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Chapter 21: Measuring Vital Signs

Test Bank

MULTIPLE CHOICE

1.The nurse would anticipate a patient diagnosed with damage to the hypothalamus after
suffering a head injury from a fall to exhibit:

a. a blood pressure elevation.

b. a temperature abnormality.
c. a decrease in pulse rate.
d. depressed respirations.

ANS: B

The hypothalamus, which is located between the cerebral hemispheres, controls body
temperature. Any damage to the hypothalamus prevents the body from regulating its
temperature.

DIF: Cognitive Level: Comprehension REF: p. 335 OBJ: Theory #1

TOP: Vital Signs: Temperature KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: physiological adaptation

2.The nurse documents vital signs on a newly admitted patient as: “blood pressure is 148/94 mm
Hg, the pulse is 80 beats/min, and the respirations are 16 breaths/min.” The nurse would record
the pulse pressure as _____ mm Hg.

a. 14
b. 54
c. 64
d. 80

ANS: B

In calculating pulse pressure, take the difference between the systolic and diastolic
pressures (i.e., 148 – 94 = 54).

DIF: Cognitive Level: Analysis REF: p. 356 OBJ: Clinical Practice #4

TOP: Vital Signs: Blood Pressure KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: physiological adaptation

3.A patient has been admitted with hypothermia after lying unconscious overnight in an
unheated apartment. The most appropriate route to assess the patient’s core temperature
would be:

a. rectal.
b. tympanic arterial thermometer.
c. axillary.
d. tympanic.

ANS: D

The same blood vessels serve the hypothalamus and the tympanic membrane, so the tympanic
temperature is an excellent indicator of core body temperature, although it can be affected by ear
wax.

DIF: Cognitive Level: Application REF: p. 339

OBJ: Theory #3 | Clinical Practice #1 TOP: Vital Signs: Temperature

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: physiological adaptation

4.The nurse would document a patient as being febrile if the patient’s temperature was over
_____ F.

a. 99.5
b. 99.8
c. 100
d. 100.5

ANS: D

A patient with a temperature above the normal range (100.2° F) is called febrile.

DIF: Cognitive Level: Knowledge REF: p. 339 OBJ: Theory #3

TOP: Vital Signs: Temperature KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: physiological adaptation

5.To ensure an accurate reading when using a glass oral thermometer, it is necessary to:

a. rinse the thermometer with water.

b. wipe the thermometer with alcohol.
c. shake down the galinstan alloy to below normal.
d. dry the thermometer with a dry cotton ball.

ANS: C

Oral thermometers remain at the last reading until they are shaken down; therefore, for
accuracy, the thermometer must be below normal range before using.

DIF: Cognitive Level: Application REF: p. 342 OBJ: Clinical Practice #1

TOP: Vital Signs: Temperature KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: basic care and comfort

6.The nurse taking an apical pulse would place the stethoscope at:

a. the left of the sternum at the third intercostal space.

b. directly below the sternum.
c. slightly above the left nipple.
d. the left midclavicular line at the fifth intercostal space.

ANS: D

The apical pulse is determined by placing a stethoscope on a point midway between the imaginary
line running from the midclavicle through the left nipple in the fifth intercostal space.

DIF: Cognitive Level: Application REF: p. 350, Skill 21-4

OBJ: Theory #2 | Clinical Practice #2 TOP: Vital Signs: Pulse

KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: basic care and comfort

7.The nurse would record a pulse as bradycardic if the rate were _____ beats/min.
a. 64
b. 62
c. 60
d. 59

ANS: D

Bradycardia indicates a slow pulse that is less than 60 beats/min.

DIF: Cognitive Level: Comprehension REF: p. 349 OBJ: Theory #3

TOP: Vital Signs: Pulse KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: basic care and comfort

8.The nurse is aware that the use of an oral glass thermometer would be contraindicated in a:

a. 5-year-old with a facial laceration.

b. 12-year-old patient with a recent seizure.
c. 15-year-old with an abscessed tooth.
d. 20-year-old with severe dehydration.

ANS: B

The rectal method is best for patients who have seizure activity so as not to put them at risk for
biting and breaking the thermometer.

DIF: Cognitive Level: Application REF: p. 339 OBJ: Clinical Practice #1

TOP: Vital Signs: Temperature KEY: Nursing Process Step: Planning

MSC: NCLEX: Physiological Integrity: basic care and comfort

9.The nurse anticipates that if the stroke volume of a patient is reduced, the pulse will be:

a. stronger.
b. weaker.
c. bradycardic.
d. irregular.
ANS: B

A weak pulse will result if the stroke volume is reduced, because this decreases circulating
volume.

DIF: Cognitive Level: Comprehension REF: p. 337 OBJ: Theory #2

TOP: Vital Signs: Pulse KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: basic care and comfort

10. When caring for a victim with a gunshot wound to the abdomen who has lost a
significant amount of blood, the nurse would anticipate the vital signs to reflect:

a. increase in temperature.
b. decrease in blood pressure.
c. decrease in pulse.
d. decrease in respirations.

ANS: B

If blood volume decreases, as with bleeding, blood pressure decreases.

DIF: Cognitive Level: Analysis REF: p. 351, Table 21-2

OBJ: Theory #2 TOP: Vital Signs: Blood Pressure

KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: physiological adaptation

11. When a frail 83-year-old patient whose temperature was 96.8° F at 8:00 AM
shows a temperature of 98.6° F at 4:00 PM, the nurse is:

a. pleased that the temperature has come up to normal.

b. satisfied that the patient is warm enough.
c. concerned about the evidence of fever.
d. relieved that the patient is improving.

ANS: C
In older patients who have a frail frame, the normal temperature is often 97.2° F. An elevation
of 2° F is indicative of fever.

DIF: Cognitive Level: Application REF: p. 340, Elder Care

OBJ: Theory #4 TOP: Vital Signs in the Elderly

KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: physiological adaptation

12.A patient who is terminally ill is described during shift report as having Cheyne-Stokes
breathing. On assessment, the nurse anticipates finding:

a. a breathing pattern of dyspnea followed by a short period of apnea.

b. rapid wheezing respirations for two or three breaths with short periods of apnea.
c. quick shallow respirations with long periods of apnea.
d. respirations gradually decreasing in rate and depth.

ANS: A

Cheyne-Stokes respirations are faster and deeper rather than slower and are followed by a period
of no breathing.

DIF: Cognitive Level: Analysis REF: pp. 354-355 OBJ: Theory #5

TOP: Vital Signs: Respirations KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: physiological adaptation

13. The nurse explains to a patient that the pulse oximeter can measure the arterial oxygen
by:

a. assessing the amount of blood passing through the sensor.

b. assessing the relative warmth of the skin on the monitored part.
c. measuring the oxygenated hemoglobin through a capillary bed.
d. measuring the respirations to the blood pressure via infrared rays.

ANS: C

The pulse oximeter measures oxygen saturation by means of a sensor/probe attached to

peripheral digits, an earlobe, the nose, or the forehead as it passes through the capillary bed.
Oxygenated blood absorbs more infrared than red light.
DIF: Cognitive Level: Comprehension REF: p. 355 OBJ: Theory #5

TOP: Vital Signs: Pulse KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: basic care and comfort

14.Because the elderly have non-elastic blood vessels, they are prone to orthostatic hypotension.
A priority intervention for a patient with orthostatic hypotension is to:

a. keep the patient in bed in a high Fowler’s position.

b. allow the patient to sit on the side of the bed for a minute before standing.
c. instruct the patient to use the wheelchair for all mobility activity.
d. help the patient to rise quickly and support the patient for a minute.

ANS: B

The elderly often experience orthostatic hypotension and are at risk for falls and should be
encouraged to sit on the side of the bed a minute before standing. These patients also
benefit from the use of elastic stockings.

DIF: Cognitive Level: Application REF: p. 361, Elder Care

OBJ: Theory #2 TOP: Orthostatic Hypotension

KEY: Nursing Process Step: Planning

MSC: NCLEX: Safe Effective Care Environment: safety and infection control

15.An elderly patient has a tympanic temperature of 96.2° F (35.7° C). What
nursing intervention would best meet this patient’s need?

a. Take the patient’s vital signs every 4 hours, including temperature.

b. Provide fluids to increase circulation.
c. Increase room temperature to 72° F (22.2° C) and add blankets to the bed.
d. Check the temperature orally to confirm the accuracy of the reading.

ANS: C

Nursing interventions for treating hypothermia should focus on reducing heat loss and supplying
additional warmth, such as increasing the room temperature and adding blankets to the bed.

DIF: Cognitive Level: Application REF: p. 341 OBJ: Theory #3

TOP: Vital Signs: Temperature KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: basic care and comfort

16.The nurse using either a regular or an electronic sphygmomanometer would ensure that the
cuff is the correct size by:

a. using a narrow cuff for an obese patient.

b. making sure the width of the bladder is at least 3 inches.
c. confirming that the bladder goes around three fourths of the arm.
d. always using a wide cuff.

ANS: C

For accuracy in a BP reading, the cuff of the sphygmomanometer should have a bladder
that goes around three fourths of the arm.

DIF: Cognitive Level: Comprehension REF: p. 358, Skill 21-6

OBJ: Clinical Practice #4 TOP: Vital Signs: Blood Pressure

KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: basic care and comfort

17. For the nurse to assess the most accurate respiration count, the nurse should:

a. inform the patient about his respirations and ask him to breathe normally.
b. count each inhalation and expiration for 1 full minute.
c. watch the patient’s chest rise and fall from a distance.
continue to hold the patient’s radial pulse, and count the respirations for 30 seconds and
d. multiply them by 2.

ANS: D

The respirations should be counted for 30 seconds and multiplied by 2 if they are regular. If the
patient knows the nurse is assessing the respiration, he or she may alter breathing.

DIF: Cognitive Level: Application REF: p. 350, Skill 21-5

OBJ: Clinical Practice #3 TOP: Vital Signs: Respirations

KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: basic care and comfort

18.Elderly patients with hypertension may have an auscultatory gap in their Korotkoff sounds. It
is important when taking their blood pressure measurement to:

a. continue to listen until the cuff is deflated.

b. pump up the cuff until no sound is heard and then let the air out.
c. make sure the bell of the stethoscope is placed firmly over the artery.
d. stop midway and begin to inflate again.

ANS: A

Many older adults with hypertension have an auscultatory gap in their Korotkoff sounds,
making it important to listen until the cuff is deflated to avoid mistaking the auscultatory gap as
the Korotkoff sound.

DIF: Cognitive Level: Application REF: p. 360 OBJ: Theory #6

TOP: Vital Signs in the Elderly KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: basic care and comfort

19.Regarding the blood pressure in children, the diastolic pressure is assessed by the
auscultation of a:

a. clear tapping that gradually grows louder.

b. murmur or swishing sound that increases with depression of the cuff.
c. sudden change or muffling of the sound.
d. louder knocking sound that occurs with each heartbeat.

ANS: C

A sudden change or muffling sound (Phase IV) indicates the diastolic pressure in children and
in some adults.

DIF: Cognitive Level: Application REF: p. 360 OBJ: Clinical Practice #4

TOP: Vital Signs in Children KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: basic care and comfort

20. The nurse covers a newborn baby’s head with a cap, because the head:

a. is wet and needs to be dried.

b. has large fontanels.
c. allows loss of body heat.
d. can be reshaped more quickly.

ANS: C

Infants lose considerable body heat through the scalp; therefore a cap helps prevent heat loss.

DIF: Cognitive Level: Application REF: p. 341, Elder Care

OBJ: Theory #3 TOP: Vital Signs: Infant Temperature

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: basic care and comfort

21.The nurse is caring for a patient who had a cardiac catheterization 2 hours ago and has a
pressure dressing to his left groin. In addition to taking routine vital signs, the nurse should
also check the:

a. strength of the femoral pulse.

b. presence of the pedal pulse.
c. temperature of the right foot.
d. ability to move the left toes.

ANS: B

Pedal pulses are checked to determine whether there is any blockage in the artery following
a cardiac catheterization.

DIF: Cognitive Level: Application REF: p. 351 OBJ: Clinical Practice #7

TOP: Pedal Pulse KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: basic care and comfort

22. The accuracy in measuring the apical pulse is enhanced when the nurse:
a. counts the radial pulse at the same time.
b. counts the beats for one minute.
c. keeps the patient warm.
d. uses the bell of the stethoscope.

ANS: B

Using the diaphragm of the stethoscope, the nurse counts the beats for 1 full minute.

DIF: Cognitive Level: Application REF: p. 350, Skill 21-4

OBJ: Clinical Practice #2 TOP: Counting Apical Pulse

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: basic care and comfort

23.A 45-year-old patient who is alert and oriented has a blood pressure of 98/66 mm Hg, radial
pulse of 76 beats/min (irregular), and respirations of 18 breaths/min (regular). The best nursing
intervention is to:

a. notify the charge nurse of the hypotension.

b. notify the doctor of the bradycardia.
c. check medications that might be the cause of the irregularity.
d. check the patient’s record to determine his baseline blood pressure.

ANS: D

Check to see what the patient’s baseline vital signs indicate regarding the cardiac arrhythmia.

DIF: Cognitive Level: Application REF: p. 350, Skill 21-4

OBJ: Clinical Practice #6 TOP: Vital Signs

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: basic care and comfort

24.A nurse is caring for a patient with a cardiac disease history. When measuring vital signs,
the nurse finds that the radial pulse is 102 beats/min and irregular. The nurse correctly:

a. listens to the apical pulse for 1 full minute.

b. takes the pulse for 30 seconds on the other wrist.
c. records the findings on the graphic sheet.
d. takes the pulse for 1 full minute on the other wrist.

ANS: A

An apical pulse is measured whenever the radial pulse is irregular or when the patient has a
cardiac disease history.

DIF: Cognitive Level: Application REF: p. 358, Skill 21-6

OBJ: Clinical Practice #2 TOP: Vital Signs: Pulse

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: basic care and comfort

25.The nurse caring for a 30-year-old postsurgical patient would assess that the patient is in
pain as indicated by:

a. a temperature of 102° F.
b. respirations of 16 breaths/min.
c. a pulse rate of 120 beats/min.
d. blood pressure of 128/86 mm Hg.

ANS: C

Pain increases the pulse rate.

DIF: Cognitive Level: Application REF: p. 351, Table 21-2

OBJ: Theory #2 TOP: Vital Signs KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: basic care and comfort

26.The nurse explains that one method of environmental heat loss is convection, which is
exemplified by body heat being reduced by:

a. being transferred to ice packs.

b. production of sweat.
c. being removed by fast air currents from a fan.
d. exposure to a cool environment.

ANS: C

Heat loss through convection can be accomplished by the use of a fan, which produces fast
air currents.

DIF: Cognitive Level: Comprehension REF: p. 335 OBJ: Theory #1

TOP: Heat Loss by Convection KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: physiological adaptation

The home health nurse is instructing a caregiver about caring for a patient with hypothermia.
27.
The nurse recognizes that further instruction is warranted when the caregiver states, “I will:

a. offer warm fluids to the patient, if permitted.”

b. instruct the patient to remain on strict bed rest.”
c. provide the patient with additional blankets.”
d. encourage the patient to increase his muscle activity.”

ANS: B

Nursing activities for treating the patient with a below-normal body temperature should focus
on reducing heat loss and supplying additional warmth. These activities may include (1)
providing additional clothing or blankets for warmth (an electric blanket is most effective for
raising temperature); (2) giving warm fluids, if permitted; (3) adjusting the temperature of the
room to 72 F or higher; (4) eliminating drafts; and (5) increasing the patient’s muscle activity.

DIF: Cognitive Level: Analysis REF: p. 341 OBJ: Theory #3

TOP: Vital Signs: Hypothermia KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: basic care and comfort

COMPLETION

28. The nurse clarifies the average cardiac output in the adult is about _____ L/minute.

ANS:

five
The average cardiac output of the normal adult is about 5 L/minute.

DIF: Cognitive Level: Knowledge REF: p. 337 OBJ: Theory #2

TOP: Cardiac Output KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: physiological adaptation

29. The nurse converts the Fahrenheit temperature of 99.2° to a Celsius reading of ______°.

ANS:

37.3

To convert Fahrenheit to Celsius: subtract 32 from the Fahrenheit reading and multiply by 5/9:
99.2 – 32 = 67.2  5 = 336 / 9 = 37.3.

DIF: Cognitive Level: Analysis REF: p. 338, Table 21-1

OBJ: Clinical Practice #1 TOP: Conversion of Fahrenheit to Celsius

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: basic care and comfort

MULTIPLE RESPONSE

30.Standards of the Joint Commission state that pain is the fifth vital sign and should
be documented by assessments of: (Select all that apply.)

a. location.
b. duration.
c. usual methods of relief.
d. character.
e. intensity.

ANS: A, B, D, E

Pain should be monitored when vital signs are monitored, to closely assess for any cardiac
changes. Pain is documented by assessments relative to location, intensity, character, frequency,
and duration.

DIF: Cognitive Level: Application REF: p. 362 OBJ: Theory #7

TOP: Pain Assessment KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: basic care and comfort

31.The nurse would refrain from applying a blood pressure cuff on the affected arm of a patient
who has a: (Select all that apply.)

a. previous mastectomy.
b. patent IV line.
c. injured hand.
d. 2-year-old hand amputation.
e. dialysis shunt.

ANS: A, B, E

Arms affected by previous mastectomies, patent IVs, or dialysis shunts should not be used to
assess the blood pressure using an inflatable cuff.

DIF: Cognitive Level: Application REF: p. 358, Skill 21-6

OBJ: Clinical Practice #4

TOP: Contraindications for Blood Pressure Cuff Application

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: basic care and comfort

32.The nurse assesses that the 86-year-old patient is experiencing orthostatic hypotension when
assessments indicate: (Select all that apply.)

a. dizziness upon rising to a standing position.

b. a drop of 15 to 20 mm Hg from baseline when changing position.
c. nausea.
d. syncope.
e. blurred vision.

ANS: A, B, D, E

Assessment of dizziness, drop in up to 20 mm Hg from baseline BP, syncope, and blurred vision
are all indicative of orthostatic hypotension.

DIF: Cognitive Level: Application REF: p. 362 OBJ: Clinical Practice #6

TOP: Orthostatic Hypotension KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: physiological adaptation