Vital signs, monitoring and system-specific assessment

68 NCLEX-RN practice questions on Vital signs, monitoring and system-specific assessment, part of Reduction of Risk Potential. The first 25 are below; the first 5 with answers and explanations (tap Show answer after you have chosen), the rest in Learn with a free account.

Question 1 · Medium · Matrix
The nurse is reviewing telemetry alerts on a medical unit. For each finding, indicate whether it requires immediate action.
For each row, choose: Immediate action / No immediate action
1. Ventricular fibrillation in a client who does not respond
2. Third-degree heart block at 34/min with dizziness
3. New atrial fibrillation at 150/min with BP 82/50 mm Hg
4. First-degree AV block with PR 0.24 s in a stable client
5. Sinus tachycardia at 104/min in a client with a fever
6. Sinus arrhythmia varying with breathing in a teenager
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Answer:
- Ventricular fibrillation in a client who does not respond: Immediate action
- Third-degree heart block at 34/min with dizziness: Immediate action
- New atrial fibrillation at 150/min with BP 82/50 mm Hg: Immediate action
- First-degree AV block with PR 0.24 s in a stable client: No immediate action
- Sinus tachycardia at 104/min in a client with a fever: No immediate action
- Sinus arrhythmia varying with breathing in a teenager: No immediate action
Prioritise hypotheses: the rhythm matters less than whether the client is stable. Pulselessness, hypotension and symptomatic bradycardia need action now; a stable first-degree block, fever tachycardia and respiratory sinus arrhythmia do not.
- Ventricular fibrillation in a client who does not respond: A pulseless rhythm needs CPR and defibrillation at once.
- Third-degree heart block at 34/min with dizziness: Symptomatic complete block needs pacing preparation now.
- New atrial fibrillation at 150/min with BP 82/50 mm Hg: Unstable tachycardia with hypotension needs urgent treatment.
- First-degree AV block with PR 0.24 s in a stable client: A stable first-degree block needs monitoring, not emergency care.
- Sinus tachycardia at 104/min in a client with a fever: An expected response to fever; treat the cause and monitor.
- Sinus arrhythmia varying with breathing in a teenager: Rate change with respiration is a normal finding in the young.
Question 2 · Medium · Matrix
A client receiving IV opioid by patient-controlled analgesia has continuous capnography and pulse oximetry. For each finding, indicate whether it is expected or requires follow-up.
For each row, choose: Expected / Requires follow-up
1. Respiratory rate 8/min with loud snoring
2. Slightly drowsy but easy to rouse
3. Drifts off to sleep in mid-sentence
4. End-tidal CO2 of 38 mm Hg
5. End-tidal CO2 rising to 58 mm Hg
6. Pain rated 3 on a 0-10 scale
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Answer:
- Respiratory rate 8/min with loud snoring: Requires follow-up
- Slightly drowsy but easy to rouse: Expected
- Drifts off to sleep in mid-sentence: Requires follow-up
- End-tidal CO2 of 38 mm Hg: Expected
- End-tidal CO2 rising to 58 mm Hg: Requires follow-up
- Pain rated 3 on a 0-10 scale: Expected
Evaluate outcomes: sedation and ventilation are checked together. Rising end-tidal CO2, a slow rate with snoring and falling asleep mid-conversation all signal opioid excess before oxygen saturation drops.
- Respiratory rate 8/min with loud snoring: Slow breathing with snoring signals airway obstruction and opioid excess.
- Slightly drowsy but easy to rouse: Mild drowsiness that is easy to rouse is acceptable.
- Drifts off to sleep in mid-sentence: This sedation level comes before respiratory depression; the dose is reduced.
- End-tidal CO2 of 38 mm Hg: Normal end-tidal CO2 is 35-45 mm Hg.
- End-tidal CO2 rising to 58 mm Hg: Rising CO2 shows hypoventilation, often before SpO2 falls.
- Pain rated 3 on a 0-10 scale: Pain is controlled.
Question 3 · Medium · Select all that apply
A client has a nasogastric tube connected to low intermittent suction after abdominal surgery. Which actions should the nurse include in the care plan?
1. APush a displaced tube further in without rechecking it
2. BGive mouth care and lubricate the lips often
3. CMeasure and record the drainage amount and colour each shift
4. DInspect the nostril for pressure injury from the tube
5. ESwitch to high continuous suction if drainage slows
6. FOffer unlimited ice chips to relieve thirst
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Answer: B, C, D
Generate solutions: care of a decompression tube includes measuring output, mouth and nose care and skin checks. Unlimited ice chips cause electrolyte loss, and suction settings and tube position are changed only after assessment and per orders.
- A: Placement must be verified before the tube is used again.
- E: High suction can injure the gastric mucosa; slowing drainage is assessed first.
- F: Large amounts of ice are suctioned out and wash out electrolytes.
Question 4 · Hard · Select all that apply
A client with an upper GI bleed has these findings. Which ones suggest the client is going into hypovolaemic shock?
1. ANew restlessness and anxiety
2. BBP 112/94 mm Hg with a narrowing pulse pressure
3. CPulse rising from 88 to 118/min
4. DUrine output 15 mL/h
5. ECool, clammy skin
6. FPulse 52/min and regular
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Answer: A, B, C, D, E
Recognise cues: early shock often has a near-normal systolic pressure. Tachycardia, a narrowing pulse pressure, cool skin, low urine output and restlessness are the earlier cues; hypotension comes later.
- F: Bradycardia is not a compensatory sign of volume loss.
Question 5 · Hard · Select all that apply
A client's monitor shows new atrial fibrillation at 152/min. The client is dizzy and clammy, BP 80/50 mm Hg, and has a pulse. Which actions should the nurse take?
1. AStart chest compressions
2. BPlace the defibrillator pads on the chest
3. CCall the rapid response team
4. DEnsure working IV access
5. EObtain a 12-lead ECG if it does not delay treatment
6. FPrepare for synchronized cardioversion
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Answer: B, C, D, E, F
Take action: tachycardia with hypotension, dizziness and clamminess is unstable. The nurse calls for help, applies pads, secures IV access and prepares for synchronized cardioversion; compressions are only for pulselessness.
- A: The client has a pulse; compressions are not indicated.
Question 6 · Medium · Select all that apply
A client is receiving continuous epidural analgesia with an opioid and a local anaesthetic after abdominal surgery. Which actions should the nurse include in monitoring?
1. AMonitor blood pressure for hypotension
2. BAssess sensory level and leg movement
3. CCheck respiratory rate and sedation level at set intervals
4. DTreat new severe back pain with fever as expected
5. EGive extra IV opioid doses for any breakthrough pain
6. FKeep naloxone available at the bedside
Answer and explanation in LearnFree account
Question 7 · Medium · Matrix
The nurse is caring for a client with a chest tube on water-seal drainage. For each action, indicate whether it is indicated or contraindicated.
For each row, choose: Indicated / Contraindicated
1. Stripping the tubing every hour
2. Keeping the drainage unit below the chest
3. Coiling tubing on the bed with no dependent loops
4. Clamping the tube while the client walks in the hall
5. Encouraging deep breathing and coughing
Answer and explanation in LearnFree account
Question 8 · Hard · Select all that apply
A client has a radial arterial line for continuous blood pressure monitoring. Which actions are correct?
1. ACheck colour, warmth and refill of the hand
2. BLevel the transducer at the phlebostatic axis
3. CGive IV antibiotics through the arterial line
4. DZero the transducer once a week only
5. EFlush the line forcefully with a 10 mL syringe
6. FKeep the pressure bag inflated to 150 mm Hg
Answer and explanation in LearnFree account
Question 9 · Easy · Select all that apply
The nurse checks the wet-suction chest drainage system of a client who had a chest tube placed yesterday for a pneumothorax. Which findings are expected?
1. ABrief bubbling in the water-seal chamber when the client coughs
2. BVigorous continuous bubbling in the water-seal chamber
3. CGentle continuous bubbling in the suction-control chamber
4. DBright red drainage of 150 mL in the past hour
5. EDrainage unit hanging below the level of the chest
6. FWater in the water-seal chamber rises on inspiration and falls on expiration
Answer and explanation in LearnFree account
Question 10 · Medium · Matrix
The nurse assesses a client 6 hours after a total thyroidectomy. For each finding, indicate whether it is expected or requires follow-up.
For each row, choose: Expected / Requires follow-up
1. New high-pitched noise on inspiration
2. Small amount of serous drainage on the dressing
3. Neck swelling with a feeling of tightness when swallowing
4. Tingling around the mouth and in the fingertips
5. Mild sore throat from the breathing tube
Answer and explanation in LearnFree account
Question 11 · Medium · Select all that apply
Which factors can make a finger pulse oximeter reading unreliable?
1. ADarkly pigmented skin
2. BOxygen given by nasal cannula
3. CShivering or hand movement
4. DDark nail polish or artificial nails
5. ECold, vasoconstricted fingers
6. FCarbon monoxide poisoning
Answer and explanation in LearnFree account
Question 12 · Medium · Matrix
For each ECG finding, indicate the electrolyte imbalance it most suggests.
For each row, choose: Hyperkalaemia / Hypokalaemia
1. Widened QRS complexes
2. Tall, peaked T waves
3. Prominent U waves
4. Flattened or absent P waves
5. Flattened T waves with ST depression
Answer and explanation in LearnFree account
Question 13 · Hard · Matrix
The nurse receives report on five clients. For each client, indicate whether the nurse should see the client first or can see the client later.
For each row, choose: See first / Can wait
1. Leg cast; pain not eased by morphine and worse on moving toes
2. Nasogastric tube; 200 mL of green drainage this shift
3. Post-thyroidectomy; new tingling around the mouth
4. Chest tube day 1; tidaling stopped and new sudden breathlessness
5. Taking metoprolol; pulse 58/min, BP 118/72, no symptoms
Answer and explanation in LearnFree account
Question 14 · Medium · Matrix
The nurse checks a client 2 hours after a cardiac catheterization through the right femoral artery. For each finding, indicate whether it is expected or requires follow-up.
For each row, choose: Expected / Requires follow-up
1. Right pedal pulse palpable and equal to the left
2. Small flat bruise at the site with no swelling
3. New numbness and tingling in the right toes
4. Right foot cool and pale compared with the left
5. Capillary refill of 2 seconds in the right toes
Answer and explanation in LearnFree account
Question 15 · Hard · Matrix
The nurse performs hourly neurological checks on a client with a head injury. For each finding, indicate whether it shows a stable or a worsening condition.
For each row, choose: Stable / Worsening
1. Glasgow Coma Scale falls from 14 to 11
2. Flexion of the arms toward the chest to pain
3. Pupils equal, 3 mm and briskly reactive
4. BP 172/56 mm Hg with pulse 50/min
5. Oriented to person, place and time
Answer and explanation in LearnFree account
Question 16 · Hard · Select all that apply
A client returned from a right lobectomy 4 hours ago. Chest tube drainage was 40-60 mL/h of serosanguineous fluid, but in the last hour it was 280 mL of bright red fluid. Which actions should the nurse take?
1. AKeep the drainage unit below the chest
2. BStrip the tubing hard to clear clots
3. CNotify the surgeon promptly
4. DClamp the chest tube to slow the bleeding
5. EAssess blood pressure, pulse and respiratory status
Answer and explanation in LearnFree account
Question 17 · Medium · Select all that apply
The nurse is preparing the room for a client returning with a new tracheostomy. Which items should be kept at the bedside?
1. AA spare tube of the same size and one size smaller
2. BA bag-valve device connected to oxygen
3. CWorking suction equipment with sterile catheters
4. DSterile water for inflating the cuff
5. EHydrogen peroxide for routine stoma cleaning
6. FThe obturator for the tracheostomy tube
Answer and explanation in LearnFree account
Question 18 · Hard · Matrix
The nurse reviews rhythm strip descriptions for three clients. For each description, indicate the rhythm it fits.
For each row, choose: Atrial fibrillation / Atrial flutter / Ventricular tachycardia
1. Wavy baseline with an irregular ventricular rate of 130/min
2. Irregularly irregular rhythm with no identifiable P waves
3. Regular wide QRS at 180/min with no visible P waves
4. Regular ventricular rate of 75/min with 4:1 conduction
5. Sawtooth waves at about 300/min between QRS complexes
Answer and explanation in LearnFree account
Question 19 · Medium · Select all that apply
A client with a spinal cord injury at T4 suddenly reports a pounding headache. BP is 196/104 mm Hg, pulse 52/min, and the face is flushed and sweaty. Which actions should the nurse take?
1. ACheck the rectum for impaction using anaesthetic gel
2. BRaise the head of the bed to a sitting position
3. CLoosen tight clothing and leg straps
4. DCheck the urinary catheter for kinks or a full bladder
5. ELay the client flat with the legs raised
6. FWait 30 minutes and then recheck the blood pressure
Answer and explanation in LearnFree account
Question 20 · Hard · Select all that apply
A client with chronic kidney disease has a serum potassium of 6.8 mEq/L and peaked T waves on the monitor. Which actions should the nurse anticipate?
1. ATurn off the telemetry alarms to reduce noise
2. BOral potassium chloride with meals
3. CIV calcium gluconate
4. DIV regular insulin with dextrose
5. EContinuous cardiac monitoring
6. FEncourage orange juice and bananas
Answer and explanation in LearnFree account
Question 21 · Hard · Matrix
For each finding, indicate whether it points to a tension pneumothorax, cardiac tamponade or both.
For each row, choose: Tension pneumothorax / Cardiac tamponade / Both
1. Distended neck veins
2. Absent breath sounds on one side
3. Trachea shifted away from one side
4. Hyperresonance on one side of the chest
5. Hypotension with tachycardia
6. Muffled heart sounds
Answer and explanation in LearnFree account
Question 22 · Medium · Select all that apply
Following a left carotid endarterectomy this morning, a client is back on the surgical unit. Which findings require follow-up?
1. AOral temperature 37.3 °C (99.1 °F)
2. BHeart rate 76/min and regular
3. CDrooping of the right side of the mouth
4. DIncision pain rated 3 out of 10
5. ESpO2 96% on room air
6. FNeck swelling with noisy breathing
Answer and explanation in LearnFree account
Question 23 · Medium · Select all that apply
A client had a permanent ventricular demand pacemaker set at 70/min inserted yesterday. Which findings require follow-up?
1. AApical pulse of 74/min
2. BClient keeping the arm on that side below shoulder height
3. CPacer spikes on the monitor not followed by a QRS
4. DApical pulse of 52/min
5. EMild tenderness at the incision
6. FPersistent hiccups
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Question 24 · Easy · Select all that apply
The nurse is caring for a client with a tracheostomy who is on mechanical ventilation. Which findings indicate the client needs suctioning?
1. AVentilator low-pressure alarm sounding
2. BCoarse rhonchi heard over the trachea
3. CClear breath sounds in all lung fields
4. DSecretions visible in the tracheostomy tube
5. EVentilator high peak-pressure alarm sounding
6. FRespiratory rate 16/min with even breathing
Answer and explanation in LearnFree account
Question 25 · Medium · Select all that apply
A seated client's cuff reading is 152/94 mm Hg, well above the usual values in the chart. Which positioning or technique problems could have raised it?
1. AThe arm resting on a table at heart level
2. BThe arm raised above the level of the heart
3. CThe client sitting with the legs crossed
4. DThe client talking during the measurement
5. EA cuff bladder that is too wide for the arm
6. FThe arm hanging below the level of the heart
Answer and explanation in LearnFree account

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Vital signs, monitoring and system-specific assessment

The nurse is reviewing telemetry alerts on a medical unit. For each finding, indicate whether it requires immediate action.

A client receiving IV opioid by patient-controlled analgesia has continuous capnography and pulse oximetry. For each finding, indicate whether it is expected or requires follow-up.

A client has a nasogastric tube connected to low intermittent suction after abdominal surgery. Which actions should the nurse include in the care plan?

A client with an upper GI bleed has these findings. Which ones suggest the client is going into hypovolaemic shock?

A client's monitor shows new atrial fibrillation at 152/min. The client is dizzy and clammy, BP 80/50 mm Hg, and has a pulse. Which actions should the nurse take?

A client is receiving continuous epidural analgesia with an opioid and a local anaesthetic after abdominal surgery. Which actions should the nurse include in monitoring?

The nurse is caring for a client with a chest tube on water-seal drainage. For each action, indicate whether it is indicated or contraindicated.

A client has a radial arterial line for continuous blood pressure monitoring. Which actions are correct?

The nurse checks the wet-suction chest drainage system of a client who had a chest tube placed yesterday for a pneumothorax. Which findings are expected?

The nurse assesses a client 6 hours after a total thyroidectomy. For each finding, indicate whether it is expected or requires follow-up.

Which factors can make a finger pulse oximeter reading unreliable?

For each ECG finding, indicate the electrolyte imbalance it most suggests.

The nurse receives report on five clients. For each client, indicate whether the nurse should see the client first or can see the client later.

The nurse checks a client 2 hours after a cardiac catheterization through the right femoral artery. For each finding, indicate whether it is expected or requires follow-up.

The nurse performs hourly neurological checks on a client with a head injury. For each finding, indicate whether it shows a stable or a worsening condition.

A client returned from a right lobectomy 4 hours ago. Chest tube drainage was 40-60 mL/h of serosanguineous fluid, but in the last hour it was 280 mL of bright red fluid. Which actions should the nurse take?

The nurse is preparing the room for a client returning with a new tracheostomy. Which items should be kept at the bedside?

The nurse reviews rhythm strip descriptions for three clients. For each description, indicate the rhythm it fits.

A client with a spinal cord injury at T4 suddenly reports a pounding headache. BP is 196/104 mm Hg, pulse 52/min, and the face is flushed and sweaty. Which actions should the nurse take?

A client with chronic kidney disease has a serum potassium of 6.8 mEq/L and peaked T waves on the monitor. Which actions should the nurse anticipate?

For each finding, indicate whether it points to a tension pneumothorax, cardiac tamponade or both.

Following a left carotid endarterectomy this morning, a client is back on the surgical unit. Which findings require follow-up?

A client had a permanent ventricular demand pacemaker set at 70/min inserted yesterday. Which findings require follow-up?

The nurse is caring for a client with a tracheostomy who is on mechanical ventilation. Which findings indicate the client needs suctioning?

A seated client's cuff reading is 152/94 mm Hg, well above the usual values in the chart. Which positioning or technique problems could have raised it?