Nursing 220-Exam # 1 2025
Questions and Answers
Four Vital Signs - ✔✔-temperature
-pulse
-respiratory rate
-blood pressure
5th vital sign - ✔✔pain
normal temperature ranges for adults - ✔✔36-38 celcius ot 96.8 to 100.4 F
influencing factors of temperature - ✔✔-age
-exercise
-hormones
-environment
-stress
where to measure temperature - ✔✔-oral
-rectal
-tymphanic membrane (ear)
COPYRIGHT © 2025 BY OLIVIA WEST, ALL RIGHTS RESERVED 1
,when to measure vitals - ✔✔-on admission
-during assessments
-doctors orders
-before/after surgery
-before, during, after blood transfusions
-before, during, after medications
-patient change
-patient feels funny
-routinely in hospital
-before, during, after nursing interventions
what would happen if blood pressure cuff too big.... - ✔✔false low reading
what would happen if blood pressure cuff to small... - ✔✔false high reading
positions for respirations - ✔✔-body straight promotes good respirations
-body slumped impaired respirations
-body laying down prevents full chest expansion
position for pulse - ✔✔-supine/sitting
position for blood pressure - ✔✔-sitting with arm at heart level
normal pulse for adult - ✔✔60-100 beats/min
normal pulse of adolescent - ✔✔60-90 beats/min
normal pulse for toddler - ✔✔90-140 beats/min
COPYRIGHT © 2025 BY OLIVIA WEST, ALL RIGHTS RESERVED 2
, normal pulse for infant - ✔✔120-160 beats/min
normal pulse oximetry - ✔✔>= 90%
normal respiration rate for adults - ✔✔12-20 breaths/min
normal respiration rate for adolescent - ✔✔16-20 breaths/min
normal respiration rate for toddler - ✔✔25-32 breaths/min
normal respiration rate for infant - ✔✔30-50 breaths.min
normal respiration rate for newborn - ✔✔30-60 breaths/min
normal blood pressure for adults - ✔✔Systolic <120 mm Hg
Diastolic <80 mm Hg
Pulse pressure: 30 to 50 mm Hg
The nurse is caring for a client who has an oral temperature of 99.6 °F at 0800. The
client's orders indicate that vital signs should be taken once a shift. In planning care for
the client, which action is most appropriate?
A. Ensure that the temperature is taken promptly at 1600.
B. Call the physician for a more frequent order.
C. Take the temperature as necessary.
D. Begin cooling measures - ✔✔C
Blood pressure - ✔✔-"force exerted on the walls f=of artery by pulsing blood under
pressure from the heart"
-DONT take BP on side of mastectomy or side of dialysis or shunt (can cause
lymphoma)
COPYRIGHT © 2025 BY OLIVIA WEST, ALL RIGHTS RESERVED 3
Questions and Answers
Four Vital Signs - ✔✔-temperature
-pulse
-respiratory rate
-blood pressure
5th vital sign - ✔✔pain
normal temperature ranges for adults - ✔✔36-38 celcius ot 96.8 to 100.4 F
influencing factors of temperature - ✔✔-age
-exercise
-hormones
-environment
-stress
where to measure temperature - ✔✔-oral
-rectal
-tymphanic membrane (ear)
COPYRIGHT © 2025 BY OLIVIA WEST, ALL RIGHTS RESERVED 1
,when to measure vitals - ✔✔-on admission
-during assessments
-doctors orders
-before/after surgery
-before, during, after blood transfusions
-before, during, after medications
-patient change
-patient feels funny
-routinely in hospital
-before, during, after nursing interventions
what would happen if blood pressure cuff too big.... - ✔✔false low reading
what would happen if blood pressure cuff to small... - ✔✔false high reading
positions for respirations - ✔✔-body straight promotes good respirations
-body slumped impaired respirations
-body laying down prevents full chest expansion
position for pulse - ✔✔-supine/sitting
position for blood pressure - ✔✔-sitting with arm at heart level
normal pulse for adult - ✔✔60-100 beats/min
normal pulse of adolescent - ✔✔60-90 beats/min
normal pulse for toddler - ✔✔90-140 beats/min
COPYRIGHT © 2025 BY OLIVIA WEST, ALL RIGHTS RESERVED 2
, normal pulse for infant - ✔✔120-160 beats/min
normal pulse oximetry - ✔✔>= 90%
normal respiration rate for adults - ✔✔12-20 breaths/min
normal respiration rate for adolescent - ✔✔16-20 breaths/min
normal respiration rate for toddler - ✔✔25-32 breaths/min
normal respiration rate for infant - ✔✔30-50 breaths.min
normal respiration rate for newborn - ✔✔30-60 breaths/min
normal blood pressure for adults - ✔✔Systolic <120 mm Hg
Diastolic <80 mm Hg
Pulse pressure: 30 to 50 mm Hg
The nurse is caring for a client who has an oral temperature of 99.6 °F at 0800. The
client's orders indicate that vital signs should be taken once a shift. In planning care for
the client, which action is most appropriate?
A. Ensure that the temperature is taken promptly at 1600.
B. Call the physician for a more frequent order.
C. Take the temperature as necessary.
D. Begin cooling measures - ✔✔C
Blood pressure - ✔✔-"force exerted on the walls f=of artery by pulsing blood under
pressure from the heart"
-DONT take BP on side of mastectomy or side of dialysis or shunt (can cause
lymphoma)
COPYRIGHT © 2025 BY OLIVIA WEST, ALL RIGHTS RESERVED 3
