STNA Vital Signs and Clinical Observations 1 — Questions and Answers
Question 1: What is the normal resting heart rate range for a healthy adult?
- 40–60 beats per minute
- 60–100 beats per minute (Correct answer)
- 100–120 beats per minute
- 50–70 beats per minute
Correct answer: 60–100 beats per minute
A normal adult resting heart rate is 60–100 beats per minute; values outside this range may require reporting to the nurse.
Question 2: When counting respirations, the nurse aide should:
- Tell the patient you are counting their breaths
- Count without informing the patient, often while appearing to take the pulse (Correct answer)
- Count only for 15 seconds and multiply by 4
- Ask the patient to take deep breaths during counting
Correct answer: Count without informing the patient, often while appearing to take the pulse
Patients alter their breathing pattern if they know it is being counted, so respiration rate is typically measured discreetly while the patient believes the pulse is still being taken.
Question 3: Which finding requires the nurse aide to immediately report a blood pressure reading?
- 120/80 mmHg
- 118/76 mmHg
- 90/60 mmHg or lower (Correct answer)
- 125/82 mmHg
Correct answer: 90/60 mmHg or lower
A blood pressure of 90/60 mmHg or lower indicates hypotension, a potentially dangerous condition requiring immediate nursing assessment.
Question 4: Which site is most commonly used for measuring an adult's temperature orally?
- Under the arm (axillary)
- Sublingual (under the tongue) (Correct answer)
- Rectal
- Temporal artery
Correct answer: Sublingual (under the tongue)
The sublingual (oral) route is the most common method for alert adults and provides a reliable core body temperature reading.
Question 5: A nurse aide measures a patient's axillary temperature at 99.6°F. Compared to a normal oral temperature, the axillary reading is typically:
- The same as oral temperature
- 1 degree Fahrenheit lower than oral (Correct answer)
- 1 degree Fahrenheit higher than oral
- 2 degrees Fahrenheit lower than oral
Correct answer: 1 degree Fahrenheit lower than oral
Axillary temperature is typically 1°F lower than oral temperature because the axilla is an external body surface, not a body cavity.
Question 6: What does an oxygen saturation (SpO2) reading of 88% indicate?
- Normal oxygenation for an older adult
- Adequate oxygenation requiring no action
- Low oxygen level that must be reported to the nurse immediately (Correct answer)
- A calibration error in the pulse oximeter
Correct answer: Low oxygen level that must be reported to the nurse immediately
A normal SpO2 is 95–100%; a reading of 88% indicates hypoxemia and requires immediate notification of the supervising nurse.
STNA Vital Signs and Clinical Observations 1
What is the normal resting heart rate range for a healthy adult?