NR 224 Week 2 EDAPTS –
Vital Signs 2026 |
Questions, Answers &
Rationales Study Guide
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success|
Updated 2026 Questions and Answers
100% Verified Exam Prep and Comprehensive
Rationales
Included
,In order to analyze vital signs data for signs of a problem -Does the client's diagnosis typically cause this type of change in vital signs?
or a change in condition, the nurse knows that there are -Is this measurement typical for the client?
several factors to consider before taking action. Which -Do the client's baseline vital signs usually run this high/low?
statements are true? Select all that apply. -Is the vital signs equipment working properly?
-Does the client's diagnosis typically cause this type of
change in vital signs?
-Do these vital sign measurements impact the upcoming
medication administration?
-Is the vital signs equipment working properly?
-Do the client's baseline vital signs usually run this
high/low?
-Is the client asleep?
-Is this measurement typical for the client?
The nurse is preparing to document the client's vital sign -Document the route used to obtain vital signs.
measurements in the electronic health record (EHR). -Document the follow-up actions taken after abnormal findings were obtained.
What are the correct statements? Select all that apply. -Document the client's response to abnormal findings.
-Document the follow-up actions taken after abnormal
findings were obtained.
-First document, then analyze the abnormal vital sign
findings.
-Document the client's response to abnormal findings.
-First document, then inform the healthcare provider of
abnormal findings.
-The route used to obtain vital signs is not typically
necessary to document.
-Document the route used to obtain vital signs.
The nurse is caring for a client and obtaining a set of vital -After completing a nursing assessment and determining there are no other
signs along with a nursing assessment. The client concerns, the nurse administers the client's dose of antihypertensive medication.
(preferred pronouns: he/him/his) has a history of -The nurse completes the nursing assessment and analyzes any additional areas of
hypertension for which he is taking antihypertensive concern.
medication. The ordered parameters are to administer the
medication for blood pressure above 130/75. His
medication is now due for administration. His current
blood pressure is 160/80, which is around what his
baseline blood pressure typically runs. What are the
correct statements?
, The nurse is assessing a client's vital signs and obtains the -Assess the client for additional cues of respiratory distress
following results: -Stabilize the client in regard to airway, breathing, and circulation (ABCs)
Blood pressure: 156/94 mmHg
Temperature: 99.8°F orally
Apical pulse: 104 beats/minute
Respirations: 25 breaths/minute and regular
Pulse oximetry: 95%
The nurse recognizes that these results are not within the
parameters of normal vital signs. All of the following
actions may be appropriate with the cues the nurse has,
but what two (2) things does the nurse do first?
-Immediately alert the healthcare provider
-Ask the client if they just had something warm to drink
-Administer prescribed antihypertensive medication
-Assess the client for additional cues of respiratory
distress
-Stabilize the client in regard to airway, breathing, and
circulation (ABCs)
The nurse has just started a shift and is receiving a report -Review the results and analyze them for cues of a possible problem.
from the previous shift nurse. The previous shift nurse -Complete the nursing assessment, including apical pulse.
reports that the client is stable, and they have, therefore,
delegated the vital signs to the Unlicensed Assistive
Personnel (UAP) as this is the practice in the unit. As the
new shift nurse is reviewing the client's electronic health
record (EHR) at the nurse's station to prepare for the
nursing assessment, the nursing assistant reports the
following results:
Blood pressure: 110/60, Apical pulse rate: 72, Respirations:
12/minute, Temperature: 98.0°F, SpO2: 99%.
Identify the correct statements below and put them in the
correct sequence.
Step 1______________________
Step 2 ____________________
The nurse is obtaining a set of vital signs. The results -Has the client recently been active (walking in the hallway, etc.)?
indicate an elevated pulse rate. What other information is -Are there cues in the client's health status and history that are contributing to this
needed to determine a course of action? Select all that finding?
apply. -What is the client's normal baseline pulse rate range?
-No other information is needed beyond this result in
order to take action.
-Has the client recently been active (walking in the
hallway, etc.)?
-What is the client's normal baseline pulse rate range?
-Are there cues in the client's health status and history
that are contributing to this finding?
-If the client is over the age of 65, this finding would not
be of concern as this is typical with this age group.
Vital Signs 2026 |
Questions, Answers &
Rationales Study Guide
|Graded A+ | Guaranteed
success|
Updated 2026 Questions and Answers
100% Verified Exam Prep and Comprehensive
Rationales
Included
,In order to analyze vital signs data for signs of a problem -Does the client's diagnosis typically cause this type of change in vital signs?
or a change in condition, the nurse knows that there are -Is this measurement typical for the client?
several factors to consider before taking action. Which -Do the client's baseline vital signs usually run this high/low?
statements are true? Select all that apply. -Is the vital signs equipment working properly?
-Does the client's diagnosis typically cause this type of
change in vital signs?
-Do these vital sign measurements impact the upcoming
medication administration?
-Is the vital signs equipment working properly?
-Do the client's baseline vital signs usually run this
high/low?
-Is the client asleep?
-Is this measurement typical for the client?
The nurse is preparing to document the client's vital sign -Document the route used to obtain vital signs.
measurements in the electronic health record (EHR). -Document the follow-up actions taken after abnormal findings were obtained.
What are the correct statements? Select all that apply. -Document the client's response to abnormal findings.
-Document the follow-up actions taken after abnormal
findings were obtained.
-First document, then analyze the abnormal vital sign
findings.
-Document the client's response to abnormal findings.
-First document, then inform the healthcare provider of
abnormal findings.
-The route used to obtain vital signs is not typically
necessary to document.
-Document the route used to obtain vital signs.
The nurse is caring for a client and obtaining a set of vital -After completing a nursing assessment and determining there are no other
signs along with a nursing assessment. The client concerns, the nurse administers the client's dose of antihypertensive medication.
(preferred pronouns: he/him/his) has a history of -The nurse completes the nursing assessment and analyzes any additional areas of
hypertension for which he is taking antihypertensive concern.
medication. The ordered parameters are to administer the
medication for blood pressure above 130/75. His
medication is now due for administration. His current
blood pressure is 160/80, which is around what his
baseline blood pressure typically runs. What are the
correct statements?
, The nurse is assessing a client's vital signs and obtains the -Assess the client for additional cues of respiratory distress
following results: -Stabilize the client in regard to airway, breathing, and circulation (ABCs)
Blood pressure: 156/94 mmHg
Temperature: 99.8°F orally
Apical pulse: 104 beats/minute
Respirations: 25 breaths/minute and regular
Pulse oximetry: 95%
The nurse recognizes that these results are not within the
parameters of normal vital signs. All of the following
actions may be appropriate with the cues the nurse has,
but what two (2) things does the nurse do first?
-Immediately alert the healthcare provider
-Ask the client if they just had something warm to drink
-Administer prescribed antihypertensive medication
-Assess the client for additional cues of respiratory
distress
-Stabilize the client in regard to airway, breathing, and
circulation (ABCs)
The nurse has just started a shift and is receiving a report -Review the results and analyze them for cues of a possible problem.
from the previous shift nurse. The previous shift nurse -Complete the nursing assessment, including apical pulse.
reports that the client is stable, and they have, therefore,
delegated the vital signs to the Unlicensed Assistive
Personnel (UAP) as this is the practice in the unit. As the
new shift nurse is reviewing the client's electronic health
record (EHR) at the nurse's station to prepare for the
nursing assessment, the nursing assistant reports the
following results:
Blood pressure: 110/60, Apical pulse rate: 72, Respirations:
12/minute, Temperature: 98.0°F, SpO2: 99%.
Identify the correct statements below and put them in the
correct sequence.
Step 1______________________
Step 2 ____________________
The nurse is obtaining a set of vital signs. The results -Has the client recently been active (walking in the hallway, etc.)?
indicate an elevated pulse rate. What other information is -Are there cues in the client's health status and history that are contributing to this
needed to determine a course of action? Select all that finding?
apply. -What is the client's normal baseline pulse rate range?
-No other information is needed beyond this result in
order to take action.
-Has the client recently been active (walking in the
hallway, etc.)?
-What is the client's normal baseline pulse rate range?
-Are there cues in the client's health status and history
that are contributing to this finding?
-If the client is over the age of 65, this finding would not
be of concern as this is typical with this age group.
