Nightingale College BSN 206 Exam 2 (pdf) | 2026/2027 | Hallmark
Q&A | Nursing
1. When measuring a patient’s blood pressure, the nurse uses a cuff that 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 only affect the diastolic pressure
C) The reading will be accurate
D) The reading will be falsely high
Correct Answer: The reading will be falsely high
Rationale: Using a blood pressure cuff that is too narrow or too small results
in a reading that is falsely elevated. The cuff cannot properly compress the
artery unless it covers the appropriate surface area. The bladder width
should be approximately 40% of the arm circumference for accuracy. A cuff
that is too wide will result in a falsely low reading.
2. A nurse is performing a primary assessment on a patient who has just
been admitted. Which step of the nursing process is the nurse currently
performing?
A) Implementation
B) Diagnosis
C) Assessment
D) Planning
Correct Answer: Assessment
Rationale: The assessment phase is the first step of the nursing process
where data is collected about the patient's health status. It involves
systematic and continuous collection, validation, and communication of
,patient data. This phase provides the foundation for the subsequent steps of
the nursing process.
3. A nurse is caring for a patient on Droplet Precautions. Which piece of
personal protective equipment (PPE) is mandatory when entering the room?
A) N95 respirator
B) Goggles only
C) Surgical mask
D) Shoe covers
Correct Answer: Surgical mask
Rationale: Droplet precautions require a surgical mask when working within
three feet of the patient to prevent transmission of large-particle droplets.
Unlike airborne precautions, an N95 respirator is not typically required unless
an aerosol-generating procedure is performed. Standard precautions like
hand hygiene should also be strictly followed.
4. Which documentation entry is the most accurate and objective?
A) Patient was angry and uncooperative during the bath
B) Patient seems to be feeling much better today
C) The patient ate a good amount of their lunch
D) Abdominal dressing is saturated with 5 cm of serosanguinous drainage
Correct Answer: Abdominal dressing is saturated with 5 cm of
serosanguinous drainage
Rationale: Accurate documentation uses specific, measurable, and
descriptive terms rather than vague opinions or generalizations. Describing
the size and type of drainage provides a clear picture for any healthcare
,provider reading the chart. Subjective terms like "angry," "seems," and "good
amount" should be avoided in documentation.
5. A nurse is assisting a patient with limited mobility to transfer from the bed
to a chair. Which action demonstrates the correct use of body mechanics?
A) Bending at the waist with the back curved
B) Bending at the knees and keeping the back straight
C) Twisting at the waist while lifting
D) Keeping feet close together while lifting
Correct Answer: Bending at the knees and keeping the back straight
Rationale: Proper body mechanics involve bending at the knees, keeping the
back straight, and using the strong muscles of the legs and arms to lift. This
prevents back injury and protects the nurse from musculoskeletal strain. The
feet should be shoulder-width apart for a stable base of support.
6. Which of the following would require follow-up based on respiratory rate?
A) An adult with a respiratory rate of 10 breaths per minute
B) A child with a respiratory rate of 20 breaths per minute
C) An adolescent with a respiratory rate of 16 breaths per minute
D) A newborn with a respiratory rate of 40 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. A newborn's normal respiratory rate is 30-60 breaths
per minute, a child's is 20-30, and an adolescent's is 16-20.
, 7. Which of the following vital signs recorded for an older adult would be
considered acceptable (within normal limits)?
A) Temp 98.0°F, P-76, BP 110/70, O2 sat 88%
B) Temp 96.8°F, P-60, R-18, BP 160/90, O2 sat 93%
C) Temp 97.0°F, P-60, R-16, BP 116/78, O2 sat 95%
D) Temp 98.6°F, P-56, R-20, BP 120/80, O2 sat 91%
Correct Answer: Temp 97.0°F, P-60, R-16, BP 116/78, O2 sat 95%
Rationale: Normal values for an older adult are: average body temperature
approximately 96.8-98.6°F, heart rate 60-100 beats per minute, respiratory
rate 16-25 breaths per minute, average BP less than 120/80, and pulse
oximetry 95% to 100%. A BP greater than 140/90 may indicate hypertension,
and SpO2 below 92% indicates hypoxia.
8. A healthy 30-year-old male arrives at the clinic for a physical. The nurse is
responsible for collecting his vital signs. Which of these can be delegated to
UAP? (Select all that apply.)
A) Temperature
B) Blood pressure
C) Pulse
D) Pulse oximetry
E) Respiration
Correct Answer: Temperature, Blood pressure, Pulse, Pulse oximetry,
Respiration
Rationale: All of these vital signs can be delegated to UAP for stable patients.
The UAP should be instructed on the correct technique and what changes to
Q&A | Nursing
1. When measuring a patient’s blood pressure, the nurse uses a cuff that 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 only affect the diastolic pressure
C) The reading will be accurate
D) The reading will be falsely high
Correct Answer: The reading will be falsely high
Rationale: Using a blood pressure cuff that is too narrow or too small results
in a reading that is falsely elevated. The cuff cannot properly compress the
artery unless it covers the appropriate surface area. The bladder width
should be approximately 40% of the arm circumference for accuracy. A cuff
that is too wide will result in a falsely low reading.
2. A nurse is performing a primary assessment on a patient who has just
been admitted. Which step of the nursing process is the nurse currently
performing?
A) Implementation
B) Diagnosis
C) Assessment
D) Planning
Correct Answer: Assessment
Rationale: The assessment phase is the first step of the nursing process
where data is collected about the patient's health status. It involves
systematic and continuous collection, validation, and communication of
,patient data. This phase provides the foundation for the subsequent steps of
the nursing process.
3. A nurse is caring for a patient on Droplet Precautions. Which piece of
personal protective equipment (PPE) is mandatory when entering the room?
A) N95 respirator
B) Goggles only
C) Surgical mask
D) Shoe covers
Correct Answer: Surgical mask
Rationale: Droplet precautions require a surgical mask when working within
three feet of the patient to prevent transmission of large-particle droplets.
Unlike airborne precautions, an N95 respirator is not typically required unless
an aerosol-generating procedure is performed. Standard precautions like
hand hygiene should also be strictly followed.
4. Which documentation entry is the most accurate and objective?
A) Patient was angry and uncooperative during the bath
B) Patient seems to be feeling much better today
C) The patient ate a good amount of their lunch
D) Abdominal dressing is saturated with 5 cm of serosanguinous drainage
Correct Answer: Abdominal dressing is saturated with 5 cm of
serosanguinous drainage
Rationale: Accurate documentation uses specific, measurable, and
descriptive terms rather than vague opinions or generalizations. Describing
the size and type of drainage provides a clear picture for any healthcare
,provider reading the chart. Subjective terms like "angry," "seems," and "good
amount" should be avoided in documentation.
5. A nurse is assisting a patient with limited mobility to transfer from the bed
to a chair. Which action demonstrates the correct use of body mechanics?
A) Bending at the waist with the back curved
B) Bending at the knees and keeping the back straight
C) Twisting at the waist while lifting
D) Keeping feet close together while lifting
Correct Answer: Bending at the knees and keeping the back straight
Rationale: Proper body mechanics involve bending at the knees, keeping the
back straight, and using the strong muscles of the legs and arms to lift. This
prevents back injury and protects the nurse from musculoskeletal strain. The
feet should be shoulder-width apart for a stable base of support.
6. Which of the following would require follow-up based on respiratory rate?
A) An adult with a respiratory rate of 10 breaths per minute
B) A child with a respiratory rate of 20 breaths per minute
C) An adolescent with a respiratory rate of 16 breaths per minute
D) A newborn with a respiratory rate of 40 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. A newborn's normal respiratory rate is 30-60 breaths
per minute, a child's is 20-30, and an adolescent's is 16-20.
, 7. Which of the following vital signs recorded for an older adult would be
considered acceptable (within normal limits)?
A) Temp 98.0°F, P-76, BP 110/70, O2 sat 88%
B) Temp 96.8°F, P-60, R-18, BP 160/90, O2 sat 93%
C) Temp 97.0°F, P-60, R-16, BP 116/78, O2 sat 95%
D) Temp 98.6°F, P-56, R-20, BP 120/80, O2 sat 91%
Correct Answer: Temp 97.0°F, P-60, R-16, BP 116/78, O2 sat 95%
Rationale: Normal values for an older adult are: average body temperature
approximately 96.8-98.6°F, heart rate 60-100 beats per minute, respiratory
rate 16-25 breaths per minute, average BP less than 120/80, and pulse
oximetry 95% to 100%. A BP greater than 140/90 may indicate hypertension,
and SpO2 below 92% indicates hypoxia.
8. A healthy 30-year-old male arrives at the clinic for a physical. The nurse is
responsible for collecting his vital signs. Which of these can be delegated to
UAP? (Select all that apply.)
A) Temperature
B) Blood pressure
C) Pulse
D) Pulse oximetry
E) Respiration
Correct Answer: Temperature, Blood pressure, Pulse, Pulse oximetry,
Respiration
Rationale: All of these vital signs can be delegated to UAP for stable patients.
The UAP should be instructed on the correct technique and what changes to
