General Inspection and Measurement of Vital Signs

MULTIPLE CHOICE

1. Which body system does the nurse assess primarily by inspection?
a. Respiratory
b. Gastrointestinal
c. Skin
d. Cardiovascular
ANS: C

Feedback
A The respiratory system is assessed primarily using auscultation, but also percussion and inspection when observing pale or cyanotic skin from hypoxia.
B The gastrointestinal system is assessed primarily by auscultation and palpation, but also with inspection when looking at the contour of the abdomen.
C Skin is assessed primarily using inspection, but also palpation.
D The cardiovascular system is assessed primarily with auscultation and palpation, but also by inspection when looking at the color of extremities for evidence of perfusion or edema.
DIF: Cognitive Level: Remember REF: 37
TOP: Nursing Process: Assessment
MSC: NCLEX: Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific Assessments

2. A patient is sitting slightly forward bracing his arms on his knees in a tripod position. This position is associated with which symptom?
a. Abdominal pain
b. Spinal deformity
c. Back pain
d. Breathing difficulty
ANS: D

Feedback
A Positions used by patients with abdominal pain vary depending upon what organ is involved. For example, patients with appendicitis tend to lie very still; those with acute pancreatitis prefer the fetal position for pain relief.
B Spinal deformity usually affects the patient’s gait or causes a slumped posture.
C Back pain usually affects the patient’s gait or causes a slumped posture.
D Breathing difficulty is associated with the tripod position, which allows maximal expansion of the muscles of respiration.
DIF: Cognitive Level: Remember REF: 37
TOP: Nursing Process: Assessment
MSC: NCLEX: Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific Assessments

3. The temperature of a patient is measured every 6 hours at 6 AM, 12 PM, 6 PM, and 12 AM. Which temperature reading is expected to be low due to a normal variation?
a. The measurement at 6 AM
b. The measurement at 12 PM
c. The measurement at 6 PM
d. The measurement at 12 AM
ANS: A

Feedback
A Early in the morning is the time of the lowest temperature of the day due to circadian rhythms.
B A low temperature due to circadian rhythms is not expected at this time.
C The highest temperature occurs in the late afternoon and early evening due to circadian rhythms.
D A low temperature due to circadian rhythms is not expected at this time.
DIF: Cognitive Level: Understand REF: 38
TOP: Nursing Process: Assessment
MSC: NCLEX: Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific Assessments

4. Which statement is correct regarding taking or interpreting axillary temperatures?
a. Axillary temperatures should not be used in patients less than 2 years of age.
b. Readings may be less accurate.
c. The thermometer is left in place for no more than 3 minutes.
d. The thermometer is placed in the axilla with the shoulder abducted.
ANS: B

Feedback
A The axilla is a common site for temperature measurement on infants and children.
B Multiple studies have shown temperature measurements at the axillary site are less accurate compared with alternative sites.
C The thermometer is left in place until the audible signal occurs and the temperature appears on the screen.
D Place the probe in the middle of the axilla, with the arm held against the body (adducted).
DIF: Cognitive Level: Understand REF: 39
TOP: Nursing Process: Assessment
MSC: NCLEX: Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific Assessments

5. A temperature of 99.8° F taken in the axilla is equivalent to which temperature value taken orally?
a. 100.8° F
b. 99.8° F
c. 98.8° F
d. 97.8° F
ANS: A

Feedback
A Normal temperature readings from the axilla are about 1° F below the normal oral temperature.
B Normal temperature readings from the axilla are about 1° F below the normal oral temperature.
C Normal temperature readings from the axilla are about 1° F below the normal oral temperature.
D Normal temperature readings from the axilla are about 1° F below the normal oral temperature.
DIF: Cognitive Level: Apply REF: 39
TOP: Nursing Process: Assessment
MSC: NCLEX: Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific Assessments

6. The nurse suspects an irregularity in the rhythm of the patient’s radial pulse. What is the most appropriate action for this nurse to take at this time?
a. Document this rhythm as normal for the patient.
b. Use a Doppler to check the brachial pulse.
c. Count the patient’s apical pulse for a full minute.
d. Count the radial pulse again for 15 seconds and multiply by 4.
ANS: C

Feedback
A An irregular rhythm is not a normal finding. The pulsation between each beat should be the same or regular.
B A Doppler is not indicated in this case; it is used when the pulse cannot be palpated.
C When an irregular pulse is palpated, the nurse counts the number of pulsations for a full minute.
D Counting the radial pulse again for 15 seconds and multiplying by 4 may reconfirm the initial findings, but does not provide additional data for the nurse on this patient.
DIF: Cognitive Level: Apply REF: 39
TOP: Nursing Process: Assessment
MSC: NCLEX: Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific Assessments

7. The patient with a respiratory rate that is within normal limits is the _____ whose respiratory rate is _____ breaths/min.
a. 16-month-old; 36
b. 6-year-old; 20
c. 14-year-old;26
d. 40-year-old; 10
ANS: B

Feedback
A A toddler’s respiratory rate ranges from 24 to 32.
B A school-age child’s respiratory rate ranges from 18 to 26.
C An adolescent’s respiratory rate ranges from 12 to 16.
D An adult’s respiratory rate ranges from 12 to 20.
DIF: Cognitive Level: Apply REF: 40
TOP: Nursing Process: Assessment
MSC: NCLEX: Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific Assessments

8. A nurse is taking vital signs of an adult patient whose oxygen saturation is 96%. The patient’s temperature is 102° F, blood pressure is 130/86, pulse is 100 beats/min, and respiratory rate is 26 breaths/min. Which factor may be contributing to the elevated respiratory rate?
a. The patient’s temperature
b. The patient’s oxygen saturation
c. The patient’s pulse rate
d. The patient’s blood pressure
ANS: A

Feedback
A Fever is a factor that may increase respiratory rate, and this patient’s temperature is 102° F.
B The patient’s oxygen saturation is a measure of the oxygen carried by hemoglobin and it is within expected limits—above 90%.
C The patient’s pulse rate may be due to the high temperature, but a pulse of 100 does not contribute to an elevated respiratory rate in this case.
D The patient’s blood pressure is higher than normal, but does not contribute to an elevated respiratory rate in this case.
DIF: Cognitive Level: Apply REF: 40
TOP: Nursing Process: Assessment
MSC: NCLEX: Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific Assessments

9. Nurses understand that a patient’s diastolic pressure represents which physiologic function?
a. The pressure needed to open the aortic and pulmonic valves
b. The pressure in blood vessels when the ventricles contract
c. The pressure of the blood returning to the heart from the venous system
d. The pressure in blood vessels when the ventricles are relaxed
ANS: D

Feedback
A The pressure needed to open the aortic and pulmonic valves is called the afterload.
B The pressure in blood vessels when the ventricles contract is the definition of the systolic pressure.
C The pressure of the blood returning to the heart from the venous system is incorrect.
D The pressure in blood vessels when the ventricles are relaxed is the definition of the diastolic pressure.
DIF: Cognitive Level: Understand REF: 41
TOP: Nursing Process: Assessment
MSC: NCLEX: Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific Assessments

10. According to research findings, which site is preferred for measuring blood pressure when the nurse is unable to use the patient’s upper arms?
a. Ankle
b. Thigh
c. Calf
d. Wrist
ANS: A

Feedback
A A study comparing accuracy among sites recommended the ankle as an alternative site for blood pressure measurement.
B The thigh is an alternative site, but the ankle is the preferred site.
C A study comparing accuracy among sites recommended the ankle site in preference to the calf as an alternative site for blood pressure measurement if the upper arm is unavailable.
D Approaches to measuring blood pressure using the wrist and finger sites have been developed, but these lack acceptable accuracy and cost efficiency to be recommended for clinical practice.
DIF: Cognitive Level: Remember REF: 41
TOP: Nursing Process: Assessment
MSC: NCLEX: Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific Assessments

11. A patient’s blood pressure has been averaging 120/72 when using the upper arms. Today the nurse uses this patient’s thigh to measure the blood pressure. What is the expected systolic pressure using the thigh that is equivalent to a systolic pressure of 120?
a. A systolic reading of 110 mm Hg
b. A systolic reading of 120 mm Hg
c. A systolic reading of 140 mm Hg
d. A systolic reading of 170 mm Hg
ANS: C

Feedback
A A systolic reading of 110 mm Hg is too low.
B A systolic reading of 120 mm Hg is too low.
C Normally the systolic blood pressure is 10 to 40 mm Hg higher in the leg than in the arm.
D A systolic reading of 170 mm Hg is too high.
DIF: Cognitive Level: Apply REF: 41
TOP: Nursing Process: Assessment
MSC: NCLEX: Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific Assessments

12. A nurse notices that the patient has gained 11 lb. If this increase in weight is related to fluid retention, the patient is retaining approximately how many liters of fluid?
a. 1 L
b. 5 L
c. 11 L
d. 24 L
ANS: B

Feedback
A Every kg equals a liter of fluid. Thus, 11 lb ÷ 2.2 = 5 L.
B Every kilogram (kg) equals a liter of fluid. Thus, 11 lb ÷ 2.2 = 5 L.
C Every kg equals a liter of fluid. Thus, 11 lb ÷ 2.2 = 5 L.
D Every kg equals a liter of fluid. Thus, 11 lb ÷ 2.2 = 5 L. This answer is obtained by multiplying 11 by 2.2 instead of dividing.
DIF: Cognitive Level: Apply REF: 43
TOP: Nursing Process: Assessment
MSC: NCLEX: Patient Needs: Physiologic Integrity: Physiologic Adaptation: Fluid and Electrolyte Imbalances

MULTIPLE RESPONSE

1. Which method of temperature measurement indirectly reflects inner core temperature?
Select all that apply.
a. Axillary temperature
b. Oral temperature
c. Tympanic temperature
d. Rectal temperature
e. Temporal artery temperature
ANS: B, E
Correct: Inner core temperature is measured indirectly because the probe is placed near an artery. For oral temperature, the probe is placed near the carotid artery and the temporal artery is used for the temporal artery temperature.
Incorrect: For axillary, tympanic, and rectal temperatures, the probe is not placed close to any major blood vessels.

DIF: Cognitive Level: Understand REF: 38
TOP: Nursing Process: Assessment
MSC: NCLEX: Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific Assessments

2. Which method of temperature measurement does a nurse choose when assessing children?
Select all that apply.
a. Axillary temperature
b. Rectal temperature
c. Temporal artery temperature
d. Oral temperature
e. Tympanic membrane temperature
ANS: A, C, D, E
Correct: Axillary, temporal artery, oral, and tympanic membrane temperatures are appropriate for children.
Incorrect: Rectal temperature measurement is considered safe and accurate for adults only.

DIF: Cognitive Level: Apply REF: 38-39
TOP: Nursing Process: Assessment
MSC: NCLEX: Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific Assessments

3. Which action by the nurse results in the patient’s blood pressure measurement being falsely high? Select all that apply.
a. Using a blood pressure cuff that is too narrow for the patient’s upper arm
b. Deflating the blood pressure cuff too rapidly
c. Wrapping the blood pressure cuff too loosely
d. Reinflating the blood pressure cuff before it completely deflates
e. Positioning the patient’s arm above the level of the heart
ANS: A, C, D, E
Correct: Using a blood pressure cuff that is too narrow for the patient’s upper arm, wrapping the cuff too loosely, reinflating the cuff before it completely deflates, and positioning the patient’s arm above the level of the heart all result in readings that are falsely high.
Incorrect: Deflating the blood pressure cuff too rapidly causes the blood pressure reading to be falsely low.

DIF: Cognitive Level: Remember REF: 43
TOP: Nursing Process: Assessment
MSC: NCLEX: Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific Assessments

4. Which action by the nurse results in the patient’s blood pressure measurement being falsely low? Select all that apply.
a. Using a blood pressure cuff that is too wide for the patient’s arm
b. Not inflating the blood pressure cuff enough
c. Positioning the patient’s arm above the level of the heart
d. Wrapping the cuff too loosely around the arm
e. Deflating the cuff too rapidly
ANS: A, B, E
Correct: Using a blood pressure cuff that is too wide for the patient’s arm, not inflating the blood pressure cuff enough, and deflating the cuff too rapidly could result in a false low reading.
Incorrect: Positioning the patient’s arm above the level of the heart and wrapping the cuff too loosely around the arm causes the blood pressure to be falsely high.

DIF: Cognitive Level: Remember REF: 43
TOP: Nursing Process: Assessment
MSC: NCLEX: Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific Assessments

5. The nurse taking a patient’s blood pressure recognizes that several factors may cause an increased blood pressure reading. Which factors below can increase blood pressure? Select all that apply.
a. The patient rates pain at a level of 7 on a scale of 0 to 10.
b. The cuff was reinflated before being completely deflated.
c. The patient drank cold milk just before the reading.
d. The time of day is late afternoon.
e. The cuff is too wide for the extremity.
ANS: A, B, D
Correct: Rating pain at a level of 7 on a scale of 0 to 10, reinflating the cuff before being completely deflated, and taking the reading in late afternoon are all factors that can increase blood pressure.
Incorrect: Drinking cold milk just before the reading will not affect blood pressure, but drinking caffeine such as coffee or cola may increase blood pressure. A wide cuff makes the reading lower than it actually is rather than higher.

DIF: Cognitive Level: Apply REF: 43
TOP: Nursing Process: Assessment
MSC: NCLEX: Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific Assessments

COMPLETION

1. A female patient admitted with fluid retention has been in diuretic therapy to remove fluid. She weighed 187 lb on admission. Today she weighs 179 lb. Since admission, this patient has lost _____ L from fluid loss.

ANS:
3.6
1 kg (2.2 lb) = 1 L; 187 – 179 = 8 lb weight loss divided by 2.2 = 3.6 L.

DIF: Cognitive Level: Apply REF: 43
TOP: Nursing Process: Assessment
MSC: NCLEX: Patient Needs: Physiologic Integrity: Physiologic Adaptation: Fluid and Electrolyte Imbalances