Vital Signs
1. A nurse takes a patient's vital signs. Which of the following is considered a vital sign?
A) mental status
B) visual acuity
C) blood
... [Show More] pressure
D) urinary output
2. Which of the following patients should have their vital signs monitored at least every 4
hours?
A) a patient in a critical care unit
B) a patient hospitalized for high blood pressure
C) a resident in a long-term care facility
D) a long-term care resident on Medicare A
3. In which of the following situations is it protocol for the nurse to take a patient's vital
signs? Select all that apply.
A) upon admitting a patient to a hospital
B) at a healthcare screening
C) when medications are given for a cardiac arrhythmia
D) following a diagnostic procedure
E) prior to an invasive procedure
F) when daily medications are dispensed
4. A nurse has an order to take the core temperature of a patient. At which of the following
sites would a core body temperature be measured?
A) tympanic
B) oral
C) axillary
D) skin surface
5. Which of the following is the primary source of heat in the body?
A) hormones
B) metabolism
C) blood circulation
D) muscles
6. A nurse places a fan in the room of a patient who is overheated. This is an example of
heat loss related to which of the following mechanisms of heat transfer?
A) evaporation
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B) radiation
C) conduction
D) convection
7. Which of the following is an average normal temperature in Centigrade for a healthy
adult?
A) oral: 37.0∞C
B) rectal: 36.5∞C
C) axillary: 37.5∞C
D) tympanic: 34.4∞C
8. What anatomic site regulates the pulse rate and force?
A) thermoregulatory center
B) cardiac sinoatrial node
C) cardiac atria and valves
D) peripheral chemoreceptors
9. A patient is constipated and trying to have a bowel movement. How does holding the
breath and pushing down (the Valsalva maneuver) affect the pulse?
A) left ventricle pumps more forcefully; pulse is stronger
B) stimulates the vagus nerve to increase the rate
C) stimulates the vagus nerve to decrease the rate
D) right ventricle is less efficient; pulse is thready
10. The arterial blood gases for a patient in shock demonstrate increased carbon dioxide and
decreased oxygen. What type of respirations would the nurse expect to assess based on
these findings?
A) absent and infrequent
B) shallow and slow
C) rapid and deep
D) noisy and difficult
11. A nurse walks into a patient's room and finds him having difficulty breathing and
complaining of chest pain. He has bradycardia and hypotension. What should the nurse
do next?
A) Take vital signs again in 15 to 30 minutes.
B) Document the data and report it later.
C) Ask the patient if he is anxious or afraid.
D) Report findings to the physician immediately.
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12. Which of the following pathologic conditions would result in release of ADH by the
posterior pituitary?
A) hemorrhage
B) allergies
C) obesity
D) asthma
13. A student is reading the medical record of an assigned patient and notes the patient has
been afebrile for the past 12 hours. What does the term ìafebrileî indicate?
A) normal body temperature
B) decreased body temperature
C) increased body temperature
D) fluctuating body temperature
14. A nurse is assessing a patient who has a fever, has an infection of a flank incision, and is
in severe pain. What type of pulse rate would be likely?
A) bradycardia
B) tachycardia
C) dysrhythmia
D) bigeminal
15. While assessing vital signs of a patient with a head injury and increased intracranial
pressure (IICP), a nurse notes that the patient's respiratory rate is 8 breaths/min. How
will the nurse interpret this finding?
A) bradypnea is uncommon in patient with IICP
B) IICP most commonly results in tachypnea
C) bradypnea is a response to IICP
D) this is a normal respiratory rate
16. A nurse is conducting a health history for a patient with a chronic respiratory problem.
What question might the nurse ask to assess for orthopnea?
A) ìDo you have problems breathing when you walk up stairs?î
B) ìDoes your medication help you breathe better?î
C) ìHow many pillows do you sleep on at night to breathe better?î
D) ìTell me about your breathing difficulties since you stopped smoking.î
17. What population is at greatest risk for hypertension?
A) Hispanic
B) White
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C) Asian
D) African American
18. A middle-aged, overweight adult man has had hypertension for 15 years. What
pathologic event is he most at risk for?
A) stroke
B) anemia
C) cancer
D) infection
19. A nurse educator is teaching a patient about a healthy diet. What information would be
included to reduce the risk of hypertension?
A) ìEat a diet high in fruits and vegetables.î
B) ìRemember to drink 8 to 10 glasses of water a day.î
C) ìIt is important to have increased fats in your diet.î
D) ìPut away the salt shaker and eat low-salt foods.î
20. A nurse is caring for a patient who is ambulating for the first time after surgery. Upon
standing, the patient complains of dizziness and faintness. The patient's blood pressure
is 90/50. What is the name for this condition?
A) orthostatic hypotension
B) orthostatic hypertension
C) ambulatory bradycardia
D) ambulatory tachycardia
21. What site for taking body temperature with a glass thermometer is contraindicated in
patients who are unconscious?
A) rectal
B) tympanic
C) oral
D) axillary
22. A patient has been diagnosed with peripheral vascular disease of the lower extremities.
What site would the nurse use to assess circulation of the legs?
A) radial artery
B) dorsalis pedis artery
C) temporal artery
D) carotid artery
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23. A nurse is taking a patient's temperature and wants the most accurate measurement,
based on core body temperature. What site should be used?
A) rectal
B) oral
C) axillary
D) forehead
24. A student nurse assesses a blood pressure on an adult and finds it to be 140/86. What
term is used for the top number (140)?
A) systolic pressure
B) diastolic pressure
C) pulse pressure
D) hypotension
25. A hospital unit has a policy that rectal temperatures may not be taken on patients who
have had cardiac surgery. What rationale supports this policy?
A) It is an embarrassing and painful assessment.
B) Thermometer insertion stimulates the vagus nerve.
C) It is less expensive to take oral temperatures.
D) It is to avoid perforating the wall of the rectum.
26. As adults age, the walls of their arterioles become less elastic, increasing resistance and
decreasing compliance. How does this affect the blood pressure?
A) The blood pressure does not change.
B) The blood pressure is erratic.
C) The blood pressure decreases.
D) The blood pressure increases.
27. What equipment is needed to take an apical pulse?
A) sphygmomanometer
B) electronic thermometer
C) stethoscope
D) no specific equipment
28. Two nurses collaborate in assessing an apical-radial pulse on a patient. The pulse deficit
is 16 beats/min. What does this indicate?
A) The radial pulse is more rapid than the apical pulse.
B) This is a normal finding and should be ignored.
C) The patient's arteries are very compliant.
D) Not all of the heartbeats are reaching the periphery.
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29. A nurse is assessing the blood pressure on an obese woman. What error might occur if
the cuff used is too narrow?
A) reading is erroneously high
B) reading is erroneously low
C) pressure on the cuff with be painful
D) it will be difficult to pump up the bladder
30. Various sounds are heard when assessing a blood pressure. What does the first sound
heard through the stethoscope represent?
A) systolic pressure
B) diastolic pressure
C) auscultatory gap
D) pulse pressure
31. An adult patient is assessed as having an apical pulse of 140. How would the nurse
document this finding?
A) bradycardia
B) tachycardia
C) dysrhythmia
D) normal pulse
32. A patient in a physician's office has a single blood pressure (BP) reading of 150/92.
Should the patient be taught about hypertension?
A) It depends on the time of day the BP was taken.
B) It depends on whether the patient is male or female.
C) No, a single BP reading should not be used.
D) Yes, this reading is high enough to be significant.
33. All of the following patients have a body temperature of 38∞C (100.4∞F). About which
patient would a nurse be most concerned?
A) an older adult
B) a pregnant adolescent
C) a junior high football player
D) a 2-month-old infant
34. A home healthcare nurse notices that his assigned patient uses a mercury thermometer.
He asks the nurse what to do if it breaks. Which of the following is not correct?
A) ìJust flush the glass and mercury down the toilet.î
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B) ìDo not vacuum the area where it breaks.î
C) ìOpen the windows and close off the room for an hour.î
D) ìThrow away any clothing exposed to the mercury.î
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Answer Key
1. C
2. B
3. A, B, C, D, E [Show Less]