STNA Vital Signs and Clinical Observations 2 — Questions and Answers
Question 1: When taking a radial pulse, the nurse aide should use which fingers?
- The thumb and index finger
- The index and middle fingers (Correct answer)
- All four fingers pressed firmly
- The pinky and ring fingers only
Correct answer: The index and middle fingers
The index and middle fingers are used because they have sensitive pads; the thumb is avoided because it has its own pulse that can be confused with the patient's.
Question 2: A patient is breathing 28 times per minute. This finding is called:
- Bradypnea
- Eupnea
- Tachypnea (Correct answer)
- Apnea
Correct answer: Tachypnea
Tachypnea is defined as a respiratory rate above 20 breaths per minute in an adult; 28 breaths per minute is significantly elevated and should be reported.
Question 3: The nurse aide is unable to feel a radial pulse. The most appropriate next action is:
- Document 'no pulse' and continue with other care
- Try the other wrist; if still absent, report to the nurse immediately (Correct answer)
- Assume the patient is fine and recheck in one hour
- Increase pressure on the wrist until a pulse is felt
Correct answer: Try the other wrist; if still absent, report to the nurse immediately
An absent radial pulse is a critical finding; trying the opposite wrist first rules out positioning issues, and persistent absence requires immediate nursing notification.
Question 4: Which factor should be considered before measuring a patient's oral temperature?
- The patient's age
- Whether the patient has eaten, drunk, or smoked in the past 15–20 minutes (Correct answer)
- The time of day
- The patient's weight
Correct answer: Whether the patient has eaten, drunk, or smoked in the past 15–20 minutes
Eating, drinking, or smoking in the 15–20 minutes before oral temperature measurement can falsely alter the reading; waiting ensures accuracy.
Question 5: What is the primary purpose of measuring and recording vital signs?
- To complete documentation requirements only
- To provide a baseline and detect changes in the patient's health status (Correct answer)
- To satisfy billing requirements
- To give patients information about their own condition
Correct answer: To provide a baseline and detect changes in the patient's health status
Vital signs establish a baseline and allow the care team to detect deterioration or improvement in a patient's condition over time.
Question 6: Which blood pressure cuff size should be used on an obese patient?
- Standard adult cuff regardless of arm size
- Pediatric cuff to get a tighter fit
- A larger cuff appropriate for the patient's arm circumference (Correct answer)
- Two standard cuffs connected together
Correct answer: A larger cuff appropriate for the patient's arm circumference
Using a cuff that is too small gives a falsely elevated reading; a larger cuff matched to the patient's arm circumference is required for accuracy.
STNA Vital Signs and Clinical Observations 2
When taking a radial pulse, the nurse aide should use which fingers?