Nursing Fundamentals Exam 2 Study Guide 2026 |Galen College
1. Which vital sign should the nurse assess first if a patient appears restless and
confused?
A. Temperature
B. Weight
C. Blood Pressure
D. Oxygen Saturation
Answer: D
Rationale: Restlessness and confusion are early signs of hypoxia (low oxygen levels);
therefore, oxygen saturation is the priority assessment.
2. When measuring blood pressure, what is the effect of using a cuff that is too
narrow?
A. A falsely low reading
B. An accurate reading if placed on the leg
C. No effect on the reading
D. A falsely high reading
Answer: D
Rationale: A blood pressure cuff that is too small or narrow will result in a falsely high
reading because it requires more pressure to occlude the artery.
,3. A patient has a heart rate of 115 beats per minute. How should the nurse
document this finding?
A. Bradycardia
B. Eupnea
C. Bradypnea
D. Tachycardia
Answer: D
Rationale: Tachycardia is defined as a heart rate greater than 100 beats per minute in an
adult.
4. Which assessment site is most accurate for measuring core body
temperature?
A. Axillary
B. Oral
C. Rectal
D. Temporal
Answer: C
Rationale: The rectal site is considered the most reliable non-invasive method for
measuring core body temperature.
5. A nurse is caring for a patient on contact precautions for C. difficile. Which
action is required?
A. Use alcohol-based hand sanitizer after care
B. Wear an N95 respirator mask
C. Wash hands with soap and water
D. Keep the room door closed at all times
Answer: C
Rationale: C. difficile spores are resistant to alcohol-based sanitizers; handwashing with
soap and water is mandatory to mechanically remove spores.
, 6. Which type of isolation precaution is necessary for a patient with Pulmonary
Tuberculosis?
A. Standard Precautions
B. Droplet Precautions
C. Airborne Precautions
D. Contact Precautions
Answer: C
Rationale: Tuberculosis is transmitted via small droplets that remain suspended in the air,
requiring Airborne Precautions and an N95 respirator.
7. What is the primary purpose of a ‘Time-Out’ before a surgical procedure?
A. To ensure correct patient, site, and procedure
B. To allow the surgeon to rest
C. To check if the patient has insurance
D. To allow the family to say goodbye
Answer: A
Rationale: A ‘Time-Out’ is a safety protocol to verify the identity of the patient, the correct
surgical site, and the correct procedure before starting.
8. A patient is experiencing orthostatic hypotension. Which action should the
nurse take?
A. Encourage the patient to stand up quickly
B. Dangle the patient’s legs over the bedside before standing
C. Limit fluid intake
D. Administer a sedative
Answer: B
Rationale: Dangling the legs allows the circulatory system to adjust to position changes,
preventing dizziness and falls associated with orthostatic hypotension.
1. Which vital sign should the nurse assess first if a patient appears restless and
confused?
A. Temperature
B. Weight
C. Blood Pressure
D. Oxygen Saturation
Answer: D
Rationale: Restlessness and confusion are early signs of hypoxia (low oxygen levels);
therefore, oxygen saturation is the priority assessment.
2. When measuring blood pressure, what is the effect of using a cuff that is too
narrow?
A. A falsely low reading
B. An accurate reading if placed on the leg
C. No effect on the reading
D. A falsely high reading
Answer: D
Rationale: A blood pressure cuff that is too small or narrow will result in a falsely high
reading because it requires more pressure to occlude the artery.
,3. A patient has a heart rate of 115 beats per minute. How should the nurse
document this finding?
A. Bradycardia
B. Eupnea
C. Bradypnea
D. Tachycardia
Answer: D
Rationale: Tachycardia is defined as a heart rate greater than 100 beats per minute in an
adult.
4. Which assessment site is most accurate for measuring core body
temperature?
A. Axillary
B. Oral
C. Rectal
D. Temporal
Answer: C
Rationale: The rectal site is considered the most reliable non-invasive method for
measuring core body temperature.
5. A nurse is caring for a patient on contact precautions for C. difficile. Which
action is required?
A. Use alcohol-based hand sanitizer after care
B. Wear an N95 respirator mask
C. Wash hands with soap and water
D. Keep the room door closed at all times
Answer: C
Rationale: C. difficile spores are resistant to alcohol-based sanitizers; handwashing with
soap and water is mandatory to mechanically remove spores.
, 6. Which type of isolation precaution is necessary for a patient with Pulmonary
Tuberculosis?
A. Standard Precautions
B. Droplet Precautions
C. Airborne Precautions
D. Contact Precautions
Answer: C
Rationale: Tuberculosis is transmitted via small droplets that remain suspended in the air,
requiring Airborne Precautions and an N95 respirator.
7. What is the primary purpose of a ‘Time-Out’ before a surgical procedure?
A. To ensure correct patient, site, and procedure
B. To allow the surgeon to rest
C. To check if the patient has insurance
D. To allow the family to say goodbye
Answer: A
Rationale: A ‘Time-Out’ is a safety protocol to verify the identity of the patient, the correct
surgical site, and the correct procedure before starting.
8. A patient is experiencing orthostatic hypotension. Which action should the
nurse take?
A. Encourage the patient to stand up quickly
B. Dangle the patient’s legs over the bedside before standing
C. Limit fluid intake
D. Administer a sedative
Answer: B
Rationale: Dangling the legs allows the circulatory system to adjust to position changes,
preventing dizziness and falls associated with orthostatic hypotension.
