Chapter 29 Vital Signs Practice Questions

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

c. 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

c. 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

b. 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. Place a cap on their heads.

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. Realize that this is a normal temperature variation.

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. Wait 30 minutes and recheck the patient’s temperature.

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. Thermometer

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. Hyperthermia occurs when the body cannot reduce heat production.

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. Place the patient on oxygen.

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. Assessing changes in body temperature

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. Tympanic

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. Tympanic

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. Brachial

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. Carotid

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. Place the tips of the first two fingers over the groove along the thumb side of the patient’s wrist.

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. Obtain without the patient knowing.

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. 80

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. Hematocrit

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. Use oxygen cautiously in this patient.

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. 50 mm Hg

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. The patient has calcium channel blockers or digitalis medication prescriptions.

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 nonadhesive 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. Place a nonadhesive sensor on the patient’s earlobe.

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. Hemoglobin level of 8.0 g/100 mL

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. 120/80 in a middle-aged adult

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. African Americans

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. Smoking result in vasoconstriction, falsely elevating BP.

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

a. This is normal for an infant.

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. The patient has a normal temperature.

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. It has no risk of injury to patient or nurse.

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. Brachial site

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. 30 to 60

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. Determine whether the toddler has a latex allergy.

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. Explain the procedure to the child.

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. A calm adolescent with P-95 and R-26

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. You will need to recalibrate the machine.

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. Perform an apical/radial pulse assessment.

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. A 20-year-old male postoperative patient whose blood pressure went from 128/70 to 100/60.

Question 38

The health care provider prescription reads “Metoprolol 50 mg PO daily. Do not give if blood pressure is less than 100 mm Hg systolic.” The patient’s blood pressure is 92/66. The nurse does not give the medication. Which action should the nurse take? a. Documents that the medication was not given because of low blood pressure. b. Does not inform the health care provider that the medication was held. c. Does not tell the patient what the blood pressure is. d. Documents only what the blood pressure was.

Answer 38

a. Documents that the medication was not given because of low blood pressure.

Question 39

After taking the patient’s temperature, the nurse documents the value and the route used to obtain the reading. What is the reason for the nurse’s action? a. Temperatures vary depending on the route used. b. Temperatures are readings of core measurements. c. Rectal temperatures are cooler than when taken orally. d. Axillary temperatures are higher than oral temperatures.

Answer 39

a. Temperatures vary depending on the route used.

Question 40

When taking an adult blood pressure, the onset of the sound the nurse hears is at 138, the muffled sound the nurse hears is at 70, and the disappearance of the sound the nurse hears is at 62. How should the nurse record this finding? a. 68 b. 76 c. 138/62 d. 138/70

Answer 40

c. 138/62

Question 41

The nursing assistive personnel (NAP) is taking vital signs and reports that a patient’s blood pressure is abnormally low. What should the nurse do next? a. Ask the NAP to retake the blood pressure. b. Instruct the NAP to assess the patient’s other vital signs. c. Disregard the report and have it rechecked at the next scheduled time. d. Retake the blood pressure personally and assess the patient’s condition

Answer 41

d. Retake the blood pressure personally and assess the patient’s condition

Question 42

A nurse is working in the intensive care unit and must obtain core temperatures on patients. Which sites can be used to obtain a core temperature? (Select all that apply.) a. Rectal b. Tympanic c. Esophagus d. Temporal artery e. Pulmonary artery

Answer 42

b. Tympanic c. Esophagus e. Pulmonary artery

Question 43

The patient has new-onset restlessness and confusion. Pulse rate is elevated, as is respiratory rate. Oxygen saturation is 94%. The nurse ignores the pulse oximeter reading and calls the health care provider for orders because the pulse oximetry reading is inaccurate. Which factors can cause inaccurate pulse oximetry readings? (Select all that apply.) a. O2 saturations (SaO2) >70% b. Carbon monoxide inhalation c. Hypothermic fingers d. Intravascular dyes e. Nail polish f. Jaundice

Answer 43

b. Carbon monoxide inhalation c. Hypothermic fingers d. Intravascular dyes e. Nail polish f. Jaundice

Question 44

The nurse is assessing the patient and family for probable familial causes of the patient’s hypertension. The nurse begins by analyzing the patient’s personal history, as well as family history and current lifestyle situation. Which findings will the nurse consider to be risk factors? (Select all that apply.) a. Obesity b. Cigarette smoking c. Recent weight loss d. Heavy alcohol intake e. Regular exercise sessions

Answer 44

a. Obesity b. Cigarette smoking d. Heavy alcohol intake

Question 45

The patient is being encouraged to purchase a portable automatic blood pressure device to monitor blood pressure at home. Which information will the nurse present as benefits for this type of treatment? (Select all that apply.) a. Patients can actively participate in their treatment. b. Self-monitoring helps with compliance and treatment. c. The risk of obtaining an inaccurate reading is decreased. d. Blood pressures can be obtained if pulse rates become irregular. e. Patients can provide information about patterns to health care providers.

Answer 45

a. Patients can actively participate in their treatment. b. Self-monitoring helps with compliance and treatment. e. Patients can provide information about patterns to health care providers.

Question 46

A nurse is teaching the staff about alterations in breathing patterns. Which information will the nurse include in the teaching session? (Select all that apply.) a. Apnea—no respirations b. Tachypnea—regular, rapid respirations c. Kussmaul’s—abnormally deep, regular, fast respirations d. Hyperventilation—labored, increased in depth and rate respirations e. Cheyne-Stokes—abnormally slow and depressed ventilation respirations f. Biot’s—irregular with alternating periods of apnea and hyperventilation respirations

Answer 46

a. Apnea—no respirations b. Tachypnea—regular, rapid respirations c. Kussmaul’s—abnormally deep, regular, fast respirations

Question 47

A nurse is assessing results of vital signs for a group of patients. Match the condition to the assessment findings the nurse is reviewing. a. Patient’s temperature is 113° F (45° C) with hot, dry skin. b. Patient’s blood pressure sitting is 130/60 and 110/40 standing. c. Patient’s pulse is 110 beats/min. d. Patient’s temperature is 93.2° F (34° C). e. Patient’s blood pressure went from 126/76 to 90/50. 1. Hypothermia 2. Shock/Hypotension 3. Heatstroke 4. Orthostatic hypotension 5. Tachycardia

Answer 47

1. d 2. e 3. a 4. b 5. c