BSN 206 Nursing Fundamentals:
Hallmark Exam Review –Questions,
Answers & Clinical Rationales
Q1. Which of the following patients would require follow-up?
A) A child with a respiratory rate of 20 breaths per minute
B) An adolescent with a respiratory rate of 16 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
Answer: D) An adult with a respiratory rate of 10 breaths per minute
Rationale: Normal respiratory rate for an adult is 12-20 breaths per minute. A
rate of 10 is bradypnea and below normal range, requiring follow-up. A child's
normal rate is 20-28, an adolescent's is 12-20, and a newborn's is 30-60 breaths
per minute.
Q2. Which of the following vital signs recorded for an older adult would be
considered acceptable (within normal limits)?
A) Temp 96.8°F (36°C), P-60, R-18, BP 160/90, O2 sat 93%
B) Temp 97.0°F (36.1°C), P-60, R-16, BP 116/78, O2 sat 95%
C) Temp 98.6°F (37°C), P-56, R-20, BP 120/80, O2 sat 91%
D) Temp 98.0°F (36.7°C), P-76, R-22, BP 110/70, O2 sat 88%
Answer: B) Temp 97.0°F (36.1°C), P-60, R-16, BP 116/78, O2 sat 95%
Rationale: Normal vital signs for an older adult: temperature 96.8-98.6°F (36-
37°C), pulse 60-100 bpm, respirations 12-20, BP <120/80, O2 sat ≥95%. Option B
is the only one where all values fall within normal limits.
,Q3. 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 type of temperature required
B) The patient's age
C) The frequency for taking or monitoring the temperature
D) The patient's diagnosis
E) What changes to report immediately to the nurse
Answer: A, C, E
Rationale: When delegating temperature assessment, the nurse must provide the
type of temperature required (oral, rectal, axillary, tympanic), the frequency for
monitoring, and what changes to report immediately. The patient's age and
diagnosis are not essential for delegation of this task.
Q4. Which of the following situations may affect a patient's vital signs? (Select
all that apply.)
A) Moving from lying to standing position
B) Time of day
C) Occupation
D) Isolation precautions
E) Pain rated as a 7 on 0-10 pain scale
Answer: A, B, E
Rationale: Position changes (orthostatic changes), time of day (circadian
rhythms), and pain can all affect vital signs. Occupation and isolation precautions
do not directly affect vital sign measurements.
Q5. Why is it necessary to take vital signs preoperatively? (Select all that apply.)
A) To provide the patient with reassurance that he or she is being cared for by
competent staff
B) To provide a set of vital signs to use for comparison during and after surgery
C) To ensure the equipment is appropriately calibrated and functional
,D) To verify the patient is not experiencing any complications that may
contraindicate surgery
Answer: B, D
Rationale: Preoperative vital signs provide a baseline for comparison during and
after surgery and help verify the patient is stable for the procedure. Reassurance
and equipment calibration are not the primary reasons for obtaining preoperative
vital signs.
Q6. What is the normal pulse range for an adult?
A) 40-60 beats per minute
B) 60-100 beats per minute
C) 80-120 beats per minute
D) 100-140 beats per minute
Answer: B) 60-100 beats per minute
Rationale: The normal resting heart rate for an adult is 60 to 100 beats per
minute. Rates below 60 (bradycardia) or above 100 (tachycardia) may require
further assessment.
Q7. Whenever there is an alteration in the radial pulse rate, rhythm, or
amplitude, the nurse should initially do which of the following?
A) Document the finding and continue monitoring
B) Auscultate the apical pulse for quality and rate
C) Notify the healthcare provider immediately
D) Reassess the radial pulse in 15 minutes
Answer: B) Auscultate the apical pulse for quality and rate
Rationale: When a peripheral pulse is altered, the nurse should auscultate the
apical pulse for a full minute to obtain an accurate heart rate and assess rhythm
and quality before determining the need for further action.
, Q8. The nurse should routinely auscultate the apical pulse with the bell side of
the stethoscope, and use the diaphragm side to identify heart murmurs.
A) True
B) False
Answer: B) False
Rationale: The diaphragm of the stethoscope is used to auscultate high-pitched
sounds such as normal heart sounds (S1, S2) and breath sounds. The bell is used
for low-pitched sounds such as heart murmurs and bruits.
Q9. What is the normal respiratory rate for a newborn?
A) 12-20 breaths per minute
B) 20-30 breaths per minute
C) 30-60 breaths per minute
D) 40-80 breaths per minute
Answer: C) 30-60 breaths per minute
Rationale: Newborns have a normal respiratory rate of 30-60 breaths per minute.
Their respiratory systems are immature, and they have higher metabolic
demands, requiring faster breathing rates.
Q10. What is an appropriate nursing intervention for an adult patient with a
respiratory rate of 30 breaths per minute? (Select all that apply.)
A) Administer oxygen immediately
B) Notify the healthcare provider
C) Document the finding
D) Assess for underlying causes
E) Monitor oxygen saturation
Answer: D, E
Rationale: A respiratory rate of 30 is tachypnea (above normal 12-20). The nurse
should assess for underlying causes and monitor oxygen saturation. Immediate
Hallmark Exam Review –Questions,
Answers & Clinical Rationales
Q1. Which of the following patients would require follow-up?
A) A child with a respiratory rate of 20 breaths per minute
B) An adolescent with a respiratory rate of 16 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
Answer: D) An adult with a respiratory rate of 10 breaths per minute
Rationale: Normal respiratory rate for an adult is 12-20 breaths per minute. A
rate of 10 is bradypnea and below normal range, requiring follow-up. A child's
normal rate is 20-28, an adolescent's is 12-20, and a newborn's is 30-60 breaths
per minute.
Q2. Which of the following vital signs recorded for an older adult would be
considered acceptable (within normal limits)?
A) Temp 96.8°F (36°C), P-60, R-18, BP 160/90, O2 sat 93%
B) Temp 97.0°F (36.1°C), P-60, R-16, BP 116/78, O2 sat 95%
C) Temp 98.6°F (37°C), P-56, R-20, BP 120/80, O2 sat 91%
D) Temp 98.0°F (36.7°C), P-76, R-22, BP 110/70, O2 sat 88%
Answer: B) Temp 97.0°F (36.1°C), P-60, R-16, BP 116/78, O2 sat 95%
Rationale: Normal vital signs for an older adult: temperature 96.8-98.6°F (36-
37°C), pulse 60-100 bpm, respirations 12-20, BP <120/80, O2 sat ≥95%. Option B
is the only one where all values fall within normal limits.
,Q3. 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 type of temperature required
B) The patient's age
C) The frequency for taking or monitoring the temperature
D) The patient's diagnosis
E) What changes to report immediately to the nurse
Answer: A, C, E
Rationale: When delegating temperature assessment, the nurse must provide the
type of temperature required (oral, rectal, axillary, tympanic), the frequency for
monitoring, and what changes to report immediately. The patient's age and
diagnosis are not essential for delegation of this task.
Q4. Which of the following situations may affect a patient's vital signs? (Select
all that apply.)
A) Moving from lying to standing position
B) Time of day
C) Occupation
D) Isolation precautions
E) Pain rated as a 7 on 0-10 pain scale
Answer: A, B, E
Rationale: Position changes (orthostatic changes), time of day (circadian
rhythms), and pain can all affect vital signs. Occupation and isolation precautions
do not directly affect vital sign measurements.
Q5. Why is it necessary to take vital signs preoperatively? (Select all that apply.)
A) To provide the patient with reassurance that he or she is being cared for by
competent staff
B) To provide a set of vital signs to use for comparison during and after surgery
C) To ensure the equipment is appropriately calibrated and functional
,D) To verify the patient is not experiencing any complications that may
contraindicate surgery
Answer: B, D
Rationale: Preoperative vital signs provide a baseline for comparison during and
after surgery and help verify the patient is stable for the procedure. Reassurance
and equipment calibration are not the primary reasons for obtaining preoperative
vital signs.
Q6. What is the normal pulse range for an adult?
A) 40-60 beats per minute
B) 60-100 beats per minute
C) 80-120 beats per minute
D) 100-140 beats per minute
Answer: B) 60-100 beats per minute
Rationale: The normal resting heart rate for an adult is 60 to 100 beats per
minute. Rates below 60 (bradycardia) or above 100 (tachycardia) may require
further assessment.
Q7. Whenever there is an alteration in the radial pulse rate, rhythm, or
amplitude, the nurse should initially do which of the following?
A) Document the finding and continue monitoring
B) Auscultate the apical pulse for quality and rate
C) Notify the healthcare provider immediately
D) Reassess the radial pulse in 15 minutes
Answer: B) Auscultate the apical pulse for quality and rate
Rationale: When a peripheral pulse is altered, the nurse should auscultate the
apical pulse for a full minute to obtain an accurate heart rate and assess rhythm
and quality before determining the need for further action.
, Q8. The nurse should routinely auscultate the apical pulse with the bell side of
the stethoscope, and use the diaphragm side to identify heart murmurs.
A) True
B) False
Answer: B) False
Rationale: The diaphragm of the stethoscope is used to auscultate high-pitched
sounds such as normal heart sounds (S1, S2) and breath sounds. The bell is used
for low-pitched sounds such as heart murmurs and bruits.
Q9. What is the normal respiratory rate for a newborn?
A) 12-20 breaths per minute
B) 20-30 breaths per minute
C) 30-60 breaths per minute
D) 40-80 breaths per minute
Answer: C) 30-60 breaths per minute
Rationale: Newborns have a normal respiratory rate of 30-60 breaths per minute.
Their respiratory systems are immature, and they have higher metabolic
demands, requiring faster breathing rates.
Q10. What is an appropriate nursing intervention for an adult patient with a
respiratory rate of 30 breaths per minute? (Select all that apply.)
A) Administer oxygen immediately
B) Notify the healthcare provider
C) Document the finding
D) Assess for underlying causes
E) Monitor oxygen saturation
Answer: D, E
Rationale: A respiratory rate of 30 is tachypnea (above normal 12-20). The nurse
should assess for underlying causes and monitor oxygen saturation. Immediate
