1.

The taking of John’s vital signs includes

a. Temperature, blood pressure, respirations. and pulse

b. blood pressure, respirations, pulse and ROM
c. temperature, I&O, respirations, pulse and blood pressure
d. All of the above

2. When taking John’s blood pressure, you should make certain that

a. The cuff is the correct size

b. John is lying on his left side
c. The cuff is positioned dependent to his elbow
d. The cuff is pumped to at least 20 mm above his baseline b/p

3. The most accurate temperature is obtained when taken

a. Under the arm

b. Rectally
c. At the groin
In the ear

4. When counting the pulse rate, you may use the pulse at what points?

a. The carotid artery

b. The radial artery
c. The apical area of the heart via the chest using a stethoscope
d. All of the above

5. A client has developed pneumonia, and his temperature has increased to 37. 7° C. The client
is shivering and “feels uncomfortable. ” Which of the following is true concerning the
physiology of heat production in this client?
a. The increased BMR is probably causing the febrile condition
b. Encouraging the client to ambulate would help decrease heat production
c. The shivering is likely the cause of the increase in temperature
d. The client may need to consume more nutrients during the febrile condition

6. A 74-year-old client currently has a temperature reading of 36° C. The client walks 1 mile
every day and takes naps during the day. Which of the following is most likely the reason for
the lowered body temperature?

a. The lowered temperature is a natural result of the aging processes.

b. Increased stress from exercise has probably reduced the temperature.
c. The individual circadian rhythm requiring daytime naps lowers the temperature.
d. Hormone levels are the most probable cause of the hypothermic condition.

7. A construction worker comes to the emergency room with low blood pressure, normal
pulse, cool skin temperature, diaphoresis, and weakness. These are clinical signs of:
a. Heat exhaustion
b. Heat stroke
c. Heat cramp
d. Hypothermia
8. The nurse is ready to take vital signs on a 6-year-old child. The child has just enjoyed a grape
popsicle. An appropriate action would be to:
a. Take the rectal temperature
b. Take the oral temperature as planned
c. Have the child rinse out the mouth with warm water
d. Wait 30 minutes and take the oral temperature

9.The client’s pulse is 72/minute, easily palpated. In

addition, the pedal pulses are equal in strength in both feet.
To best assess for an irregularity in the pulses, the nurse
should:
a. . Determine the rate of the pedal pulses
b. Auscultate for the strength of the apical pulse
c. Examine the electrocardiogram's reading
d. Ask the client if there is a pulsation that is abnormal

10. Which of the following is an appropriate site for taking the pulse of a 2-year-old?
a. Radial
b. Apical
c. Femoral
d. Pedal
11. The client begins to breathe rapidly. The nurse should:
a. Ask the client if there have been any stressful visitors
b. Measure the oxygen saturation level
c. Count the rate of respirations
d. Take the radial pulse
 12. A client complains of pain and asks the nurse for pain medication. The nurse first assesses
vital signs: blood pressure, 134/92; pulse, 100; and respiration 32. The nurse’s most appropriate
action is to:
a. Ask if the client is anxious
b. Check the client's dressing for bleeding
c. Give the medication as ordered by the physician
d. Recheck the client's vital signs in 30 minutes

13. If measuring blood pressure is necessary in the leg, the nurse expects the
diastolic pressure to be:

 A. 10 to 40 mm Hg higher than in the brachial artery

 B. 20 to 30 mm Hg lower than in the brachial artery

 C. 50 mm Hg higher than in the brachial artery
 D. Essentially the same as that in the brachial artery

14.An 84-year-old diabetic client is admitted for insulin

regulation. Which of the following blood pressure, pulse,
and respiration measurements, respectively, is considered
within the expected limits for this client?

 148/90, 68, 16

 B. 94/52, 68, 30

 C. 108/80, 112, 15
 D. 132/74, 90, 24