C HAPTER 21: M EASURING V ITAL S IGNS
Williams: deWit's Fundamental Concepts and Skills for Nursing, 5th
Edition
MULTIPLE CHOICE
1. An older adult patient has a t ympanic temperature of 96.2° F (35.7° C).
What nursing intervention would best meet this patient’s need?
a. Take the patient’s vital signs every 4 hours, including temperature.
b. Provide fluids to increase circulation.
c. Increase room temperature to 72° F (22.2° C) and add blankets to
the bed.
d. Check the temperature o rall y to confirm the accuracy of the reading.
ANS: C
Nursing interventions for treating hypothermia should focus on
reducing heat loss and suppl ying additional warmth, such as increasing
the room temperature and adding blankets to the bed.
DIF: Cognitive Level: Application REF: p. 350 OBJ:
Theory #3 TOP: Vital Signs: Temperature KEY: Nursing
Process Step: Implementation MSC: NC LEX:
Physiological Integrity: Basic Care and Comfort
2. The nurse using either a regular or an electronic sphygmomanometer
would ensure that the cuff is the correct size by:
a. using a narrow cuff for an obese patient.
, b. making sure the width of the bladder is at least 3 inches.
c. confirming that the bladder goes around three fourths of the arm.
d. always using a wide cuff.
ANS: C
For accuracy in a BP reading, the cuff of the sphygmomanometer
should have a bladder that goes around three fourths of the arm.
DIF: Cognitive Level: Comprehension REF: p. 366
OBJ: Clinical Practice #4 TOP: Vital Signs: Blood
Pressure KEY: Nursing Process Step: Assessment MSC:
NCLEX: Physiological Integrit y: Basic Care and Comfort
3. For the nurse to assess the most accurate respiration count, the nurse
should:
a. inform the patient about his respirations and ask him to breathe
normall y.
b. count each inhalation and ex piration for 1 full minute.
c. watch the patient’s chest rise and fall from a distance.
d. continue to hold the patient’s radial pulse, and count the
respirations for 30 seconds and multipl y them by 2.
ANS: D
The respirations should be counted for 30 seconds an d multiplied by 2
if they are regular. If the patient knows the nurse is assessing the
respiration, he or she may alter breathing.
, DIF: Cognitive Level: Application REF: p. 361|Skill 21 -5
OBJ: Clinical Practice #3 TOP: Vital Signs:
Respirations KEY: Nursing Process Step: Assessment
MSC: NC LEX: Physiological Integrit y: Basic Care and
Comfort
4. Older adult patients with hypertension may have an auscultatory gap in
their Korotkoff sounds. It is important when taking their blood pressure
measurement to:
a. continue to listen until the cuff is deflated.
b. pump up the cuff until no sound is heard and then let the air out.
c. make sure the bell of the stethoscope is placed firml y over the
artery.
d. stop midway and begin to inflate again.
ANS: A
Many older adults with hyp ertension have an auscultatory gap in their
Korotkoff sounds, making it important to listen until the cuff is
deflated to avoid mistaking the auscultatory gap as the Korotkoff
sound.
DIF: Cognitive Level: Application REF: p. 368 OBJ:
Theory #6 TOP: Vital Signs in the Older Adult KEY: Nursing
Process Step: Assessment MSC: NC LEX: Physiological
Integrit y: Basic Care and Comfort
5. Regarding the blood pressure in children, the diastolic pressure is
assessed by the auscultation of a:
a. clear tapping that gradua ll y grows louder.
Williams: deWit's Fundamental Concepts and Skills for Nursing, 5th
Edition
MULTIPLE CHOICE
1. An older adult patient has a t ympanic temperature of 96.2° F (35.7° C).
What nursing intervention would best meet this patient’s need?
a. Take the patient’s vital signs every 4 hours, including temperature.
b. Provide fluids to increase circulation.
c. Increase room temperature to 72° F (22.2° C) and add blankets to
the bed.
d. Check the temperature o rall y to confirm the accuracy of the reading.
ANS: C
Nursing interventions for treating hypothermia should focus on
reducing heat loss and suppl ying additional warmth, such as increasing
the room temperature and adding blankets to the bed.
DIF: Cognitive Level: Application REF: p. 350 OBJ:
Theory #3 TOP: Vital Signs: Temperature KEY: Nursing
Process Step: Implementation MSC: NC LEX:
Physiological Integrity: Basic Care and Comfort
2. The nurse using either a regular or an electronic sphygmomanometer
would ensure that the cuff is the correct size by:
a. using a narrow cuff for an obese patient.
, b. making sure the width of the bladder is at least 3 inches.
c. confirming that the bladder goes around three fourths of the arm.
d. always using a wide cuff.
ANS: C
For accuracy in a BP reading, the cuff of the sphygmomanometer
should have a bladder that goes around three fourths of the arm.
DIF: Cognitive Level: Comprehension REF: p. 366
OBJ: Clinical Practice #4 TOP: Vital Signs: Blood
Pressure KEY: Nursing Process Step: Assessment MSC:
NCLEX: Physiological Integrit y: Basic Care and Comfort
3. For the nurse to assess the most accurate respiration count, the nurse
should:
a. inform the patient about his respirations and ask him to breathe
normall y.
b. count each inhalation and ex piration for 1 full minute.
c. watch the patient’s chest rise and fall from a distance.
d. continue to hold the patient’s radial pulse, and count the
respirations for 30 seconds and multipl y them by 2.
ANS: D
The respirations should be counted for 30 seconds an d multiplied by 2
if they are regular. If the patient knows the nurse is assessing the
respiration, he or she may alter breathing.
, DIF: Cognitive Level: Application REF: p. 361|Skill 21 -5
OBJ: Clinical Practice #3 TOP: Vital Signs:
Respirations KEY: Nursing Process Step: Assessment
MSC: NC LEX: Physiological Integrit y: Basic Care and
Comfort
4. Older adult patients with hypertension may have an auscultatory gap in
their Korotkoff sounds. It is important when taking their blood pressure
measurement to:
a. continue to listen until the cuff is deflated.
b. pump up the cuff until no sound is heard and then let the air out.
c. make sure the bell of the stethoscope is placed firml y over the
artery.
d. stop midway and begin to inflate again.
ANS: A
Many older adults with hyp ertension have an auscultatory gap in their
Korotkoff sounds, making it important to listen until the cuff is
deflated to avoid mistaking the auscultatory gap as the Korotkoff
sound.
DIF: Cognitive Level: Application REF: p. 368 OBJ:
Theory #6 TOP: Vital Signs in the Older Adult KEY: Nursing
Process Step: Assessment MSC: NC LEX: Physiological
Integrit y: Basic Care and Comfort
5. Regarding the blood pressure in children, the diastolic pressure is
assessed by the auscultation of a:
a. clear tapping that gradua ll y grows louder.
