NUR 231 – FUNDAMENTALS OF NURSING /
HEALTH ASSESSMENT 150 Practice Exam
Questions with Verified Answers & Rationales
Graded A+ | Final Exam Preparation
Question 1
How long do you perform hand hygiene?
A) 5-10 seconds
B) 15 seconds
C) At least 20 seconds (soap and water) or until dry (alcohol-based)
D) 60 seconds
Correct Answer: C
Rationale: CDC guidelines recommend washing with soap and water for at least 20 seconds.
Alcohol-based hand rub requires rubbing all surfaces until dry (approximately 20-30 seconds).
Question 2
Which pulse site is most commonly used to assess an adult patient's pulse?
A) Radial artery
B) Brachial artery
C) Carotid artery
D) Femoral artery
Correct Answer: A
Rationale: The radial pulse is easily accessible and commonly used in adults. Brachial is used
for blood pressure and in infants. Carotid is used in emergencies or when radial is not palpable.
Question 3
A nurse is assessing a patient's blood pressure. The cuff is too small for the patient's arm. How
will this affect the reading?
A) Falsely low reading
B) Falsely high reading
C) No effect
D) Unable to obtain a reading
,Correct Answer: B
Rationale: A cuff that is too small (undercuffing) will cause a falsely high blood pressure reading.
A cuff that is too large causes a falsely low reading.
Question 4
What is the normal adult respiratory rate?
A) 6-10 breaths per minute
B) 12-20 breaths per minute
C) 22-30 breaths per minute
D) 30-40 breaths per minute
Correct Answer: B
Rationale: Normal adult respiratory rate is 12-20 breaths per minute. Bradypnea is <12;
tachypnea is >20.
Question 5
A patient has an oral temperature of 38.5°C (101.3°F). This is classified as:
A) Hypothermia
B) Normal
C) Fever (pyrexia)
D) Hyperpyrexia
Correct Answer: C
Rationale: Normal oral temperature is 36.5-37.5°C (97.7-99.5°F). 38.5°C is a fever.
Hyperpyrexia is >41°C.
Question 6
The nurse is preparing to take a patient's apical pulse. Where should the stethoscope be
placed?
A) 2nd intercostal space, right sternal border
B) 4th intercostal space, left sternal border
C) 5th intercostal space, left midclavicular line
D) 5th intercostal space, right midclavicular line
Correct Answer: C
Rationale: The apical pulse (point of maximal impulse – PMI) is located at the 5th intercostal
space at the left midclavicular line.
,Question 7
Which of the following patients is at highest risk for a fall?
A) A 25-year-old male with a sprained ankle
B) A 70-year-old female with a history of falls and taking antihypertensives
C) A 40-year-old male with a cold
D) A 30-year-old female post-cesarean section
Correct Answer: B
Rationale: Older age, history of falls, and antihypertensive medications (which can cause
orthostatic hypotension) increase fall risk.
Question 8
The nurse is applying a restraint to a patient. How often must the patient be assessed?
A) Every 30 minutes
B) Every 1 hour
C) Every 2 hours (for skin integrity, circulation, and needs)
D) Every 4 hours
Correct Answer: C
Rationale: Patients in restraints require assessment at least every 2 hours for skin integrity,
circulation, nutrition, hydration, and elimination needs.
Question 9
A patient with an indwelling urinary catheter has cloudy, foul-smelling urine. What is the priority
action?
A) Irrigate the catheter
B) Notify the provider (possible urinary tract infection)
C) Increase fluid intake
D) Change the catheter immediately
Correct Answer: B
Rationale: Cloudy, foul-smelling urine suggests a urinary tract infection. The provider should be
notified for possible urine culture and antibiotic therapy.
Question 10
, Which of the following is a sign of a pressure injury (bed sore)?
A) Pallor
B) Non-blanchable erythema (redness that does not turn white when pressed)
C) Jaundice
D) Cyanosis
Correct Answer: B
Rationale: Non-blanchable erythema is an early sign of a pressure injury (Stage 1). Pallor,
jaundice, and cyanosis are not pressure injury indicators.
Question 11
The nurse is educating a patient about a low-sodium diet. Which food should the patient avoid?
A) Fresh chicken breast
B) Canned soup
C) Apples
D) Brown rice
Correct Answer: B
Rationale: Canned soups are high in sodium. Fresh chicken, apples, and brown rice are
naturally low in sodium.
Question 12
What is the correct order for removing personal protective equipment (PPE)?
A) Gloves, gown, mask, goggles
B) Mask, goggles, gown, gloves
C) Gown, gloves, mask, goggles
D) Gloves, goggles, gown, mask
Correct Answer: A
Rationale: Remove PPE in order: gloves (most contaminated first), then gown, then
mask/respirator, then goggles/face shield (if not attached to mask).
Question 13
A nurse is performing a sterile dressing change. Which action would contaminate the sterile
field?
A) Opening the sterile package away from the body
B) Reaching over the sterile field
C) Keeping the sterile field above waist level
HEALTH ASSESSMENT 150 Practice Exam
Questions with Verified Answers & Rationales
Graded A+ | Final Exam Preparation
Question 1
How long do you perform hand hygiene?
A) 5-10 seconds
B) 15 seconds
C) At least 20 seconds (soap and water) or until dry (alcohol-based)
D) 60 seconds
Correct Answer: C
Rationale: CDC guidelines recommend washing with soap and water for at least 20 seconds.
Alcohol-based hand rub requires rubbing all surfaces until dry (approximately 20-30 seconds).
Question 2
Which pulse site is most commonly used to assess an adult patient's pulse?
A) Radial artery
B) Brachial artery
C) Carotid artery
D) Femoral artery
Correct Answer: A
Rationale: The radial pulse is easily accessible and commonly used in adults. Brachial is used
for blood pressure and in infants. Carotid is used in emergencies or when radial is not palpable.
Question 3
A nurse is assessing a patient's blood pressure. The cuff is too small for the patient's arm. How
will this affect the reading?
A) Falsely low reading
B) Falsely high reading
C) No effect
D) Unable to obtain a reading
,Correct Answer: B
Rationale: A cuff that is too small (undercuffing) will cause a falsely high blood pressure reading.
A cuff that is too large causes a falsely low reading.
Question 4
What is the normal adult respiratory rate?
A) 6-10 breaths per minute
B) 12-20 breaths per minute
C) 22-30 breaths per minute
D) 30-40 breaths per minute
Correct Answer: B
Rationale: Normal adult respiratory rate is 12-20 breaths per minute. Bradypnea is <12;
tachypnea is >20.
Question 5
A patient has an oral temperature of 38.5°C (101.3°F). This is classified as:
A) Hypothermia
B) Normal
C) Fever (pyrexia)
D) Hyperpyrexia
Correct Answer: C
Rationale: Normal oral temperature is 36.5-37.5°C (97.7-99.5°F). 38.5°C is a fever.
Hyperpyrexia is >41°C.
Question 6
The nurse is preparing to take a patient's apical pulse. Where should the stethoscope be
placed?
A) 2nd intercostal space, right sternal border
B) 4th intercostal space, left sternal border
C) 5th intercostal space, left midclavicular line
D) 5th intercostal space, right midclavicular line
Correct Answer: C
Rationale: The apical pulse (point of maximal impulse – PMI) is located at the 5th intercostal
space at the left midclavicular line.
,Question 7
Which of the following patients is at highest risk for a fall?
A) A 25-year-old male with a sprained ankle
B) A 70-year-old female with a history of falls and taking antihypertensives
C) A 40-year-old male with a cold
D) A 30-year-old female post-cesarean section
Correct Answer: B
Rationale: Older age, history of falls, and antihypertensive medications (which can cause
orthostatic hypotension) increase fall risk.
Question 8
The nurse is applying a restraint to a patient. How often must the patient be assessed?
A) Every 30 minutes
B) Every 1 hour
C) Every 2 hours (for skin integrity, circulation, and needs)
D) Every 4 hours
Correct Answer: C
Rationale: Patients in restraints require assessment at least every 2 hours for skin integrity,
circulation, nutrition, hydration, and elimination needs.
Question 9
A patient with an indwelling urinary catheter has cloudy, foul-smelling urine. What is the priority
action?
A) Irrigate the catheter
B) Notify the provider (possible urinary tract infection)
C) Increase fluid intake
D) Change the catheter immediately
Correct Answer: B
Rationale: Cloudy, foul-smelling urine suggests a urinary tract infection. The provider should be
notified for possible urine culture and antibiotic therapy.
Question 10
, Which of the following is a sign of a pressure injury (bed sore)?
A) Pallor
B) Non-blanchable erythema (redness that does not turn white when pressed)
C) Jaundice
D) Cyanosis
Correct Answer: B
Rationale: Non-blanchable erythema is an early sign of a pressure injury (Stage 1). Pallor,
jaundice, and cyanosis are not pressure injury indicators.
Question 11
The nurse is educating a patient about a low-sodium diet. Which food should the patient avoid?
A) Fresh chicken breast
B) Canned soup
C) Apples
D) Brown rice
Correct Answer: B
Rationale: Canned soups are high in sodium. Fresh chicken, apples, and brown rice are
naturally low in sodium.
Question 12
What is the correct order for removing personal protective equipment (PPE)?
A) Gloves, gown, mask, goggles
B) Mask, goggles, gown, gloves
C) Gown, gloves, mask, goggles
D) Gloves, goggles, gown, mask
Correct Answer: A
Rationale: Remove PPE in order: gloves (most contaminated first), then gown, then
mask/respirator, then goggles/face shield (if not attached to mask).
Question 13
A nurse is performing a sterile dressing change. Which action would contaminate the sterile
field?
A) Opening the sterile package away from the body
B) Reaching over the sterile field
C) Keeping the sterile field above waist level
