NSG 3100 Vital Signs Review
1. A patient has lost a lot of blood from surgery. Which vital sign changewould the nurse not
expect to see as a result of the massive blood loss?
A. HR of 118
B.BP of 80/45
C.RR of 8
D.Temp of 100.8: C.RR of 8
2. A nurse notes that when she took an oral temp on her patient, it was much higher than the
baseline in the patient's chart. What factor could haveinfluenced that discrepancy?
A. The baseline temperature was obtained shortly after the client returned fromPhysical Therapy
and the subsequent reading was taking while patient was reading a book.
B. The baseline reading was taken axillary and the subsequent reading wastaken orally.
C. The patient ingested ice tea within 10min of the subsequent reading
D. The patient smoked shortly before the first baseline reading was obtained-
: B. The baseline reading was taken axillary and the subsequent reading was takenorally.
Axillary : 1 degree < oralOral : 1 degree < rectal
3. A hospitalized patient complains of abdominal pain that ranks 9 on a scaleof 1 to 10. After
obtaining the pain rating, what is the nurse's next best step?
A. Assess the client's vital signs to see if they match his report of pain
B. Ask the client to describe the pain
C. Check to see when the last time the patient received his pain medicationwas
D. Administer ordered pain medication: B. ask the client to describe the pain
4. A nurse is educating her patient on factors that can affect body tempera-ture. Which of the
following factors would need to be included in the teaching(select all that apply).
A. Stress
B. Age
C. Hormones
D. Environment
E. Position: A. Stress
, B. Age
C. Hormones
D. Environment
5. A nurse is instructing her CNA about caring for a client who is at risk for bleeding from a
low platelet count as a result of chemotherapy. Which instructions is the priority for measuring
vital signs in this patient?
A. Do not measure the clients temperature rectally
B. Be sure you listen to heart rate for a full minute
C. Be sure when you count respirations you do not tell the client that is whatyou are doing
D. Let the client rest for 15-30min before you measure her BP: A. Do notmeasure the clients
temperature rectally
*use less invasive method if possible, rectal method is contraindicated, risk forbleeding if
wounds/hemorrhoids are present.*
6. A nurse obtained vital signs on a previously stable patient and got atemperature of 100.7
orally. What action is appropriate at this time?
A. Document the findings
B. Call the doctor to inform him of the abnormal vital sign
C. Check the patient for other signs and symptoms of infection
D. Obtain the temperature using a different route: D.Obtain the temperature usinga different
route
7. A nurse is admitting a client with a fractured femur and obtains BP of 140/94. The client
denies any history of hypertension. What action should thenurse take FIRST?
A. Request a prescription for a anti-hypertensive medication
B. Ask the client if they are experiencing any pain.
C. Request a prescription for an anti-anxiety medication
D. Return in 30min and recheck the BP on a different extremity: B. Ask the clientif they are
experiencing any pain.
1. A patient has lost a lot of blood from surgery. Which vital sign changewould the nurse not
expect to see as a result of the massive blood loss?
A. HR of 118
B.BP of 80/45
C.RR of 8
D.Temp of 100.8: C.RR of 8
2. A nurse notes that when she took an oral temp on her patient, it was much higher than the
baseline in the patient's chart. What factor could haveinfluenced that discrepancy?
A. The baseline temperature was obtained shortly after the client returned fromPhysical Therapy
and the subsequent reading was taking while patient was reading a book.
B. The baseline reading was taken axillary and the subsequent reading wastaken orally.
C. The patient ingested ice tea within 10min of the subsequent reading
D. The patient smoked shortly before the first baseline reading was obtained-
: B. The baseline reading was taken axillary and the subsequent reading was takenorally.
Axillary : 1 degree < oralOral : 1 degree < rectal
3. A hospitalized patient complains of abdominal pain that ranks 9 on a scaleof 1 to 10. After
obtaining the pain rating, what is the nurse's next best step?
A. Assess the client's vital signs to see if they match his report of pain
B. Ask the client to describe the pain
C. Check to see when the last time the patient received his pain medicationwas
D. Administer ordered pain medication: B. ask the client to describe the pain
4. A nurse is educating her patient on factors that can affect body tempera-ture. Which of the
following factors would need to be included in the teaching(select all that apply).
A. Stress
B. Age
C. Hormones
D. Environment
E. Position: A. Stress
, B. Age
C. Hormones
D. Environment
5. A nurse is instructing her CNA about caring for a client who is at risk for bleeding from a
low platelet count as a result of chemotherapy. Which instructions is the priority for measuring
vital signs in this patient?
A. Do not measure the clients temperature rectally
B. Be sure you listen to heart rate for a full minute
C. Be sure when you count respirations you do not tell the client that is whatyou are doing
D. Let the client rest for 15-30min before you measure her BP: A. Do notmeasure the clients
temperature rectally
*use less invasive method if possible, rectal method is contraindicated, risk forbleeding if
wounds/hemorrhoids are present.*
6. A nurse obtained vital signs on a previously stable patient and got atemperature of 100.7
orally. What action is appropriate at this time?
A. Document the findings
B. Call the doctor to inform him of the abnormal vital sign
C. Check the patient for other signs and symptoms of infection
D. Obtain the temperature using a different route: D.Obtain the temperature usinga different
route
7. A nurse is admitting a client with a fractured femur and obtains BP of 140/94. The client
denies any history of hypertension. What action should thenurse take FIRST?
A. Request a prescription for a anti-hypertensive medication
B. Ask the client if they are experiencing any pain.
C. Request a prescription for an anti-anxiety medication
D. Return in 30min and recheck the BP on a different extremity: B. Ask the clientif they are
experiencing any pain.
