NSG 3100 Exam 2 Fundamentals | Nursing
Study Guide | Practice Questions, Answers &
Rationales
1. What is considered the normal respiration rate range for an adult?
• A) 8-18 breaths per minute
• B) 11-20 breaths per minute
• C) 12-20 breaths per minute
• D) 14-22 breaths per minute
Answer: C
Rationale: The normal adult respiratory rate is 12-20 breaths per minute,
reflecting efficient gas exchange and metabolic demands. Rates outside this range
can indicate respiratory distress, central nervous system depression, or metabolic
derangements.
2. A patient's blood pressure reading is 142/92 mmHg. The patient states they
are anxious about the procedure. What is the best next action?
• A) Document the reading and notify the provider
• B) Administer antihypertensive medication
• C) Wait 5 minutes and recheck the blood pressure
• D) Place the client flat in bed
Answer: C
Rationale: Anxiety can cause a temporary elevation in blood pressure. The nurse
should allow the patient to rest and recheck the reading to obtain an accurate
measurement before taking further action.
,3. The nurse is auscultating blood pressure. At which Korotkoff phase is the
systolic pressure recorded?
• A) Phase II (soft swishing sound)
• B) Phase IV (muffling)
• C) Phase I (first clear tapping sound)
• D) Phase V (disappearance of sound)
Answer: C
Rationale: Systolic pressure is recorded at the onset of clear tapping sounds
(Phase I). Phase V (disappearance of sound) is diastolic in adults.
4. A patient with orthostatic hypotension should be taught to:
• A) Keep moving to keep blood flowing
• B) Change positions slowly to prevent lightheadedness
• C) Move as quickly as possible to increase heart rate
• D) Rest at least 8 hours a day
Answer: B
Rationale: Orthostatic hypotension occurs due to inadequate autonomic
compensation upon standing. Preventive measures focus on gradual positional
changes to allow baroreceptor-mediated vascular adjustments, minimizing falls
and syncope.
5. What happens if a blood pressure cuff is too small or narrow?
• A) Falsely low reading
• B) Falsely high reading
• C) Accurate reading
• D) Inability to hear Korotkoff sounds
,Answer: B
Rationale: A cuff that is too small (narrow) requires excessive pressure to occlude
the artery, resulting in a falsely elevated reading. A too-large cuff gives a falsely
low reading.
6. What happens if a blood pressure cuff is too big?
• A) Falsely low reading
• B) Falsely high reading
• C) Accurate reading
• D) Inability to hear Korotkoff sounds
Answer: A
Rationale: A cuff that is too large does not adequately compress the artery,
resulting in a falsely low blood pressure reading.
7. What happens if the arm is not placed at the level of the heart when taking a
blood pressure?
• A) Falsely high reading
• B) Falsely low reading
• C) Accurate reading
• D) No effect on the reading
Answer: B
Rationale: If the arm is above heart level, the reading will be falsely low due to
gravity. The arm should be supported at heart level for accurate measurement.
8. A client's tympanic temperature is 38.6°C (101.5°F). The nurse expects the
heart rate to be:
, • A) Decreased from baseline
• B) Unchanged
• C) Elevated from baseline
• D) Irregular
Answer: C
Rationale: Fever increases metabolic demand, which leads to an elevated heart
rate. The pulse generally increases approximately 10 beats per minute for each
degree Fahrenheit of fever.
9. Which temperature site is considered the most accurate for reflecting core
body temperature?
• A) Oral
• B) Temporal
• C) Tympanic
• D) Rectal
Answer: D
Rationale: Rectal temperature most closely reflects core body temperature and is
minimally affected by external factors. It is preferred in critical care or when
precise measurement is imperative.
10. Factors that affect body temperature include all of the following EXCEPT:
• A) Age
• B) Environment
• C) Circadian Rhythm
• D) Positioning
• E) Exercise/Activity
Study Guide | Practice Questions, Answers &
Rationales
1. What is considered the normal respiration rate range for an adult?
• A) 8-18 breaths per minute
• B) 11-20 breaths per minute
• C) 12-20 breaths per minute
• D) 14-22 breaths per minute
Answer: C
Rationale: The normal adult respiratory rate is 12-20 breaths per minute,
reflecting efficient gas exchange and metabolic demands. Rates outside this range
can indicate respiratory distress, central nervous system depression, or metabolic
derangements.
2. A patient's blood pressure reading is 142/92 mmHg. The patient states they
are anxious about the procedure. What is the best next action?
• A) Document the reading and notify the provider
• B) Administer antihypertensive medication
• C) Wait 5 minutes and recheck the blood pressure
• D) Place the client flat in bed
Answer: C
Rationale: Anxiety can cause a temporary elevation in blood pressure. The nurse
should allow the patient to rest and recheck the reading to obtain an accurate
measurement before taking further action.
,3. The nurse is auscultating blood pressure. At which Korotkoff phase is the
systolic pressure recorded?
• A) Phase II (soft swishing sound)
• B) Phase IV (muffling)
• C) Phase I (first clear tapping sound)
• D) Phase V (disappearance of sound)
Answer: C
Rationale: Systolic pressure is recorded at the onset of clear tapping sounds
(Phase I). Phase V (disappearance of sound) is diastolic in adults.
4. A patient with orthostatic hypotension should be taught to:
• A) Keep moving to keep blood flowing
• B) Change positions slowly to prevent lightheadedness
• C) Move as quickly as possible to increase heart rate
• D) Rest at least 8 hours a day
Answer: B
Rationale: Orthostatic hypotension occurs due to inadequate autonomic
compensation upon standing. Preventive measures focus on gradual positional
changes to allow baroreceptor-mediated vascular adjustments, minimizing falls
and syncope.
5. What happens if a blood pressure cuff is too small or narrow?
• A) Falsely low reading
• B) Falsely high reading
• C) Accurate reading
• D) Inability to hear Korotkoff sounds
,Answer: B
Rationale: A cuff that is too small (narrow) requires excessive pressure to occlude
the artery, resulting in a falsely elevated reading. A too-large cuff gives a falsely
low reading.
6. What happens if a blood pressure cuff is too big?
• A) Falsely low reading
• B) Falsely high reading
• C) Accurate reading
• D) Inability to hear Korotkoff sounds
Answer: A
Rationale: A cuff that is too large does not adequately compress the artery,
resulting in a falsely low blood pressure reading.
7. What happens if the arm is not placed at the level of the heart when taking a
blood pressure?
• A) Falsely high reading
• B) Falsely low reading
• C) Accurate reading
• D) No effect on the reading
Answer: B
Rationale: If the arm is above heart level, the reading will be falsely low due to
gravity. The arm should be supported at heart level for accurate measurement.
8. A client's tympanic temperature is 38.6°C (101.5°F). The nurse expects the
heart rate to be:
, • A) Decreased from baseline
• B) Unchanged
• C) Elevated from baseline
• D) Irregular
Answer: C
Rationale: Fever increases metabolic demand, which leads to an elevated heart
rate. The pulse generally increases approximately 10 beats per minute for each
degree Fahrenheit of fever.
9. Which temperature site is considered the most accurate for reflecting core
body temperature?
• A) Oral
• B) Temporal
• C) Tympanic
• D) Rectal
Answer: D
Rationale: Rectal temperature most closely reflects core body temperature and is
minimally affected by external factors. It is preferred in critical care or when
precise measurement is imperative.
10. Factors that affect body temperature include all of the following EXCEPT:
• A) Age
• B) Environment
• C) Circadian Rhythm
• D) Positioning
• E) Exercise/Activity
