Chapter 11: Vital Signs
Fundamental Nursing Skills and Concepts 12th Edition, Timby
MULTIPLE CHOICE
1. 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 Fowlers 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: d. 361, Elder Care OBJ:
Theory #2 TOP: Orthostatic Hypotension KEY: Nursing Process
Step: Planning MSC: NCLEX: Safe Effective Care
Environment: safety and infection control
2. An elderly patient has a tympanic temperature of 96.2 F (35.7 C). What nursing
intervention would best meet this patients need?
a. Take the patients 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: d. 341 OBJ: Theory #3
TOP: Vital Signs: Temperature KEY: Nursing Process
Step: Implementation MSC: NCLEX: Physiological Integrity:
basic care and comfort
3. 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: d 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
4. 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 patients chest rise and fall from a distance.
d. continue to hold the patients radial pulse, and count the respirations for 30 seconds
and multiply them
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: d 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
5. Elderly patients with hypertension may have an auscultatory gap in their Korotkoff
sounds. Itis 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: d 360 OBJ: Theory #6
TOP: Vital Signs in the Elderly KEY: Nursing Process
Step: Assessment MSC: NCLEX: Physiological Integrity: basic
care and comfort
6. 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: d 360 OBJ: Clinical Practice #4
TOP: Vital Signs in Children KEY: Nursing Process
Step: Assessment MSC: NCLEX: Physiological Integrity: basic
care and comfort
,7. The nurse covers a new-born babys 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: d 341, Elder Care OBJ:
Theory #3 TOP: Vital Signs: Infant Temperature KEY: Nursing
Process Step: Implementation MSC: NCLEX: Physiological
Integrity: basic care and comfort
8. 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: d 351 OBJ: Clinical Practice #7
TOP: Pedal Pulse KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: basic care and comfort
9. 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: d 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
10. 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 patients record to determine his baseline blood pressure.
, ANS: D
Check to see what the patients baseline vital signs indicate regarding the cardiac
arrhythmia.
DIF: Cognitive Level: Application REF: d 350, Skill 21-4 OBJ:
Clinical Practice #6 TOP: Vital Signs KEY: Nursing Process
Step: Implementation MSC: NCLEX: Physiological Integrity:
basic care and comfort
11. 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: d 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
12. 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: d 351, Table 21-2
OBJ: Theory #2 TOP: Vital Signs KEY: Nursing Process
Step: Assessment MSC: NCLEX: Physiological Integrity: basic
care and comfort
13. A patient has been admitted with hypothermia after lying unconscious overnight in a nun-
heated apartment. The most appropriate route to assess the patients 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: d. 339 OBJ: Theory #3 | Clinical
Practice #1 TOP: Vital Signs: Temperature KEY: Nursing Process
Fundamental Nursing Skills and Concepts 12th Edition, Timby
MULTIPLE CHOICE
1. 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 Fowlers 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: d. 361, Elder Care OBJ:
Theory #2 TOP: Orthostatic Hypotension KEY: Nursing Process
Step: Planning MSC: NCLEX: Safe Effective Care
Environment: safety and infection control
2. An elderly patient has a tympanic temperature of 96.2 F (35.7 C). What nursing
intervention would best meet this patients need?
a. Take the patients 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: d. 341 OBJ: Theory #3
TOP: Vital Signs: Temperature KEY: Nursing Process
Step: Implementation MSC: NCLEX: Physiological Integrity:
basic care and comfort
3. 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: d 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
4. 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 patients chest rise and fall from a distance.
d. continue to hold the patients radial pulse, and count the respirations for 30 seconds
and multiply them
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: d 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
5. Elderly patients with hypertension may have an auscultatory gap in their Korotkoff
sounds. Itis 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: d 360 OBJ: Theory #6
TOP: Vital Signs in the Elderly KEY: Nursing Process
Step: Assessment MSC: NCLEX: Physiological Integrity: basic
care and comfort
6. 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: d 360 OBJ: Clinical Practice #4
TOP: Vital Signs in Children KEY: Nursing Process
Step: Assessment MSC: NCLEX: Physiological Integrity: basic
care and comfort
,7. The nurse covers a new-born babys 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: d 341, Elder Care OBJ:
Theory #3 TOP: Vital Signs: Infant Temperature KEY: Nursing
Process Step: Implementation MSC: NCLEX: Physiological
Integrity: basic care and comfort
8. 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: d 351 OBJ: Clinical Practice #7
TOP: Pedal Pulse KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: basic care and comfort
9. 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: d 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
10. 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 patients record to determine his baseline blood pressure.
, ANS: D
Check to see what the patients baseline vital signs indicate regarding the cardiac
arrhythmia.
DIF: Cognitive Level: Application REF: d 350, Skill 21-4 OBJ:
Clinical Practice #6 TOP: Vital Signs KEY: Nursing Process
Step: Implementation MSC: NCLEX: Physiological Integrity:
basic care and comfort
11. 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: d 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
12. 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: d 351, Table 21-2
OBJ: Theory #2 TOP: Vital Signs KEY: Nursing Process
Step: Assessment MSC: NCLEX: Physiological Integrity: basic
care and comfort
13. A patient has been admitted with hypothermia after lying unconscious overnight in a nun-
heated apartment. The most appropriate route to assess the patients 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: d. 339 OBJ: Theory #3 | Clinical
Practice #1 TOP: Vital Signs: Temperature KEY: Nursing Process
