nurse take?
a. Wait 30 minutes and recheck the patient’s temperature.
b. Assume that the patient has an infection and order blood cultures.
c. Encourage the patient to move around to increase muscular activity.
d. Be aware that temperatures this high are harmful and affect patient safety.

Answer 6

A

Question 7

A patient is experiencing pyrexia. Which piece of equipment will the nurse obtain to monitor
this condition?
a. Stethoscope
b. Thermometer
c. Blood pressure cuff
d. Sphygmomanometer

Answer 7

B

Question 8

The nurse is caring for a patient who has an elevated temperature. Which principle will the
nurse consider when planning care for this patient?
a. Hyperthermia and fever are the same thing.
b. Hyperthermia is an upward shift in the set point.
c. Hyperthermia occurs when the body cannot reduce heat production.
d. Hyperthermia results from a reduction in thermoregulatory mechanisms.

Answer 8

C

Question 9

The patient with heart failure is restless with a temperature of 102.2F (39C). Which action
will the nurse take?
a. Place the patient on oxygen.
b. Encourage the patient to cough.
c. Restrict the patient’s fluid intake.
d. Increase the patient’s metabolic rate.

Answer 9

A

Question 10

The patient requires temperatures to be taken every 2 hours. Which task will be the
responsibility of an RN?
a. Using appropriate route and device
b. Assessing changes in body temperature
c. Being aware of the usual values for the patient
d. Obtaining temperature measurement at ordered frequency

Answer 10

B

Question 11

The patient requires routine temperature assessment but is confused, easily agitated, and has a
history of seizures. Which route will the nurse use to obtain the patient’s temperature?
a. Oral
b. Rectal
c. Axillary
d. Tympanic

Answer 11

D

Question 12

The patient is being admitted to the emergency department following a motor vehicle
accident. The patient’s jaw is broken with several broken teeth. The patient is ashen, has cool
skin, and is diaphoretic. Which route will the nurse use to obtain an accurate temperature
reading?
a. Oral
b. Axillary
c. Tympanic
d. Temporal

Answer 12

C

Question 13

The nurse is caring for an infant and is obtaining the patient’s vital signs. Which artery will
the nurse use to best obtain the infant’s pulse?
a. Radial
b. Brachial
c. Femoral
d. Popliteal

Answer 13

B

Question 14

The patient is found to be unresponsive and not breathing. Which pulse site will the nurse
use?
a. Radial
b. Apical
c. Carotid
d. Brachial

Answer 14

C

Question 15

The nurse needs to obtain a radial pulse from a patient. What must the nurse do to obtain a
correct measurement?
a. Place the tips of the first two fingers over the groove along the thumb side of the
patient’s wrist.
b. Place the tips of the first two fingers over the groove along the little finger side of
the patient’s wrist.
c. Place the thumb over the groove along the little finger side of the patient’s wrist.
d. Place the thumb over the groove along the thumb side of the patient’s wrist.

Answer 15

A

Question 16

The nurse is assessing the patient’s respirations. Which action by the nurse is most
appropriate?
a. Inform the patient that she is counting respirations.
b. Do not touch the patient until completed.
c. Obtain without the patient knowing.
d. Estimate respirations.

Answer 16

C

Question 17

The patient’s blood pressure is 140/60. Which value will the nurse record for the pulse
pressure?
a. 60
b. 80
c. 140
d. 200

Answer 17

B

Question 18

The nurse reviews the laboratory results for a patient and determines the viscosity of the blood
is thick. Which laboratory result did the nurse check?
a. Arterial blood gas
b. Blood culture
c. Hematocrit
d. Potassium

Answer 18

C

Question 19

The patient is being admitted to the emergency department with reports of shortness of breath.
The patient has had chronic lung disease for many years but still smokes. What will the nurse
do?
a. Allow the patient to breathe into a paper bag.
b. Use oxygen cautiously in this patient.
c. Administer high levels of oxygen.
d. Give CO2 via mask.

Answer 19

B

Question 20

A nurse is reviewing capnography results for adult patients. Which value will cause the nurse
to follow up?
a. 35 mm Hg
b. 40 mm Hg
c. 45 mm Hg
d. 50 mm Hg

Answer 20

D

Question 21

. The nurse is caring for a patient who has a pulse rate of 48. His blood pressure is within
normal limits. Which finding will help the nurse determine the cause of the patient’s low heart
rate?
a. The patient has a fever.
b. The patient has possible hemorrhage or bleeding.
c. The patient has chronic obstructive pulmonary disease (COPD).
d. The patient has calcium channel blockers or digitalis medication prescriptions.

Answer 21

D

Question 22

The patient was found unresponsive in an apartment and is being brought to the emergency
department. The patient has arm, hand, and leg edema, temperature is 95.6F, and hands are
cold secondary to a history of peripheral vascular disease. It is reported that the patient has a
latex allergy. What should the nurse do to quickly measure the patient’s oxygen saturation?
a. Attach a finger probe to the patient’s index finger.
b. Place a non-adhesive sensor on the patient’s earlobe.
c. Attach a disposable adhesive sensor to the bridge of the patient’s nose.
d. Place the sensor on the same arm that the electronic blood pressure cuff is on.

Answer 22

B

Question 23

The patient is admitted with shortness of breath and chest discomfort. Which laboratory value
could account for the patient’s symptoms?
a. Red blood cell count of 5.0 million/mm3
b. Hemoglobin level of 8.0 g/100 mL
c. Hematocrit level of 45%
d. Pulse oximetry of 95%

Answer 23

B

Question 24

A nurse reviews blood pressures of several patients. Which finding will the nurse report as
prehypertension?
a. 98/50 in a 7-year-old child
b. 115/70 in an infant
c. 120/80 in a middle-aged adult
d. 146/90 in an older adult

Answer 24

C

Question 25

The nurse is providing a blood pressure clinic for the community. Which group will the nurse
most likely address?
a. Non-Hispanic Caucasians
b. European Americans
c. African Americans
d. Asian Americans

Answer 25

C

Question 26

A nurse is caring for a patient who smokes and drinks caffeine. Which point is important for
the nurse to understand before assessing the patient’s blood pressure (BP)?
a. Smoking increases BP for up to 3 hours.
b. Caffeine increases BP for up to 15 minutes.
c. Smoking result in vasoconstriction, falsely elevating BP.
d. Caffeine intake should not have occurred 30 to 40 minutes before BP
measurement.

Answer 26

C

Question 27

When taking the pulse of an infant, the nurse notices that the rate is 145 beats/min and the
rhythm is regular. How should the nurse interpret this finding?
a. This is normal for an infant.
b. This is too fast for an infant.
c. This is too slow for an infant.
d. This is not a rate for an infant but for a toddler.

Answer 27

B

Question 28

The nurse is caring for an older-adult patient and notes that the temperature is 96.8F (36C).
How will the nurse interpret this finding?
a. The patient has hyperthermia.
b. The patient has a normal temperature.
c. The patient is suffering from hypothermia.
d. The patient is demonstrating increased metabolism.

Answer 28

B

Question 29

When assessing the temperature of newborns and children, the nurse decides to utilize a
temporal artery thermometer. What is the rationale for the nurse’s action?
a. It is not affected by skin moisture.
b. It has no risk of injury to patient or nurse.
c. It reflects rapid changes in radiant temperature.
d. It is accurate even when the forehead is covered with hair.

Answer 29

B

Question 30

The nurse is caring for a small child and needs to obtain vital signs. Which site choice from
the nursing assistive personnel (NAP) will cause the nurse to have confidence in the NAP?
a. Ulnar site
b. Radial site
c. Brachial site
d. Femoral site

Answer 30

C

Question 31

The nurse is caring for a newborn infant in the hospital nursery and notices that the infant is
breathing rapidly but is pink, warm, and dry. Which normal respiratory rate will the nurse
consider when planning care for this newborn?
a. 30 to 60
b. 22 to 28
c. 16 to 20
d. 10 to 15

Answer 31

A

Question 32

The nurse is preparing to obtain an oxygen saturation reading on a toddler. Which action will
the nurse take?
a. Secure the sensor to the toddler’s earlobe.
b. Determine whether the toddler has a latex allergy.
c. Place the sensor on the bridge of the toddler’s nose.
d. Overlook variations between an oximeter pulse rate and the toddler’s pulse rate.

Answer 32

B

Question 33

The nurse is preparing to assess the blood pressure of a 3-year-old. How should the nurse
proceed?
a. Use the diaphragm portion of the stethoscope to detect Korotkoff sounds.
b. Obtain the reading before the child has a chance to ―settle down.‖
c. Choose the cuff that says ―Child‖ instead of ―Infant.‖
d. Explain the procedure to the child.

Answer 33

D

Question 34

. A nurse is caring for a group of patients. Which patient will the nurse see first?
a. A crying infant with P-165 and R-54
b. A sleeping toddler with P-88 and R-23
c. A calm adolescent with P-95 and R-26
d. An exercising adult with P-108 and R-24

Answer 34

c

Question 35

The nurse is caring for a patient who is being discharged from the hospital after being treated
for hypertension. The patient is instructed to take blood pressure 3 times a day and to keep a
record of the readings. The nurse recommends that the patient purchase a portable electronic
blood pressure device. Which other information will the nurse share with the patient?
a. You can apply the cuff in any manner.
b. You will need to recalibrate the machine.
c. You can move your arm during the reading.
d. You will need to use a stethoscope properly.

Answer 35

B

Question 36

The nurse is caring for a patient who reports feeling light-headed and ―woozy.‖ The nurse
checks the patient’s pulse and finds that it is irregular. The patient’s blood pressure is 100/72.
It was 113/80 an hour earlier. What should the nurse do?
a. Apply more pressure to the radial artery to feel pulse.
b. Perform an apical/radial pulse assessment.
c. Call the health care provider immediately.
d. Obtain arterial blood gases.

Answer 36

B

Question 37

A nurse is caring for a group of patients. Which patient will the nurse see first?
a. A 17-year-old male who has just returned from outside ―for a smoke‖ who needs a
temperature taken.
b. A 20-year-old male postoperative patient whose blood pressure went from 128/70
to 100/60.
c. A 27-year-old male patient reporting pain whose blood pressure went from 124/70
to 130/74.
d. An 87-year-old male suspected of hypothermia whose temperature is below
normal

Answer 37

B