Taking Vital Signs – Nursing Practice Test Questions

Taking Vital Signs is a critical part of nursing and appears on many nursing and nursing assistant, nursing aide certification exams.

Nursing Assistant/Nursing Aide – CNA, NNAAP,
Medical Assistant – RMA, CMA,

John, a 78 year old man with Dementia has been assigned to you. He fell out of his bed and sprained his wrist. He is diabetic and suffers from left-sided weakness due to a stroke. He requires total care and assistance with everything he does. He has dentures. He can no longer walk alone, feed himself, bathe or dress himself, and he is incontinent of urine and stool. His vital signs are to be monitored q 4 hrs.

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.

5. C
Always double-check your vital signs to make certain there is a valid problem.

6. B
Count his respirations while taking his pulse.

7. D
The respiratory assessment should ALWAYS include the number of respirations, the quality of them and accompanying breath sounds.

8. D
A child of this age could have her b/p assessed on any of the above mentioned areas using a child’s cuff.