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Potter: Canadian Fundamentals of Nursing, 5th Edition
Lesson 1 Post Test
Answer Key for Vital Signs Module Post Tests and Exam
(Since questions may be reordered with each usage, the question number in the answer key may
not correspond to the number that the student reports for a particular quiz item).
1. Which of the following patients would require follow-up?
a) A child with a respiratory rate of 24 breaths per minute
b) An adolescent with a respiratory rate of 16 breaths per minute
c) An adult with a respiratory rate of 10 breaths per minute
d) A newborn with a respiratory rate of 50 breaths per minute
Correct answer: c
Rationale: The normal respiratory rate for a newborn is 30 to 60 breaths per minute. The normal
respiratory rate of a child is 20 to 30 breaths per minute. The normal respiratory rate for a
teenager is 16 to 19 breaths per minute. The normal respiratory rate for an adult is 12 to 20
breaths per minute. A rate of 10 would require follow-up.
2. Which of the following vital signs recorded for an older adult would be considered acceptable
(i.e., within normal limits)?
a) Temp 96.8° F, P 60, R 18, BP 160/90, O2 sat 93%
b) Temp 97.0° F, P 60, R 16, BP 116/78, O2 sat 95%
c) Temp 98.6° F, P 56, R 20, BP 120/80, O2 sat 91%
d) Temp 98.0° F, P 76, R 22, BP 110/70, O2 sat 88%
Correct answer: b
Rationale: Normal values for an older adult are: average body temperature approximately 36° C
(96.8° F), heart rate 60 to 100 beats per minute, respiratory rate 12 to 20 breaths per minute,
average BP less than 120 over 80, and pulse oximetry 90% to 100%. A BP greater than 140 over
90 may be an indication of hypertension.
3. A 56-year-old female patient has been admitted with a diagnosis of pneumonia. Which
information should be provided to the NAP delegated to take her temperature? (Select all that
a) The patient’s age
b) The type of temperature required
c) The patient’s diagnosis
d) The frequency for taking or monitoring the temperature
e) What changes to report immediately to you, the physician, or their delegate
Correct answer: b, d, e
Rationale: It is more important that the temperature be done on time by the correct route and
with the correct equipment, as well as that the identified changes be reported as requested.
4. Which of the following situations may affect a patient’s vital signs?
a)Time of day
c) Moving from a lying to a standing position
d) Pain rated as a 7 on a 1 to 10 pain scale
e) Isolation precautions
Correct answer: a, c, d
Rationale: Factors that may alter vital signs include time of day, stress (emotional and physical),
temperature alterations / weather conditions, exercise and/or activity, emotions, medication,
postural changes, acute pain, smoking, disease/ injury status, noise, food /liquid consumption,
and odors. The person’s occupation and isolation precautions do not alter vital signs. If a
person’s job requires an activity that increases exertion or stress, the activity affects vital signs,
not the occupation.
5. You are supposed to take your patient’s vital signs preoperatively and record them on the
patient’s record as part of the patient’s preparation for surgery. Why is it necessary to take
vital signs preoperatively? (Select all that apply.)
a) To see if the patient is “feeling funny”
b) To provide a set of vital signs to use for comparison during and after surgery
c) To make sure the patient is not experiencing any complications such as a high fever
that may contraindicate surgery or require intervention at this time
d) To provide the patient with reassurance that he or she is being cared for by a
Correct answer: b, c
Rationale: The patient who is going to surgery is going to experience a change in condition and
an invasive procedure. Vital signs are necessary so that the operative team has a baseline for
comparison as well as to rule out any complications before beginning the surgical event.
Providing reassurance to the patient can be done verbally.
Lesson 2 Post Test
1. Who would you expect to have the lowest body temperature?
a) A 16 year old who ran 1 mile
b) An 80 year old who walked half a mile
c) A toddler who is febrile
d) A child who is playing softball
Correct answer: b
Rationale: The 80 year old would have a lower starting temperature and, therefore, would most
likely have the lowest body temperature, although it may take longer to return to baseline after
exercise. A 16 year old will have a higher starting body temperature and exercise will increase
the body temperature further. To be febrile means to have a fever. The toddler would fail to have
the lowest body temperature. A child will have a higher starting temperature, and exercise will
increase the body temperature further.
2. The NAP is preparing to measure a patient’s vital signs. The patient reports having eaten a
bowl of warm soup. The NAP asks the RN what he should do. What is the best response?
a) “Ask the patient not to eat, drink, or smoke for 15 minutes, and then assess the
patient’s oral temperature.”
b) “Since the soup was not hot, go ahead and take the patient’s temperature.”
c) “Change to the red thermometer probe, and take the patient’s temperature rectally.”
d) “Take the patient’s temperature using the axillary route, and when you record the
reading, add 1° F.”
Correct answer: a
Rationale: The temperature of food or liquid could impair the accuracy of the reading. The NAP
should ask the patient not to eat, drink, or smoke for 15 minutes, and then assess the oral
temperature. Taking a rectal temperature can be needlessly embarrassing and uncomfortable for
the patient. Although the axillary route could be used, it is less accurate than the oral route.
Furthermore, when recording a temperature reading taken axillary, the site is documented, but
the reading itself is unchanged.
3. For which patient would a tympanic thermometer be the preferred thermometer to use?
a) A marathon runner who developed weakness during the race
b) A newborn in the intensive care unit who requires continuous temperature monitoring
c) A child who had tubes surgically placed in the ears
d) A tachypneic patient who is receiving oxygen by nasal cannula
Correct answer: d
Rationale: An advantage to the tympanic thermometer is that it can be used for tachypneic
patients. A continuous measurement cannot be obtained with the tympanic thermometer. The
tympanic thermometer is contraindicated in patients who have had surgery of the ear or tympanic
membrane and does not accurately measure core temperature after exercise.
4. Which of the following patients would you expect to need to monitor their temperature more
a) A patient receiving a blood transfusion for chronic anemia
b) An elderly patient who needs assistance with feeding and dressing
c) A 43-year-old female who has undergone a hysterectomy
d) A child who is small for his age
e) A 19 year old with a white blood cell count of 15,000
Correct answer: a, c, e
Rationale: An elderly person who needs assistance with activities of daily living is not
necessarily at risk for an alteration in temperature. Being small for age or small in stature does
not place a patient at risk for temperature alteration.
5. A NAP reports that a patient’s temperature is 39° C. Which of the following are appropriate
a) Place the patient’s feet in a tub of cool water with ice.
b) Apply a hyperthermia blanket as ordered.
c) Remove the patient’s blankets.
d) Limit the patient’s fluid intake.
e) Administer antipyretic to the patient as ordered.
Correct answer: c, e
Rationale: Although the task of temperature assessment may be delegated, it is the nurse’s
responsibility to determine the accuracy of the measurement and to assess for further indication
of infection. Fluids should be increased to 3 L daily, unless contraindicated. The nurse should
administer an antipyretic as ordered and reassess the temperature in 30 minutes and every 4
hours until the temperature has stabilized within normal limits. A cool wet washcloth may be
provided, but the patient should not be excessively chilled, such as with ice. Cooling the
temperature in the room will aid in reducing the temperature; reducing the amount of external
covering will promote heat loss. A hyperthermia blanket is used to raise body temperature.
6. Which of the following actions, if made by the NAP would require intervention and further
instruction by the nurse?
a) The NAP inserts the red-tipped electronic thermometer probe into the patient’s mouth
after applying a probe cover.
b) The NAP wipes the single-use chemical dot thermometer and places it back in the
patient’s drawer for future use.
c) The NAP waits until a tone sounds to read the tympanic thermometer.
d) The NAP uses a blue-tipped electronic probe for assessing a patient’s axillary
e) The NAP pulls the pinna up, back, and out for an adult when inserting the tympanic
Correct answer: a, b
Rationale: The electronic thermometers are differentiated by the probe cover tips: blue for oral
or axillary and red for rectal. Even though a probe cover is applied, a red-tipped probe should not
be placed into a patient’s mouth. The single-use chemical dot thermometer is plastic and can
only be used once. All electronic thermometers (i.e., oral, axillary, rectal) and the tympanic
thermometer have a tone that sounds when the measurement is complete. The temporal artery
thermometer will stop clicking when the reading is complete. Pull the pinna up, back, and out in
an adult when inserting the tympanic thermometer.
7. Identify the factors that may have an effect on an 82-year-old patient’s temperature:
a) Drinking a cold glass of water
b) Participating in strenuous physical therapy exercises
d) Room temperature
e) Patient’s body weight
Correct answer: a, b, c, d
Rationale: The average body temperature of older adults is lower (i.e., 96.8 °F). Cold water and
a cool room temperature would lower the patient’s temperature. A warm room, exercise, and
infection would raise the patient’s temperature.
8. If a 52-year-old patient has a normal temperature, what range should the patient’s temperature
a) 95.9° F to 99.5° F
b) 96.8° F to 100.4° F
c) 96.8° F to 98.6° F
d) 35° C to 36° C
Correct answer: b
Rationale: The normal temperature range for an adult is 96.8° F to 100.4° F (36° C to 38° C).
The normal temperature range for a newborn is 95.9° F to 99.5° F.
9. Your newborn patient’s temperature has been rising rapidly, and the baby has been crying.
Which of the following thermometers would be the best to use in measuring the patient’s
a) Temporal artery
c) Chemical dot
d) Rectal electronic
Correct answer: a
Rationale: The temporal artery thermometer reflects rapid change in core temperature and can
be used on newborns. The tympanic membrane sensor is unable to accurately measure core
temperature changes during and after exercise. Chemical dot thermometers are inappropriate for
use when there is a sudden and/or variable rise in temperature. It would be unnecessary to use a
rectal thermometer and could cause bowel perforation if inserted too far on a newborn.
Lesson 3 Post Test
1. Which of the following would be appropriate to delegate the task of pulse assessment?
a) An apical pulse of a patient who is going to receive digoxin (Lanoxin)
b) A radial pulse on a patient with a 1500 mL fluid restriction
c) A radial pulse of a patient in the emergency room with chest patin
d) A femoral pulse following a lower leg amputation
e) The temporal pulse of a child
Correct answer: b, e
Rationale: The skill of pulse measurement can be delegated to an NAP unless the patient is
considered unstable or you are evaluating a response to a treatment or medication. The pulse of a
patient on a fluid restriction may be delegated to NAP, as well as the temporal pulse of a child
providing the NAP knows how to locate this pulse site.
2. Which of the following patients would you suspect to be at risk for having an alteration in
a) A 76 year old with diabetes who is otherwise healthy
b) A patient who was just informed of a diagnosis of cancer
c) A patient with peripheral vascular disease
d) A patient who is receiving bolus IV fluids
e) A patient with Alzheimer’s disease
Correct answer: b, c, d
Rationale: Certain conditions place patients at risk for pulse alterations. This may include a
person with heart disease, a patient who is experiencing anxiety, and a patient who received a
sudden infusion of IV fluids. Diabetes and Alzheimer’s disease fail to directly relate to pulse
3. Whenever there is an alteration in the radial pulse rate, rhythm, or amplitude, you should
a) Checking the carotid pulse
b) Using a stethoscope and assessing the quality of the apical pulse as well as the rate
c) Counting the pulse again for 30 seconds and multiplying the results by two
d) Checking the radial pulse on the opposite side
Correct answer: b
Rationale: You should assess the quality and rate of the apical pulse. The rate should be counted
over a full minute to ensure greater accuracy.
4. What is the normal pulse range for an adult?
a) 120 to 160 beats per minute
b) 90 to 140 beats per minute
c) 60 to 100 beats per minute
d) 50 to 80 beats per minute
Correct answer: c
Rationale: The normal pulse range for an adult is 60 to 100 beats per minute. The normal pulse
rate of a newborn is 120 to 160 beats per minute. The normal pulse rate of a 2 year old is
between 90 and 140 beats per minute.
5. You should routinely auscultate the apical pulse with the bell side of the stethoscope.
Correct answer: b
Rationale: For routine auscultation of the apical pulse, you should rely on the diaphragm side of
the chest piece, because it is designed to pick up higher-pitched heart sounds like that of the
6. Which of the following patients would you expect to find a decrease in pulse rate? (Select all
a) A newborn
b) A patient returning from the operating room after having a hip replacement
c) A patient who receive Morphine for severe cancer pain
d) A student who is getting ready to take a final examination
e) A patient who had a bleeding episode
Correct answer: b, c
Rationale: Having general anesthesia or receiving an opioid analgesic may decrease the pulse
rate. A newborn has a higher pulse rate than an adult. Sympathetic stimulation such as anxiety
will increase the pulse rate. Having a decreased fluid volume will increase the pulse rate as the
heart attempts to compensate to maintain cardiac output.
Lesson 4 Post Test
1. How can you best obtain an accurate measurement of a patient’s respiratory rate?
a) Inform the patient that you are monitoring his or her respirations.
b) Assess the respirations while the patient is talking.
c) Auscultate the lung sounds while asking the patient to take a deep breath in through the
nose and exhale slowly through the mouth.
d) Continue to act as though you are taking the patient’s pulse while discretely observing
the rise and fall of the patient’s chest.
Correct answer: d
Rationale: If your patient is aware that you are monitoring his or her respirations, the patient
will most likely alter the breathing pattern. It is best to discretely observe the rise and fall of the
patient’s chest. Assessing the patient’s respirations while they are talking may make it more
difficult to assess and may affect the rate. Auscultation will enable the nurse to identify lung
sounds, but having the patient take deep breaths would affect the accuracy of the rate.
2. What should you do if you observe your patient taking more than 20 breaths per minute?
(Select all that apply.)
a) Count again for a full 60 seconds (1 minute).
b) Tell the patient that you are counting breaths so that the patient will slow the rate of
c) Assess physiologic factors that may be the patient to breathe so fast.
d) Administer a bronchodilator that will decrease the respiratory rate.
Correct answer: a, c
Rationale: If the patient has a respiratory rate greater than 20 breaths per minute, you should
count the respiratory rate again over a full minute and assess for factors causing the patient’s
elevated respiratory rate. Administering a bronchodilator would require a physician’s order and
may not treat the cause (e.g., pain could be the cause of the increased rate). You should attempt
to assess the patient’s respiratory rate inconspicuously in order to prevent the patient from
altering the rate of breathing.
3. Which of the following may increase the respiration rate and depth? (Select all that apply.)
a) Walking 1 mile briskly
b) Having a pain level rating at a 7
c) Feeling anxious when taking a test
d) Smoking a cigarette
e) Taking an opioid to relieve pain
f) Having an addiction problem with amphetamines/cocaine
g) Using a bronchodilator prior to exercise
h) Incurring a head injury from a motor vehicle accident
Correct answer: a, c, f
Rationale: Exercise, anxiety, and amphetamines/cocaine increase both respiratory rate and
depth. Respiratory rate may increase when the patient is in pain, but breathing becomes shallow.
Smoking also increases the respiratory rate, but depth is unaffected. Opioids may depress both
the respiratory rate and depth. It is clinically significant when both the rate and depth are
affected. Bronchodilators decrease the respiratory rate. Damage to the brain stem impairs the
respiratory center and alters the rate and rhythm.
4. Match the animation to the description:
1. Bradypnea rate is regular but less than 12 breaths per minute
2. Tachypnea rate is regular but greater than 20 breaths per minute
3. Hyperpnea respiration is deeper than normal, usually during exercise
4. Cheyne-Stokes irregular rate and depth of respiration with mixed periods of apnea and
5. Kussmaul’s deep regular respiration, common with diabetics
Correct match: A:5, B:1, C:4, D:2, E:3
Rationale: Bradypnea is characterized by a regular rate of less than 12 breaths per minute.
Tachypnea is a regular rate of more than 20 breaths per minute. Hyperpnea, commonly seen with
exercise, is a respiration that is deeper than normal and at an increased rate. Cheyne-Stokes
respirations have an irregular rate and depth of respiration characterized by periods of increasing
depth of respiration followed by periods of apnea. Kussmaul’s respirations are characteristically
regular and deep, commonly seen with complications of diabetes.
5. You are taking a patient’s vital signs. When you assess the respiratory rate, you are having
difficulty seeing the patient’s chest rise and fall with inspiration and expiration. What is your
a) Have someone else assess the patient’s respiratory rate.
b) Remove the patient’s gown so that you have better visualization of the patient’s chest
c) Document the inability to visualize inspiration and expiration.
d) While holding the patient’s wrist, move the patient’s arm over the chest or abdomen,
then feel the rise and fall of inspiration and expiration and assess the rate.
Correct answer: d
Rationale: If you are unable to visualize respirations, discreetly feel the patient’s respirations.
You should first attempt to hold the patient’s wrist and move it over the patient’s chest or
abdomen, feel the rise and fall of inspiration and expiration, and assess the rate. Removing the
patient’s gown is unnecessary and could cause the patient embarrassment and/or chilling. You
need to obtain the patient’s respiratory rate. Documenting that you are unable to visualize
respirations may imply that the patient is deceased or that you are incompetent.
6. You are validating the NAP’s skill with respiratory rate assessment. Which of the following
actions, if made by the NAP, indicates that further instruction is needed?
a) When a patient inhales a breath, the NAP counts that as one; when the patient exhales
the breath, the NAP counts that as two.
b) When the patient’s respiratory rate is irregular, the NAP counts the patient’s
respirations for 1 full minute.
c) When the patient’s respiratory rate is less than 12 breaths per minute or greater than 20
breaths per minute, the NAP counts the patient’s respirations for 1 full minute.
d) After taking the patient’s pulse, the NAP continues to hold the patient’s wrist, moves
the arm across the patient’s chest, and focuses on the patient’s breathing.
Correct answer: a
Rationale: The respiratory rate is equivalent to the number of respiratory cycles (one inspiration
and one expiration) per minute. The NAP should assess the patient’s respiratory rate for 1 full
minute if the patient’s respiratory rhythm is irregular, less than 12 breaths per minute, or greater
Lesson 5 Post Test
1. Match the blood pressure to the image.
a) Figure A
b) Figure B
c) Figure C
d) Figure D
a) Figure A 2) 120/80
b) Figure B 1) 138/84
c) Figure C 4) 140/90
d) Figure D 3) 128/76
Rationale: The beginning of phase 1 indicates systolic pressure; the beginning of phase 5
indicates diastolic pressure.
2. Why do you take the blood pressure in both arms on a “new” patient?
a) To practice your technique
b) To ensure that you obtain an accurate blood pressure reading
c) Because there is a difference in the dominant and nondominant hands, and it is good to
know what it is.
d) To assess for a pulse deficit
Correct answer: b
Rationale: If readings are different by more than 5 mm Hg, additional readings are necessary.
Report the differences to a physician. Although practice is a good idea, it is better to practice
with your friends and family. The primary reason for taking the blood pressure in both arms is to
assess for differences between arms. A pulse deficit measures the differences in apical and radial
pulses, not the differences in blood pressure.
3. Which of the following patients would be considered hypertensive after having two or more
consistent readings of these values?
a) An African-American patient with a systolic BP of 100
b) A football player with a diastolic BP of 94
c) An elderly patient with a systolic BP of 88
d) A pregnant woman with a diastolic BP of 67
Correct answer: b
Rationale: Hypertensive patients typically have a systolic BP greater than 140 and a diastolic BP
greater than 90. Hypotensive patients have a systolic BP of less than 90 mm Hg. Although
African-Americans and the elderly are more likely to have hypertension, race and age alone does
not determine who may be hypertensive.
4. Which patient should you avoid using a leg pressure cuff (thigh cuff) to assess the blood
a) A patient without arms
b) A patient with a deep vein thrombosis (blood clot, usually in the lower extremities)
c) A patient with a history of a CVA (stroke)
d) A patient who has an arteriovenous shunt located in the forearm for hemodialysis
Correct answer: b
Rationale: Leg pressure cuffs should be avoided on patients with deep vein thrombosis.
5. The student nurse is unsure of the blood pressure measurement. What should the student nurse
a) Repeat the measurement on the same arm within 30 seconds.
b) Measure the blood pressure in the other arm.
c) Get the RN to assess the blood pressure.
d) Determine whether the patient has had his blood pressure medication.