CKE Vital Signs and Basic Assessment 2 — Questions and Answers
Question 1: When placing a blood pressure cuff on the arm, the lower edge of the cuff should be positioned:
- Directly over the antecubital fossa
- Approximately 1 inch (2–3 cm) above the antecubital fossa (Correct answer)
- At least 3 inches above the antecubital fossa
- Over clothing at mid-upper arm
Correct answer: Approximately 1 inch (2–3 cm) above the antecubital fossa
Positioning the cuff 1 inch above the antecubital fossa allows the stethoscope to be placed over the brachial artery without touching the cuff, preventing inaccurate readings.
Question 2: For the most accurate respiratory rate assessment, how long should respirations be counted?
- 15 seconds, then multiply by 4
- 20 seconds, then multiply by 3
- 30 seconds, then multiply by 2 if regular; 60 seconds if irregular (Correct answer)
- 10 seconds, then multiply by 6
Correct answer: 30 seconds, then multiply by 2 if regular; 60 seconds if irregular
Counting for 60 seconds is most accurate; 30 seconds multiplied by 2 is acceptable only when breathing is regular and unlabored.
Question 3: The apical pulse is best assessed by placing a stethoscope at the:
- Second intercostal space, right sternal border
- Third intercostal space, left sternal border
- Fifth intercostal space at the midclavicular line (Correct answer)
- Fourth intercostal space at the anterior axillary line
Correct answer: Fifth intercostal space at the midclavicular line
The apical pulse is located at the point of maximal impulse (PMI), found at the 5th intercostal space, midclavicular line in adults.
Question 4: Which technique is correct when palpating a radial pulse?
- Use the thumb, applying firm pressure
- Use the index and middle fingers with moderate pressure (Correct answer)
- Use all four fingers simultaneously
- Use the palm of the hand over the wrist
Correct answer: Use the index and middle fingers with moderate pressure
The index and middle fingers provide the most sensitive tactile feedback; the thumb is avoided because it has its own pulse that can cause a false reading.
Question 5: Orthostatic hypotension is assessed by measuring blood pressure and heart rate in which sequence?
- Only while standing for 5 minutes
- While supine, then seated, then standing after 1–3 minutes in each position (Correct answer)
- Only in the seated and standing positions
- While walking and immediately after stopping
Correct answer: While supine, then seated, then standing after 1–3 minutes in each position
Orthostatic (postural) hypotension is confirmed by comparing readings in supine, seated, and standing positions after allowing stabilization time in each position.
Question 6: Blood pressure should NOT be measured in an arm that has which of the following conditions?
- A peripheral IV, AV fistula, or is on the side of a mastectomy (Correct answer)
- Visible veins at the antecubital fossa
- A healed fracture with no current cast
- Previously recorded a higher BP than the opposite arm
Correct answer: A peripheral IV, AV fistula, or is on the side of a mastectomy
Taking BP in an arm with an IV line, AV fistula, or on the side of a mastectomy risks inaccurate readings and can cause harm such as clotting or lymphedema.
Question 7: Axillary temperature readings are generally how much lower than core (rectal) temperature?
- 0.2–0.4°F lower
- 0.5–1.0°F lower
- 1.0–2.0°F lower (Correct answer)
- Axillary is typically higher than rectal
Correct answer: 1.0–2.0°F lower
Axillary temperature is typically 1.0–2.0°F (0.5–1.0°C) lower than rectal temperature because the axilla is an external, open body site.
CKE Vital Signs and Basic Assessment 2
When placing a blood pressure cuff on the arm, the lower edge of the cuff should be positioned: