07: Vital Signs

Multiple Choice

1. The patient’s oral temperature is 39  C (102.2 F). Which conclusion can the nurse make about the patient on the basis of this information?

a. The patient is febrile.

b. The patient is afebrile.

c. An infection is present.

d. Inflammation is present.

ANS: A

A temperature of 39 C is above normal, and the patient with an above-average temperature is febrile. Afebrile indicates a lack of fever but does not necessarily imply a subnormal temperature. An infection often causes a fever in the patient, but a physical examination and laboratory work or culture are necessary before concluding that the patient has an infection. A patient with an inflammation can have a fever, but the patient can have an inflammation without being febrile.

DIF: Cognitive Level: Understanding OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Diagnosis a. Documentation of vital signs requires timely and accurate recording. b. Normal limits are very narrow and are generally the same for all patients. c. Measuring equipment must be used correctly and appropriately. d. Environmental factors play a minor role on patient vital signs.

2. The nurse is preparing to obtain a set of vital signs. Which is the most important factor for the nurse to consider when measuring patient vital signs?

ANS: C

It is important that each device be used correctly and appropriately to ensure patient safety and to obtain correct, complete patient information. Improper equipment distorts the results, increasing the risk of patient injury. If data are obtained with improper equipment and patient treatment is based on the faulty data, the people who use the improper equipment and the faulty data are liable for the results. Documentation is an important part of taking vital signs; however, if the nurse uses improper equipment or technique to obtain vital signs, accurate and prompt recording is to no avail. Depending on the parameter, the normal limits are not relatively narrow. The benefit of a wider normal range is that the body is able to respond to stress and recover while remaining within normal limits. Environmental factors play a significant role on vital signs (e.g., an overly warm room affects patient temperature).

DIF: Cognitive Level: Remembering OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. The rectum b. The axilla c. Under the tongue d. The tympanic membrane

3. A patient has a severe upper respiratory and ear infection and has been experiencing diarrhea. Assessment of the temperature would be most accurate if the nurse checked the temperature using which site?

ANS: B

The axilla is the only area listed where there is no infection or health issue and where there is no interference to its accuracy. The rectum is an inappropriate site because of the diarrhea. The oral route, under the tongue, is an inappropriate site because of the severe upper respiratory infection. If the patient cannot breathe through the nose, mouth breathing occurs, and the mouth cannot be closed to create a seal for an accurate temperature measurement. The tympanic membrane is an inappropriate site because of the ear infection.

DIF: Cognitive Level: Analyzing OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Assessment a. Compress the bell of the stethoscope over the apex of the heart. b. Locate the pulsations in the antecubital space. c. Palpate the superficial artery on the medial side of the wrist. d. Place the thumb and forefinger along the ridge on the outer side of the wrist.

4. The nurse is validating the measurement of an infant’s pulse by a nursing student. Which method should the nurse use to obtain the most accurate count?

ANS: B

Counting the pulsations in the antecubital fossa from the brachial artery would give the most accurate count. Compressing the bell of the stethoscope turns it into a diaphragm; the bell is never compressed during use. Placing the thumb and forefinger along the ridge on the outer side of the wrist locates the radial artery, the preferred site for measuring an adult’s pulse.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. Femoral b. Carotid c. Brachial d. Popliteal

5. A patient born without arms needs to have a blood pressure assessment. Which artery should the nurse use to most accurately obtain this measurement?

ANS: D

The nurse can use the popliteal artery to measure blood pressure by applying a properly sized cuff to the patient’s thigh. The femoral artery does not provide an area for assessment of the blood pressure. The brachial arteries are in the arm. The carotid artery, which is in the neck, is impossible to use for blood pressure measurement because applying cuff pressure to temporarily occlude both carotid arteries would stop blood flow to the brain and risk cerebral hypoxia.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. Use a cuff with a cuff width that is 40% wider than the circumference of the arm. b. Limit the cuff deflation rate to 10 mm Hg per second or heartbeat. c. Record the second Korotkoff sound as the systolic pressure. d. Apply the diaphragm of the stethoscope lightly over the brachial artery.

6. The nurse is running a blood pressure screening clinic at the community health center. Which action should the nurse implement to obtain an accurate measurement of a patient’s blood pressure on an upper extremity?

ANS: A

For accurate results, a properly sized blood pressure cuff is at least 40% wider than the circumference of the patient’s arm on which the blood pressure is measured. Deflating the cuff at 10 mm Hg is excessively fast. The systolic blood pressure is the first Korotkoff sound. The diaphragm is placed firmly over the brachial artery to prevent environmental sound from interfering with blood pressure auscultation.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. Check when the device was last calibrated. b. Know that the device adheres to current medical industry standards. c. Take a manual blood pressure within several minutes of the electronic reading. d. Verify that the systolic pressure is within 20% of patient baseline.

7. The patient is unstable, so the nurse is using an electronic blood pressure device to measure blood pressures every 15 minutes. What should the nurse do to verify the accuracy of the electronic blood pressure measurements?

ANS: C

If the blood pressure readings from the electronic blood pressure measurement device are close to the patient’s blood pressure on auscultation using a sphygmomanometer, the nurse assumes that the electronic device is accurate. Knowing when the device was calibrated does not guarantee its current accuracy. Maintaining medical industry standards also does not mean the device is currently accurate. A systolic measurement accurate within 20% of the patient’s baseline is grossly inaccurate and using such a measurement can potentially lead to catastrophic results.

DIF: Cognitive Level: Understanding OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. The cuff is positioned carefully on the gown sleeve for comfort. b. The cuff is removed every 2 hours for a skin assessment. c. The alarm limits on the electronic device are checked frequently. d. The cuff is rotated to the other extremity every few hours as possible.

8. A patient has an electronic blood pressure cuff that inflates every 15 minutes for a reading. Which activity by the nursing student would require the nurse to intervene?

ANS: A

The cuff should be directly on the patient’s skin, not over the gown, for an accurate reading. All other actions are appropriate.

DIF: Cognitive Level: Remembering OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Planning a. 10-year-old patient with a left leg fracture b. 12-hour-old infant in the newborn nursery c. 5-year-old patient with bilateral otitis media d. 15-year-old patient who had bilateral tympanoplasties today

9. The nurse delegates temperature measurement to nursing assistive personnel (NAP). For which patient should the nurse instruct the NAP to use the tympanic thermometer?

ANS: A

The 10-year-old patient is a suitable candidate for use of the tympanic thermometer if the NAP uses proper technique for positioning the sensor because of the age and condition of the child. The anatomy of the ear canal makes it difficult to position the probe accurately in neonates. Whenever ear infections are present, a tympanic thermometer can cause injury and record an inaccurate reading because of fluid, wax, or infectious material in the ear. Tympanic temperatures are prohibited when ear surgery has just been performed because they increase the risk for injury and infection.

DIF: Cognitive Level: Remembering OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Planning a. Rectal b. Axillary c. Tympanic d. Disposable

10. The nurse needs to measure the adult patient’s temperature, but the patient has just finished a cup of coffee. Which is the best type of temperature for the nurse to obtain accurate results efficiently?

ANS: C

The nurse obtains a tympanic temperature because the hot coffee will affect an oral reading. A tympanic temperature is a more reliable indicator of body temperature than the oral reading because a tympanic temperature is a core temperature. Rectal temperatures for adult patients are reserved for occasions when continuous temperature monitoring is required or if no other core temperature site is available; in addition, rectal temperatures are embarrassing for an alert adult patient. Axillary temperatures are not as reliable as tympanic temperatures and do not reflect core temperature. Disposable thermometers are the least accurate method.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Planning a. 1.3 cm (1/2 inch) b. 3.5 cm (1 1/2 inches) c. 5.1 cm (2 inches) d. 6.4 cm (2 1/2 inches)

11. The nurse is preparing to obtain a rectal temperature. Nursing care is correct if the nurse inserts the thermometer how far into the rectum of an adult?

ANS: B

The nurse inserts the thermometer 2.5–3.5 cm (1–1 1/2 inches) to obtain a rectal temperature on an adult. The sensor tip will be deep enough into the rectum to eliminate environmental effects but not too deep to risk penetration or trauma to intestinal tissue. 1.3 cm (1/2 inch) is not far enough for an accurate reading. 5.1 and 6.4 cm (2 and 2 1/2 inches) are too far to insert the thermometer into an adult.

DIF: Cognitive Level: Understanding OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. Remove the thermometer immediately. b. Ask the patient to take a few deep breaths. c. Apply mild pressure to advance the thermometer. d. Remove the thermometer and reinsert gently.

12. While inserting a rectal thermometer, the nurse encounters resistance. What action should the nurse take?

ANS: A

If resistance is felt, the nurse should remove the thermometer probe. Applying pressure to advance the thermometer is contraindicated to prevent complications such as harm to the mucosa. If there is an obstruction or a large amount of stool, having the patient take a few deep breaths will not solve the problem. The obstruction or impaction will have to be dealt with first. If the nurse removes and then reinserts the thermometer, the stimulation reactivates the sphincter reflex. The resistance will more than likely still be present.

DIF: Cognitive Level: Remembering OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. Check the leukocyte count. b. Collaborate for cultures. c. Ask the patient to drink some fluid. d. Offer the patient another blanket.

13. The nurse notes that the patient’s tympanic temperature is 37.88  C (100.2  F) at 4 PM on the patient’s second postoperative day. What should the nurse do initially?

ANS: C

The nurse should ask the patient to drink more fluid and cough and deep breathe, because low-grade temperatures frequently indicate dehydration and atelectasis in postoperative patients; in addition, patient temperatures generally peak in late afternoon. The nurse evaluates the patient’s temperature again in 2 hours and expects to obtain a lower temperature. If not, the nurse assesses the patient for infection and collaborates with the provider to plan care. Until the nurse tries fluid and verifies the temperature, collaborating for specimen cultures is premature; in addition, the provider potentially will not want to culture for a low-grade temperature.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. Pull the pinna down and back. b. Pull the pinna up and back. c. Place the probe loosely into the ear canal. d. Point the probe toward the eye.

14. The nurse is teaching a family member how to check a teenager’s temperature using a tympanic thermometer. Which step is most important for the nurse to include in order to obtain an accurate reading?

ANS: B

To obtain a tympanic temperature using proper technique, the nurse inserts the thermometer tip into the ear, and pulls the pinna up and back for children older than 3. The tip must fit securely in the ear canal to block environmental effects. The tip of the thermometer should point toward the patient’s nose for proper positioning.

DIF: Cognitive Level: Understanding OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Assessment a. One nurse counts the apical pulse while another counts the radial pulse at the same time. b. The nurse delegates the task to two experienced nursing assistants. c. The nurse feels the radial pulse while watching the cardiac monitor. d. The nurse takes the apical pulse first, followed by the radial pulse.

15. A patient taking a new cardiac medication suddenly develops an irregular pulse. The nurse plans to obtain an apical-radial pulse. What action by the nurse is best?

ANS: A

The correct technique for measuring the apical-radial pulse for a deficit is for one nurse to take the apical pulse while another nurse takes the apical pulse at the same time for 60 seconds. The two measurements are compared. A difference of 2 beats is significant. Since the patient has had a change in status, this task cannot be delegated. The other two described techniques are incorrect.

DIF: Cognitive Level: Understanding OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Assessment a. Use the extremity closest to the nurse. b. The cuff size must match the extremity being used. c. The brachial artery is always the best one to use. d. The temporal artery is used if neither arm is available.

16. The nurse is preparing to measure the patient’s blood pressure with an electronic blood pressure device. Which concept is most important for the nurse to consider?

ANS: B

The cuff must be the appropriate size for the extremity used. If the thigh is used, the nurse must use a larger cuff. The extremity used has nothing to do with proximity to the nurse. It depends on the patient’s status. In some instances, the brachial artery in the upper arm is not available for blood pressure assessment. The temporal artery is impossible to use for blood pressure measurement because the temporal arteries are on the lateral aspects of the skull.

DIF: Cognitive Level: Understanding OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Planning a. At the fifth intercostal space at the left sternal border b. At the fifth left intercostal space at the midclavicular line c. At the second intercostal space at the left midclavicular line d. At the second right intercostal space at the midclavicular line

17. The nurse is preparing to assess the apical pulse. At which location should the nurse listen to obtain an accurate apical pulse on an adult patient?

ANS: B

To auscultate an adult’s apical pulse, the nurse places the stethoscope at the left fifth intercostal space at the midclavicular line directly over the point of maximal impulse and the location for auscultating the mitral valve. The fifth left intercostal space at the left sternal border locates the tricuspid valve. The second intercostal space at the left midclavicular line locates the pulmonic valve. The second right intercostal space at the midclavicular line locates the aortic valve.

DIF: Cognitive Level: Remembering OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Assessment a. 25 respirations per minute for a toddler b. 38 respirations per minute for a newborn c. 12 respirations per minute for an 8-year-old child d. 14 respirations per minute for an adult patient

18. The nursing assistant reports the following vital signs for four patients just evaluated. Which patient should the nurse see first?

ANS: C

A child’s respiratory rate should be 18–30 breaths per minute. A respiratory rate of 12 is too low, so the nurse assesses this patient as the priority. The other values are within normal limits.

DIF: Cognitive Level: Applying OBJ: NCLEX: Safe and Effective Care Environment

TOP: Nursing Process: Assessment a. 2.5 cm (1 inch) b. 0.6 cm (1/4 inch) c. 1.3 cm (1/2 inch) d. 5.1 cm (2 inches)

19. At what distance above the antecubital fossa does the nurse position a blood pressure (BP) cuff when using the brachial artery to measure BP?

ANS: A

The nurse positions the BP cuff 2.5 cm (1 inch) above the antecubital fossa when using the brachial artery. This allows proper placement of the stethoscope.

DIF: Cognitive Level: Understanding OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. The Korotkoff sounds will not be heard. b. Only a palpable BP can be obtained. c. The stethoscope cannot be positioned correctly. d. A false high BP reading will occur.

20. The nurse uses a blood pressure (BP) cuff that is too narrow for the arm of a patient with morbid obesity. What problem will the nurse encounter because of the cuff used?

ANS: D

Using a cuff that is too narrow results in a false high BP measurement and makes care planning impossible. A properly sized cuff should be obtained as quickly as possible. Until it arrives, the nurse should continue to measure BP with the smaller cuff and observe the patient to ensure safety. Obesity potentially leads to diminished Korotkoff sounds. The assessment finding will warrant further investigation such as rechecking the blood pressure in several minutes. A palpable BP provides a systolic pressure only; the nurse obtains a palpable BP by inflating the cuff to occlude the artery and then palpating the brachial or radial pulse. The point at which the pulse returns is the systolic pressure. The nurse should have less difficulty positioning the stethoscope because the narrow cuff exposes more skin.

DIF: Cognitive Level: Remembering OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Evaluation a. “I should take vital signs upon admission.” b. “I should take vital signs when there is any change in condition.” c. “I should take vital signs at the beginning and end of a blood transfusion.” d. “I should take vital signs if a patient reports feeling different.”

21. The nurse is assessing a new orientee’s knowledge of when to take vital signs. The following statement indicates a need for more education.

ANS: C

Vital signs should be taken in all of those situations including before and after blood transfusions, but they also need to be taken during blood transfusions. The nurse would want to clarify that statement to make sure the nurse knows to check the vital signs during blood transfusions.

DIF: Cognitive Level: Evaluating OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Evaluation a. “This method prevents any problems in obtaining an accurate reading.” b. “This method helps the arm relax so the reading will be correct.” c. “I want you to be as comfortable as possible during this time.” d. “Just sit back and relax and let me get this reading right now.”

22. While positioning the patient for a routine blood pressure check, the patient asks the nurse why a support was placed under the arm before the BP cuff was applied. Which response by the nurse is most accurate?

ANS: B

Supporting the arm ensures the muscles are relaxed, improving the likelihood for an accurate reading. Comfort is important but not the primary reason for providing support. Many variables can cause an inaccurate reading, including the wrong cuff size or improper placement of the stethoscope. Telling the patient to just “sit back and relax” ignores the patient’s question and is not an appropriate response.

DIF: Cognitive Level: Understanding OBJ: NCLEX: Physiological Integrity

TOP: Integrated Process: Teaching-Learning a. Biot’s respirations b. Cheyne-Stokes respirations c. Kussmaul’s respirations d. Hyperpneic respirations

23. The nurse assesses the patient’s respirations and notes the patient routinely takes two to three breaths followed by an irregular period of apnea. How does the nurse document this finding?

ANS: A

This is an accurate description of Biot’s respirations. Cheyne-Stokes respirations have an irregular rate and depth characterized by alternating periods of apnea and hyperventilation. Kussmaul’s respirations are abnormally deep but regular. Hyperpneic respirations are increased in depth and can often be seen during exercise.

DIF: Cognitive Level: Understanding OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Assessment a. Place the patient in high-Fowler’s position. b. Assess the remaining vital signs. c. Reassess the respiratory rate. d. Notify the health care provider.

24. The nurse is caring for a lethargic, 18-year-old patient with a respiratory rate of 32 breaths per minute. What is the first action the nurse should take?

ANS: A

The patient’s head should be elevated quickly to promote better lung expansion. The remaining vital signs can be assessed after taking actions to improve the patient’s breathing. The health care provider will be notified, but the nurse’s first responsibility is to the patient.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation

25. The nurse has delegated the task of obtaining a pulse oximetry reading to the NAP. Which of the following statements by the NAP indicates a need for further education?

N a. “The pulse oximetry reading was 95%.” b. “The patient’s pulse rate was 78 according to the readout.” c. “I made sure the patient did not have nail polish on.” d. “I made sure the patient was not receiving a respiratory treatment.”

ANS: B

Pulse oximetry is used to determine the percentage of hemoglobin saturated with oxygen, not the patient’s pulse rate. The patient’s nail polish should be removed and the patient should not be receiving respiratory treatments or PT during the readings because it can affect them. The readings are given in percentages.

DIF: Cognitive Level: Evaluating OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Evaluation a. Administer acetaminophen 650 mg by mouth now. b. Offer the patient an additional blanket. c. Document that the patient is afebrile. d. Compare this with the patient’s prior readings.

26. The patient’s oral temperature is 37.1 C (98.78 F) at 1 PM. Which of the following actions should the nurse take next?

ANS: C

This temperature is within normal limits. Because the temperature reading is within normal limits, other interventions are not needed. Providing a blanket would increase the temperature. Comparing the temperature with other readings would be done if the temperature was outside of the normal range. Treating the patient with acetaminophen would be done if the patient’s temperature was elevated and you had a health care provider order.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation

Multiple Response

1. The nurse is going to measure the patient’s oxygen saturation. The nurse knows pulse oximetry readings can be influenced by which of the following factors. (Select all that apply.)

a. Nail polish b. Respiratory treatments c. Poor circulation to the site d. Tremors e. Hemoglobin levels f. Latex allergy

ANS: A, B, C, D, E

There are many factors that can influence pulse oximetry readings, including nail polish on the fingers where the reading is taken, poor circulation to the extremities, tremors, respiratory treatments, and hemoglobin or hematocrit levels. It is important to select the correct site to take the reading to get the best accuracy. Latex allergy would not affect the reading but would preclude the use of disposable sensors.

DIF: Cognitive Level: Remembering OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation