Nursing Fundamentals Comprehensive Final Exam - 100 New
Questions with Detailed Answers & Rationales (Vital Signs,
Safety, Mobility, Wound Care, Oxygen Therapy, Suctioning,
Infection Control)
Question 1
The nurse is caring for a patient with a fever of 103°F (39.4°C). Which
intervention should the nurse implement first?
A) Administer an antipyretic medication
B) Apply a cooling blanket
C) Remove excess blankets and clothing
D) Increase the patient's fluid intake
Answer: C
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 can be used if the temperature does not
decrease.
,Question 2
A patient's oral temperature is 98.6°F (37°C) at 8:00 AM and 100.2°F
(37.9°C) at 4:00 PM. What is the most likely explanation for this change?
A) The patient is developing an infection
B) The patient has been drinking cold fluids
C) Normal circadian rhythm variation
D) The thermometer is malfunctioning
Answer: C
Rationale: Body temperature normally 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 3
Which route of temperature measurement is considered the most accurate
for core body temperature?
A) Oral
B) Axillary
,C) Tympanic
D) Rectal
Answer: D
Rationale: Rectal temperature measurement is considered the most
accurate for core body temperature because it reflects the temperature of
internal organs. However, it is invasive and used selectively.
Question 4
The nurse is assessing a patient's pulse and notes a rhythm that 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
C) Document the finding as an irregular pulse
D) Notify the healthcare provider immediately
Answer: B
Rationale: When a peripheral pulse is irregular, the nurse should auscultate
the apical pulse for one full minute to accurately assess the rate and
rhythm. This provides more reliable data than a peripheral pulse count.
Question 5
Which pulse site is most commonly used for routine assessment of an adult
patient?
, A) Apical
B) Brachial
C) Radial
D) Carotid
Answer: C
Rationale: The radial pulse is the most commonly used site for routine
assessment because it is easily accessible and provides accurate
information about heart rate and rhythm in stable patients.
Question 6
A patient's radial pulse is 52 beats per minute. Which of the following
actions should the nurse take first?
A) Notify the healthcare provider immediately
B) Assess the patient's apical pulse
C) Document the finding as bradycardia
D) Administer atropine as ordered
Answer: B
Questions with Detailed Answers & Rationales (Vital Signs,
Safety, Mobility, Wound Care, Oxygen Therapy, Suctioning,
Infection Control)
Question 1
The nurse is caring for a patient with a fever of 103°F (39.4°C). Which
intervention should the nurse implement first?
A) Administer an antipyretic medication
B) Apply a cooling blanket
C) Remove excess blankets and clothing
D) Increase the patient's fluid intake
Answer: C
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 can be used if the temperature does not
decrease.
,Question 2
A patient's oral temperature is 98.6°F (37°C) at 8:00 AM and 100.2°F
(37.9°C) at 4:00 PM. What is the most likely explanation for this change?
A) The patient is developing an infection
B) The patient has been drinking cold fluids
C) Normal circadian rhythm variation
D) The thermometer is malfunctioning
Answer: C
Rationale: Body temperature normally 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 3
Which route of temperature measurement is considered the most accurate
for core body temperature?
A) Oral
B) Axillary
,C) Tympanic
D) Rectal
Answer: D
Rationale: Rectal temperature measurement is considered the most
accurate for core body temperature because it reflects the temperature of
internal organs. However, it is invasive and used selectively.
Question 4
The nurse is assessing a patient's pulse and notes a rhythm that 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
C) Document the finding as an irregular pulse
D) Notify the healthcare provider immediately
Answer: B
Rationale: When a peripheral pulse is irregular, the nurse should auscultate
the apical pulse for one full minute to accurately assess the rate and
rhythm. This provides more reliable data than a peripheral pulse count.
Question 5
Which pulse site is most commonly used for routine assessment of an adult
patient?
, A) Apical
B) Brachial
C) Radial
D) Carotid
Answer: C
Rationale: The radial pulse is the most commonly used site for routine
assessment because it is easily accessible and provides accurate
information about heart rate and rhythm in stable patients.
Question 6
A patient's radial pulse is 52 beats per minute. Which of the following
actions should the nurse take first?
A) Notify the healthcare provider immediately
B) Assess the patient's apical pulse
C) Document the finding as bradycardia
D) Administer atropine as ordered
Answer: B
