Chapter 46 Vital Signs

1.
A nurse takes vital signs of the client as ordered or may use judgment to determine
whether a client requires more frequent assessment of vital signs. The nurse educator asks
a student nurse to identify the measurements that constitute vital signs. Which response
by the student nurse best identifies vital signs?
A) Respirations and blood pressure
B) Temperature, blood pressure, respirations
C) Temperature, pulse, respirations
D) Blood pressure, temperature, pulse, respirations
2.Which precaution should a nurse take when assessing the body temperature of a client
when using the oral measurement?
A) Wait if the client has had cold water before measurement.
B) Ensure that the client is resting during the measurement.
C) Ensure that the client is not wearing any constrictive clothing.
D) Record the temperature to the even six-tenths of a degree.
3.The licensed nurse is getting a report from an unlicensed assistive person in relation to
the morning vital signs. Which statement would indicate that the rectal temperature needs
to be taken via a different route?
A) “The client was on oxygen when I took the reading.”
B) “I was unable to read the temperature because there was a small amount of stool on
the thermometer.”
C) “Because the client was confused, I took the temperature rectally.”
D) “The client has had diarrhea three times this morning.”
4.The nurse is reviewing with a group of student nurses that the normal adult body
temperature has an average normal range in different body areas. What is the range of
normal temperatures by the axillary route?
A) 35.5°C–37.5°C (95.9°F–99.5°F)
B) 36.6°C–38°C (97.9°F–100.4°F)
C) 34.7°C–37.3°C (94.5°F–99.1°F)
D) 35.8°C–38°C (96.4°F–100.4°F)
5.The nurse is reviewing with a group of student nurses that the normal adult body
temperature has an average normal range in different body areas. What is the range of
normal temperatures by the rectal route?
A) 35.5°C–37.5°C (95.9°F–99.5°F)
B) 36.6°C–38°C (97.9°F–100.4°F)
C) 34.7°C–37.3°C (94.5°F–99.1°F)
D) 35.8°C–38°C (96.4°F–100.4°F)
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6.The nurse documents in the client chart that the client has an intermittent fever. Based on
this information, what does the student nurse know about the assigned client's fever?
A) A temperature that alternates between a fever and a normal or subnormal reading
B) A temperature that rises several degrees above normal and returns to normal or near
normal
C) A temperature that stays elevated
D) A sudden drop from fever to normal temperature
7.The nurse documents in the client chart that the client has a remittent fever. Based on this
information, what does the student nurse know about the assigned client's fever?
A) A temperature that alternates between a fever and a normal or subnormal reading
B) A temperature that rises several degrees above normal and returns to normal or near
normal
C) A temperature that stays elevated
D) A sudden drop from fever to normal temperature
8.The hand-off report nurse states to the student nurse that the client was febrile during the
night. Based on this information, what is considered a fever by the oral route?
A) 35.5°C–37.5°C (95.9°F–99.5°F)
B) 36.6°C–38°C (97.9°F–100.4°F)
C) 34.7°C–37.3°C (94.5°F–99.1°F)
D) 37.5°C–39.4°C (100°F–103°F)
9.A client has been placed on Contact Precautions. Which type of thermometer should the
nurse use with this client?
A) Temporal artery
B) Rectal
C) Disposable single use
D) Tympanic
10.The student nurse has been ordered to take vital signs of a group of clients. Which type of
thermometer would provide the student nurse with the quickest and most noninvasive
method for obtaining the client's temperature?
A) Temporal artery
B) Rectal
C) Disposable single use
D) Tympanic
11.The nurse is taking care of an 18-month-old child. When planning to take vital signs,
what is the most accurate pulse for the nurse to assess in an 18-month-old child?
A) Radial pulse
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B) Apical pulse
C) Pedal pulse
D) Carotid pulse
12.The nurse is assessing a client who is in shock and has an abnormal pulse rate. What is
the most important technique for the nurse to use when assessing a client's carotid pulse?
A) Avoid reaching across the client's neck to count the pulse.
B) Count the pulse beats for 30 seconds.
C) Use the first finger to check the pulse.
D) Assess both carotid pulses simultaneously.
13.The nurse has to take a client's radial pulse and apical pulse because the primary care
provider suspects that the client's heart is not effectively pumping blood. Which readings
by the nurse would best represent a pulse deficit for the client who needs to be entered in
the electronic medical record?
A) Apical 72 Radial 82
B) Apical 82 Radial 60
C) Apical 96 Radial 90
D) Apical 104 Radial 100
14.The student nurse is obtaining a client's respirations. Which action is appropriate when
the student nurse is counting the adult client's respirations?
A) Keep fingertips on the client's pulse when counting respirations.
B) Count respirations when the client is sleeping or resting.
C) Apply pressure on the client's chest when counting respirations.
D) Count the client's respirations for 1 minute.
15.The student nurse hears in a hand-off report that an adult client's respirations were eupnea
on the night shift. Based on this information what respiratory rate best reflects tachypnea?
A) 8–10 breaths per minute
B) 12–18 breaths per minute
C) 20–24 breaths per minute
D) 25–35 breaths per minute
16.When assessing the respiration of a client, a nurse observes a hissing, crowing sound.
Based on this information, the nurse recognizes that which is the possible cause of this
sound?
A) Spasms and edema of the bronchi
B) Air passing through secretions present in the air passages
C) Obstruction near the glottis
D) Air passageway being partially blocked
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17.When measuring the blood pressure (BP) of a client with vascular disease, the nurse
obtains readings of greater than a 10-point difference between both arms. This is an
indication of which condition?
A) Sign of a circulatory problem
B) Arterial occlusion in the arm with the lower pressure
C) Hemorrhage or shock
D) Orthostatic hypotension
18.A nurse is required to document an adult client's blood pressure. Which nursing
intervention will help ensure that the systolic reading is not underestimated?
A) Assist the client to a comfortable position before assessing the pressure.
B) Center the cuff's bladder above the site where the brachial pulse is palpated.
C) Check that the aneroid manometer is vertical and at eye level.
D) Inflate the cuff to a pressure 30 mm Hg above the point where the pulse disappears.
19.Which is an appropriate nursing intervention when using an alternate site for taking blood
pressure (BP)?
A) Do not use the same site continuously throughout the client's care.
B) Document the site where BP values were measured.
C) Place the client in semi-Fowler's position.
D) Measure the respiratory rate along with the BP.
20.A nurse is assessing the vital signs of a group of clients. Which vital sign indicates an
abnormal finding for a healthy adult?
A) Blood pressure 118/74
B) Temperature 37°C
C) Pulse 66 beats per minute
D) Respiration rate 25 breaths per minute
21.The nurse educator is reviewing Korotkoff's sounds with a group of student nurses. What
is the best response by the student nurse about phase II Korotkoff's sounds?
A) Systolic pressure
B) Auscultatory gap
C) Diastolic pressure in children
D) Diastolic pressure in adults
22.The nurse is obtaining a pulse oximetry reading on a client. The client asks the nurse
what the reading of 96% means. Based on this information, what is the best response by
the nurse?
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A) Indicates the percentage of carbon dioxide in the hemoglobin
B) Indicates the percentage of oxygen saturation in the hemoglobin
C) Indicates the percentage of potassium saturation in the blood
D) Indicates the percentage of sodium in the blood
23.The nurse is reviewing the principles of systolic and diastolic blood pressure with a group
of nursing students. What are the best responses by the student nurses about what
determines the reading as the ventricles contract and rest?
1. Pressure the blood exerts on the walls of the arteries
2. Rate and force of heartbeat
3. Blood vessel condition
4. Blood volume
A) 1, 2, 3
B) 1, 2, 4
C) 1, 3, 4
D) 2, 3, 4
24.The nurse is obtaining a pulse oximetry reading on a client. What are common locations
that the nurse can place the pulse oximetry sensor?
1. Finger
2. Toe
3. Hand
4. Earlobe
A) 1, 2, 3
B) 1, 2, 4
C) 1, 3, 4
D) 2, 3, 4
25.The nurse notices that a client is experiencing an orthostatic drop in blood pressure. The
nurse reviews the medication administration record. What classification of medication
commonly causes orthostatic hypotension?
1. Antipsychotics
2. Antibiotics
3. Antilipidemia
4. Antiseizure
A) 1, 2
B) 1, 4
C) 2, 3
D) 3, 4
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Answer Key
1.D
2.A
3.D
4.C
5.B
6.A
7.B
8.D
9.C
10.A
11.B
12.A
13.A
14.A
15.B
16.C
17.B
18.D
19.B
20.D
21.B
22.B
23.D
24.B
25.B
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