.Fundamentals Final Reviewer Test bank - Questions
and Answers Vital Signs
MULTIPLE CHOICE
1. A nurse notes a patient has abnormal vital signs. What action by the nurse is best?
c. Compare with prior readings.
2. A patient returned from a procedure and has vital sign measurements ordered every hour. The
patient’s blood pressure has dropped from 132/82 mm Hg an hour ago to 90/66 mm Hg.
What action by the nurse is most appropriate?
d. Plan to take the vital signs more often.
3. A nurse is told in the hand-off report that a patient is afebrile. What assessment finding
correlates with this statement?
b. Temperature 98.4° F (36.8° C)
4. A nurse is caring for a patient who has a high temperature. The nurse plans to help the
patient regain a normal temperature through conduction. What technique does the nurse use?
b. Putting ice packs in the patient’s axillae
5. A nurse is going to take a patient’s oral temperature. The patient has been drinking coffee.
What action by the nurse is best?
b. Return in 30 minutes to take the patient’s temperature.
6. A nurse observes a student taking an adult patient’s tympanic temperature. What action by
the student requires the nurse to intervene?
b. Student pulls the pinna of the patient’s ear down and back
7. A nurse assesses a patient’s radial pulse rate to be 110 beats/min and regular. What action by
the nurse is best?
a. Assess the patient for causes of tachycardia.
8. The student nurse is assessing a patient’s pulses. What action by the student requires the nurse
to intervene?
b. Assessing the doralis pedis pulse by palpating behind the patient’s knee
9. The nurse assesses a patient’s pulse and finds it hard to obliterate with palpation. What action
by the nurse is best?
a. Assess the patient for fluid volume overload.
,.Fundamentals Final Reviewer Test bank - Questions
and Answers Vital Signs
10. The nursing faculty member is observing a student taking a patient’s carotid pulse. What
action by the student requires intervention by the faculty member?
c. Compares pulses in both carotid arteries at the same time.
11. A nurse is caring for a patient who has orthopnea. What action by the nurse is most appropriate?
c. Keep the head of the bed elevated.
12. The nurse has applied a pulse oximeter to the finger of a patient who is hypothermic. The
pulse oximeter does not provide a good reading. What action by the nurse is best?
b. Assess the fingers for good circulation.
13. A patient’s blood pressure is 142/76 mm Hg. What does the nurse chart as the pulse pressure?
d. 66
14. A nurse performs orthostatic blood pressure readings on a patient with the following
results: lying 148/76 mm Hg, standing 110/60 mm Hg. What action by the nurse is best?
a. Instruct the patient not to get up without help.
15. The nurse is caring for a woman who had a right-sided mastectomy 2 years ago. What action
by the nurse is most appropriate?
a. Place a sign above the bed: “No blood pressures on the right arm.”
16. A nurse works on a postoperative care unit and sees many patients who have orthopedic surgery.
One patient complains of significantly more pain than the other postoperative patients usually
do. What action by the nurse is best?
b. Ask the patient to rate and describe the pain.
17. The nurse receives a handoff report on four patients. Which patient should the nurse assess first?
c. Pulse 42 beats/min
18. A nursing student is caring for a patient with metabolic acidosis. The student asks the
registered nurse why the patient’s respiratory rate is so high. What response by the nurse is
best?
b. “The lungs are trying to rid the body of
extra carbon dioxide.”
1. The nursing student learns that the purpose of measuring vital signs includes which
rationale? (Select all that apply.)
,.Fundamentals Final Reviewer Test bank - Questions
and Answers Vital Signs
a. Monitor body systems functioning.
b. Identify early signs of problems.
c. Evaluate effectiveness of interventions.
e. Provide a baseline to compare against.
ANS: A, B, C, E
2. The nurse is delegating taking vital signs to an unlicensed assistive personnel (UAP).
What instructions does the nurse provide the UAP? (Select all that apply.)
b. “Take Mrs. Jones’ blood pressure every 15 minutes.”
c. “Call me if Ms. Walsh’s systolic blood pressure drops to under 100 mm Hg.”
d. “Do you want me to demonstrate using the electronic blood pressure cuff?”
e. “I’ll take Mr. Derby’s blood pressure since he is not stable.”
3. The nurse understands that which factors can increase blood pressure? (Select all that apply.)
a. Head injury
c. Increasing age
d. Recent food intake
e. Pain
4. The nurse assessing respirations understands that problems in what organs can directly affect
the process of respiration? (Select all that apply.)
a. Brain
b. Lungs
c. Heart
5. A nurse is teaching a patient and the patient’s family about self-care measures for
hypertension. Which topics does the nurse include? (Select all that apply.)
b. Maintain a normal body weight
d. Reduce dietary sodium to 2.4 g/day
e. Follow the DASH diet
6. Which parameters does the nurse include when assessing pain? (Select all that apply.)
a. Facial expression
c. Shallow respirations
, .Fundamentals Final Reviewer Test bank - Questions
and Answers Vital Signs
d. Immobility
7. A nurse is caring for an unconscious patient. What objective assessments does the nurse use
to help evaluate pain in this patient? (Select all that apply.)
a. Agitation
b. Restlessness
d. Vital signs
Health History and Physical Assessment
1. A nurse is conducting a physical assessment in a clinic with a partly undressed patient. What
action by the nurse is most appropriate?
b. Provide a method for ensuring the patient stays warm.
2. A patient wishes to review his medical record. What response by the nurse is best?
c. “Yes, I can sit with you while you look at it so you can ask questions.”
3. A clinic nurse is examining an older, confused patient on an examination table and realizes a piece
of needed equipment was left outside in the hall. What action by the nurse is best?
b. Call for another staff member to bring the equipment.
4.A student nurse is preparing to auscultate a patient’s lungs. What action by the student leads the instructor
to intervene?
c. Student uses the stethoscope bell to listen to bowel sounds.
5. The nurse is assessing a patient’s alcohol intake. What question is most appropriate?
d. “How much alcohol do you drink daily?”
6. The nurse is planning to educate four patients on preventing skin cancer and early warning
signs. Which patient is the priority for this education?
a. Adolescent who uses a tanning bed
7. A nurse has assessed a patient’s capillary refill, which was 5 seconds. What action by the nurse
is most appropriate?
d. Assess the patient for signs of hypoxia.
and Answers Vital Signs
MULTIPLE CHOICE
1. A nurse notes a patient has abnormal vital signs. What action by the nurse is best?
c. Compare with prior readings.
2. A patient returned from a procedure and has vital sign measurements ordered every hour. The
patient’s blood pressure has dropped from 132/82 mm Hg an hour ago to 90/66 mm Hg.
What action by the nurse is most appropriate?
d. Plan to take the vital signs more often.
3. A nurse is told in the hand-off report that a patient is afebrile. What assessment finding
correlates with this statement?
b. Temperature 98.4° F (36.8° C)
4. A nurse is caring for a patient who has a high temperature. The nurse plans to help the
patient regain a normal temperature through conduction. What technique does the nurse use?
b. Putting ice packs in the patient’s axillae
5. A nurse is going to take a patient’s oral temperature. The patient has been drinking coffee.
What action by the nurse is best?
b. Return in 30 minutes to take the patient’s temperature.
6. A nurse observes a student taking an adult patient’s tympanic temperature. What action by
the student requires the nurse to intervene?
b. Student pulls the pinna of the patient’s ear down and back
7. A nurse assesses a patient’s radial pulse rate to be 110 beats/min and regular. What action by
the nurse is best?
a. Assess the patient for causes of tachycardia.
8. The student nurse is assessing a patient’s pulses. What action by the student requires the nurse
to intervene?
b. Assessing the doralis pedis pulse by palpating behind the patient’s knee
9. The nurse assesses a patient’s pulse and finds it hard to obliterate with palpation. What action
by the nurse is best?
a. Assess the patient for fluid volume overload.
,.Fundamentals Final Reviewer Test bank - Questions
and Answers Vital Signs
10. The nursing faculty member is observing a student taking a patient’s carotid pulse. What
action by the student requires intervention by the faculty member?
c. Compares pulses in both carotid arteries at the same time.
11. A nurse is caring for a patient who has orthopnea. What action by the nurse is most appropriate?
c. Keep the head of the bed elevated.
12. The nurse has applied a pulse oximeter to the finger of a patient who is hypothermic. The
pulse oximeter does not provide a good reading. What action by the nurse is best?
b. Assess the fingers for good circulation.
13. A patient’s blood pressure is 142/76 mm Hg. What does the nurse chart as the pulse pressure?
d. 66
14. A nurse performs orthostatic blood pressure readings on a patient with the following
results: lying 148/76 mm Hg, standing 110/60 mm Hg. What action by the nurse is best?
a. Instruct the patient not to get up without help.
15. The nurse is caring for a woman who had a right-sided mastectomy 2 years ago. What action
by the nurse is most appropriate?
a. Place a sign above the bed: “No blood pressures on the right arm.”
16. A nurse works on a postoperative care unit and sees many patients who have orthopedic surgery.
One patient complains of significantly more pain than the other postoperative patients usually
do. What action by the nurse is best?
b. Ask the patient to rate and describe the pain.
17. The nurse receives a handoff report on four patients. Which patient should the nurse assess first?
c. Pulse 42 beats/min
18. A nursing student is caring for a patient with metabolic acidosis. The student asks the
registered nurse why the patient’s respiratory rate is so high. What response by the nurse is
best?
b. “The lungs are trying to rid the body of
extra carbon dioxide.”
1. The nursing student learns that the purpose of measuring vital signs includes which
rationale? (Select all that apply.)
,.Fundamentals Final Reviewer Test bank - Questions
and Answers Vital Signs
a. Monitor body systems functioning.
b. Identify early signs of problems.
c. Evaluate effectiveness of interventions.
e. Provide a baseline to compare against.
ANS: A, B, C, E
2. The nurse is delegating taking vital signs to an unlicensed assistive personnel (UAP).
What instructions does the nurse provide the UAP? (Select all that apply.)
b. “Take Mrs. Jones’ blood pressure every 15 minutes.”
c. “Call me if Ms. Walsh’s systolic blood pressure drops to under 100 mm Hg.”
d. “Do you want me to demonstrate using the electronic blood pressure cuff?”
e. “I’ll take Mr. Derby’s blood pressure since he is not stable.”
3. The nurse understands that which factors can increase blood pressure? (Select all that apply.)
a. Head injury
c. Increasing age
d. Recent food intake
e. Pain
4. The nurse assessing respirations understands that problems in what organs can directly affect
the process of respiration? (Select all that apply.)
a. Brain
b. Lungs
c. Heart
5. A nurse is teaching a patient and the patient’s family about self-care measures for
hypertension. Which topics does the nurse include? (Select all that apply.)
b. Maintain a normal body weight
d. Reduce dietary sodium to 2.4 g/day
e. Follow the DASH diet
6. Which parameters does the nurse include when assessing pain? (Select all that apply.)
a. Facial expression
c. Shallow respirations
, .Fundamentals Final Reviewer Test bank - Questions
and Answers Vital Signs
d. Immobility
7. A nurse is caring for an unconscious patient. What objective assessments does the nurse use
to help evaluate pain in this patient? (Select all that apply.)
a. Agitation
b. Restlessness
d. Vital signs
Health History and Physical Assessment
1. A nurse is conducting a physical assessment in a clinic with a partly undressed patient. What
action by the nurse is most appropriate?
b. Provide a method for ensuring the patient stays warm.
2. A patient wishes to review his medical record. What response by the nurse is best?
c. “Yes, I can sit with you while you look at it so you can ask questions.”
3. A clinic nurse is examining an older, confused patient on an examination table and realizes a piece
of needed equipment was left outside in the hall. What action by the nurse is best?
b. Call for another staff member to bring the equipment.
4.A student nurse is preparing to auscultate a patient’s lungs. What action by the student leads the instructor
to intervene?
c. Student uses the stethoscope bell to listen to bowel sounds.
5. The nurse is assessing a patient’s alcohol intake. What question is most appropriate?
d. “How much alcohol do you drink daily?”
6. The nurse is planning to educate four patients on preventing skin cancer and early warning
signs. Which patient is the priority for this education?
a. Adolescent who uses a tanning bed
7. A nurse has assessed a patient’s capillary refill, which was 5 seconds. What action by the nurse
is most appropriate?
d. Assess the patient for signs of hypoxia.
