NR 224 Week 2 EDAPTS – Vital Signs 2026 |
Questions, Answers & Rationales Study
Guide
Chapter 1: Foundations of Vital Signs
Question 1
A nurse is preparing to document a patient's vital signs in the electronic health
record. Which information is most critical to include alongside the numerical
values to ensure comprehensive documentation?
A. The time the patient last ate
B. The specific route used to obtain the measurements
C. The manufacturer of the equipment used
D. The patient's room temperature
Correct Answer: B. The specific route used to obtain the measurements
Rationale: Documenting the specific route (e.g., oral, tympanic, axillary,
temporal) is vital because baseline values and normal ranges vary slightly
depending on the anatomical site used. This ensures consistency for future
comparisons and trends. While timing relative to meals may matter for glucose
monitoring, it is not standard for all vital signs. Equipment manufacturer and
room temperature are not routinely documented.
Question 2
After identifying a critically abnormal blood pressure reading in a post-operative
patient, which action should the nurse take first regarding documentation and
communication?
A. Inform the charge nurse before logging the data
B. Document the findings in the chart immediately, then notify the healthcare
provider
C. Wait for the next scheduled vital sign cycle to confirm the trend
,D. Retake the blood pressure on the opposite arm three more times before
logging
Correct Answer: B. Document the findings in the chart immediately, then
notify the healthcare provider
Rationale: The priority sequence for managing abnormal data is to first
document the findings accurately to establish a legal and clinical record, and then
immediately inform the primary healthcare provider to secure necessary
intervention orders. Waiting or retaking multiple times delays necessary
intervention. Notifying the charge nurse may be appropriate but does not replace
provider notification.
Question 3
A nurse is reviewing the provider's orders for a patient scheduled to receive an
antihypertensive medication. The order states: "Give medication for systolic BP >
130 or diastolic BP > 75." The patient's current BP is 160/80 mmHg, which is
consistent with their baseline. What is the correct nursing action?
A. Hold the medication and document that the blood pressure is stable
B. Administer the medication as ordered and complete a comprehensive
assessment
C. Notify the healthcare provider that the blood pressure is too high to safely give
the drug
D. Request a lower dose from the pharmacy because the diastolic is only 5 points
over
Correct Answer: B. Administer the medication as ordered and complete a
comprehensive assessment
Rationale: The parameters are clearly met (systolic 160 > 130; diastolic 80
> 75). The nurse should administer the medication as ordered and assess the
patient for any symptoms related to hypertension or effects of the medication.
Holding the medication would violate the order. The BP is within the parameters
for administration despite being consistent with baseline.
,Question 4
Which of the following patients should the nurse prioritize for the most frequent
vital sign monitoring?
A. An alert elderly patient with a history of chronic stable angina
B. A patient who underwent a radical nasal septoplasty two hours ago
C. A patient admitted for observation following a syncopal episode
D. A patient who has been resting quietly in bed for thirty minutes
Correct Answer: B. A patient who underwent a radical nasal septoplasty
two hours ago
Rationale: Recent oral or nasal surgeries, or conditions where a patient
cannot close their mouth safely, contraindicate oral temperature probes due to
altered airflow, pain, and the risk of localized trauma. Additionally, post-surgical
patients require frequent monitoring for complications including bleeding and
airway compromise. The syncopal episode patient also requires monitoring, but
the immediate post-surgical patient has more acute physiological instability.
Question 5
A nurse needs to assess an apical pulse on a patient experiencing an irregular
peripheral pulse. Where should the nurse anatomically place the stethoscope?
A. Fifth intercostal space, left midclavicular line
B. Second intercostal space, right sternal border
C. Fourth intercostal space, left sternal border
D. Third intercostal space, right midclavicular line
Correct Answer: A. Fifth intercostal space, left midclavicular line
Rationale: The apical pulse is best heard at the apex of the heart, which is
located at the fifth intercostal space at the left midclavicular line (also called the
point of maximal impulse, PMI). The other locations correspond to other valve
areas: second right sternal border is the aortic area, second left sternal border is
the pulmonic area, and fourth left sternal border is the tricuspid area.
, Question 6
A nurse is teaching a patient about factors that can affect vital signs. Which
statement by the patient indicates a need for further teaching?
A. "My blood pressure might be higher when I'm in pain."
B. "Drinking coffee right before my appointment could raise my heart rate."
C. "My temperature is usually lower in the evening than in the morning."
D. "Stress can affect my blood pressure and heart rate."
Correct Answer: C. "My temperature is usually lower in the evening than
in the morning."
Rationale: Body temperature typically follows a circadian rhythm, with
the lowest temperature in the early morning (around 4:00 AM) and the highest in
the late afternoon/evening (around 6:00 PM). The statement that temperature is
lower in the evening is incorrect. Pain, caffeine, and stress are all recognized
factors that can elevate heart rate and blood pressure.
Question 7
Which of the following are considered the traditional five vital signs? Select all
that apply.
A. Temperature
B. Pulse
C. Respirations
D. Blood pressure
E. Pain
F. Oxygen saturation
Correct Answer: A, B, C, D, E
Rationale: The traditional five vital signs are temperature, pulse,
respirations, blood pressure, and pain. Oxygen saturation is increasingly referred
to as the "sixth vital sign" but is not part of the traditional five. Pain was formally
designated as the fifth vital sign by the Joint Commission in 2001.
Questions, Answers & Rationales Study
Guide
Chapter 1: Foundations of Vital Signs
Question 1
A nurse is preparing to document a patient's vital signs in the electronic health
record. Which information is most critical to include alongside the numerical
values to ensure comprehensive documentation?
A. The time the patient last ate
B. The specific route used to obtain the measurements
C. The manufacturer of the equipment used
D. The patient's room temperature
Correct Answer: B. The specific route used to obtain the measurements
Rationale: Documenting the specific route (e.g., oral, tympanic, axillary,
temporal) is vital because baseline values and normal ranges vary slightly
depending on the anatomical site used. This ensures consistency for future
comparisons and trends. While timing relative to meals may matter for glucose
monitoring, it is not standard for all vital signs. Equipment manufacturer and
room temperature are not routinely documented.
Question 2
After identifying a critically abnormal blood pressure reading in a post-operative
patient, which action should the nurse take first regarding documentation and
communication?
A. Inform the charge nurse before logging the data
B. Document the findings in the chart immediately, then notify the healthcare
provider
C. Wait for the next scheduled vital sign cycle to confirm the trend
,D. Retake the blood pressure on the opposite arm three more times before
logging
Correct Answer: B. Document the findings in the chart immediately, then
notify the healthcare provider
Rationale: The priority sequence for managing abnormal data is to first
document the findings accurately to establish a legal and clinical record, and then
immediately inform the primary healthcare provider to secure necessary
intervention orders. Waiting or retaking multiple times delays necessary
intervention. Notifying the charge nurse may be appropriate but does not replace
provider notification.
Question 3
A nurse is reviewing the provider's orders for a patient scheduled to receive an
antihypertensive medication. The order states: "Give medication for systolic BP >
130 or diastolic BP > 75." The patient's current BP is 160/80 mmHg, which is
consistent with their baseline. What is the correct nursing action?
A. Hold the medication and document that the blood pressure is stable
B. Administer the medication as ordered and complete a comprehensive
assessment
C. Notify the healthcare provider that the blood pressure is too high to safely give
the drug
D. Request a lower dose from the pharmacy because the diastolic is only 5 points
over
Correct Answer: B. Administer the medication as ordered and complete a
comprehensive assessment
Rationale: The parameters are clearly met (systolic 160 > 130; diastolic 80
> 75). The nurse should administer the medication as ordered and assess the
patient for any symptoms related to hypertension or effects of the medication.
Holding the medication would violate the order. The BP is within the parameters
for administration despite being consistent with baseline.
,Question 4
Which of the following patients should the nurse prioritize for the most frequent
vital sign monitoring?
A. An alert elderly patient with a history of chronic stable angina
B. A patient who underwent a radical nasal septoplasty two hours ago
C. A patient admitted for observation following a syncopal episode
D. A patient who has been resting quietly in bed for thirty minutes
Correct Answer: B. A patient who underwent a radical nasal septoplasty
two hours ago
Rationale: Recent oral or nasal surgeries, or conditions where a patient
cannot close their mouth safely, contraindicate oral temperature probes due to
altered airflow, pain, and the risk of localized trauma. Additionally, post-surgical
patients require frequent monitoring for complications including bleeding and
airway compromise. The syncopal episode patient also requires monitoring, but
the immediate post-surgical patient has more acute physiological instability.
Question 5
A nurse needs to assess an apical pulse on a patient experiencing an irregular
peripheral pulse. Where should the nurse anatomically place the stethoscope?
A. Fifth intercostal space, left midclavicular line
B. Second intercostal space, right sternal border
C. Fourth intercostal space, left sternal border
D. Third intercostal space, right midclavicular line
Correct Answer: A. Fifth intercostal space, left midclavicular line
Rationale: The apical pulse is best heard at the apex of the heart, which is
located at the fifth intercostal space at the left midclavicular line (also called the
point of maximal impulse, PMI). The other locations correspond to other valve
areas: second right sternal border is the aortic area, second left sternal border is
the pulmonic area, and fourth left sternal border is the tricuspid area.
, Question 6
A nurse is teaching a patient about factors that can affect vital signs. Which
statement by the patient indicates a need for further teaching?
A. "My blood pressure might be higher when I'm in pain."
B. "Drinking coffee right before my appointment could raise my heart rate."
C. "My temperature is usually lower in the evening than in the morning."
D. "Stress can affect my blood pressure and heart rate."
Correct Answer: C. "My temperature is usually lower in the evening than
in the morning."
Rationale: Body temperature typically follows a circadian rhythm, with
the lowest temperature in the early morning (around 4:00 AM) and the highest in
the late afternoon/evening (around 6:00 PM). The statement that temperature is
lower in the evening is incorrect. Pain, caffeine, and stress are all recognized
factors that can elevate heart rate and blood pressure.
Question 7
Which of the following are considered the traditional five vital signs? Select all
that apply.
A. Temperature
B. Pulse
C. Respirations
D. Blood pressure
E. Pain
F. Oxygen saturation
Correct Answer: A, B, C, D, E
Rationale: The traditional five vital signs are temperature, pulse,
respirations, blood pressure, and pain. Oxygen saturation is increasingly referred
to as the "sixth vital sign" but is not part of the traditional five. Pain was formally
designated as the fifth vital sign by the Joint Commission in 2001.
