Test Bank For Nursing Skills Version 5.0
for Clinical Nursing Skills and
Techniques, 10th Edition
Authors :
Anne G. Perry & Patricia A. Potter & Wendy R. Ostendorf
,Module 01: Vital Signs
1. Which of the following is considered the most accurate method of measuring body
temperature in an adult?
a. Oral
b. Rectal
c. Axillary
d. Temporal artery
Answer: b. Rectal
Rationale: Rectal temperature measurement is considered the most accurate method for
assessing core body temperature in adults. It reflects the body's internal temperature closely and
is less affected by external factors. Oral temperatures are commonly used but can be influenced
by recent eating, drinking, or breathing patterns. Axillary temperatures are often lower and less
reliable than oral and rectal measurements. Temporal artery thermometers are less invasive but
can be influenced by sweating or external environmental factors.
2. A nurse is measuring a patient's blood pressure. Which of the following actions will
provide an accurate reading?
a. The patient should be lying down when the measurement is taken.
b. The cuff should be placed directly over the patient’s clothing.
c. The patient’s arm should be at heart level during measurement.
d. The nurse should inflate the cuff slowly to prevent discomfort.
Answer: c. The patient’s arm should be at heart level during measurement.
Rationale: Accurate blood pressure measurements are best obtained when the patient's arm is at
heart level. This ensures that the measurement reflects the true pressure in the arteries. Placing
the cuff over clothing can interfere with the accuracy of the reading, and taking the measurement
while the patient is lying down may alter the reading. Inflating the cuff too slowly can increase
the time it takes to get a measurement, but it does not directly affect the accuracy.
3. A nurse is assessing a patient's respiratory rate. Which of the following findings would
be considered normal for an adult?
a. 8-12 breaths per minute
b. 12-20 breaths per minute
c. 20-30 breaths per minute
d. 30-40 breaths per minute
Answer: b. 12-20 breaths per minute
Rationale: The normal respiratory rate for an adult is 12-20 breaths per minute. A rate outside of
this range may indicate a respiratory abnormality. A rate of 8-12 breaths per minute suggests
bradypnea (slow breathing), while 20-30 or 30-40 breaths per minute suggests tachypnea (rapid
breathing), which could indicate respiratory distress or other underlying health issues.
4. When measuring pulse oximetry on a patient, which of the following is important for the
nurse to remember?
,a. The device must be placed on the finger only.
b. It provides a measurement of hemoglobin levels.
c. Nail polish may interfere with the accuracy of the reading.
d. It is a direct measurement of oxygen delivery to tissues.
Answer: c. Nail polish may interfere with the accuracy of the reading.
Rationale: Pulse oximetry measures the percentage of hemoglobin that is saturated with oxygen
in the blood, but it can be affected by factors like nail polish, poor circulation, and ambient light.
It is important to place the device on a site that allows for optimal circulation, such as the finger,
ear lobe, or toe, though nails should be free of polish. It does not directly measure oxygen
delivery to tissues or hemoglobin levels; rather, it estimates oxygen saturation levels.
5. What is the best position to assess a patient's blood pressure?
a. Sitting with the legs crossed
b. Sitting with the legs uncrossed and arm supported
c. Lying flat with the arm at the side
d. Standing with the arm elevated above the head
Answer: b. Sitting with the legs uncrossed and arm supported
Rationale: To obtain an accurate blood pressure measurement, the patient should be sitting with
their legs uncrossed and their arm supported at heart level. Crossing the legs or having the arm
unsupported can cause inaccurate readings. Lying flat may affect blood pressure due to changes
in the vascular system's pressure, and standing with the arm above the head can cause a false low
reading.
6. When taking an adult's temperature, the nurse observes that the thermometer reads
99.8°F. How should this be interpreted?
a. The patient is experiencing a fever.
b. The patient has a normal body temperature.
c. The patient’s temperature is subnormal.
d. The reading is invalid and needs to be retaken.
Answer: b. The patient has a normal body temperature.
Rationale: A normal body temperature for adults typically ranges from 97°F to 99°F (36.1°C to
37.2°C). A reading of 99.8°F is within the normal range and does not indicate a fever. A fever is
generally considered to be a body temperature above 100.4°F (38°C).
7. The nurse is assessing a patient’s pain level using a 0 to 10 scale. The patient rates their
pain as a 7. How should the nurse interpret this?
a. The pain is moderate and the patient needs further intervention.
b. The patient is experiencing minimal pain.
c. The pain is severe and requires immediate medication.
d. The pain is non-existent and needs no treatment.
Answer: a. The pain is moderate and the patient needs further intervention.
Rationale: A pain rating of 7 on a 0-10 scale indicates moderate to severe pain. The nurse
, should assess the patient's pain further and intervene appropriately, such as by administering pain
medication or exploring non-pharmacological pain management strategies. A rating of 7 suggests
that the patient may be in distress, and addressing their pain is essential for their comfort and
healing.
8. A nurse is measuring a patient's blood pressure. The first sound heard through the
stethoscope is a faint tapping sound. What does this indicate?
a. The patient’s blood pressure is low.
b. The systolic pressure has been reached.
c. The diastolic pressure has been reached.
d. The cuff was inflated too much.
Answer: b. The systolic pressure has been reached.
Rationale: The first sound heard through the stethoscope when measuring blood pressure is the
Korotkoff sound, which indicates the systolic pressure, or the pressure in the arteries when the
heart contracts. The last sound heard corresponds to the diastolic pressure. If the cuff is inflated
too much, it may cause discomfort or lead to inaccurate readings, but the first sound always
marks the systolic measurement.
9. When assessing a patient’s vital signs, which of the following findings would require
immediate attention?
a. Respiratory rate of 18 breaths per minute
b. Blood pressure of 140/90 mmHg
c. Pulse rate of 110 beats per minute
d. Temperature of 98.6°F
Answer: c. Pulse rate of 110 beats per minute
Rationale: A pulse rate of 110 beats per minute is considered tachycardia and may require
immediate attention, especially if it is accompanied by other symptoms such as chest pain,
shortness of breath, or dizziness. While a blood pressure reading of 140/90 mmHg is elevated, it
is not as urgent as a significantly high pulse rate. A temperature of 98.6°F is normal, and a
respiratory rate of 18 breaths per minute is within the normal range.
10. What is the primary purpose of measuring a patient's vital signs?
a. To diagnose specific medical conditions
b. To assess the patient's baseline health status
c. To monitor trends over time and detect changes in health
d. To predict future health outcomes
Answer: c. To monitor trends over time and detect changes in health
Rationale: The primary purpose of measuring vital signs is to monitor trends in a patient’s
health status over time. Changes in vital signs can indicate early signs of health problems or
deteriorating conditions. Vital signs, when taken regularly, allow healthcare providers to detect
changes in the patient's health that might require intervention. Vital signs alone cannot diagnose
conditions, although they provide important information that aids in diagnosis.