NR 224: Fundamentals of Nursing Exam 2 Prep (Weeks 3-4) 2026
|Chamberlain
1. When measuring blood pressure, what is the most likely result if the nurse
uses a cuff that is too narrow for the patient’s arm?
A. A falsely low reading
B. A falsely high reading
C. An accurate reading if positioned correctly
D. No reading can be obtained
Answer: B
Rationale: A blood pressure cuff that is too narrow or small will result in a falsely high
reading because the cuff must generate more pressure to occlude the artery.
2. A nurse is assessing a patient for a pulse deficit. How should the nurse
perform this assessment?
A. Count the apical pulse and radial pulse simultaneously for one full minute.
B. Count the apical pulse and radial pulse simultaneously for 30 seconds.
C. Measure the radial pulse and wait 5 minutes to measure the apical pulse.
D. Count the radial pulse for 30 seconds and multiply by two.
Answer: A
Rationale: A pulse deficit is the difference between the apical and radial pulse rates. To be
accurate, they must be measured simultaneously for one full minute by two nurses.
,3. Which of the following is the most significant indicator of orthostatic
hypotension?
A. A decrease in diastolic BP by 5 mmHg when standing.
B. An increase in heart rate by 5 beats per minute when sitting up.
C. A decrease in systolic BP by at least 20 mmHg when moving from supine to standing.
D. A slight feeling of dizziness that resolves in 5 seconds.
Answer: C
Rationale: Orthostatic hypotension is defined by a drop in systolic BP of 20 mmHg or
more, or a drop in diastolic BP of 10 mmHg or more within 3 minutes of standing.
4. What is the normal range for adult respiration rate per minute?
A. 12 to 20 breaths per minute
B. 8 to 12 breaths per minute
C. 16 to 24 breaths per minute
D. 20 to 30 breaths per minute
Answer: A
Rationale: The standard normal range for an adult at rest is 12 to 20 breaths per minute.
5. At which anatomical location should the nurse place the stethoscope to
auscultate the apical pulse?
A. Second intercostal space at the right sternal border.
B. Fourth intercostal space at the left sternal border.
C. Second intercostal space at the left midclavicular line.
D. Fifth intercostal space at the left midclavicular line.
Answer: D
Rationale: The apical pulse (PMI) is located at the 5th intercostal space at the
midclavicular line.
, 6. In what order should the nurse perform the physical assessment of the
abdomen?
A. Inspection, Palpation, Percussion, Auscultation
B. Palpation, Percussion, Auscultation, Inspection
C. Inspection, Percussion, Palpation, Auscultation
D. Inspection, Auscultation, Percussion, Palpation
Answer: D
Rationale: Auscultation is done before percussion and palpation to avoid stimulating
bowel sounds that were not originally present.
7. The Braden Scale is used by nurses to assess a patient’s risk for which
condition?
A. Pressure injury development
B. Fall risk level
C. Deep vein thrombosis
D. Nutritional deficiency
Answer: A
Rationale: The Braden Scale evaluates factors like sensory perception, moisture, activity,
mobility, nutrition, and friction/shear to determine pressure injury risk.
8. During a physical exam, the nurse notes that a patient has +2 pitting edema in
the lower extremities. How deep is the indentation for +2 edema?
A. 4 mm
B. 2 mm
C. 6 mm
D. 8 mm
Answer: A
Rationale: +1 is 2mm, +2 is 4mm, +3 is 6mm, and +4 is 8mm.
|Chamberlain
1. When measuring blood pressure, what is the most likely result if the nurse
uses a cuff that is too narrow for the patient’s arm?
A. A falsely low reading
B. A falsely high reading
C. An accurate reading if positioned correctly
D. No reading can be obtained
Answer: B
Rationale: A blood pressure cuff that is too narrow or small will result in a falsely high
reading because the cuff must generate more pressure to occlude the artery.
2. A nurse is assessing a patient for a pulse deficit. How should the nurse
perform this assessment?
A. Count the apical pulse and radial pulse simultaneously for one full minute.
B. Count the apical pulse and radial pulse simultaneously for 30 seconds.
C. Measure the radial pulse and wait 5 minutes to measure the apical pulse.
D. Count the radial pulse for 30 seconds and multiply by two.
Answer: A
Rationale: A pulse deficit is the difference between the apical and radial pulse rates. To be
accurate, they must be measured simultaneously for one full minute by two nurses.
,3. Which of the following is the most significant indicator of orthostatic
hypotension?
A. A decrease in diastolic BP by 5 mmHg when standing.
B. An increase in heart rate by 5 beats per minute when sitting up.
C. A decrease in systolic BP by at least 20 mmHg when moving from supine to standing.
D. A slight feeling of dizziness that resolves in 5 seconds.
Answer: C
Rationale: Orthostatic hypotension is defined by a drop in systolic BP of 20 mmHg or
more, or a drop in diastolic BP of 10 mmHg or more within 3 minutes of standing.
4. What is the normal range for adult respiration rate per minute?
A. 12 to 20 breaths per minute
B. 8 to 12 breaths per minute
C. 16 to 24 breaths per minute
D. 20 to 30 breaths per minute
Answer: A
Rationale: The standard normal range for an adult at rest is 12 to 20 breaths per minute.
5. At which anatomical location should the nurse place the stethoscope to
auscultate the apical pulse?
A. Second intercostal space at the right sternal border.
B. Fourth intercostal space at the left sternal border.
C. Second intercostal space at the left midclavicular line.
D. Fifth intercostal space at the left midclavicular line.
Answer: D
Rationale: The apical pulse (PMI) is located at the 5th intercostal space at the
midclavicular line.
, 6. In what order should the nurse perform the physical assessment of the
abdomen?
A. Inspection, Palpation, Percussion, Auscultation
B. Palpation, Percussion, Auscultation, Inspection
C. Inspection, Percussion, Palpation, Auscultation
D. Inspection, Auscultation, Percussion, Palpation
Answer: D
Rationale: Auscultation is done before percussion and palpation to avoid stimulating
bowel sounds that were not originally present.
7. The Braden Scale is used by nurses to assess a patient’s risk for which
condition?
A. Pressure injury development
B. Fall risk level
C. Deep vein thrombosis
D. Nutritional deficiency
Answer: A
Rationale: The Braden Scale evaluates factors like sensory perception, moisture, activity,
mobility, nutrition, and friction/shear to determine pressure injury risk.
8. During a physical exam, the nurse notes that a patient has +2 pitting edema in
the lower extremities. How deep is the indentation for +2 edema?
A. 4 mm
B. 2 mm
C. 6 mm
D. 8 mm
Answer: A
Rationale: +1 is 2mm, +2 is 4mm, +3 is 6mm, and +4 is 8mm.
