Nursing Fundamentals Midterm Exam - 80 Questions with Detailed
Answers & Rationales (Vital Signs, Safety, Mobility, Wound Care, Oxygen
Therapy, Infection Control)
Question 1
The nurse is assessing a patient's vital signs. Which finding is outside the
normal range for a healthy adult?
A) Temperature 98.6°F (37°C)
B) Pulse 72 beats per minute
C) Respirations 22 breaths per minute
D) Blood pressure 118/76 mmHg
Answer: C*Rationale: Normal respiratory rate for a healthy adult is 12-20
breaths per minute. 22 breaths per minute is tachypnea and outside the
normal range. Temperature (96.8-100.4°F), pulse (60-100 bpm), and BP
(<120/80) are all within normal limits.
## Question 2
A patient's temperature is 103.2°F (39.6°C). Which nursing intervention
should be implemented first?
,A) Administer prescribed antipyretic medication
B) Remove excess blankets and clothing
C) Apply a cooling blanket
D) Offer the patient a cold beverage
Answer: B
Rationale: The first intervention for fever is to remove excess blankets and
clothing to promote heat loss through radiation and convection.
Antipyretics and cooling blankets may be used if the temperature does not
respond to simple measures.
Question 3
The NAP reports that a patient's oral temperature is 99.8°F (37.7°C). The
patient just finished drinking a cup of hot coffee. What should the nurse
do?
A) Document the temperature as an elevated reading
B) Notify the healthcare provider
C) Ask the NAP to wait 15-30 minutes and recheck the temperature
D) Administer an antipyretic medication
Answer: C
,Rationale: Hot beverages can artificially elevate oral temperature readings.
The nurse should wait 15-30 minutes for the oral cavity to return to
baseline temperature before rechecking.
## Question 4
Which patient is most at risk for hypothermia?
A) A 25-year-old who just completed a marathon
B) A 70-year-old with decreased subcutaneous fat
C) A 40-year-old with a fever
D) A 30-year-old who is overweight
Answer: B
Rationale: Older adults are at increased risk for hypothermia due to
decreased subcutaneous fat, decreased metabolic rate, and impaired
thermoregulatory mechanisms. Exercise increases temperature, fever
indicates elevated temperature, and overweight patients have more
insulation.
, Question 5
A patient has a temperature of 99.2°F (37.3°C) at 8:00 AM and 100.4°F
(38°C) at 4:00 PM. This pattern is most likely due to:
A) Developing infection
B) Normal circadian rhythm
C) Improper thermometer use
D) Dehydration
Answer: B
Rationale: Body temperature naturally fluctuates throughout the day, with
the lowest temperature occurring in the early morning and the highest in
the late afternoon/early evening. This is a normal circadian rhythm
variation.
Question 6
The nurse is assessing a patient's radial pulse and notes it is irregular. What
should the nurse do next?
A) Count the pulse for 15 seconds and multiply by 4
B) Auscultate the apical pulse for one full minute
Answers & Rationales (Vital Signs, Safety, Mobility, Wound Care, Oxygen
Therapy, Infection Control)
Question 1
The nurse is assessing a patient's vital signs. Which finding is outside the
normal range for a healthy adult?
A) Temperature 98.6°F (37°C)
B) Pulse 72 beats per minute
C) Respirations 22 breaths per minute
D) Blood pressure 118/76 mmHg
Answer: C*Rationale: Normal respiratory rate for a healthy adult is 12-20
breaths per minute. 22 breaths per minute is tachypnea and outside the
normal range. Temperature (96.8-100.4°F), pulse (60-100 bpm), and BP
(<120/80) are all within normal limits.
## Question 2
A patient's temperature is 103.2°F (39.6°C). Which nursing intervention
should be implemented first?
,A) Administer prescribed antipyretic medication
B) Remove excess blankets and clothing
C) Apply a cooling blanket
D) Offer the patient a cold beverage
Answer: B
Rationale: The first intervention for fever is to remove excess blankets and
clothing to promote heat loss through radiation and convection.
Antipyretics and cooling blankets may be used if the temperature does not
respond to simple measures.
Question 3
The NAP reports that a patient's oral temperature is 99.8°F (37.7°C). The
patient just finished drinking a cup of hot coffee. What should the nurse
do?
A) Document the temperature as an elevated reading
B) Notify the healthcare provider
C) Ask the NAP to wait 15-30 minutes and recheck the temperature
D) Administer an antipyretic medication
Answer: C
,Rationale: Hot beverages can artificially elevate oral temperature readings.
The nurse should wait 15-30 minutes for the oral cavity to return to
baseline temperature before rechecking.
## Question 4
Which patient is most at risk for hypothermia?
A) A 25-year-old who just completed a marathon
B) A 70-year-old with decreased subcutaneous fat
C) A 40-year-old with a fever
D) A 30-year-old who is overweight
Answer: B
Rationale: Older adults are at increased risk for hypothermia due to
decreased subcutaneous fat, decreased metabolic rate, and impaired
thermoregulatory mechanisms. Exercise increases temperature, fever
indicates elevated temperature, and overweight patients have more
insulation.
, Question 5
A patient has a temperature of 99.2°F (37.3°C) at 8:00 AM and 100.4°F
(38°C) at 4:00 PM. This pattern is most likely due to:
A) Developing infection
B) Normal circadian rhythm
C) Improper thermometer use
D) Dehydration
Answer: B
Rationale: Body temperature naturally fluctuates throughout the day, with
the lowest temperature occurring in the early morning and the highest in
the late afternoon/early evening. This is a normal circadian rhythm
variation.
Question 6
The nurse is assessing a patient's radial pulse and notes it is irregular. What
should the nurse do next?
A) Count the pulse for 15 seconds and multiply by 4
B) Auscultate the apical pulse for one full minute
