BSN 206 Hallmark Exam Actual Exam
2026/2027 | Foundations of Nursing
Fundamentals | Nightingale | Questions
with Verified Answers | 100% Correct |
Pass Guaranteed
Question 1
A patient was brought to the emergency department following a motor vehicle
accident. He appears drowsy, but will arouse to his name being called. He is
bleeding profusely from an injury to his leg. What would the nurse expect his vital
signs to be?
A. 98.6°F (37°C), 84, 20, 120/80
B. 97.8°F (36.5°C), 110, 24, 80/40
C. 99.0°F (37.2°C), 88, 16, 130/80
D. 100.4°F (38°C), 76, 24, 140/90
Correct Answer: B. 97.8°F (36.5°C), 110, 24, 80/40
Rationale: The nurse would expect vital signs to be reflective of hypovolemic shock:
tachycardic (elevated heart rate), tachypneic (increased respirations), and hypotensive
(low blood pressure) .
Question 2
The nurse was assigned to care for five patients. Which of the following vital sign
measurements would be cause for concern? (Select all that apply.)
A. 75-year-old with pulse oximetry of 88% on room air
B. 65-year-old with blood pressure of 140/90
C. 8-year-old with respiratory rate of 24 breaths/minute
,D. 88-year-old with temperature of 96.8°F (36°C)
E. 22-year-old with heart rate of 90 beats/minute
Correct Answer: A, B. 75-year-old with pulse oximetry of 88% on room air; 65-year-old
with blood pressure of 140/90
Rationale: A pulse oximetry of 88% indicates hypoxia and requires intervention. A blood
pressure of 140/90 is elevated (Stage 1 hypertension). A respiratory rate of 24 in an 8-
year-old is normal (20-28). A temperature of 96.8°F is slightly below normal but not
alarming for an older adult. A heart rate of 90 is within normal range .
Question 3
The nurse reads the following nurse's note in the patient's health record: "9/21/21
1800 Patient complains of headaches, almost daily, occurring more frequently in
the evening. BP 164/98. P. Johnson N.A.P." What is the priority nursing
intervention based on this information?
A. Inform the patient it is normal to have a higher BP reading in the evening.
B. Instruct the NAP to repeat the BP measurement using a manual cuff.
C. Obtain a complete set of vital signs and gather further assessment data.
D. Administer acetaminophen (Tylenol) to relieve the patient's headache.
Correct Answer: C. Obtain a complete set of vital signs and gather further assessment
data.
Rationale: It is the responsibility of the nurse to verify abnormal vital signs. The nurse
will want to gather a complete set of vital signs and additional data, such as: Does the
patient take antihypertensive medications? If so, when was it last taken? Is this a usual
BP reading for the patient compared to baseline? .
Question 4
A nursing student is assigned to take the vital signs on a patient and finds the
radial pulse to be irregular. What action should the nursing student take?
,A. Ask a fellow student to assess the pulse.
B. Check the client's previous pulse reading.
C. Assess the apical pulse for a full minute.
D. Document the pulse as irregular and continue.
Correct Answer: C. Assess the apical pulse for a full minute.
Rationale: When a peripheral pulse is irregular, the most accurate method to determine
the heart rate is to auscultate the apical pulse for one full minute. This allows the nurse
to identify the actual heart rhythm and count every beat, including those that might not
reach the periphery .
Question 5
Which of the following patients would require follow-up based on respiratory
rate?
A. A child with a respiratory rate of 20 breaths per minute.
B. An adolescent with a respiratory rate of 16 breaths per minute.
C. A newborn with a respiratory rate of 40 breaths per minute.
D. An adult with a respiratory rate of 10 breaths per minute.
Correct Answer: D. An adult with a respiratory rate of 10 breaths per minute.
Rationale: A normal respiratory rate for an adult is 12-20 breaths per minute. A rate of
10 is below normal (bradypnea) and requires further assessment. A child (20) and
adolescent (16) have normal rates; a newborn (40) is at the upper end of normal (30-
60) .
Question 6
Which of the following vital signs recorded for an older adult would be considered
acceptable (within normal limits)?
A. Temp 96.8°F (36°C), P-60, R-18, BP 160/90, O2 sat 93%
B. Temp 97.0°F (36.1°C), P-60, R-16, BP 116/78, O2 sat 95%
, C. Temp 98.6°F (37°C), P-56, R-20, BP 120/80, O2 sat 91%
D. Temp 98.0°F (36.7°C), P-76, R-22, BP 110/70, O2 sat 88%
Correct Answer: B. Temp 97.0°F (36.1°C), P-60, R-16, BP 116/78, O2 sat 95%
Rationale: All values in Option B are within acceptable ranges for an older adult. The BP
of 160/90 (A) is elevated; O2 sat of 91% (C) is below normal; O2 sat of 88% (D) indicates
hypoxia and requires intervention .
Question 7
The nurse has delegated the task of temperature assessment to the NAP. Which
information should be provided to the NAP? (Select all that apply.)
A. The type of temperature required.
B. The patient's age.
C. The frequency for taking or monitoring the temperature.
D. The patient's diagnosis.
E. What changes to report immediately to the nurse.
Correct Answer: A, C, E. The type of temperature required; The frequency for taking or
monitoring the temperature; What changes to report immediately to the nurse.
Rationale: When delegating tasks, the nurse must provide clear instructions including:
the specific task (type of temperature), the frequency of monitoring, and which findings
to report (e.g., fever, abnormal readings). The patient's age and diagnosis may be
relevant but are not the primary delegation instructions .
Question 8
Which of the following situations may affect a patient's vital signs? (Select all that
apply.)
A. Moving from lying to standing position.
B. Time of day.
C. Occupation.
2026/2027 | Foundations of Nursing
Fundamentals | Nightingale | Questions
with Verified Answers | 100% Correct |
Pass Guaranteed
Question 1
A patient was brought to the emergency department following a motor vehicle
accident. He appears drowsy, but will arouse to his name being called. He is
bleeding profusely from an injury to his leg. What would the nurse expect his vital
signs to be?
A. 98.6°F (37°C), 84, 20, 120/80
B. 97.8°F (36.5°C), 110, 24, 80/40
C. 99.0°F (37.2°C), 88, 16, 130/80
D. 100.4°F (38°C), 76, 24, 140/90
Correct Answer: B. 97.8°F (36.5°C), 110, 24, 80/40
Rationale: The nurse would expect vital signs to be reflective of hypovolemic shock:
tachycardic (elevated heart rate), tachypneic (increased respirations), and hypotensive
(low blood pressure) .
Question 2
The nurse was assigned to care for five patients. Which of the following vital sign
measurements would be cause for concern? (Select all that apply.)
A. 75-year-old with pulse oximetry of 88% on room air
B. 65-year-old with blood pressure of 140/90
C. 8-year-old with respiratory rate of 24 breaths/minute
,D. 88-year-old with temperature of 96.8°F (36°C)
E. 22-year-old with heart rate of 90 beats/minute
Correct Answer: A, B. 75-year-old with pulse oximetry of 88% on room air; 65-year-old
with blood pressure of 140/90
Rationale: A pulse oximetry of 88% indicates hypoxia and requires intervention. A blood
pressure of 140/90 is elevated (Stage 1 hypertension). A respiratory rate of 24 in an 8-
year-old is normal (20-28). A temperature of 96.8°F is slightly below normal but not
alarming for an older adult. A heart rate of 90 is within normal range .
Question 3
The nurse reads the following nurse's note in the patient's health record: "9/21/21
1800 Patient complains of headaches, almost daily, occurring more frequently in
the evening. BP 164/98. P. Johnson N.A.P." What is the priority nursing
intervention based on this information?
A. Inform the patient it is normal to have a higher BP reading in the evening.
B. Instruct the NAP to repeat the BP measurement using a manual cuff.
C. Obtain a complete set of vital signs and gather further assessment data.
D. Administer acetaminophen (Tylenol) to relieve the patient's headache.
Correct Answer: C. Obtain a complete set of vital signs and gather further assessment
data.
Rationale: It is the responsibility of the nurse to verify abnormal vital signs. The nurse
will want to gather a complete set of vital signs and additional data, such as: Does the
patient take antihypertensive medications? If so, when was it last taken? Is this a usual
BP reading for the patient compared to baseline? .
Question 4
A nursing student is assigned to take the vital signs on a patient and finds the
radial pulse to be irregular. What action should the nursing student take?
,A. Ask a fellow student to assess the pulse.
B. Check the client's previous pulse reading.
C. Assess the apical pulse for a full minute.
D. Document the pulse as irregular and continue.
Correct Answer: C. Assess the apical pulse for a full minute.
Rationale: When a peripheral pulse is irregular, the most accurate method to determine
the heart rate is to auscultate the apical pulse for one full minute. This allows the nurse
to identify the actual heart rhythm and count every beat, including those that might not
reach the periphery .
Question 5
Which of the following patients would require follow-up based on respiratory
rate?
A. A child with a respiratory rate of 20 breaths per minute.
B. An adolescent with a respiratory rate of 16 breaths per minute.
C. A newborn with a respiratory rate of 40 breaths per minute.
D. An adult with a respiratory rate of 10 breaths per minute.
Correct Answer: D. An adult with a respiratory rate of 10 breaths per minute.
Rationale: A normal respiratory rate for an adult is 12-20 breaths per minute. A rate of
10 is below normal (bradypnea) and requires further assessment. A child (20) and
adolescent (16) have normal rates; a newborn (40) is at the upper end of normal (30-
60) .
Question 6
Which of the following vital signs recorded for an older adult would be considered
acceptable (within normal limits)?
A. Temp 96.8°F (36°C), P-60, R-18, BP 160/90, O2 sat 93%
B. Temp 97.0°F (36.1°C), P-60, R-16, BP 116/78, O2 sat 95%
, C. Temp 98.6°F (37°C), P-56, R-20, BP 120/80, O2 sat 91%
D. Temp 98.0°F (36.7°C), P-76, R-22, BP 110/70, O2 sat 88%
Correct Answer: B. Temp 97.0°F (36.1°C), P-60, R-16, BP 116/78, O2 sat 95%
Rationale: All values in Option B are within acceptable ranges for an older adult. The BP
of 160/90 (A) is elevated; O2 sat of 91% (C) is below normal; O2 sat of 88% (D) indicates
hypoxia and requires intervention .
Question 7
The nurse has delegated the task of temperature assessment to the NAP. Which
information should be provided to the NAP? (Select all that apply.)
A. The type of temperature required.
B. The patient's age.
C. The frequency for taking or monitoring the temperature.
D. The patient's diagnosis.
E. What changes to report immediately to the nurse.
Correct Answer: A, C, E. The type of temperature required; The frequency for taking or
monitoring the temperature; What changes to report immediately to the nurse.
Rationale: When delegating tasks, the nurse must provide clear instructions including:
the specific task (type of temperature), the frequency of monitoring, and which findings
to report (e.g., fever, abnormal readings). The patient's age and diagnosis may be
relevant but are not the primary delegation instructions .
Question 8
Which of the following situations may affect a patient's vital signs? (Select all that
apply.)
A. Moving from lying to standing position.
B. Time of day.
C. Occupation.
