NR 224 Nursing Skills Edapts -Vital Signs
Exam 2026/2027|AView of 150 Real Past
Papers Questions with Answers with
Rationales|(New!) Already Graded A+
1. The nurse is obtaining a client's vital signs. In order to ensure accurate results, which
actions would the nurse need to complete? Select all that apply.
-Use careful technique.
-Use only vital signs to provide the basis for problem solving.
-Assess vital signs at the same time at set intervals.
-Use cues obtained from vital signs in addition to nursing assessment to deter-
mine the response to an intervention.
-Use cues obtained from vital signs in addition to nursing assessment to identify
priority hypotheses and to generate solutions.
-Obtain the vital signs at the beginning of the nursing assessment.
-Use only vital signs as the basis for indications of body functioning.: -Obtain the
vital signs at the beginning of the nursing assessment.
-Assess vital signs at the same time at set intervals.
-Use cues obtained from vital signs in addition to nursing assessment to determine
the response to an intervention.
-Use cues obtained from vital signs in addition to nursing assessment to identify
priority hypotheses and to generate solutions.
-Use careful technique.
2. There are many causes for abnormal vital signs upon which the nurse can act. Match
each possible nursing diagnosis to a possible cause for the diagnosis.
-Acute pain
-Ineffective peripheral tissue perfusion
-Anxiety
-Decreased cardiac output
-Impaired gas exchange
Word Bank:
-Increased pulse rate
-Ineffective, rapid respirations
-Postoperative surgical procedure
-Decreased pulse oximetry
-Low heart rate: -Postoperative surgical procedure
-Decreased pulse oximetry
,-Increased pulse rate
-Low heart rate
-In-effective, rapid respirations
3. The nurse is documenting the client's vital signs following the nursing assessment.
The electronic health record (EHR) triggers an alert based on these findings. Which
statements are true? Select all that apply.
-The nurse must notify the healthcare provider immediately.
-Further investigation is necessary based on the alert triggered.
-The early warning scores (EWS) system is often triggered incorrectly, and the nurse
should ignore the warning.
-The early warning scores (EWS) system has identified a subtle change in the
client's condition.: -The early warning scores (EWS) system has identified a subtle
change in the client's condition.
-Further investigation is necessary based on the alert triggered.
4. In which scenario below will radiant heat loss occur?
-Client is sweating moderately
-A cool surgical room while the client's skin is exposed
-Removing a client's clothing or blankets
-A person using a fan to cool down: A cool surgical room while the client's skin is
exposed
5. Which statements are true regarding the treatment of fever? Select all that apply.
-It is important to avoid causing shivering when treating a fever.
-When a client with a fever begins to shiver, it is a sign that the fever is beginning to
resolve.
-Shivering greatly increases heat production; however, it is counterproductive in a
client with a fever.
-Fever is best treated by the use of a tepid sponge bath.: -It is important to avoid
causing shivering when treating a fever.
-Shivering greatly increases heat production; however, it is counterproductive in a
client with a fever.
6. The nurse should understand that which statement about use of a tympanic
thermometer for routine screening is true?
-Tympanic measurements are more accurate than oral, axillary, and rectal
measurements.
-Tympanic thermometers provide a reading very quickly.
-Tympanic thermometer measurements are influenced by environmental
temperatures
-Tympanic thermometer measurements are reflective of body surface temperature.: -
Tympanic thermometers provide a reading very quickly.
,7. Thermoregulation
The nurse is completing a nursing assessment on Tom (preferred pronouns: he, him, his)
and notes Tom's oral temperature is 103° F (39.5° C) and his forehead is cool and
moist when touched. Based on prior knowledge, the nurse understands that:
The optimal adult temperature range is (36° to 38°C37° to 39°C. )
Tom's current temperature along with the fact that he is perspiring indicates his
temperature is (elevated or normal), and the perspiration is his body's attempt to
(maintain or decrease) his temperature by means of (radiant, conductive,
convective, or evaporative) heat (loss or production.): 36 - 38C
elevated decrease
evaporative loss
Select the cues that the nurse should recognize as normal and relevant to
the client's thermoregulation.
8. The nurse is completing a nursing assessment on Rebecca (preferred pro- nouns:
she, her), an 80-year-old woman, at the beginning of the day shift. The nurse assesses a
set of vital signs at 0700 including a core body temperature reading of 35.2⁰C. The
nurse also obtains an oral temperature to verify the first result and obtains a reading of
36.3°C. Rebecca is alert and oriented, her skin is warm to touch and mucous
membranes are pink.: -vital signs at 0700
-core body temperature reading of 35.2C
-obtains an oral temperature
-a reading of 36.3C
-warm to touch
-mucous membranes are pink
Match the type of elevated body temperature with the data collected upon
admission.
Elevated Body Temperature/Cue:
Pyrexia Hyperthermia Heatstroke
Heat Exhaustion
Word Bank:
-Discovery of disease in the hypothalamus
-Exposure to someone with Influenza A
-Sweat through t-shirt and shorts
-No sweating observed: -Exposure to someone with Influenza A
-Discovery of disease in the hypothalamus
-No sweating observed
-Sweat through t-shirt and shorts
, The nurse is assessing the client's (preferred pronouns: he, his, him) vital signs. He
is a 35-year-old man who has recently had surgery and is now alert, oriented and taking
sips of water easily, but is perspiring some on his
forehead. The client still has a skin thermometer in place on his forehead from
post-operation. Based on this knowledge, the nurse should assess the client's
temperature using which of the following thermometers and sites? Choose the
correct site and rationale.: -Site: Oral electronic thermometer 30 minutes after last
drink
-Rationale: Easily accessible, comfortable for the client, accurate
The nurse on a medical-surgical unit measures the temperature using an infrared
thermometer that measures cutaneous blood temperatures across the forehead and
behind the ear. Which type of thermometer is being used?
-Skin thermometer strip
-Tympanic membrane
-Superficial temporal artery
-Indwelling pulmonary artery: -Superficial temporal artery
Nursing Interventions
An adult client with a history of cardiovascular disease has been admitted to the hospital
with an oral temperature of 103.4 °F (39.8 °C). Which interventions should the nurse
anticipate implementing? Select all that apply.
-Hourly assessment of vital signs
-Decrease fluid intake
-Administer prescribed antipyretic medication
-Obtain sputum, blood, and urine cultures
-Maintain nothing by mouth (NPO): -Administer prescribed antipyretic medication
-Obtain sputum, blood, and urine cultures
-Hourly assessment of vital signs
After obtaining a set of vital signs on a client, the nurse determines that the
results are abnormal for this client. Which factors may have impacted the client's
vital signs?: -The client just returned from a walk in the hallway.
-The client's room is very warm.
-The blood pressure (BP) cut used by the nurse might have been too small.
The nurse is measuring vital signs on a pediatric client. When analyzing the data
obtained, the nurse considers that, compared with adults, children tend to have
which of the following?
Select all that apply.
-Lower respiratory rates than adults
-Higher blood pressure than adults
-Higher respiratory rate than adults
Exam 2026/2027|AView of 150 Real Past
Papers Questions with Answers with
Rationales|(New!) Already Graded A+
1. The nurse is obtaining a client's vital signs. In order to ensure accurate results, which
actions would the nurse need to complete? Select all that apply.
-Use careful technique.
-Use only vital signs to provide the basis for problem solving.
-Assess vital signs at the same time at set intervals.
-Use cues obtained from vital signs in addition to nursing assessment to deter-
mine the response to an intervention.
-Use cues obtained from vital signs in addition to nursing assessment to identify
priority hypotheses and to generate solutions.
-Obtain the vital signs at the beginning of the nursing assessment.
-Use only vital signs as the basis for indications of body functioning.: -Obtain the
vital signs at the beginning of the nursing assessment.
-Assess vital signs at the same time at set intervals.
-Use cues obtained from vital signs in addition to nursing assessment to determine
the response to an intervention.
-Use cues obtained from vital signs in addition to nursing assessment to identify
priority hypotheses and to generate solutions.
-Use careful technique.
2. There are many causes for abnormal vital signs upon which the nurse can act. Match
each possible nursing diagnosis to a possible cause for the diagnosis.
-Acute pain
-Ineffective peripheral tissue perfusion
-Anxiety
-Decreased cardiac output
-Impaired gas exchange
Word Bank:
-Increased pulse rate
-Ineffective, rapid respirations
-Postoperative surgical procedure
-Decreased pulse oximetry
-Low heart rate: -Postoperative surgical procedure
-Decreased pulse oximetry
,-Increased pulse rate
-Low heart rate
-In-effective, rapid respirations
3. The nurse is documenting the client's vital signs following the nursing assessment.
The electronic health record (EHR) triggers an alert based on these findings. Which
statements are true? Select all that apply.
-The nurse must notify the healthcare provider immediately.
-Further investigation is necessary based on the alert triggered.
-The early warning scores (EWS) system is often triggered incorrectly, and the nurse
should ignore the warning.
-The early warning scores (EWS) system has identified a subtle change in the
client's condition.: -The early warning scores (EWS) system has identified a subtle
change in the client's condition.
-Further investigation is necessary based on the alert triggered.
4. In which scenario below will radiant heat loss occur?
-Client is sweating moderately
-A cool surgical room while the client's skin is exposed
-Removing a client's clothing or blankets
-A person using a fan to cool down: A cool surgical room while the client's skin is
exposed
5. Which statements are true regarding the treatment of fever? Select all that apply.
-It is important to avoid causing shivering when treating a fever.
-When a client with a fever begins to shiver, it is a sign that the fever is beginning to
resolve.
-Shivering greatly increases heat production; however, it is counterproductive in a
client with a fever.
-Fever is best treated by the use of a tepid sponge bath.: -It is important to avoid
causing shivering when treating a fever.
-Shivering greatly increases heat production; however, it is counterproductive in a
client with a fever.
6. The nurse should understand that which statement about use of a tympanic
thermometer for routine screening is true?
-Tympanic measurements are more accurate than oral, axillary, and rectal
measurements.
-Tympanic thermometers provide a reading very quickly.
-Tympanic thermometer measurements are influenced by environmental
temperatures
-Tympanic thermometer measurements are reflective of body surface temperature.: -
Tympanic thermometers provide a reading very quickly.
,7. Thermoregulation
The nurse is completing a nursing assessment on Tom (preferred pronouns: he, him, his)
and notes Tom's oral temperature is 103° F (39.5° C) and his forehead is cool and
moist when touched. Based on prior knowledge, the nurse understands that:
The optimal adult temperature range is (36° to 38°C37° to 39°C. )
Tom's current temperature along with the fact that he is perspiring indicates his
temperature is (elevated or normal), and the perspiration is his body's attempt to
(maintain or decrease) his temperature by means of (radiant, conductive,
convective, or evaporative) heat (loss or production.): 36 - 38C
elevated decrease
evaporative loss
Select the cues that the nurse should recognize as normal and relevant to
the client's thermoregulation.
8. The nurse is completing a nursing assessment on Rebecca (preferred pro- nouns:
she, her), an 80-year-old woman, at the beginning of the day shift. The nurse assesses a
set of vital signs at 0700 including a core body temperature reading of 35.2⁰C. The
nurse also obtains an oral temperature to verify the first result and obtains a reading of
36.3°C. Rebecca is alert and oriented, her skin is warm to touch and mucous
membranes are pink.: -vital signs at 0700
-core body temperature reading of 35.2C
-obtains an oral temperature
-a reading of 36.3C
-warm to touch
-mucous membranes are pink
Match the type of elevated body temperature with the data collected upon
admission.
Elevated Body Temperature/Cue:
Pyrexia Hyperthermia Heatstroke
Heat Exhaustion
Word Bank:
-Discovery of disease in the hypothalamus
-Exposure to someone with Influenza A
-Sweat through t-shirt and shorts
-No sweating observed: -Exposure to someone with Influenza A
-Discovery of disease in the hypothalamus
-No sweating observed
-Sweat through t-shirt and shorts
, The nurse is assessing the client's (preferred pronouns: he, his, him) vital signs. He
is a 35-year-old man who has recently had surgery and is now alert, oriented and taking
sips of water easily, but is perspiring some on his
forehead. The client still has a skin thermometer in place on his forehead from
post-operation. Based on this knowledge, the nurse should assess the client's
temperature using which of the following thermometers and sites? Choose the
correct site and rationale.: -Site: Oral electronic thermometer 30 minutes after last
drink
-Rationale: Easily accessible, comfortable for the client, accurate
The nurse on a medical-surgical unit measures the temperature using an infrared
thermometer that measures cutaneous blood temperatures across the forehead and
behind the ear. Which type of thermometer is being used?
-Skin thermometer strip
-Tympanic membrane
-Superficial temporal artery
-Indwelling pulmonary artery: -Superficial temporal artery
Nursing Interventions
An adult client with a history of cardiovascular disease has been admitted to the hospital
with an oral temperature of 103.4 °F (39.8 °C). Which interventions should the nurse
anticipate implementing? Select all that apply.
-Hourly assessment of vital signs
-Decrease fluid intake
-Administer prescribed antipyretic medication
-Obtain sputum, blood, and urine cultures
-Maintain nothing by mouth (NPO): -Administer prescribed antipyretic medication
-Obtain sputum, blood, and urine cultures
-Hourly assessment of vital signs
After obtaining a set of vital signs on a client, the nurse determines that the
results are abnormal for this client. Which factors may have impacted the client's
vital signs?: -The client just returned from a walk in the hallway.
-The client's room is very warm.
-The blood pressure (BP) cut used by the nurse might have been too small.
The nurse is measuring vital signs on a pediatric client. When analyzing the data
obtained, the nurse considers that, compared with adults, children tend to have
which of the following?
Select all that apply.
-Lower respiratory rates than adults
-Higher blood pressure than adults
-Higher respiratory rate than adults
