C HAPTER 4: B EGINNING THE P HYSICAL
E XAMINATION : G ENERAL S URVEY , V ITAL
S IGNS , AND P AIN
MULTIPLE CHOICE
1. Which of these actions illustrates the correct technique the nurse should
use when assessing oral temperature with a mercury thermometer?
a. Wait 30 minutes if the patient has ingested hot or iced liquids.
b. Leave the thermometer in place 3 to 4 minutes if the patient is
afebrile.
c. Place the thermometer in front of the tongue, and ask the patient to
close his or her lips.
d. Shake the mercury-in-glass thermometer down to below 36.6 C
before taking the temperature.
ANS: B
The thermometer should be left in place 3 to 4 minutes if the person is
afebrile and up to 8 minutes if the pe rson is febrile. The nurse should
wait 15 minutes if the person has just ingested hot or iced liquids and 2
minutes if he or she has just smoked.
DIF: Cognitive Level: Appl ying (Application) REF: p. 133 MSC:
Client Needs: Safe and Effective Care Environm ent: Management of
Care
,2. The nurse is taking temperatures in a clinic with a TMT. Which statement
is true regarding use of the TMT?
a. A t ympanic temperature is more time consuming than a rectal
temperature.
b. The t ympanic method is more invasive and uncomforta ble than the
oral method.
c. The risk of cross -contamination is reduced, compared with the
rectal route.
d. The t ympanic membrane most accuratel y reflects the temperature in
the ophthalmic artery.
ANS: C
The TMT is a non -invasive, nontraumatic device that is e xtremel y
quick and efficient. The chance of cross -contamination with the TMT
is minimal because the ear canal is lined with skin, not mucous
membranes.
DIF: Cognitive Level: Understanding (Comprehension) REF: p. 134
MSC: Client Needs: Safe and Effective Care Environment:
Management of Care
3. To assess a rectal temperature accuratel y in an adult, the nurse would:
a. Use a lubricated blunt tip thermometer.
b. Insert the thermometer 2 to 3 inches into the rectum.
c. Leave the thermometer in place up to 8 minutes i f the patient is
febrile.
d. Wait 2 to 3 minutes if the patient has recentl y smoked a cigarette.
ANS: A
, A lubricated rectal thermometer (with a short, blunt tip) is inserted
onl y 2 to 3 cm (1 inch) into the adult rectum and left in place for 2
minutes. Cigarette smoking does not alter rectal temperatures.
DIF: Cognitive Level: Understanding (Comprehension) REF: p. 133
MSC: Client Needs: Safe and Effective Care Environment:
Management of Care
4. Which technique is correct when the nurse is assessing the rad ial pulse of
a patient? The pulse is counted for:
a. 1 minute, if the rhythm is irregular.
b. 15 seconds and then multiplied by 4, if the rhythm is regular.
c. 2 full minutes to detect any variation in amplitude.
d. 10 seconds and then multiplied by 6, if the pati ent has no history of
cardiac abnormalities.
ANS: A
Recent research suggests that the 30 -second interval multiplied by 2 is
the most accurate and efficient technique when heart rates are normal
or rapid and when rhythms are regular. If the rhythm is irre gular, then
the pulse is counted for 1 full minute.
DIF: Cognitive Level: Appl ying (Application) REF: p. 134 MSC:
Client Needs: Safe and Effective Care Environment: Management of
Care
E XAMINATION : G ENERAL S URVEY , V ITAL
S IGNS , AND P AIN
MULTIPLE CHOICE
1. Which of these actions illustrates the correct technique the nurse should
use when assessing oral temperature with a mercury thermometer?
a. Wait 30 minutes if the patient has ingested hot or iced liquids.
b. Leave the thermometer in place 3 to 4 minutes if the patient is
afebrile.
c. Place the thermometer in front of the tongue, and ask the patient to
close his or her lips.
d. Shake the mercury-in-glass thermometer down to below 36.6 C
before taking the temperature.
ANS: B
The thermometer should be left in place 3 to 4 minutes if the person is
afebrile and up to 8 minutes if the pe rson is febrile. The nurse should
wait 15 minutes if the person has just ingested hot or iced liquids and 2
minutes if he or she has just smoked.
DIF: Cognitive Level: Appl ying (Application) REF: p. 133 MSC:
Client Needs: Safe and Effective Care Environm ent: Management of
Care
,2. The nurse is taking temperatures in a clinic with a TMT. Which statement
is true regarding use of the TMT?
a. A t ympanic temperature is more time consuming than a rectal
temperature.
b. The t ympanic method is more invasive and uncomforta ble than the
oral method.
c. The risk of cross -contamination is reduced, compared with the
rectal route.
d. The t ympanic membrane most accuratel y reflects the temperature in
the ophthalmic artery.
ANS: C
The TMT is a non -invasive, nontraumatic device that is e xtremel y
quick and efficient. The chance of cross -contamination with the TMT
is minimal because the ear canal is lined with skin, not mucous
membranes.
DIF: Cognitive Level: Understanding (Comprehension) REF: p. 134
MSC: Client Needs: Safe and Effective Care Environment:
Management of Care
3. To assess a rectal temperature accuratel y in an adult, the nurse would:
a. Use a lubricated blunt tip thermometer.
b. Insert the thermometer 2 to 3 inches into the rectum.
c. Leave the thermometer in place up to 8 minutes i f the patient is
febrile.
d. Wait 2 to 3 minutes if the patient has recentl y smoked a cigarette.
ANS: A
, A lubricated rectal thermometer (with a short, blunt tip) is inserted
onl y 2 to 3 cm (1 inch) into the adult rectum and left in place for 2
minutes. Cigarette smoking does not alter rectal temperatures.
DIF: Cognitive Level: Understanding (Comprehension) REF: p. 133
MSC: Client Needs: Safe and Effective Care Environment:
Management of Care
4. Which technique is correct when the nurse is assessing the rad ial pulse of
a patient? The pulse is counted for:
a. 1 minute, if the rhythm is irregular.
b. 15 seconds and then multiplied by 4, if the rhythm is regular.
c. 2 full minutes to detect any variation in amplitude.
d. 10 seconds and then multiplied by 6, if the pati ent has no history of
cardiac abnormalities.
ANS: A
Recent research suggests that the 30 -second interval multiplied by 2 is
the most accurate and efficient technique when heart rates are normal
or rapid and when rhythms are regular. If the rhythm is irre gular, then
the pulse is counted for 1 full minute.
DIF: Cognitive Level: Appl ying (Application) REF: p. 134 MSC:
Client Needs: Safe and Effective Care Environment: Management of
Care
