Vital Signs Assessment — Knowledge Check

NCLEX-NG formative assessment covering vital signs measurement technique, normal ranges, critical values, clinical interpretation, special populations, pulse oximetry, pain assessment, and SBAR communication.

14 questions Pass: 75% 30 min

Question 0 of 14 answered 0%

A nurse is preparing to measure a patient's blood pressure. The nurse selects a cuff that is too small for the patient's arm. Which of the following describes the effect this will have on the reading?

A The reading will be falsely low B The reading will be falsely high C The reading will be accurate if the cuff is positioned correctly D The diastolic reading will be affected but not the systolic

A nurse assesses a patient and finds: temperature 38.8°C oral, heart rate 114 bpm, blood pressure 96/58 mmHg, respiratory rate 24 bpm, and SpO₂ 94% on 2L/NC. The patient was admitted for a surgical site infection. Which of these findings requires the MOST immediate nursing action?

A Temperature 38.8°C — administer prescribed antipyretic B Heart rate 114 bpm — obtain a 12-lead ECG C Blood pressure 96/58 mmHg — notify the provider using SBAR D SpO₂ 94% — increase supplemental oxygen to 4L/NC

A nurse is measuring a patient's pulse and finds the rhythm irregular. What is the most appropriate next action?

A Document the finding and continue with the assessment B Auscultate the apical pulse for one full minute and compare it to the radial rate C Repeat the radial pulse measurement using the other wrist D Notify the provider that the patient is in atrial fibrillation

A patient who was admitted for carbon monoxide poisoning following a house fire has a pulse oximetry reading of 99%. The nurse should recognize which of the following about this finding?

A The patient is well-oxygenated and no further intervention is needed B Pulse oximetry cannot differentiate oxyhemoglobin from carboxyhemoglobin and the reading is falsely normal C A pulse oximetry reading above 95% always indicates adequate oxygenation D The elevated SpO₂ indicates the patient has compensated for the CO exposure

The nurse is caring for a patient with COPD who has a documented SpO₂ target of 88–92%. The patient's current SpO₂ is 90% on 2L/NC. The nurse should:

A Increase the oxygen to 4L/NC to bring the SpO₂ above 95% B Recognize this is within the prescribed target range and continue monitoring C Notify the provider that the patient is hypoxic D Discontinue supplemental oxygen since the patient is above 88%

A nurse counts a patient's respirations while still holding the patient's wrist after measuring the pulse. The patient's respiratory rate is 24 breaths per minute, shallow, with use of accessory muscles. What is the nurse's priority action?

A Document the findings and reassess in 4 hours per routine vital signs schedule B Instruct the patient to take deeper breaths and recount the respiratory rate C Perform a comprehensive respiratory assessment and notify the provider D Apply supplemental oxygen at 2L/NC and reassess SpO₂ in 30 minutes

A 4-year-old child is brought to the pediatric clinic with fever and irritability. Which pain assessment scale is MOST appropriate for this patient?

A Numerical Rating Scale (NRS, 0–10) B Visual Analog Scale (VAS) C CPOT (Critical-Care Pain Observation Tool) D Wong-Baker FACES Pain Scale

A nurse assesses an 80-year-old patient's vital signs and finds a temperature of 37.6°C. The patient appears more confused than their usual baseline, with decreased appetite and dysuria. What is the nurse's best interpretation of this finding?

A The temperature is normal; confusion is unrelated to vital signs findings B A temperature of 37.6°C in an older adult with new confusion and dysuria may represent a significant febrile response and requires further assessment C The patient has hyperthermia; apply cooling measures immediately D The temperature is slightly elevated; reassess in 4 hours before taking action

A nurse takes a patient's blood pressure in both arms and obtains readings of 148/92 mmHg in the right arm and 118/74 mmHg in the left arm. What is the significance of this finding?

A This is a normal variation; use the average of the two readings B A difference of > 10–15 mmHg between arms may indicate arterial disease such as aortic dissection or subclavian artery stenosis and should be reported C Use the left arm reading as blood pressure should always be measured on the non-dominant side D The higher reading is inaccurate; repeat the right arm measurement

The nurse obtains the following sequential vital signs for a post-operative patient over 6 hours: HR 76, 82, 88, 97, 104 bpm. BP 122/74, 118/70, 110/68, 102/64, 94/60 mmHg. Which of the following best describes the clinical significance of this trend?

A These values are within normal limits; continue routine monitoring B The tachycardia is concerning but the blood pressure remains adequate at this time C This trend suggests progressive hemodynamic compromise that may indicate hemorrhage, sepsis, or other serious complication requiring immediate provider notification D The patient should be encouraged to increase oral fluid intake and reassessed in 2 hours

A nurse is documenting a patient's vital signs. The patient's blood pressure was measured in the left arm, in a sitting position. The correct documentation is:

A BP 136/88 mmHg B BP 136/88 L arm sitting C BP 136/88, lying flat D BP 136/88 mmHg, left arm, sitting position

The nurse is preparing to use SBAR to call a provider about a patient's abnormal vital signs. Which of the following statements correctly represents the 'Assessment' component of SBAR?

A 'The patient is Mr. Johnson in room 412.' B 'The patient was admitted 2 days ago for pneumonia and has been on IV antibiotics.' C 'I believe this patient may be developing septic shock based on trending hypotension, tachycardia, and fever unresponsive to antibiotics.' D 'I am requesting that you come evaluate the patient and consider ordering a fluid bolus.'

True or false: A respiratory rate of 18 breaths per minute measured by counting for 30 seconds (count of 9, multiplied by 2) is as accurate as a 60-second count for all patients.

T True F False

Explain the clinical difference between measuring pain in a verbally communicative adult patient versus a non-verbal, cognitively impaired older adult patient, and name one validated tool appropriate for each.

Vital Signs Assessment — Knowledge Check

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