Nightingale College BSN 205 Exam 2 (pdf) | 2026/2027 |
Fundamentals Q&A | Nursing
1. A nurse is measuring a patient's blood pressure and finds the cuff is too
small for the patient's arm. What effect will this have on the reading?
A) The reading will be falsely low
B) The reading will not be affected
C) The reading will be falsely high
D) The diastolic pressure will be low and systolic will be high
Correct Answer: The reading will be falsely high
Rationale: A blood pressure cuff that is too narrow or small will result in a
falsely high blood pressure reading because the cuff must be inflated more to
occlude the artery. Conversely, a cuff that is too wide will result in a falsely
low reading. Using the correct cuff size is essential for accurate blood
pressure measurement.
2. Where is the apical pulse located in an adult patient?
A) Second intercostal space, right sternal border
B) Fourth intercostal space, left sternal border
C) Third intercostal space, midaxillary line
D) Fifth intercostal space, left midclavicular line
Correct Answer: Fifth intercostal space, left midclavicular line
Rationale: The apical pulse is located at the apex of the heart, which is found
at the fifth intercostal space at the left midclavicular line. This is the point of
maximal impulse (PMI) and is used for accurate assessment of heart rate and
rhythm, particularly in patients with irregular pulses.
,3. When performing hand hygiene with soap and water, how long should the
nurse scrub their hands?
A) At least 5 seconds
B) At least 20 seconds
C) At least 10 seconds
D) At least 1 minute
Correct Answer: At least 20 seconds
Rationale: CDC guidelines recommend scrubbing hands with soap and water
for at least 20 seconds to effectively remove microorganisms. This is the
single most effective practice to prevent the transmission of healthcare-
associated infections.
4. Which of the following is considered a subjective assessment finding?
A) Blood pressure 140/90 mmHg
B) Patient reports 'I feel dizzy'
C) Respiratory rate of 22 breaths per minute
D) Skin warm and dry to the touch
Correct Answer: Patient reports 'I feel dizzy'
Rationale: Subjective data are information from the patient's point of view,
including feelings, perceptions, and concerns that cannot be objectively
measured. Blood pressure, respiratory rate, and skin temperature are
objective data that can be observed and measured.
5. Which patient would require follow-up based on respiratory rate?
A) An adolescent with a respiratory rate of 16 breaths per minute
,B) A child with a respiratory rate of 20 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: An adult with a respiratory rate of 10 breaths per minute
Rationale: An adult with a respiratory rate of 10 breaths per minute is
bradypneic and would require follow-up. Normal adult respiratory rate is 12-
20 breaths per minute. Adolescents, children, and newborns have different
normal ranges.
6. Which of the following vital signs recorded for an older adult would be
considered acceptable (within normal limits)?
A) Temp 98.6°F, P-56, R-20, BP 120/80, O2 sat 91%
B) Temp 97.0°F, P-60, R-16, BP 116/78, O2 sat 95%
C) Temp 96.8°F, P-60, R-18, BP 160/90, O2 sat 93%
D) Temp 98.0°F, P-76, R-22, BP 110/70, O2 sat 88%
Correct Answer: Temp 97.0°F, P-60, R-16, BP 116/78, O2 sat 95%
Rationale: This set of vital signs is within normal limits for an older adult.
Normal oxygen saturation should be 95% or higher. BP 160/90 is elevated, R-
22 is tachypneic, and O2 sat 88% indicates hypoxia.
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 patient's diagnosis
B) The frequency for taking or monitoring the temperature
C) The patient's age
, D) The type of temperature required
E) What changes to report immediately to the nurse
Correct Answer: B, D, and E
Rationale: When delegating temperature assessment, the nurse should
provide clear instructions including the frequency for monitoring, the type of
temperature required (oral, rectal, axillary, tympanic), and what changes to
report immediately. The patient's diagnosis and age are not essential for the
NAP to perform the delegated task.
8. Which of the following situations may affect a patient's vital signs? (Select
all that apply.)
A) Isolation precautions
B) Time of day
C) Occupation
D) Pain rated as a 7 on 0-10 pain scale
E) Moving from lying to standing position
Correct Answer: B, D, and E
Rationale: Vital signs can be affected by time of day, pain, and position
changes. Isolation precautions and occupation do not typically affect vital
signs. Pain can elevate heart rate and blood pressure, and position changes
can cause orthostatic changes.
9. Why is it necessary to take vital signs preoperatively? (Select all that
apply.)
A) To provide a set of vital signs to use for comparison during and after
surgery
Fundamentals Q&A | Nursing
1. A nurse is measuring a patient's blood pressure and finds the cuff is too
small for the patient's arm. What effect will this have on the reading?
A) The reading will be falsely low
B) The reading will not be affected
C) The reading will be falsely high
D) The diastolic pressure will be low and systolic will be high
Correct Answer: The reading will be falsely high
Rationale: A blood pressure cuff that is too narrow or small will result in a
falsely high blood pressure reading because the cuff must be inflated more to
occlude the artery. Conversely, a cuff that is too wide will result in a falsely
low reading. Using the correct cuff size is essential for accurate blood
pressure measurement.
2. Where is the apical pulse located in an adult patient?
A) Second intercostal space, right sternal border
B) Fourth intercostal space, left sternal border
C) Third intercostal space, midaxillary line
D) Fifth intercostal space, left midclavicular line
Correct Answer: Fifth intercostal space, left midclavicular line
Rationale: The apical pulse is located at the apex of the heart, which is found
at the fifth intercostal space at the left midclavicular line. This is the point of
maximal impulse (PMI) and is used for accurate assessment of heart rate and
rhythm, particularly in patients with irregular pulses.
,3. When performing hand hygiene with soap and water, how long should the
nurse scrub their hands?
A) At least 5 seconds
B) At least 20 seconds
C) At least 10 seconds
D) At least 1 minute
Correct Answer: At least 20 seconds
Rationale: CDC guidelines recommend scrubbing hands with soap and water
for at least 20 seconds to effectively remove microorganisms. This is the
single most effective practice to prevent the transmission of healthcare-
associated infections.
4. Which of the following is considered a subjective assessment finding?
A) Blood pressure 140/90 mmHg
B) Patient reports 'I feel dizzy'
C) Respiratory rate of 22 breaths per minute
D) Skin warm and dry to the touch
Correct Answer: Patient reports 'I feel dizzy'
Rationale: Subjective data are information from the patient's point of view,
including feelings, perceptions, and concerns that cannot be objectively
measured. Blood pressure, respiratory rate, and skin temperature are
objective data that can be observed and measured.
5. Which patient would require follow-up based on respiratory rate?
A) An adolescent with a respiratory rate of 16 breaths per minute
,B) A child with a respiratory rate of 20 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: An adult with a respiratory rate of 10 breaths per minute
Rationale: An adult with a respiratory rate of 10 breaths per minute is
bradypneic and would require follow-up. Normal adult respiratory rate is 12-
20 breaths per minute. Adolescents, children, and newborns have different
normal ranges.
6. Which of the following vital signs recorded for an older adult would be
considered acceptable (within normal limits)?
A) Temp 98.6°F, P-56, R-20, BP 120/80, O2 sat 91%
B) Temp 97.0°F, P-60, R-16, BP 116/78, O2 sat 95%
C) Temp 96.8°F, P-60, R-18, BP 160/90, O2 sat 93%
D) Temp 98.0°F, P-76, R-22, BP 110/70, O2 sat 88%
Correct Answer: Temp 97.0°F, P-60, R-16, BP 116/78, O2 sat 95%
Rationale: This set of vital signs is within normal limits for an older adult.
Normal oxygen saturation should be 95% or higher. BP 160/90 is elevated, R-
22 is tachypneic, and O2 sat 88% indicates hypoxia.
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 patient's diagnosis
B) The frequency for taking or monitoring the temperature
C) The patient's age
, D) The type of temperature required
E) What changes to report immediately to the nurse
Correct Answer: B, D, and E
Rationale: When delegating temperature assessment, the nurse should
provide clear instructions including the frequency for monitoring, the type of
temperature required (oral, rectal, axillary, tympanic), and what changes to
report immediately. The patient's diagnosis and age are not essential for the
NAP to perform the delegated task.
8. Which of the following situations may affect a patient's vital signs? (Select
all that apply.)
A) Isolation precautions
B) Time of day
C) Occupation
D) Pain rated as a 7 on 0-10 pain scale
E) Moving from lying to standing position
Correct Answer: B, D, and E
Rationale: Vital signs can be affected by time of day, pain, and position
changes. Isolation precautions and occupation do not typically affect vital
signs. Pain can elevate heart rate and blood pressure, and position changes
can cause orthostatic changes.
9. Why is it necessary to take vital signs preoperatively? (Select all that
apply.)
A) To provide a set of vital signs to use for comparison during and after
surgery
