NR 224 WEEK 2 EDAPTS – VITAL SIGNS PRACTICE EXAM QUESTIONS
AND ANSWERS WITH DETAILED RATIONALES EACH | CURRENTLY
TESTING AND FREQUENTLY TESTED QUESTIONS | EXPERT VERIFIED
FOR GUARANTEED PASS
SECTION 1: INTRODUCTION TO VITAL SIGNS & GENERAL PRINCIPLES
(Questions 1–25)
1. Which of the following best describes the primary purpose of measuring vital
signs?
A) To provide a definitive diagnosis for all medical conditions
B) To evaluate the body's basic physiological functions and detect changes
C) To replace the need for a comprehensive physical examination
D) To determine the patient's psychological status
Answer: B
Rationale: Vital signs provide objective data about the body's basic physiological
functioning. They are a screening tool to detect deviations from normal, but they
do not provide definitive diagnoses on their own.
2. The traditional five vital signs include temperature, pulse, respirations, blood
pressure, and:
A) Oxygen saturation
B) Pain
C) Blood glucose
D) Urine output
Answer: B
Rationale: Pain is now widely recognized as the fifth vital sign, reflecting the
importance of subjective pain assessment alongside objective measurements.
Oxygen saturation is often called the sixth vital sign.
3. A nursing assistant reports a patient's vital signs to the RN. The RN's primary
responsibility is to:
A) Record the values in the chart without review
B) Ask the nursing assistant to repeat the measurements
C) Review the data, interpret trends, and determine if further assessment is
needed
D) Immediately contact the provider for every abnormal value
1
,Answer: C
Rationale: The RN is accountable for interpreting vital sign data. Abnormal values
require clinical judgment to determine if a provider notification is warranted.
Reviewing and trending is the core nursing responsibility.
4. When preparing to take vital signs, the nurse should first:
A) Gather all necessary equipment and ensure it is in working order
B) Ask the patient what they want to eat for dinner
C) Turn off the room lights for comfort
D) Immediately take the blood pressure without explaining the procedure
Answer: A
Rationale: Proper preparation includes gathering and checking equipment (e.g.,
thermometer, sphygmomanometer, stethoscope, pulse oximeter) to ensure
accuracy and efficiency before entering or after greeting the patient.
5. Which of the following factors can artificially elevate a patient's vital signs?
A) Recent exercise, anxiety, or pain
B) Sleeping peacefully
C) Taking antihypertensive medications as prescribed
D) Consuming a cold beverage immediately before measurement
Answer: A
Rationale: Sympathetic nervous system stimulation from exercise, anxiety, or pain
increases heart rate, respiratory rate, and blood pressure. These factors should be
controlled for (e.g., resting 5 minutes before measurement).
6. A patient's vital signs are 98.6°F, HR 88, RR 18, BP 118/76. The nurse interprets
this as:
A) Hypertensive crisis
B) Within normal limits for an adult
C) Indicative of hypothermia
D) Tachycardic and febrile
Answer: B
Rationale: These values fall within normal adult ranges: temperature 98.6°F
(normal), HR 60–100 (normal), RR 12–20 (normal), BP <120/80 (normal). No acute
concerns are indicated by these numbers alone.
2
,7. The nurse notes that a patient's vital signs are significantly different from the
previous shift's readings. The most appropriate action is to:
A) Document the new values and disregard the change
B) Reassess the vital signs and compare with the patient's baseline
C) Assume the previous shift made an error
D) Immediately start CPR
Answer: B
Rationale: Significant deviations require re-assessment to confirm accuracy,
evaluate technique, and correlate with the patient's clinical presentation and
baseline. Trend analysis is critical.
8. Which of the following is a correct principle regarding vital sign measurement?
A) Vital signs should always be measured in the same order for every patient
B) The frequency of vital sign measurement is determined solely by hospital policy
C) Vital signs should be measured based on the patient's condition, acuity, and
provider orders
D) Vital signs are only needed on admission to a unit
Answer: C
Rationale: Frequency depends on the patient's clinical status, acuity level, and
specific provider orders. Stable patients may have vital signs checked once per
shift, while unstable patients may require continuous monitoring.
9. A patient who just finished walking down the hallway to their room needs vital
signs. The nurse should:
A) Take vital signs immediately in the hallway
B) Allow the patient to rest for 5–10 minutes before measuring
C) Take the blood pressure while walking
D) Skip vital signs for this shift
Answer: B
Rationale: Physical activity elevates heart rate, respiratory rate, and blood
pressure. A resting period of 5–10 minutes allows these values to return to
baseline, providing a more accurate reflection of resting status.
10. Which of the following is NOT a component of the "EDAPTS" framework for
vital signs?
A) Equipment
B) Delegation
3
, C) Assessment
D) Preparation
Answer: D
Rationale: While preparation is implied, the EDAPTS framework specifically stands
for: Equipment, Delegation, Assessment, Planning, Teaching, and Safety (or
similar variations depending on the curriculum). Preparation is a general step, not
a distinct EDAPTS component.
11. A nurse is teaching a patient about why vital signs are being measured
frequently. Which statement is correct?
A) "We measure them to see if you are being honest about your symptoms."
B) "Vital signs help us track how your body is responding to treatment and detect
early warning signs."
C) "We only measure them because the computer requires us to."
D) "Vital signs tell us exactly what disease you have."
Answer: B
Rationale: Patient teaching should emphasize that vital signs provide objective
data to monitor response to treatment and detect deterioration early. They are
not used to test honesty or to make definitive diagnoses.
12. The nurse delegates vital sign measurement to an unlicensed assistive
personnel (UAP). The UAP reports that the patient's BP is 180/110. The nurse
should:
A) Instruct the UAP to chart the finding
B) Ask the UAP to re-measure and then independently assess the patient
C) Call the provider immediately without verifying
D) Tell the patient to ignore the reading
Answer: B
Rationale: The RN must verify critical or unexpected findings. The nurse should re-
measure the BP to ensure accuracy and then perform a focused assessment to
evaluate the patient's overall status before notifying the provider.
13. Which of the following patients would require the most frequent vital sign
monitoring?
A) A 45-year-old ambulatory patient with a sprained ankle
B) A 70-year-old post-operative patient with unstable vital signs
C) A 30-year-old patient admitted for routine observation
4
AND ANSWERS WITH DETAILED RATIONALES EACH | CURRENTLY
TESTING AND FREQUENTLY TESTED QUESTIONS | EXPERT VERIFIED
FOR GUARANTEED PASS
SECTION 1: INTRODUCTION TO VITAL SIGNS & GENERAL PRINCIPLES
(Questions 1–25)
1. Which of the following best describes the primary purpose of measuring vital
signs?
A) To provide a definitive diagnosis for all medical conditions
B) To evaluate the body's basic physiological functions and detect changes
C) To replace the need for a comprehensive physical examination
D) To determine the patient's psychological status
Answer: B
Rationale: Vital signs provide objective data about the body's basic physiological
functioning. They are a screening tool to detect deviations from normal, but they
do not provide definitive diagnoses on their own.
2. The traditional five vital signs include temperature, pulse, respirations, blood
pressure, and:
A) Oxygen saturation
B) Pain
C) Blood glucose
D) Urine output
Answer: B
Rationale: Pain is now widely recognized as the fifth vital sign, reflecting the
importance of subjective pain assessment alongside objective measurements.
Oxygen saturation is often called the sixth vital sign.
3. A nursing assistant reports a patient's vital signs to the RN. The RN's primary
responsibility is to:
A) Record the values in the chart without review
B) Ask the nursing assistant to repeat the measurements
C) Review the data, interpret trends, and determine if further assessment is
needed
D) Immediately contact the provider for every abnormal value
1
,Answer: C
Rationale: The RN is accountable for interpreting vital sign data. Abnormal values
require clinical judgment to determine if a provider notification is warranted.
Reviewing and trending is the core nursing responsibility.
4. When preparing to take vital signs, the nurse should first:
A) Gather all necessary equipment and ensure it is in working order
B) Ask the patient what they want to eat for dinner
C) Turn off the room lights for comfort
D) Immediately take the blood pressure without explaining the procedure
Answer: A
Rationale: Proper preparation includes gathering and checking equipment (e.g.,
thermometer, sphygmomanometer, stethoscope, pulse oximeter) to ensure
accuracy and efficiency before entering or after greeting the patient.
5. Which of the following factors can artificially elevate a patient's vital signs?
A) Recent exercise, anxiety, or pain
B) Sleeping peacefully
C) Taking antihypertensive medications as prescribed
D) Consuming a cold beverage immediately before measurement
Answer: A
Rationale: Sympathetic nervous system stimulation from exercise, anxiety, or pain
increases heart rate, respiratory rate, and blood pressure. These factors should be
controlled for (e.g., resting 5 minutes before measurement).
6. A patient's vital signs are 98.6°F, HR 88, RR 18, BP 118/76. The nurse interprets
this as:
A) Hypertensive crisis
B) Within normal limits for an adult
C) Indicative of hypothermia
D) Tachycardic and febrile
Answer: B
Rationale: These values fall within normal adult ranges: temperature 98.6°F
(normal), HR 60–100 (normal), RR 12–20 (normal), BP <120/80 (normal). No acute
concerns are indicated by these numbers alone.
2
,7. The nurse notes that a patient's vital signs are significantly different from the
previous shift's readings. The most appropriate action is to:
A) Document the new values and disregard the change
B) Reassess the vital signs and compare with the patient's baseline
C) Assume the previous shift made an error
D) Immediately start CPR
Answer: B
Rationale: Significant deviations require re-assessment to confirm accuracy,
evaluate technique, and correlate with the patient's clinical presentation and
baseline. Trend analysis is critical.
8. Which of the following is a correct principle regarding vital sign measurement?
A) Vital signs should always be measured in the same order for every patient
B) The frequency of vital sign measurement is determined solely by hospital policy
C) Vital signs should be measured based on the patient's condition, acuity, and
provider orders
D) Vital signs are only needed on admission to a unit
Answer: C
Rationale: Frequency depends on the patient's clinical status, acuity level, and
specific provider orders. Stable patients may have vital signs checked once per
shift, while unstable patients may require continuous monitoring.
9. A patient who just finished walking down the hallway to their room needs vital
signs. The nurse should:
A) Take vital signs immediately in the hallway
B) Allow the patient to rest for 5–10 minutes before measuring
C) Take the blood pressure while walking
D) Skip vital signs for this shift
Answer: B
Rationale: Physical activity elevates heart rate, respiratory rate, and blood
pressure. A resting period of 5–10 minutes allows these values to return to
baseline, providing a more accurate reflection of resting status.
10. Which of the following is NOT a component of the "EDAPTS" framework for
vital signs?
A) Equipment
B) Delegation
3
, C) Assessment
D) Preparation
Answer: D
Rationale: While preparation is implied, the EDAPTS framework specifically stands
for: Equipment, Delegation, Assessment, Planning, Teaching, and Safety (or
similar variations depending on the curriculum). Preparation is a general step, not
a distinct EDAPTS component.
11. A nurse is teaching a patient about why vital signs are being measured
frequently. Which statement is correct?
A) "We measure them to see if you are being honest about your symptoms."
B) "Vital signs help us track how your body is responding to treatment and detect
early warning signs."
C) "We only measure them because the computer requires us to."
D) "Vital signs tell us exactly what disease you have."
Answer: B
Rationale: Patient teaching should emphasize that vital signs provide objective
data to monitor response to treatment and detect deterioration early. They are
not used to test honesty or to make definitive diagnoses.
12. The nurse delegates vital sign measurement to an unlicensed assistive
personnel (UAP). The UAP reports that the patient's BP is 180/110. The nurse
should:
A) Instruct the UAP to chart the finding
B) Ask the UAP to re-measure and then independently assess the patient
C) Call the provider immediately without verifying
D) Tell the patient to ignore the reading
Answer: B
Rationale: The RN must verify critical or unexpected findings. The nurse should re-
measure the BP to ensure accuracy and then perform a focused assessment to
evaluate the patient's overall status before notifying the provider.
13. Which of the following patients would require the most frequent vital sign
monitoring?
A) A 45-year-old ambulatory patient with a sprained ankle
B) A 70-year-old post-operative patient with unstable vital signs
C) A 30-year-old patient admitted for routine observation
4
