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Davis’s Nursing Skills Videos Test Bank
Measuring Vital Signs
MULTIPLE CHOICE
1. Where should the nurse place the tip of the
thermometer?
A. To the front of the underarm
B. Anywhere under the arm is fine
C. Toward the back of the underarm for maximum coverage
D. In the middle of the axilla
ANS: D
Topic: Measuring Vital Signs
Video Title: Taking an Axillary Temperature
Concept: Assessment
Rationale: It is important to place the thermometer in the middle of the axilla for the most
accurate reading. None of the other positions will allow the thermometer to function properly.
2. What should the nurse do if the patient has a fever?
A. Take the temperature by a different route.
B. Retake the temperature using the axillary method to be sure it is accurate.
C. Call the physician to report the temperature.
D. Provide the patient with a cool cloth to bring down the fever.
ANS: A
Topic: Measuring Vital Signs
Video Title: Taking an Axillary Temperature
Concept: Assessment
Rationale: Taking an axillary temperature is not the most accurate method so the nurse would
need to take the temperature using an alternative, more accurate method. The nurse would
then follow the physician’s orders regarding increased temperature.
3. In what position should the nurse place the patient’s arm?
A. Place the patient’s arm straight down at their side.
B. Place the patient’s arm upright with the hand above the heart.
C. Place the patient’s arm at their side with the lower arm across the chest.
D. Place the patient’s arm at their side with the elbow bent and forearm up.
,Davis’s Nursing Skills Videos Test Bank
ANS: C
Topic: Measuring Vital Signs
Video Title: Taking an Axillary Temperature
Concept: Assessment
Rationale: For the most accurate reading, the patient’s arm should be placed in a comfortable
position that encases the thermometer. None of the other positions listed hold the thermometer
in place while providing a comfortable position for the patient.
4. Where under the tongue should the nurse position the thermometer?
A. Anywhere inside the patient’s mouth
B. On the top of the tongue
C. Just inside the lips where the patient can hold the thermometer with their teeth
D. In the posterior sublingual pocket
ANS: D
Topic: Measuring Vital Signs
Video Title: Taking an Oral Temperature
Concept: Assessment
Rationale: The thermometer needs to be placed far enough back under the patient’s tongue to
receive an accurate reading. The patient should never bite the thermometer and it is not an
accurate reading just inside the lips.
5. How long should the nurse leave the digital thermometer in place?
A. Until the number stops flashing
B. Until the number starts flashing
C. Until it beeps
D. For 30 seconds
ANS: C
Topic: Measuring Vital Signs
Video Title: Taking an Oral Temperature
Concept: Assessment
Rationale: Digital thermometers are designed to beep when they have reached the temperature
of the patient. Taking it out too soon will not provide an accurate reading and leaving it in too
long will cause discomfort for the patient.
6. What should the nurse do if there is no cover available for the thermometer?
,Davis’s Nursing Skills Videos Test Bank
A. Forego taking the patient’s temperature.
B. Use an antimicrobial wipe and thoroughly clean the probe.
C. Throw the thermometer away.
D. Use the thermometer only for that patient.
ANS: B
Topic: Measuring Vital Signs
Video Title: Taking an Oral Temperature
Concept: Assessment
Rationale: Cleaning the probe with an antimicrobial wipe will ensure that there are no germs
present. The temperature needs to be taken as part of the vital sign group and it is not cost
effective to throw the thermometer away or only use the machine for one patient.
7. How would the nurse position an adult when taking a rectal temperature?
A. Side-lying
B. Sims’
C. Prone
D. Semi-Fowler’s
ANS: B
Topic: Measuring Vital Signs
Video Title: Taking a Rectal Temperature
Concept: Assessment
Rationale: The Sims’ position is the most comfortable for the patient and creates the greatest
accessibility. Having the patient lie prone or in the side-lying position would not be
comfortable and it would be impossible to put in a rectal thermometer with the patient in the
semi-Fowler’s position.
8. How far do you insert the rectal thermometer on an infant?
A. 0.9 inches or 2.5 cm
B. 1 to 1.5 inches or 2.5 to 3.7 cm
C. 0.5 inches or 1.5 cm
D. 2 inches or 5 cm
ANS: C
Topic: Measuring Vital Signs
Video Title: Taking a Rectal Temperature
Concept: Assessment
Rationale: An infant has a small rectum and the nurse does not want to risk perforation. The
other numbers listed are for a child or an adult. The answer 2 inches or 5 cm is too far.
9. What position should a child be in when taking a rectal temperature?
A. Prone
B. Side-lying
C. Sims’
D. Upright
ANS: A
Topic: Measuring Vital Signs
Video Title: Taking a Rectal Temperature
Concept: Assessment
Rationale: Having the child lie prone or across a parent’s lap will make insertion easier. Do
not have the child lie on their side or in the Sims’ position.
10. Which direction should the nurse move the thermometer across the forehead?
A. In a circular motion
B. Up and down
C. Medially to laterally
D. From left to right only
ANS: C
Topic: Measuring Vital Signs
Video Title: Taking a Temporal Artery Temperature
Concept: Assessment
Rationale: The nurse moves the temporal thermometer from the midline of the body to the
side of the body. Up and down, left to right, or in a circular motion will not provide an
accurate reading.
11. When should the nurse push the button on the device?
A. Push only to start the machine.
B. Push and hold the button down while taking the temperature.
C. Push the button after the procedure.
D. There is no need to push the button during the procedure.
ANS: B
Topic: Measuring Vital Signs
Video Title: Taking a Temporal Artery Temperature
Concept: Assessment
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