NURS 101L | Fundamentals of Nursing Skills Lab | Vital Signs
Measurement Techniques | 2026 Update WCU
1. When assessing a patient for orthostatic hypotension, which finding indicates
a positive result after moving the patient from a supine to a standing position?
A. A decrease in systolic blood pressure of 10 mmHg.
B. An increase in diastolic blood pressure of 5 mmHg.
C. A decrease in systolic blood pressure of 20 mmHg or more.
D. A decrease in heart rate by 15 beats per minute.
Answer: C
Rationale: Orthostatic hypotension is defined as a decrease in systolic BP of at least 20
mmHg or a decrease in diastolic BP of at least 10 mmHg within three minutes of standing.
2. A nurse is preparing to measure a patient’s blood pressure. Which action will
lead to a falsely high reading?
A. Using a cuff with a bladder that is too wide.
B. Wrapping the cuff too loosely around the arm.
C. Positioning the arm above the level of the heart.
D. Deflating the cuff at a rate of 2 to 3 mmHg per second.
Answer: B
Rationale: A loose cuff or a cuff that is too small results in a falsely high blood pressure
reading because the bladder must inflate more to occlude the artery.
,3. What is the correct anatomical location for auscultating the apical pulse in an
adult patient?
A. Fifth intercostal space at the left midclavicular line.
B. Fourth intercostal space at the left sternal border.
C. Second intercostal space at the right sternal border.
D. Second intercostal space at the left sternal border.
Answer: A
Rationale: The apical pulse (Point of Maximal Impulse) is found at the fifth intercostal
space, left midclavicular line.
4. Which physiological mechanism is responsible for the body’s primary heat
loss through electromagnetic waves?
A. Conduction
B. Radiation
C. Convection
D. Evaporation
Answer: B
Rationale: Radiation is the transfer of heat from the surface of one object to the surface of
another without direct contact, accounting for up to 60% of body heat loss.
5. A nurse notes a patient’s pulse is ‘bounding’ and difficult to obliterate. How
should this be documented on a 0 to 4+ scale?
A. 1+
B. 2+
C. 4+
D. 3+
Answer: C
Rationale: On a standard 4-point scale, 0 is absent, 1+ is diminished/weak, 2+ is normal,
3+ is full/increased, and 4+ is bounding.
, 6. When measuring a rectal temperature in an adult, how far should the probe
be inserted into the anus?
A. 1.5 inches (3.5 cm)
B. 0.5 inches (1.2 cm)
C. 2.5 inches (6 cm)
D. 3 inches (7.5 cm)
Answer: A
Rationale: For an adult, the rectal probe should be inserted approximately 1 to 1.5 inches
(2.5 to 3.5 cm) toward the umbilicus.
7. Which respiratory pattern is characterized by alternating periods of apnea
and hyperventilation?
A. Kussmaul’s respirations
B. Cheyne-Stokes respirations
C. Biot’s respirations
D. Bradypnea
Answer: B
Rationale: Cheyne-Stokes respirations involve a gradual increase in depth followed by a
decrease and then a period of apnea, often seen in end-of-life or heart failure.
8. An auscultatory gap is most commonly observed in which patient population?
A. Newborns and infants
B. Athletes with bradycardia
C. Hypertensive older adults
D. Patients with hypotension
Answer: C
Rationale: An auscultatory gap is a temporary disappearance of sounds between the first
and second Korotkoff sounds, common in older adults with hypertension.
Measurement Techniques | 2026 Update WCU
1. When assessing a patient for orthostatic hypotension, which finding indicates
a positive result after moving the patient from a supine to a standing position?
A. A decrease in systolic blood pressure of 10 mmHg.
B. An increase in diastolic blood pressure of 5 mmHg.
C. A decrease in systolic blood pressure of 20 mmHg or more.
D. A decrease in heart rate by 15 beats per minute.
Answer: C
Rationale: Orthostatic hypotension is defined as a decrease in systolic BP of at least 20
mmHg or a decrease in diastolic BP of at least 10 mmHg within three minutes of standing.
2. A nurse is preparing to measure a patient’s blood pressure. Which action will
lead to a falsely high reading?
A. Using a cuff with a bladder that is too wide.
B. Wrapping the cuff too loosely around the arm.
C. Positioning the arm above the level of the heart.
D. Deflating the cuff at a rate of 2 to 3 mmHg per second.
Answer: B
Rationale: A loose cuff or a cuff that is too small results in a falsely high blood pressure
reading because the bladder must inflate more to occlude the artery.
,3. What is the correct anatomical location for auscultating the apical pulse in an
adult patient?
A. Fifth intercostal space at the left midclavicular line.
B. Fourth intercostal space at the left sternal border.
C. Second intercostal space at the right sternal border.
D. Second intercostal space at the left sternal border.
Answer: A
Rationale: The apical pulse (Point of Maximal Impulse) is found at the fifth intercostal
space, left midclavicular line.
4. Which physiological mechanism is responsible for the body’s primary heat
loss through electromagnetic waves?
A. Conduction
B. Radiation
C. Convection
D. Evaporation
Answer: B
Rationale: Radiation is the transfer of heat from the surface of one object to the surface of
another without direct contact, accounting for up to 60% of body heat loss.
5. A nurse notes a patient’s pulse is ‘bounding’ and difficult to obliterate. How
should this be documented on a 0 to 4+ scale?
A. 1+
B. 2+
C. 4+
D. 3+
Answer: C
Rationale: On a standard 4-point scale, 0 is absent, 1+ is diminished/weak, 2+ is normal,
3+ is full/increased, and 4+ is bounding.
, 6. When measuring a rectal temperature in an adult, how far should the probe
be inserted into the anus?
A. 1.5 inches (3.5 cm)
B. 0.5 inches (1.2 cm)
C. 2.5 inches (6 cm)
D. 3 inches (7.5 cm)
Answer: A
Rationale: For an adult, the rectal probe should be inserted approximately 1 to 1.5 inches
(2.5 to 3.5 cm) toward the umbilicus.
7. Which respiratory pattern is characterized by alternating periods of apnea
and hyperventilation?
A. Kussmaul’s respirations
B. Cheyne-Stokes respirations
C. Biot’s respirations
D. Bradypnea
Answer: B
Rationale: Cheyne-Stokes respirations involve a gradual increase in depth followed by a
decrease and then a period of apnea, often seen in end-of-life or heart failure.
8. An auscultatory gap is most commonly observed in which patient population?
A. Newborns and infants
B. Athletes with bradycardia
C. Hypertensive older adults
D. Patients with hypotension
Answer: C
Rationale: An auscultatory gap is a temporary disappearance of sounds between the first
and second Korotkoff sounds, common in older adults with hypertension.
