NURS-502 | Ch. 28 Vital Signs UPDATED ACTUAL Questions
and CORRECT Answers
1) An older client has an oral temperature reading of Answer: 4
97.2°F. The nurse realizes that this client's low temperature Explanation: This client is older and research shows that older people are at risk
could be due to which observation? for
1. The anxiety level of the client has increased. hypothermia. When one ages, subcutaneous fat is lost.
2. Hormones have fluctuated in this client. Page Ref: 507
3. Muscle activity has increased during the client's Cognitive Level: Analyzing
therapy session. Client Need/Sub: Physiological Integrity: Physiological Adaptation
4. Loss of subcutaneous fat is noted. Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple
dimensions of
patient-centered care | AACN Essentials Competencies: IX. 1. Conduct
comprehensive and
focused physical, behavioral, psychological, spiritual, socioeconomic, and
environmental
assessments of health and illness parameters in patients, using developmentally
and culturally
appropriate approaches | NLN Competencies: Context and Environment;
Practice-Know-How;
Apply health promotion/disease prevention strategies | Nursing/Integrated
Concepts: Evaluation
Learning Outcome: 2. Identify the variations in normal body temperature, pulse,
respirations,
and blood pressure that occur from infancy to old age.
MNL Learning Outcome: 2. Examine the factors that influence the measured
results of vital
signs.
,2) The nurse is preparing to measure a client's Answer: 1
temperature. What is the first thing that the nurse Explanation: If the equipment is not working properly, no accuracy will be
should do to ensure an accurate temperature reading? obtained in the
1. Assess that the equipment used is working properly. readings.
2. Place the client in a position that is most comfortable Page Ref: 514
for the healthcare provider. Cognitive Level: Applying
3. Take the temperature with a chemical disposable Client Need/Sub: Physiological Integrity: Reduction of Risk Potential
thermometer when the client is perspiring. Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple
4. Wait at least 10 minutes before taking the temperature dimensions of
after a client has been smoking. patient-centered care | AACN Essentials Competencies: IX. 1. Conduct
comprehensive and
focused physical, behavioral, psychological, spiritual, socioeconomic, and
environmental
assessments of health and illness parameters in patients, using developmentally
and culturally
appropriate approaches | NLN Competencies: Context and Environment;
Practice-Know-How;
Apply health promotion/disease prevention strategies | Nursing/Integrated
Concepts: Assessment
Learning Outcome: 3. Verbalize the steps used in: a. Assessing body temperature.
MNL Learning Outcome: 3. Apply the principles of assessing vital signs in patient
care.
Page 587
3) The nurse needs to measure the temperature of a Answer: 2
client who has a history of heart disease and Explanation: Body temperature is frequently measured orally even if the client has
has eaten a bowl of vegetable soup 45 minutes ago. eaten or
Which site should the nurse use? drank something cold or hot. One only needs to wait 30 minutes, and then this site
1. Axilla can be used.
2. Oral Page Ref: 511
3. Popliteal Cognitive Level: Applying
4. Rectal Client Need/Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple
dimensions of
patient-centered care | AACN Essentials Competencies: IX. 1. Conduct
comprehensive and
focused physical, behavioral, psychological, spiritual, socioeconomic, and
environmental
assessments of health and illness parameters in patients, using developmentally
and culturally
appropriate approaches | NLN Competencies: Context and Environment;
Practice-Know-How;
Apply health promotion/disease prevention strategies | Nursing/Integrated
Concepts: Assessment
Learning Outcome: 3. Verbalize the steps used in: a. Assessing body temperature.
MNL Learning Outcome: 3. Apply the principles of assessing vital signs in patient
care.
, 4) While waiting for the physician to respond regarding a Answer: 3
client's elevated temperature, what can Explanation: Elevated body temperature contributes to dehydration, which leads
the nurse do to assist the client? to body tissues
1. Bathe the client with ice water. drying out and malfunctioning. Rehydrating the client's tissues will allow the
2. Give the client an antipyretic. temperature to
3. Increase fluid intake. return to normal.
4. Lower the room temperature. Page Ref: 510
Cognitive Level: Applying
Client Need/Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple
dimensions of
patient-centered care | AACN Essentials Competencies: IX. 3. Implement holistic,
patient-
centered care that reflects an understanding of human growth and development,
pathophysiology, pharmacology, medical management, and nursing management
across the
health—illness continuum, across lifespan, and in all healthcare settings | NLN
Competencies:
Context and Environment; Practice-Know-How; Apply health promotion/disease
prevention
strategies | Nursing/Integrated Concepts: Implementation
Learning Outcome: 4. Describe appropriate nursing care for alterations in vital
signs.
MNL Learning Outcome: 4. Utilize the nursing process for patients with alterations
in vital
signs across the lifespan.
Page 588
5) While assessing the dorsalis pedis pulse of a client, the Answer: 4
nurse determines that the pulse is Explanation: Too firm of pressure on a pulse site will obliterate that pulse because
absent. However, the extremity is warm and pink with nail assessing the
beds blanching at 2-3 seconds of dorsalis pedis pulse requires one to apply some pressure over the dorsalis pedis
capillary refilling time. How would the nurse explain these artery.
findings? Page Ref: 519
1. A change in the client's health status has occurred. Cognitive Level: Analyzing
2. The client has thrown a blood clot in that extremity. Client Need/Sub: Physiological Integrity: Reduction of Risk Potential
3. The RN's watch has stopped working. Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple
4. Too much pressure was applied over the pulse site. dimensions of
patient-centered care | AACN Essentials Competencies: IX. 1. Conduct
comprehensive and
focused physical, behavioral, psychological, spiritual, socioeconomic, and
environmental
assessments of health and illness parameters in patients, using developmentally
and culturally
appropriate approaches | NLN Competencies: Context and Environment;
Practice-Know-How;
Apply health promotion/disease prevention strategies | Nursing/Integrated
Concepts: Assessment
Learning Outcome: 3. Verbalize the steps used in: b. Assessing a peripheral pulse.
MNL Learning Outcome: 3. Apply the principles of assessing vital signs in patient
care.
and CORRECT Answers
1) An older client has an oral temperature reading of Answer: 4
97.2°F. The nurse realizes that this client's low temperature Explanation: This client is older and research shows that older people are at risk
could be due to which observation? for
1. The anxiety level of the client has increased. hypothermia. When one ages, subcutaneous fat is lost.
2. Hormones have fluctuated in this client. Page Ref: 507
3. Muscle activity has increased during the client's Cognitive Level: Analyzing
therapy session. Client Need/Sub: Physiological Integrity: Physiological Adaptation
4. Loss of subcutaneous fat is noted. Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple
dimensions of
patient-centered care | AACN Essentials Competencies: IX. 1. Conduct
comprehensive and
focused physical, behavioral, psychological, spiritual, socioeconomic, and
environmental
assessments of health and illness parameters in patients, using developmentally
and culturally
appropriate approaches | NLN Competencies: Context and Environment;
Practice-Know-How;
Apply health promotion/disease prevention strategies | Nursing/Integrated
Concepts: Evaluation
Learning Outcome: 2. Identify the variations in normal body temperature, pulse,
respirations,
and blood pressure that occur from infancy to old age.
MNL Learning Outcome: 2. Examine the factors that influence the measured
results of vital
signs.
,2) The nurse is preparing to measure a client's Answer: 1
temperature. What is the first thing that the nurse Explanation: If the equipment is not working properly, no accuracy will be
should do to ensure an accurate temperature reading? obtained in the
1. Assess that the equipment used is working properly. readings.
2. Place the client in a position that is most comfortable Page Ref: 514
for the healthcare provider. Cognitive Level: Applying
3. Take the temperature with a chemical disposable Client Need/Sub: Physiological Integrity: Reduction of Risk Potential
thermometer when the client is perspiring. Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple
4. Wait at least 10 minutes before taking the temperature dimensions of
after a client has been smoking. patient-centered care | AACN Essentials Competencies: IX. 1. Conduct
comprehensive and
focused physical, behavioral, psychological, spiritual, socioeconomic, and
environmental
assessments of health and illness parameters in patients, using developmentally
and culturally
appropriate approaches | NLN Competencies: Context and Environment;
Practice-Know-How;
Apply health promotion/disease prevention strategies | Nursing/Integrated
Concepts: Assessment
Learning Outcome: 3. Verbalize the steps used in: a. Assessing body temperature.
MNL Learning Outcome: 3. Apply the principles of assessing vital signs in patient
care.
Page 587
3) The nurse needs to measure the temperature of a Answer: 2
client who has a history of heart disease and Explanation: Body temperature is frequently measured orally even if the client has
has eaten a bowl of vegetable soup 45 minutes ago. eaten or
Which site should the nurse use? drank something cold or hot. One only needs to wait 30 minutes, and then this site
1. Axilla can be used.
2. Oral Page Ref: 511
3. Popliteal Cognitive Level: Applying
4. Rectal Client Need/Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple
dimensions of
patient-centered care | AACN Essentials Competencies: IX. 1. Conduct
comprehensive and
focused physical, behavioral, psychological, spiritual, socioeconomic, and
environmental
assessments of health and illness parameters in patients, using developmentally
and culturally
appropriate approaches | NLN Competencies: Context and Environment;
Practice-Know-How;
Apply health promotion/disease prevention strategies | Nursing/Integrated
Concepts: Assessment
Learning Outcome: 3. Verbalize the steps used in: a. Assessing body temperature.
MNL Learning Outcome: 3. Apply the principles of assessing vital signs in patient
care.
, 4) While waiting for the physician to respond regarding a Answer: 3
client's elevated temperature, what can Explanation: Elevated body temperature contributes to dehydration, which leads
the nurse do to assist the client? to body tissues
1. Bathe the client with ice water. drying out and malfunctioning. Rehydrating the client's tissues will allow the
2. Give the client an antipyretic. temperature to
3. Increase fluid intake. return to normal.
4. Lower the room temperature. Page Ref: 510
Cognitive Level: Applying
Client Need/Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple
dimensions of
patient-centered care | AACN Essentials Competencies: IX. 3. Implement holistic,
patient-
centered care that reflects an understanding of human growth and development,
pathophysiology, pharmacology, medical management, and nursing management
across the
health—illness continuum, across lifespan, and in all healthcare settings | NLN
Competencies:
Context and Environment; Practice-Know-How; Apply health promotion/disease
prevention
strategies | Nursing/Integrated Concepts: Implementation
Learning Outcome: 4. Describe appropriate nursing care for alterations in vital
signs.
MNL Learning Outcome: 4. Utilize the nursing process for patients with alterations
in vital
signs across the lifespan.
Page 588
5) While assessing the dorsalis pedis pulse of a client, the Answer: 4
nurse determines that the pulse is Explanation: Too firm of pressure on a pulse site will obliterate that pulse because
absent. However, the extremity is warm and pink with nail assessing the
beds blanching at 2-3 seconds of dorsalis pedis pulse requires one to apply some pressure over the dorsalis pedis
capillary refilling time. How would the nurse explain these artery.
findings? Page Ref: 519
1. A change in the client's health status has occurred. Cognitive Level: Analyzing
2. The client has thrown a blood clot in that extremity. Client Need/Sub: Physiological Integrity: Reduction of Risk Potential
3. The RN's watch has stopped working. Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple
4. Too much pressure was applied over the pulse site. dimensions of
patient-centered care | AACN Essentials Competencies: IX. 1. Conduct
comprehensive and
focused physical, behavioral, psychological, spiritual, socioeconomic, and
environmental
assessments of health and illness parameters in patients, using developmentally
and culturally
appropriate approaches | NLN Competencies: Context and Environment;
Practice-Know-How;
Apply health promotion/disease prevention strategies | Nursing/Integrated
Concepts: Assessment
Learning Outcome: 3. Verbalize the steps used in: b. Assessing a peripheral pulse.
MNL Learning Outcome: 3. Apply the principles of assessing vital signs in patient
care.
