VS Quiz

Question 1

A nurse is assessing a patient’s vital signs and finds the following readings: temperature 38.2°C (100.8°F), pulse 110 beats per minute, blood pressure 130/80 mmHg, respiration 20 breaths per minute, and oxygen saturation 95%. Which vital sign falls outside the acceptable range?

A. Pulse
B. Blood pressure
C. Respiration
D. Oxygen saturation

Answer 1

A. Pulse

Rationale:
The acceptable range for pulse is 60 to 100 beats per minute. In this case, the patient’s pulse of 110 beats per minute falls outside the normal range, indicating a potential concern. The nurse should further assess the patient’s condition and report the findings to the healthcare provider.

Question 2

A nurse is caring for a patient with a temperature of 38.6°C (101.5°F). What action should the nurse take based on the information provided?

A. Administer antipyretic medication
B. Document the findings and continue monitoring
C. Apply a cooling blanket
D. Notify the healthcare provider

Answer 2

B. Document the findings and continue monitoring

Rationale:
The patient’s temperature is within the acceptable range for adults (36°C to 38°C or 96.8°F to 100.4°F). In this case, the nurse should document the findings and continue monitoring the patient. Antipyretic medication or interventions to reduce fever are not necessary unless the temperature exceeds the acceptable range.

Question 3

A nurse is assessing a patient’s blood pressure and finds a reading of 140/92 mmHg. What action should the nurse take?

A. Document the findings as normal
B. Reassess the blood pressure in 15 minutes
C. Administer an antihypertensive medication
D. Encourage the patient to increase salt intake

Answer 3

Answer 3:
B. Reassess the blood pressure in 15 minutes

Rationale:
The blood pressure reading of 140/92 mmHg is elevated. The nurse should reassess the blood pressure to confirm the accuracy of the reading and determine if further intervention is necessary. Immediate administration of antihypertensive medication is not warranted based on a single reading.

Question 4

A nurse is caring for a postoperative patient and notes a respiratory rate of 10 breaths per minute. What is the nurse’s priority action?

A. Administer supplemental oxygen
B. Document the findings as normal
C. Encourage deep breathing exercises
D. Notify the healthcare provider

Answer 4

Answer 4:
D. Notify the healthcare provider

Rationale:
A respiratory rate of 10 breaths per minute is below the normal range (12 to 20 breaths per minute). The nurse should notify the healthcare provider promptly to address potential respiratory issues and ensure appropriate interventions are initiated

Question 5

During a routine assessment, a nurse measures a pulse of 55 beats per minute. What is the nurse’s appropriate action?

A. Document the findings as normal
B. Initiate cardiac monitoring
C. Administer atropine
D. Encourage the patient to exercise

Answer 5

A. Document the findings as normal

Rationale:
A pulse of 55 beats per minute falls within the acceptable range of 60 to 100 beats per minute for adults. In this case, the nurse should document the findings as normal. Initiating cardiac monitoring, administering atropine, or encouraging exercise is not necessary for a pulse within the normal range.

Question 6

6. A nurse is assessing a patient’s blood pressure and obtains a reading of 130/70 mmHg. How should the nurse interpret this blood pressure?

A. Normal
B. Elevated
C. Hypertensive
D. Hypotensive

Answer 6

Answer 1:
B. Elevated

Rationale:
The normal blood pressure range is 90/60 mmHg to 120/80 mmHg. A reading of 130/70 mmHg falls outside this range, indicating an elevated blood pressure. The nurse should further assess the patient’s condition and consider appropriate interventions based on institutional guidelines.

Question 7

A patient’s pulse pressure is measured at 60 mmHg. What does this finding suggest about the patient’s cardiovascular status?

A. Normal
B. Hypovolemia
C. Hypertension
D. Bradycardia

Answer 7

Answer 2:
C. Hypertension

Rationale:
Pulse pressure is the difference between systolic and diastolic blood pressure and normally ranges from 30 to 50 mmHg. A pulse pressure of 60 mmHg suggests increased pressure within the arterial system, which may be indicative of hypertension. The nurse should monitor the patient closely and report findings to the healthcare provider.

Question 8

During a routine assessment, a nurse observes a patient’s respiratory rate at 24 breaths per minute. How should the nurse interpret this finding?

A. Normal
B. Bradypnea
C. Tachypnea
D. Hyperventilation

Answer 8

Answer 3:
C. Tachypnea

Rationale:
The normal respiratory rate is 12 to 20 breaths per minute. A respiratory rate of 24 breaths per minute is above the normal range, indicating tachypnea. The nurse should assess the patient’s respiratory status further, looking for signs of respiratory distress or underlying issues.

Question 9

9. A nurse is caring for a patient with a pulse oximetry reading of 92%. What action should the nurse take based on this information?

A. Administer supplemental oxygen
B. Document the findings and continue monitoring
C. Encourage deep breathing exercises
D. Notify the healthcare provider

Answer 9

Answer 4:
A. Administer supplemental oxygen

Rationale: The normal oxygen saturation level is 95% to 100%. A reading of 92% indicates hypoxemia, and the nurse should intervene promptly by administering supplemental oxygen to improve oxygenation. This action helps prevent complications associated with low oxygen saturation.

Question 10

When is it essential to measure vital signs according to the mnemonic “B.A.S.S.H”?

A. After medication administration
B. During blood product transfusion
C. Routine hospital schedule
D. Patient’s admission

Answer 10

Answer 5:
B. During blood product transfusion

Rationale:
“B.A.S.S.H” stands for Before, After, During blood products transfusion, After medication administration, During nursing interventions, and Admission. Monitoring vital signs during blood product transfusion is crucial to identify and manage any transfusion reactions promptly. This ensures patient safety during the procedure.

Question 11

11. A nurse is preparing to measure a patient’s body temperature. What action should the nurse take after identifying the patient?

A. Explain the procedure to the patient
B. Wash hands before preparing materials
C. Provide privacy for the patient
D. Dispose all disposables accordingly

Answer 11

Answer 1:
C. Provide privacy for the patient

Rationale:
Providing privacy ensures the patient’s dignity and comfort during the vital signs assessment. It is essential to create an environment that respects the patient’s confidentiality and promotes open communication. After identifying the patient, providing privacy is the next step before explaining the procedure.

Question 12

12. During a temperature assessment, a nurse measures a patient’s core temperature and obtains a reading of 38.2°C. How should the nurse interpret this finding?

A. Normal
B. Hypothermia
C. Fever (pyrexia)
D. Hyperthermia

Answer 12

Answer 2:
C. Fever (pyrexia)

Rationale:
The normal body temperature range is 36.5°C to 37.5°C. A core temperature of 38.2°C indicates an elevated temperature, suggesting fever (pyrexia). Fever is often a result of an immune response to infection. The nurse should further assess the patient for signs of infection and report findings accordingly.

Question 13

13. What is the primary organ responsible for thermoregulation in the body?

A. Liver
B. Kidneys
C. Hypothalamus
D. Lungs

Answer 13

Answer 3:
C. Hypothalamus

Rationale:
The hypothalamus is the primary organ responsible for thermoregulation. It detects signals from skin receptors and sends signals to effectors to regulate body temperature. The hypothalamus plays a crucial role in maintaining core temperature through various mechanisms, such as vasoconstriction and vasodilation.

Question 14

14. A patient exhibits signs of increased heart rate, respiratory rate, and thirst, with warm skin during the plateau phase of fever. What nursing interventions are appropriate during this phase?

A. Provide warm blankets for comfort
B. Encourage deep breathing exercises
C. Administer antipyretic medications
D. Offer oral fluids and monitor for dehydration

Answer 14

Answer 4:
D. Offer oral fluids and monitor for dehydration

Rationale:
During the plateau phase of fever, patients may experience increased thirst and mild to severe dehydration. Nursing interventions should focus on providing oral fluids to prevent dehydration and monitoring the patient’s fluid balance. Administering antipyretic medications may have been done earlier during the cold/chill phase.

Question 15

14. A patient exhibits signs of increased heart rate, respiratory rate, and thirst, with warm skin during the plateau phase of fever. What nursing interventions are appropriate during this phase?

A. Provide warm blankets for comfort
B. Encourage deep breathing exercises
C. Administer antipyretic medications
D. Offer oral fluids and monitor for dehydration

Answer 15

Answer 4:
D. Offer oral fluids and monitor for dehydration

Rationale:
During the plateau phase of fever, patients may experience increased thirst and mild to severe dehydration. Nursing interventions should focus on providing oral fluids to prevent dehydration and monitoring the patient’s fluid balance. Administering antipyretic medications may have been done earlier during the cold/chill phase.

Question 16

15. A nurse observes a patient’s body temperature returning to normal for a day but recurring afterward. How would this fever pattern be classified?

A. Sustained
B. Intermittent
C. Remittent
D. Relapsing

Answer 16

Answer 5:
D. Relapsing

Rationale:
A relapsing fever pattern is characterized by the return of body temperature to normal for a day but recurring afterward. This pattern distinguishes relapsing fever from sustained, intermittent, or remittent fever types. The nurse should consider this pattern when assessing and managing the patient’s fever.

Question 17

15. A nurse observes a patient’s body temperature returning to normal for a day but recurring afterward. How would this fever pattern be classified?

A. Sustained
B. Intermittent
C. Remittent
D. Relapsing

Answer 17

Answer 5:
D. Relapsing

Rationale:
A relapsing fever pattern is characterized by the return of body temperature to normal for a day but recurring afterward. This pattern distinguishes relapsing fever from sustained, intermittent, or remittent fever types. The nurse should consider this pattern when assessing and managing the patient’s fever.

Question 18

16. A patient presents with signs of prolonged exposure to heat, including confusion, excess thirst, and dry skin. The nurse suspects a hyperthermic condition. Which condition aligns with these symptoms?

A. Heat exhaustion
B. Heat stroke
C. Hypothermia
D. Hyperthermia

Answer 18

Answer 1:
B. Heat stroke

Rationale:
The symptoms described, such as confusion, excess thirst, and hot, dry skin, are indicative of heat stroke. In heat stroke, the body temperature rises to 40°C, and the skin becomes dry due to the failure of the body’s cooling mechanisms. This is a severe hyperthermic condition requiring immediate intervention.

Question 19

17. A patient is found to have a core temperature below the usual range, decreased heart rate, and cyanosis. What condition is the patient likely experiencing?

A. Heat stroke
B. Heat exhaustion
C. Hypothermia
D. Hyperthermia

Answer 19

Answer 2:
C. Hypothermia

Rationale:
The symptoms described, including a decreased heart rate, cyanosis, and decreased level of consciousness, are indicative of hypothermia. Hypothermia occurs when the body temperature drops below the normal range, leading to decreased metabolic processes and potential life-threatening complications.

Question 20

18. A nurse is assessing a patient and decides to use the tympanic site for temperature measurement. What advantage does the tympanic site offer?

A. Reflects rapid change in core temperature
B. Requires long measurement time
C. Affected by environmental factors
D. Risk of body fluid exposure

Answer 20

Answer 3:
A. Reflects rapid change in core temperature

Rationale:
The tympanic site reflects rapid changes in core temperature, making it advantageous for quickly assessing variations. It is accessible, fast, and unaffected by food intake. However, it may be affected by ear infections or improper handling.

Question 21

19. A nurse is measuring a patient’s body temperature orally and observes that the patient has recently consumed food. What is the appropriate nursing consideration in this situation?

A. Measure the temperature immediately
B. Wait 15 to 30 minutes before taking the temperature orally
C. Switch to the axillary site for measurement
D. Use a chemical dot thermometer

Answer 21

Answer 4:
B. Wait 15 to 30 minutes before taking the temperature orally

Rationale:
After the patient has consumed food, the nurse should wait 15 to 30 minutes before taking the oral temperature to obtain an accurate reading. This helps prevent inaccuracies in temperature measurement.

Question 22

20. A nurse is caring for a patient with hyperthermia. What nursing intervention aligns with the mnemonic “A.I.L.M.M.E.N.T”?

A. Administer anti-pyretics
B. Increase rest intervals
C. Limit physical activity
D. Monitor fluid intake

Answer 22

Answer 5:
A. Administer anti-pyretics

Rationale:
“A.I.L.M.M.E.N.T” stands for Administer anti-pyretics, Increase rest intervals, Limit physical activity, Maintain hydration, Educate the patient, Notify the healthcare provider, and Take temperature regularly. Administering anti-pyretics is one of the essential interventions for managing hyperthermia.