GNA Vital Signs and Physical Assessment 2 — Questions and Answers
Question 1: A nursing assistant is preparing to take a resident's blood pressure. What is the correct placement of the blood pressure cuff?
- Around the forearm, below the elbow
- Around the upper arm, about 1 inch above the elbow crease (Correct answer)
- Around the wrist, over the pulse point
- Around the upper arm, above the shoulder
Correct answer: Around the upper arm, about 1 inch above the elbow crease
The blood pressure cuff should be placed around the upper arm approximately 1 inch (2–3 cm) above the antecubital crease (elbow crease) for accurate readings.
Question 2: Which thermometer route is most appropriate for a resident who is confused and cannot follow instructions to hold the thermometer under the tongue?
- Oral
- Axillary (armpit) (Correct answer)
- Rectal
- Tympanic (ear)
Correct answer: Axillary (armpit)
The axillary route is the safest alternative for confused or uncooperative residents because it poses no risk of injury and requires no resident cooperation.
Question 3: What is the normal oral body temperature range for an adult?
- 95.0°F–97.0°F (35°C–36.1°C)
- 97.6°F–99.6°F (36.4°C–37.6°C) (Correct answer)
- 100.0°F–101.5°F (37.8°C–38.6°C)
- 102°F–104°F (38.9°C–40°C)
Correct answer: 97.6°F–99.6°F (36.4°C–37.6°C)
Normal oral body temperature for an adult is approximately 97.6°F–99.6°F (36.4°C–37.6°C), with 98.6°F (37°C) as the classic average.
Question 4: When counting a resident's pulse, the nursing assistant notices the rhythm is irregular. What is the best action?
- Ignore it since irregular pulses are common in the elderly
- Count for only 15 seconds and multiply by four for speed
- Count the pulse for a full minute and report the finding to the nurse (Correct answer)
- Ask the resident if they feel the irregularity
Correct answer: Count the pulse for a full minute and report the finding to the nurse
An irregular pulse must be counted for a full 60 seconds and reported to the nurse immediately, as it may indicate a cardiac arrhythmia.
Question 5: The nursing assistant notices a resident's skin is pale, cool, and clammy. Which vital sign change is most consistent with these findings?
- Elevated temperature and increased blood pressure
- Low blood pressure and rapid pulse (Correct answer)
- Slow pulse and elevated temperature
- Normal blood pressure and slow respiratory rate
Correct answer: Low blood pressure and rapid pulse
Pale, cool, and clammy skin combined with low blood pressure and a rapid pulse are classic signs of shock or cardiovascular compromise, requiring immediate reporting.
Question 6: How many full seconds should the nursing assistant count a regular pulse before multiplying to obtain the rate per minute?
- 15 seconds, then multiply by 4
- 20 seconds, then multiply by 3
- 30 seconds, then multiply by 2 (Correct answer)
- 60 seconds with no multiplication needed
Correct answer: 30 seconds, then multiply by 2
Counting a regular pulse for 30 seconds and multiplying by 2 is an accepted shortcut method; a full 60-second count is required for irregular pulses.
Question 7: Which of the following is an early sign of hypoxia (low blood oxygen) that the nursing assistant should report?
- Flushed, warm skin
- Increased urine output
- Restlessness and confusion (Correct answer)
- Bradycardia (slow pulse)
Correct answer: Restlessness and confusion
Restlessness and confusion are early signs of hypoxia because the brain is highly sensitive to decreased oxygen levels; these changes must be reported immediately.
GNA Vital Signs and Physical Assessment 2
A nursing assistant is preparing to take a resident's blood pressure.
What is the correct placement of the blood pressure cuff?