Fundamentals of Nursing: Vital Signs (Fundamentals of Nursing) Practice Questions

Explanation. Hot or cold oral intake alters oral mucosa temperature and produces a falsely high or low reading. The nurse should wait 15–30 minutes before measuring an oral temperature. Documenting an inaccurate value or arbitrarily subtracting a value is incorrect, and switching to a rectal route is unnecessary and more invasive when waiting solves the problem.

Explanation. A heart rate below 60 beats/min is bradycardia. The normal adult range is 60–100 beats/min. Bradycardia can be normal (well-conditioned athletes, sleep) when the client is asymptomatic, so the nurse should assess for symptoms rather than panic. It is not tachycardia (>100) and a regular rhythm is not atrial fibrillation.

Explanation. A cuff that is too narrow requires more pressure to occlude the artery, producing a falsely HIGH reading. A cuff too wide or too loose produces a falsely low reading. Proper cuff width should be about 40% of arm circumference, and the bladder should encircle 80% of the arm.

Explanation. Respirations are partly under voluntary control, so clients alter their breathing if they know it is being counted. Counting while appearing to still take the pulse keeps assessment subtle and accurate. Counting for only 5 seconds is too short to be reliable, and self-report is unreliable.

Explanation. The combination of fever, tachycardia (>90), tachypnea (>20), and hypotension meets several SIRS/sepsis criteria and signals possible infection with hemodynamic compromise. This pattern requires prompt provider notification, not dismissal as normal postoperative variation or simple pain.

Explanation. Orthostatic vital signs are measured lying, then sitting and/or standing, waiting 1–3 minutes after each position change to allow the body to respond. A drop in systolic BP of ≥20 mmHg or diastolic ≥10 mmHg, or a rise in HR ≥20 bpm, indicates orthostatic hypotension. Immediate rechecking misses the delayed response.

Explanation. For many clients with chronic CO2 retention from COPD, a target SpO2 of 88–92% is acceptable to avoid suppressing their hypoxic respiratory drive. The nurse should correlate the reading with the client's clinical status and prescribed parameters. High-flow oxygen could be harmful in this population without an order.

Explanation. When other routes fail in a young child, a rectal temperature (if not contraindicated by conditions such as diarrhea, rectal surgery, or neutropenia) is accurate. Axillary is convenient but the LEAST accurate. Temporal artery measurement is actually appropriate for children, so the option calling it contraindicated is false, and oral is unreliable in an uncooperative toddler.

Explanation. On the common 0–4+ pulse scale: 0 = absent, 1+ = weak/thready, 2+ = normal, 3+ = increased/full, 4+ = bounding. So 3+ indicates an increased or full pulse. A 2+ is the expected normal finding.

Explanation. Pulse pressure is the difference between systolic and diastolic pressures: 146 − 94 = 52 mmHg. Mean arterial pressure is a weighted average (approx diastolic + 1/3 pulse pressure), not the simple difference. Pulse deficit refers to a difference between apical and radial rates, not BP.

Explanation. A pulse deficit is the difference between the apical and radial pulse rates counted simultaneously (typically by two nurses for one full minute). It occurs when some cardiac contractions are too weak to produce a palpable peripheral pulse, as in atrial fibrillation. It is unrelated to BP differences.

Explanation. Normal adult ranges: temperature ~36.1–37.2°C (oral), heart rate 60–100 bpm, respiratory rate 12–20 breaths/min, and BP systolic <120 / diastolic <80 (with normal up to ~120/80). The set with 36.5°C, HR 72, RR 16, BP 118/76 falls within these ranges; the others contain values outside normal limits.