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What is the "Guiding Principle" a nurse should follow when assessing vital signs? A) Always trust the
machine over the patient B) Don't treat the number, treat the patient C) Only record values that fall
within the normal range D) Re-check every abnormal value four times - Answers B
Which physiological response occurs when the body becomes too cold (Hypothermia)? A)
Vasodilation and sweating B) Decreased metabolic rate and lethargy C) Shivering, inhibited sweating,
and vasoconstriction D) Increased respiratory rate and vasodilation - Answers C
What is the normal temperature range for an adult aged 18-65? A) 96.4-98.2° F B) 97.6-99.5° F C)
98.6-100.4° F D) 95.0-97.0° F - Answers B
Where is the Apical pulse (Point of Maximal Impulse) located? A) Second intercostal space, right
sternal border B) Fourth intercostal space, left midaxillary line C) Fifth intercostal space, left
midclavicular line D) Third intercostal space, left sternal border - Answers C
A nurse finds a patient's pulse to be "bounding." Using the pulse intensity scale, how should this be
documented? A) 1+ B) 2+ C) 3+ D) 4+ - Answers C
What is the normal respiratory rate for a healthy adult? A) 10-16 breaths per minute B) 12-20 breaths
per minute C) 16-24 breaths per minute D) 20-30 breaths per minute - Answers B
Which of the following would likely cause a falsely high blood pressure reading? A) Using a blood
pressure cuff that is too wide B) Using a blood pressure cuff that is too small/narrow C) Positioning
the arm above the level of the heart D) Deflating the cuff too quickly - Answers B
What is the correct formula to calculate Mean Arterial Pressure (MAP)? A) (Systolic + Diastolic) / 2 B)
(2 x Systolic + Diastolic) / 3 C) (2 x Diastolic + Systolic) / 3 D) (Systolic - Diastolic) x 3 - Answers C
A patient's blood pressure is measured while supine, sitting, and standing. Which finding indicates
Orthostatic Hypotension? A) A drop in systolic pressure of 5 mm Hg B) An increase in diastolic
pressure of 5 mm Hg C) A drop in systolic pressure of 20 mm Hg or diastolic of 10 mm Hg D) A
decrease in heart rate of 10 beats per minute - Answers C
Which task regarding vital signs is not appropriate to delegate to Unlicensed Assistive Personnel
(UAP)? A) Taking a routine oral temperature on a stable patient B) Performing the initial assessment
of a new admission C) Reporting a blood pressure value to the nurse D) Assisting a patient into a
supine position - Answers B
The FLACC pain scale is most commonly used for which patient population? A) Adults who can self-
report pain B) Patients with chronic back pain C) Infants and children who cannot verbalize pain D)
Elderly patients with hypertension - Answers C
What is the normal range for Oxygen Saturation (SaO2)? A) 85-90% B) 90-95% C) 95-100% D) 98-105%
- Answers C
What is the physiological reason for calculating Mean Arterial Pressure (MAP)? A) It measures the
maximum pressure during a heart contraction B) It represents the pressure forcing blood into tissues
averaged over the cardiac cycle C) It is a simple arithmetic average of systolic and diastolic pressures
D) It determines the exact volume of blood in the circulatory system - Answers B
Which of the following is an appropriate nursing intervention for a patient with Hypothermia? A)
Reduce physical activity to limit heat production B) Administer antipyretics like acetaminophen C)
Keep limbs close to the body and cover the head and feet D) Provide a cool sponge bath to stabilize
core temperature - Answers C
When assessing a pulse, why should a nurse avoid using their thumb? A) The thumb is not sensitive
enough to feel light tapping B) The nurse might mistake their own pulse for the patient's pulse C) The
thumb creates too much pressure and can occlude the artery D) It is harder to maintain an
independent finger position with the thumb - Answers B
What is the "ABC" priority rule in respiratory assessment? A) Assessment, Breathing, Circulation B)
Airway, Breathing, Circulation C) Airway, Blood pressure, Consciousness D) Assessment, Blood flow,
Capillary refill - Answers B
Which factor can lead to a false oxygen saturation (SaO2) reading on a pulse oximeter? A) High
hemoglobin levels B) Fast respiratory rate C) Carbon monoxide (CO) poisoning or nail polish D) Sitting
in the orthopneic position - Answers C
A nurse is delegating blood pressure measurement to a UAP. Under what condition can the UAP
perform a manual blood pressure? A) UAPs can always perform manual blood pressures B) Only if the