Nursing Practice Questions - Taking Vital Signs

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

1. A
The four components of the vital sign assessment are temperature, blood pressure, pulse, and respirations.

2. A
If the cuff is not the proper width for your patient you will get a false reading on your blood pressure check.

3. B
The rectal temperature is taken within the body cavity and therefore yields the temperature which is closest to the actual body temperature.

4. D
The pulse can accurately be counted using any of these areas, although for most initial assessments the radial pulse is used.

5. While assessing John’s temperature, you note that it is 101.2 degrees. What is your FIRST action?

a. Notify your supervisor
b. Call the doctor
c. Wait the appropriate amount of time and take the temperature again
d. Have a co-worker check your work.

6. You can count respirations while

a. Taking John’s b/p
b. Counting John’s pulse
c. Taking his temperature
d. None of the above

7. When assessing John’s respirations you should

a. Count the number of times his chest rises and falls in one minute
b. Auscultate his chest
c. Observe whether John is breathing easily or seems to be having difficulty
d. All of the above

8. If John’s 3 year old granddaughter was visiting and was watching you take her grandfather’s vital signs and became curious about how you would take hers, you might explain to her that

a. You would do it on the arm but with a smaller cuff
b. You would do it on her thigh but with a smaller cuff
c. You would do it on her ankle using a smaller cuff
d. All of the above.

Using Incorrect Units

Using the wrong units (e.g., using Celsius instead of Fahrenheit).

Tip Always double-check the units required and make sure your answer is consistent.

Wrong Technique

Using the wrong technique (e.g., incorrect placement of the blood pressure cuff or not placing the thermometer correctly).

Tip Review the proper techniques for each type of measurement and practice them to ensure accuracy.

Misreading Instruments

Misreading the scale on an instrument, such as a sphygmomanometer or thermometer.

Tip Slow down! Take your time to read the instruments carefully and make sure you understand how to interpret the readings.

Recording Data Errors

Writing down the wrong values or switching values (e.g., recording systolic and diastolic blood pressure values incorrectly).

Tip Always Double-check before turning in your answers.

Not Considering Patient Factors:

Remember to consider factors that can affect vital signs such as, recent physical activity, stress, or illness.

Tip What factors can influence vital signs? Be sure to include these when interpreting results.

Know the Normal Ranges

Make sure you know the normal ranges for vital signs for different age groups and conditions.

Tip Memorize the normal ranges for vital signs and understand how they can vary based on age, sex, and health status.

Not Following Protocol

Always follow the correct procedural steps and protocols (e.g., failing to wait an appropriate amount of time before retaking a blood pressure reading).

Tip Learn and follow standard protocols for taking each vital sign.