NR 224 Week 2 EDAPT Vital Signs Study
Guide | 200 Questions, Verified Answers &
Rationales (Latest 2026)
Question 1
A nurse is preparing to document a patient's vital signs in the electronic health
record. Which information is most critical to include alongside the numerical
values to ensure comprehensive documentation?
A. The time the patient last ate
,B. The specific route used to obtain the measurements
C. The manufacturer of the equipment used
D. The patient's room temperature
Verified Answer: B. The specific route used to obtain the measurements
Explanation: Documenting the specific route (e.g., oral, tympanic, axillary,
temporal) is vital because baseline values and normal ranges vary slightly
depending on the anatomical site used. This ensures consistency for future
comparisons and trends.
Question 2
After identifying a critically abnormal blood pressure reading in a post-
operative patient, which action should the nurse take first regarding
documentation and communication?
A. Inform the charge nurse before logging the data
B. Document the findings in the chart immediately, then notify the healthcare
provider
C. Wait for the next scheduled vital sign cycle to confirm the trend
D. Retake the blood pressure on the opposite arm three more times before
logging
Verified Answer: B. Document the findings in the chart immediately, then
notify the healthcare provider
Explanation: The priority sequence for managing abnormal data is to first
document the findings accurately to establish a legal and clinical record, and
then immediately inform the primary healthcare provider to secure necessary
intervention orders.
Question 3
A nurse is reviewing the provider's orders for a patient scheduled to receive an
antihypertensive medication. The order states: "Give medication for systolic BP
> 130 or diastolic BP > 75." The patient’s current BP is 160/80 mmHg, which is
consistent with their baseline. What is the correct nursing action?
A. Hold the medication and document that the blood pressure is stable
B. Administer the medication as ordered and complete a comprehensive
assessment
C. Notify the healthcare provider that the blood pressure is too high to safely
give the drug
D. Request a lower dose from the pharmacy because the diastolic is only 5
points over
,Verified Answer: B. Administer the medication as ordered and complete a
comprehensive assessment
Explanation: The patient's blood pressure (160/80) exceeds the established
threshold parameters (>130/75), meaning the medication is legally indicated
and safe to administer based on the patient's baseline. A comprehensive
physical assessment should accompany administration.
Question 4
An Unlicensed Assistive Personnel (UAP) reports the following vital signs for
an adult client: BP: 110/60 mmHg, Apical Pulse: 72 bpm, RR: 12 breaths/min,
Temp: 98.0°F, SpO2: 99%. What is the nurse's primary responsibility upon
receiving this report?
A. Tell the UAP to recheck all parameters in two hours
B. Review the collected data and analyze it for any subtle clinical cues or
problems
C. Immediately page the attending physician to report the respiratory rate
D. Assume the data is fully accurate and log it without review
Verified Answer: B. Review the collected data and analyze it for any subtle
clinical cues or problems
Explanation: While vital sign collection can be delegated to a UAP, the
professional nurse retains ultimate accountability. The nurse must review and
interpret the data, evaluating it within the context of the patient's overall
clinical status.
Question 5
Which physiological change represents the body's acute, direct response to an
elevated core body temperature (fever)?
A. Decreased respiratory effort and bradypnea
B. Increased respiratory rate and increased pulse rate
C. Peripheral vasoconstriction leading to cool, pale skin
D. Systematic drop in metabolic oxygen consumption
Verified Answer: B. Increased respiratory rate and increased pulse rate
Explanation: A fever raises the body's metabolic rate. To meet the increased
metabolic demand for oxygen and to actively dissipate excess heat from the
core, the respiratory rate and heart rate increase concurrently.
Question 6
, A nurse notes that a client’s radial pulse has dropped significantly from the
documented baseline taken four hours ago. Before taking any corrective clinical
action, which questions should the nurse investigate?
A. Has the client recently consumed a high-protein meal or used the restroom?
B. Was the client recently active, and what is their established baseline range?
C. Is the patient currently wearing sequential compression devices?
D. Did the client use an alcohol-based hand rub before the assessment?
Verified Answer: B. Was the client recently active, and what is their
established baseline range?
Explanation: Before reacting to a sudden variance in pulse, the nurse must
assess for confounding variables such as recent physical activity (which
temporary elevates vitals) and compare the new data against the patient's
verified historical baseline.
Question 7
During a busy shift, a nurse leaves a patient’s bed elevated at the highest
position after performing a wound dressing change. Which fundamental safety
concept has been violated?
A. Infection control standards
B. Ergonomic body mechanics for the nurse
C. Fall and injury prevention standards for the patient
D. Proper documentation of environmental factors
Verified Answer: C. Fall and injury prevention standards for the patient
Explanation: Leaving a patient's bed in an elevated position significantly
increases the severity of potential injury if the patient attempts to ambulate or
falls out of bed. The bed must always be returned to its lowest safe position
upon leaving the room.
Question 8
A nurse realizes that they accidentally administered an incorrect dose of an
antihypertensive medication. What is the nurse's first, immediate priority
action?
A. Fill out an institutional incident/occurrence report
B. Monitor the client closely for adverse reactions and ensure patient safety
C. Call the nursing supervisor to report the error anonymously
D. Change the vital sign flow sheet to match the expected outcomes
Verified Answer: B. Monitor the client closely for adverse reactions and
ensure patient safety
Guide | 200 Questions, Verified Answers &
Rationales (Latest 2026)
Question 1
A nurse is preparing to document a patient's vital signs in the electronic health
record. Which information is most critical to include alongside the numerical
values to ensure comprehensive documentation?
A. The time the patient last ate
,B. The specific route used to obtain the measurements
C. The manufacturer of the equipment used
D. The patient's room temperature
Verified Answer: B. The specific route used to obtain the measurements
Explanation: Documenting the specific route (e.g., oral, tympanic, axillary,
temporal) is vital because baseline values and normal ranges vary slightly
depending on the anatomical site used. This ensures consistency for future
comparisons and trends.
Question 2
After identifying a critically abnormal blood pressure reading in a post-
operative patient, which action should the nurse take first regarding
documentation and communication?
A. Inform the charge nurse before logging the data
B. Document the findings in the chart immediately, then notify the healthcare
provider
C. Wait for the next scheduled vital sign cycle to confirm the trend
D. Retake the blood pressure on the opposite arm three more times before
logging
Verified Answer: B. Document the findings in the chart immediately, then
notify the healthcare provider
Explanation: The priority sequence for managing abnormal data is to first
document the findings accurately to establish a legal and clinical record, and
then immediately inform the primary healthcare provider to secure necessary
intervention orders.
Question 3
A nurse is reviewing the provider's orders for a patient scheduled to receive an
antihypertensive medication. The order states: "Give medication for systolic BP
> 130 or diastolic BP > 75." The patient’s current BP is 160/80 mmHg, which is
consistent with their baseline. What is the correct nursing action?
A. Hold the medication and document that the blood pressure is stable
B. Administer the medication as ordered and complete a comprehensive
assessment
C. Notify the healthcare provider that the blood pressure is too high to safely
give the drug
D. Request a lower dose from the pharmacy because the diastolic is only 5
points over
,Verified Answer: B. Administer the medication as ordered and complete a
comprehensive assessment
Explanation: The patient's blood pressure (160/80) exceeds the established
threshold parameters (>130/75), meaning the medication is legally indicated
and safe to administer based on the patient's baseline. A comprehensive
physical assessment should accompany administration.
Question 4
An Unlicensed Assistive Personnel (UAP) reports the following vital signs for
an adult client: BP: 110/60 mmHg, Apical Pulse: 72 bpm, RR: 12 breaths/min,
Temp: 98.0°F, SpO2: 99%. What is the nurse's primary responsibility upon
receiving this report?
A. Tell the UAP to recheck all parameters in two hours
B. Review the collected data and analyze it for any subtle clinical cues or
problems
C. Immediately page the attending physician to report the respiratory rate
D. Assume the data is fully accurate and log it without review
Verified Answer: B. Review the collected data and analyze it for any subtle
clinical cues or problems
Explanation: While vital sign collection can be delegated to a UAP, the
professional nurse retains ultimate accountability. The nurse must review and
interpret the data, evaluating it within the context of the patient's overall
clinical status.
Question 5
Which physiological change represents the body's acute, direct response to an
elevated core body temperature (fever)?
A. Decreased respiratory effort and bradypnea
B. Increased respiratory rate and increased pulse rate
C. Peripheral vasoconstriction leading to cool, pale skin
D. Systematic drop in metabolic oxygen consumption
Verified Answer: B. Increased respiratory rate and increased pulse rate
Explanation: A fever raises the body's metabolic rate. To meet the increased
metabolic demand for oxygen and to actively dissipate excess heat from the
core, the respiratory rate and heart rate increase concurrently.
Question 6
, A nurse notes that a client’s radial pulse has dropped significantly from the
documented baseline taken four hours ago. Before taking any corrective clinical
action, which questions should the nurse investigate?
A. Has the client recently consumed a high-protein meal or used the restroom?
B. Was the client recently active, and what is their established baseline range?
C. Is the patient currently wearing sequential compression devices?
D. Did the client use an alcohol-based hand rub before the assessment?
Verified Answer: B. Was the client recently active, and what is their
established baseline range?
Explanation: Before reacting to a sudden variance in pulse, the nurse must
assess for confounding variables such as recent physical activity (which
temporary elevates vitals) and compare the new data against the patient's
verified historical baseline.
Question 7
During a busy shift, a nurse leaves a patient’s bed elevated at the highest
position after performing a wound dressing change. Which fundamental safety
concept has been violated?
A. Infection control standards
B. Ergonomic body mechanics for the nurse
C. Fall and injury prevention standards for the patient
D. Proper documentation of environmental factors
Verified Answer: C. Fall and injury prevention standards for the patient
Explanation: Leaving a patient's bed in an elevated position significantly
increases the severity of potential injury if the patient attempts to ambulate or
falls out of bed. The bed must always be returned to its lowest safe position
upon leaving the room.
Question 8
A nurse realizes that they accidentally administered an incorrect dose of an
antihypertensive medication. What is the nurse's first, immediate priority
action?
A. Fill out an institutional incident/occurrence report
B. Monitor the client closely for adverse reactions and ensure patient safety
C. Call the nursing supervisor to report the error anonymously
D. Change the vital sign flow sheet to match the expected outcomes
Verified Answer: B. Monitor the client closely for adverse reactions and
ensure patient safety
