Vital Signs: Assessment & Regulation Complete Notes for Nursing With MCQ and Important Questions

Vital signs are the quickest and simplest way to know how the patient’s body is working. Every nurse measures them many times a day, and a small change in temperature, pulse, respiration or blood pressure can warn us about a big problem. In this chapter we study each vital sign: physiology, regulation, factors, normal ranges, assessment and alterations. Because the chapter also covers fever, hypothermia, and their management, we also study hot and cold applications with procedure steps.

Learning objectives: explain how temperature, pulse, respiration and blood pressure are regulated; list factors affecting them; recognize assessment sites; assess them accurately; recall normal ranges at different life stages; and teach patients to measure BP and pulse at home.

Introduction and Purposes of Vital Signs

Vital signs are an important part of patient assessment because they give baseline data about the condition and functioning of the patient’s body. They include monitoring of body temperature, pulse, respiration and blood pressure.

Purposes of vital signs monitoring:

• The quickest and easiest way to monitor the patient’s condition and identify problems.
• Helpful in nursing assessment and acts as a base for planning care.
• Discharge planning is also based on stabilization of the patient’s vital signs.

Guidelines for taking vital signs (added from standard sources): wash hands and explain the procedure; use the same equipment and site each time for comparison; know the patient’s usual (baseline) values; take them when the patient is calm, not right after exercise, bath or meals; check equipment before use; record immediately; and report abnormal values at once.

Body Temperature

Body temperature is the balance between the heat production and heat loss from the human body. Body heat is measured in degrees.

Purposes of measuring body temperature: to have baseline data about the patient; to assess the patient’s condition; and to determine the effectiveness of treatment.

Core and surface temperature

Regulation of body temperature

The hypothalamus works like a thermostat. Temperature receptors send messages to it. When the body is cold, it starts heat-producing mechanisms; when the body is hot, it starts heat-releasing mechanisms. This is a negative feedback system.

Factors affecting body temperature

Assessment of body temperature: equipment

• Mercury glass thermometer: oral type and rectal type.
• Electronic or digital thermometer.
• Tympanic membrane thermometer (ear).
• Sensor touch (skin) thermometer (for example forehead).
• Disposable single-use thermometer.
• Automated monitoring devices.

Factors affecting site selection: patient’s age, state of consciousness, amount of pain, and type of treatment being provided.

Sites and methods (technique added from standard sources)

Celsius and Fahrenheit conversion

F = (C x 9/5) + 32    and    C = 5/9 x (F – 32)

(Conversion values are calculated from the formula; the textbook slide shows a similar table.)

Alterations in Body Temperature

Fever (pyrexia)

Fever is body temperature above the normal range. Causes: substances like bacteria and viruses (pyrogens), and chemicals produced in the body after tissue injury, for example myocardial infarction.

Clinical manifestations of fever: loss of appetite, headache, hot dry and flushed skin, thirst, muscle aches, fatigue, increased pulse and respiratory rate, and sometimes confusion and delirium in the elderly. (Added: stages of fever are onset or chill, course or plateau, and defervescence.)

Types of fever

Management of the rigor stages

Hyperthermia and its complications

Hyperthermia is a raised body temperature mainly due to failure of thermoregulation, leading to an uncontrolled rise in temperature.

Hypothermia

Hypothermia is a body temperature below the lower limit of normal. It happens when the body’s heat-producing and heat-retaining responses are overwhelmed by unprotected exposure to cold. Risk factors: age (neonates, elderly), acute and chronic conditions, endocrine disorders, postoperative patients and neurological disorders.

Treatment: internal (core) rewarming and external rewarming, which can be passive (blankets, warm room) or active.

Nursing management: assess body temperature and the pattern, extent and course of the problem. Nursing diagnosis: Hypothermia related to illness as evidenced by decrease in body temperature. Interventions: reassess temperature; rewarm by covering the patient with adequate layers of clothes and blankets; give warm fluids.

Hot Applications

Hot application: applying a warmer agent, in moist or dry state, to the body to relieve pain or provide warmth.

A. Hot water bottle (local dry heat)

The most common method of applying dry heat for therapeutic and comfort purposes. Indications: to relieve pain in backache, dysentery and dysmenorrhea; to relieve local muscle spasm; to reduce inflammation and congestion; to relieve retention of urine.

B. Heating lamp (local dry heat)

Flexible-necked lamps supply dry heat and are placed 18 to 30 inches from the area for 20 to 30 minutes. Distances: 25 W bulb, 35 cm; 40 W bulb, 45 cm; 60 W bulb, 60 to 75 cm.
Indications: to increase circulation to a small area such as a decubitus ulcer; reduce inflammation; dry casts and moist wounds; promote healing.
Articles: lamp with required voltage, measuring tape (to check distance), screen, Vaseline or oil (prevents burning), extra bed sheet (to drape).
Steps: screen and drape, wash hands, measure distance, focus the lamp at a proper angle, inspect for redness.

C. Fomentation (local moist heat)

The local application of moist heat to the skin using double thickness of flannel or other soft material. Two types: medical and surgical.

Medical fomentation (hot water with or without medicine). Purposes: stimulate circulation and relax muscle; relieve pain and congestion in an inflamed area; relieve retention of urine; stimulate absorption of serous exudate and effusion.

Articles: kettle with boiling water; two artery forceps or wringer rods in a basin; fomentation pad or two flannel pieces; cotton balls in a container with forceps; Vaseline or oil; paper bag; kidney tray; abdominal binder with safety pin; hot water bag with cover; screen.

Preliminary assessment: identify the patient, check the diagnosis and doctor’s order, inspect the body part, decide duration and frequency, check general condition and ability to follow instructions, check articles in the unit.

Preparation: explain the procedure, screen, drape and expose only the needed part, switch off the fan, place mackintosh and towel under the patient, keep the binder ready, apply oil or Vaseline on the part.

After care: change the compress every 3 minutes for 15 minutes (or remove the last one after 20 minutes if kept warm with a hot water bottle); dry the skin and look for redness and blisters (report; apply Vaseline if red); make the patient comfortable; chart date, time, kind, duration, body part treated and the patient’s reaction; wash and disinfect articles.
Remember: avoid chilling the patient between fomentations; ascertain the patient’s heat sensitivity by applying gradually.

Surgical fomentation: local moist heat needing surgical asepsis when the skin is broken. Purposes: stimulate circulation and relax muscle; reduce swelling around a wound; hasten separation of slough; help drainage of exudates.

Articles: kettle of boiling water; tray with two sterile basins, two sterile fomentation pads, two sterile forceps, two sterile small towels; plastic binder; kidney tray and paper bag; dressing trolley; screen.

Key steps: assess circulation of the area; check the order; open the dressing and observe the wound; clean the wound; pour water over the sterile pad and squeeze it with forceps; apply gently and mould around the wound; cover with sterile towels and plastic, fix with binder; check often for burns; remove after 30 minutes; apply a sterile dressing; document.

D. Sitz bath (local moist heat)

Local application of moist heat to the pelvic organs. The patient is immersed from the mid-thigh to the iliac crests. Water temperature 110 to 115 F (43 to 46 C); duration 15 to 30 minutes.

• Purposes: relieve pelvic congestion; relieve pain after cystoscopy; relieve inflammation and pain (hemorrhoids, cystitis); relieve pain in retention and painful urination; promote wound healing by cleaning off discharge and debris.
• Solutions used: potassium permanganate 1:5000; boric acid 1 dram to 1 pint; Dettol 1:40.
• Articles: screen, suitable tub or basin, jug with warm water, bedside stool.
• Procedure: explain; fill the tub about half full (the textbook starts at 100 F); screen; assist the patient to undress; stand behind the patient and help him sit with feet flat on the floor and no pressure on sacrum or thighs; make sure thighs, buttocks and lower abdomen are immersed; drape legs and wrap a blanket around the shoulders; observe for weakness or faintness and stop if pallor, rapid pulse or nausea occur; keep for 15 to 30 minutes; never leave the patient alone; help him out, dry and cover; clean articles; document.

E. General dry and moist heat

• Hot dry pack: to prevent chilling, relieve retention of urine, and provide a warm bed with blankets and hot water bottles to prevent and treat surgical shock. Wrap the patient in hot dry blankets, keep 2 to 3 hot water bottles around, give hot drinks, and apply a cold compress to the head if there is headache.
• Hot moist packs: hot moist blankets or flannel on a larger area, for example to relieve muscle spasm in poliomyelitis.
• Whirlpool or full immersion bath: promotes sedation, relieves pain and helps debridement of widespread burns; the body is buoyant so exercises need less effort.

Cold Applications

Cold application: applying a cooler agent, in moist or dry state, to the body to relieve pain or to reduce body temperature.

Objectives of local cold application

• Relieve pain, burning or irritation; control bleeding.
• Prevent gangrene by decreasing tissue metabolism; prevent inflammation or edema.
• Inhibit bacterial growth and prevent suppuration.
• Reduce body temperature; anaesthetize an area for a short time.

Common indications: sprains and fractures; localized hemorrhage (nosebleed, hematoma); wounds, insect bites, minor burns and after injections; headache, muscle spasm, pain due to malignancy; low and moderate pyrexia; dental extractions and surgical repairs; general cold sponging.

A. Ice bag and ice collar (local dry cold)

The ice bag, ice cap and ice collar apply dry cold. An ice collar is a long narrow rubber or plastic bag that fits around the neck.

Articles: big bowl (to keep ice), ice bag with cover, mackintosh with towel, tape or bandage, small container with salt, small spoon, duster, small ice cubes, kidney tray and paper bag.

B. Cold compress (local moist cold)

Folded layers of gauze, lint or soft linen cooled over ice chips, wrung out and applied. Purposes: to treat epistaxis; to supply moist cold to the eyes; to apply on the forehead to reduce fever and headache.
Remember: do not cover a cold compress; apply for 15 to 20 minutes at a time; replace as needed; observe for numbness and mottled bluish skin.

C. Cold pack and ice pack (local moist cold)

A cold pack is a wash cloth, towel or flannel dipped in a basin of cold water with a little ice (water kept at about 75 F), wrung out and applied; replace to maintain coolness. Ice packs are plastic bags of ice covered with a towel, used to lower the temperature of a limb before surgery or to decrease swelling, and to check inflammation and suppuration by reducing blood supply.

D. Cold sponging (general moist cold)

Used to reduce temperature in a patient with hyperpyrexia. Objectives: to soothe the nerves and promote sleep; relieve discomfort; reduce temperature.

Articles: basin of water, jug of cold water, long rubber mackintosh with two bath blankets, ice with ice cap (for the head), bottle of spirit, bath towel, six sponge cloths and two treatment towels as compress, hot water bottle with cover (for the feet, to prevent unwanted effects), TPR tray, extra ice.

Key steps: check vital signs first; screen and explain; offer the bedpan; fold bed clothes to the foot and cover with a top sheet; remove clothes; place a rubber sheet and bath blanket under the patient; place an ice cap on the head; sponge the face and dry; continue sponging each part; leave sponge cloths in both axillae, both groins and a towel on the abdomen and change them after each stroke because major blood vessels are there; check vital signs again; make the patient comfortable and record. (The final steps are completed from standard practice.)

Pulse

Pulse is a wave of blood pumped into the arterial circulation by the contraction of the left ventricle.

Physiology and regulation of pulse

The heart rate is controlled by the cardiovascular centre in the medulla oblongata. The parasympathetic (vagus nerve, cardio-inhibitory centre) slows the heart, and the sympathetic fibres (cardio-acceleratory centre) speed it up. Both act on the SA and AV nodes.

Factors affecting pulse

Assessment of pulse

Equipment: stethoscope (earpieces, aural tube, headset or binaural tubing, diaphragm, bell and chestpiece) and a watch with a second hand.

• Common peripheral sites: temporal, facial, common carotid, brachial, radial, femoral, popliteal, posterior tibial and dorsalis pedis arteries.
• Apical pulse: the preferred method for infants and children under 2 years of age. Normal pulse rate for adolescents and adults is 60 to 100 beats/min.

Technique for radial pulse (added): wash hands; position the patient comfortably with the forearm supported; place the tips of the index, middle and ring fingers lightly on the radial artery (never use the thumb); count for 30 seconds and multiply by 2 (count for a full minute if irregular); note rate, rhythm and amplitude; record.

Alterations in pulse

Respiration

Respiration is the physical and chemical process (breathing and diffusion) by which an organism supplies its cells and tissues with oxygen for metabolism and removes the carbon dioxide formed in energy-producing reactions.

Physiology: External respiration is the exchange of oxygen and carbon dioxide between the lungs (alveoli) and the blood. Internal respiration is the exchange between the blood and the body cells, where oxygen is used in the mitochondria to make ATP. (Mechanics of breathing, added: inspiration is active as the diaphragm and external intercostal muscles contract; expiration is mostly passive.)

Age-related variation in respiratory rate

Factors affecting respiration

Assessment of respirations

The nurse assesses rate, depth and rhythm by inspection (observing and listening) or by listening with a stethoscope. Other methods: pulse oximeter for oxygenation and arterial blood gas results. (Technique, added: count respirations for a full minute without telling the patient, while keeping the fingers on the wrist as if still counting the pulse, so that breathing is not changed consciously.)

Alterations in respiration (definitions added from standard sources)

Arterial oxygen saturation (SpO2)

Monitored by a pulse oximeter, a non-invasive and painless test. SpO2 is the percentage of all hemoglobin binding sites occupied by oxygen. (Normal is about 95 to 100 percent, added.) Factors affecting SpO2 reading: light, circulation, activity, carbon monoxide poisoning. Types of pulse oximeter: forehead sensor, fingertip, ear sensor, table-top and hand-held.

Blood Pressure

Blood pressure is the force of the moving blood against arterial walls. Maximum pressure is exerted on the arterial walls when the left ventricle contracts and pushes blood through the aortic valve into the aorta at the beginning of systole.

Normal blood pressure by age

(All values in mm Hg.)

Physiology and characteristics of blood pressure

Factors affecting BP: exercise, stress, medications, age, diurnal variations, disease conditions, blood volume, temperature.

Korotkoff sounds

Phase 1, the first tapping sound during deflation, is commonly used for the systolic reading. Phase 5, the last sound followed by silence, is the diastolic reading.

Sites and method of assessing BP

BP can be measured over the brachial artery (most common), radial artery or popliteal artery. Technique for brachial BP (added): patient seated or lying, rested for 5 minutes, arm supported at heart level; apply a properly sized cuff 2.5 cm above the elbow crease; palpate the brachial pulse; place the stethoscope diaphragm over it; inflate until about 30 mm Hg above the point where the pulse disappears; deflate slowly at 2 to 3 mm Hg per second; note the first sound (systolic) and last sound (diastolic); deflate completely; wait 1 to 2 minutes before repeating; record.

Special considerations (faulty readings)

Hypertension

• One of the most common health problems, also known as the silent killer.
• Occurs when BP is above normal for a sustained period. As per the chapter, hypertension is diagnosed when systolic BP is 130 mm Hg or higher or diastolic BP is 80 mm Hg or higher.

Note: different guidelines (WHO, Indian guidelines, ACC/AHA) use slightly different cut-offs, so always follow the classification in your textbook for exams.

Risk factors: history of hypertension, aging, obesity, hypercholesterolemia, lifestyle risk factors, metabolic disorders, sleep apnea.

Medical management: antihypertensive drugs, such as diuretics (decrease fluid volume), beta-adrenergic blockers (block sympathetic stimulation and decrease cardiac output), vasodilators and calcium channel blockers (relax arteriolar smooth muscle and decrease peripheral resistance).

Hypotension

Occurs when BP is lower than 90/60 mm Hg, mainly when the body’s control mechanisms cannot maintain BP due to a pathology such as hemorrhage.

Nursing diagnosis: Ineffective peripheral tissue perfusion related to hypotension as evidenced by BP changes in extremities.

Interventions: assess BP for a baseline; promote non-rapid ambulation (raise the head of the bed, then sit the patient at the bedside for a few minutes to check for dizziness, then stand; if dizzy, lay the patient supine to restore blood flow to the brain); give antihypertensives at bedtime if possible; ensure adequate hydration; give medicines to raise BP as prescribed.

Post-procedural responsibilities after monitoring BP

Documentation and Recording of Vital Signs

Vital signs are recorded on the graphic chart (TPR chart), where temperature, pulse and respiration are plotted over time as a graph, and BP is written in the space provided. Record the date, time and your signature, record immediately after measuring, circle or mark abnormal values, and report any abnormality to the doctor or nurse in charge.

Quick Revision Points

• Normal values (adults): temperature 36.5 to 37.5 C, pulse 60 to 100/min, respiration 15 to 20/min, BP about 120/80 mm Hg, SpO2 95 to 100 percent.
• Hypothalamus is the temperature regulation centre. Heat loss: conduction, convection, radiation, evaporation.
• Fever types: intermittent (malaria), remittent, relapsing, constant (typhoid), inverse, rigor.
• Heat cramps, heat exhaustion, heat stroke. Hypothermia: mild 90 to 95 F, moderate 82.4 to 90 F, severe below 82.4 F.
• Hot applications: hot water bottle, heating lamp, fomentation, sitz bath. Cold: ice bag, cold compress, cold pack, cold sponging.
• Pulse: rate, rhythm, amplitude. Tachycardia above 100, bradycardia below 60.
• BP: Korotkoff phase 1 is systolic, phase 5 is diastolic. Cuff too narrow gives falsely high reading.

Vital Signs MCQs

Q1. Vital signs include:

1. Temperature, pulse, respiration, blood pressure
2. Height and weight only
3. Blood tests
4. Urine tests

Answer: A. SpO2 is also commonly recorded.

Q2. Normal core body temperature range is:

1. 34 to 35 C
2. 36.5 to 37.5 C
3. 38 to 39 C
4. 39 to 40 C

Answer: B. Surface temperature is 97 F to 99 F (36.1 to 37.2 C).

Q3. Body temperature is the balance between:

1. Heat production and heat loss
2. Pulse and respiration
3. Food and water
4. Sleep and activity

Answer: A. Controlled by the hypothalamus.

Q4. Which is a method of heat loss?

1. Shivering
2. Radiation
3. Thyroxine
4. Basal metabolic rate

Answer: B. Others: conduction, convection, evaporation.

Q5. Heat loss by movement of warm air away from the body is:

1. Conduction
2. Convection
3. Radiation
4. Evaporation

Answer: B. Example: warm air moving to cooler places.

Q6. Heat loss through sweating is:

1. Conduction
2. Convection
3. Radiation
4. Evaporation

Answer: D. Sweating and evaporation.

Q7. Neonates and the aged are more prone to:

1. Hyperthermia
2. Hypothermia
3. Hypertension
4. Tachycardia

Answer: B. They cannot maintain body temperature well.

Q8. Progesterone in women raises body temperature during ovulation by about:

1. 0.1 F
2. 0.5 to 1.0 F
3. 3 F
4. 5 F

Answer: B. Hormonal level.

Q9. Which drug class may lower body temperature?

1. Beta blockers
2. Thyroid hormone
3. Caffeine
4. Steroid ointment

Answer: A. Thyroid hormone drugs may raise it.

Q10. The most accurate and commonly used temperature types of thermometer include all EXCEPT:

1. Glass thermometer
2. Digital thermometer
3. Tympanic thermometer
4. Stethoscope

Answer: D. The stethoscope is used for pulse, apical rate and BP.

Q11. Fever is caused by:

1. Pyrogens raising the hypothalamic set point
2. Only exercise
3. Only dehydration
4. Only anxiety

Answer: A. Bacteria, viruses and tissue injury chemicals.

Q12. Fever in which temperature fluctuates daily with periods of normal and is common in malaria is:

1. Intermittent
2. Remittent
3. Relapsing
4. Constant

Answer: A. Typhoid shows constant fever.

Q13. Remittent fever shows a difference of morning and evening temperature of more than:

1. 0.5 C
2. 1 C
3. 2 C
4. 5 C

Answer: C. It never comes to the normal range.

Q14. Fever with temperature higher in the morning than evening is:

1. Inverse fever
2. Remittent fever
3. Rigor
4. Constant fever

Answer: A. Opposite of the usual pattern.

Q15. Hyperpyrexia is a temperature above:

1. 38 C
2. 39 C
3. 40 C
4. 41.1 C (106 F)

Answer: D. As per the type of fever slide.

Q16. Acute fever lasts:

1. Less than 7 days
2. Up to 14 days
3. More than 14 days
4. More than 30 days

Answer: A. Sub-acute is up to 14 days; chronic is more than 14 days.

Q17. During the cold stage of rigor, the nurse should:

1. Provide blankets and hot drinks
2. Remove all clothing
3. Give cold sponging
4. Stop vitals

Answer: A. Also restrict activity and monitor vitals.

Q18. During the hot stage of fever, the nurse should:

1. Remove extra clothing, give cold fluids and tepid sponging
2. Give more blankets
3. Give hot drinks
4. Ignore the patient

Answer: A. Antipyretic as prescribed.

Q19. Painful muscle cramps and profuse sweating indicate:

1. Heat cramps
2. Heat stroke
3. Hypothermia
4. Fever

Answer: A. Due to dehydration and less sodium.

Q20. Hot, dry skin above 104 F with loss of consciousness suggests:

1. Heat cramps
2. Heat exhaustion
3. Heat stroke
4. Fever

Answer: C. Failure of thermoregulation.

Q21. Moderate hypothermia is a body temperature of:

1. 90 to 95 F
2. 82.4 to 90 F
3. Below 82.4 F
4. Above 98 F

Answer: B. Severe is below 82.4 F.

Q22. Shivering and increased respiratory rate are signs of:

1. Mild hypothermia
2. Severe hypothermia
3. Fever
4. Heat stroke

Answer: A. Temperature 90 to 95 F.

Q23. Hot water bottle should be filled to about:

1. Full
2. 1/3 to 1/2 or 2/3 of capacity as per the textbook (1/2 to 2/3)
3. Empty
4. Only ice

Answer: B. Expel air and cork tightly.

Q24. Distance of a 40 watt heating lamp from the body part is:

1. 35 cm
2. 45 cm
3. 60 to 75 cm
4. 100 cm

Answer: B. 25 W is 35 cm; 60 W is 60 to 75 cm.

Q25. Duration of treatment with a heating lamp is:

1. 5 to 10 minutes
2. 20 to 30 minutes
3. 1 hour
4. 2 hours

Answer: B. Distance 18 to 30 inches.

Q26. A fomentation uses double thickness of:

1. Flannel or soft material
2. Plastic
3. Paper
4. Foam

Answer: A. Medical and surgical types.

Q27. Surgical fomentation requires:

1. Surgical asepsis
2. Hot water bottle only
3. No preparation
4. Ice

Answer: A. Used when the skin is broken.

Q28. Sitz bath immerses the patient from:

1. Neck to toes
2. Mid-thigh to iliac crests
3. Only the feet
4. Only the hands

Answer: B. Water 110 to 115 F, 15 to 30 minutes.

Q29. Which is a contraindication of hot application?

1. Muscle stiffness
2. Open wounds
3. Menstrual cramps
4. Pain

Answer: B. Also cancer, paralysis, impaired organ function, very young and very old.

Q30. Which is an indication of cold application?

1. Hemorrhage
2. Open wound infection
3. Shock
4. Impaired sensation

Answer: A. Also pain, hyperthermia, edema.

Q31. Ice bag is a type of:

1. Local dry cold
2. Local moist cold
3. General dry cold
4. General moist cold

Answer: A. Cold compress is local moist.

Q32. A cold compress should be applied for:

1. 15 to 20 minutes
2. 2 hours
3. 1 minute
4. All night

Answer: A. Do not cover it.

Q33. Pulse is a wave of blood created by contraction of the:

1. Right atrium
2. Left ventricle
3. Right ventricle
4. Aorta

Answer: B. Felt in arteries.

Q34. Normal adult pulse rate is:

1. 40 to 60/min
2. 60 to 100/min
3. 100 to 140/min
4. 140 to 180/min

Answer: B. Apical pulse is preferred in children under 2 years.

Q35. Pulse rate above 100/min is:

1. Bradycardia
2. Tachycardia
3. Normal
4. Arrhythmia

Answer: B. Bradycardia is below 60/min.

Q36. A weak thready pulse occurs in:

1. Dehydration
2. Hypervolemia
3. Exercise
4. Anxiety

Answer: A. Bounding pulse is seen in hypervolemia.

Q37. Alternation of one strong and one weak beat is:

1. Pulsus alternans
2. Extrasystole
3. Sinus arrhythmia
4. Bounding pulse

Answer: A. Seen in heart failure.

Q38. Normal respiratory rate of adults is:

1. 6 to 10/min
2. 15 to 20/min
3. 30 to 40/min
4. 40 to 60/min

Answer: B. Newborn is 40 to 60/min.

Q39. Which factor decreases the respiratory rate?

1. Morphine
2. Exercise
3. Fever
4. Pain

Answer: A. Opioids depress the respiratory rate.

Q40. SpO2 is measured with a:

1. Pulse oximeter
2. Sphygmomanometer
3. Thermometer
4. Stethoscope

Answer: A. Non-invasive and painless.

Q41. Which factor affects pulse oximeter reading?

1. Carbon monoxide poisoning
2. Eye colour
3. Hair length
4. Age of the machine only

Answer: A. Also light, circulation and activity.

Q42. Blood pressure is the force of blood against:

1. Arterial walls
2. Venous valves
3. Capillary beds only
4. Lymph nodes

Answer: A. Highest during systole.

Q43. First tapping sound during cuff deflation (Korotkoff phase 1) indicates:

1. Systolic BP
2. Diastolic BP
3. Pulse pressure
4. MAP

Answer: A. Phase 5 gives diastolic BP.

Q44. A too narrow BP cuff gives a:

1. Falsely high reading
2. Falsely low reading
3. Correct reading
4. No reading

Answer: A. A too wide cuff gives a falsely low reading.

Q45. Hypotension is BP lower than:

1. 120/80
2. 100/70
3. 90/60
4. 80/50

Answer: C. As per the chapter.

Q46. When ambulating a hypotensive patient after surgery, the nurse should first:

1. Raise the head of the bed and sit the patient at the side
2. Make the patient run
3. Lower the head
4. Stand the patient quickly

Answer: A. Prevents dizziness.

Q47. Hypertension is also known as:

1. Silent killer
2. Sudden death
3. Fast pulse
4. Fever of the heart

Answer: A. Often has no symptoms.

Vital Signs Important Questions as per INC Syllabus Pattern

Long answer questions (10 to 15 marks)

1. Describe the regulation of body temperature and the factors affecting it.
2. Define fever. Explain the types, stages and nursing management of fever.
3. Describe the procedure of hot water bottle application with rationale.
4. Describe the procedure of cold sponging.
5. Explain the physiology, characteristics, assessment and alterations of pulse.
6. Define respiration. Explain the factors affecting respiration and alterations in respiration.
7. Explain the physiology, factors, assessment and alterations of blood pressure. Describe the nursing management of hypertension and hypotension.

Short answer questions (5 marks)

1. Heat production and heat loss
2. Types of fever
3. Heat cramps, heat exhaustion and heat stroke
4. Hypothermia: types and management
5. Indications and contraindications of hot and cold applications
6. Sitz bath
7. Fomentation
8. Ice bag application
9. Characteristics of pulse
10. Alterations in pulse
11. Pulse oximeter
12. Korotkoff sounds
13. Faulty BP readings

Very short answer questions (2 marks)

1. Define body temperature.
2. Write the normal range of core temperature.
3. Name four sites of temperature measurement.
4. Define hyperpyrexia.
5. Define tachycardia and bradycardia.
6. Define apnea.
7. Define blood pressure.
8. What is the silent killer?
9. Write the formula to convert Celsius to Fahrenheit.
10. Name two contraindications of hot application.

Also read:
CHAPTER 1: Introduction to Health and Illness, Nursing Foundation Unit 1 Notes PDF
CHAPTER 2: Health Care Delivery System, Nursing Foundation Unit 2 BSc Nursing Notes
Chapter 3: Nursing as a Profession and History of Nursing in India: BSc Nursing 1st Semester Notes (Nursing Foundation)
CHAPTER 4: Hospital Admission and Discharge: Complete BSc Nursing Notes | 1st Semester Notes (Nursing Foundation)
CHAPTER 5: Communication and Nurse Patient Relationship: Complete Notes | BSc Nursing 1st Semester Notes (Nursing Foundation)
Chapter 6: Patient Education in Nursing: Notes for BSc Nursing 1st Semester, Nursing Foundation Notes with MCQs & Important Questions
Chapter 7: The Nursing Process: Complete Notes for BSc Nursing, 1st Semester, Nursing Foundation
Chapter 8: Documentation and Reporting: Notes with MCQs and Important Questions for BSc Nursing 1st Year, Nursing Foundation Notes