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NUR155 FOUNDATIONS OF NURSING EXAM 2 ACTUAL
2026/2027 | Grade A | Galen College | Questions & Verified
Answers | Pass Guaranteed - A+ Graded
Section 1: Vital Signs & Physical Assessment (Q1-12)
Q1. A nurse is assessing a patient who had rectal surgery 4 hours ago and needs a
temperature measurement. Which route should the nurse avoid?
A. Oral
B. Axillary
C. Tympanic
D. Rectal [CORRECT]
Rationale: Rectal temperatures are contraindicated after rectal surgery, in patients
with diarrhea, bleeding disorders, or cardiac conditions because they can cause injury
or stimulate the vagus nerve. Oral, axillary, and tympanic routes are safe alternatives.
Correct Answer: D
Q2. A nurse is counting a patient's apical pulse and notes an irregular rhythm. Which
action is most appropriate?
A. Count the radial pulse for 30 seconds and multiply by 2
B. Count the apical pulse for 15 seconds and multiply by 4
C. Count the apical pulse for a full 60 seconds [CORRECT]
D. Count the carotid pulse for 30 seconds
Rationale: An apical pulse with an irregular rhythm must be counted for a full 60
seconds to ensure accuracy; shorter intervals can miss irregular beats. Radial and
carotid pulses are less accurate for irregular rhythms, and 15-second counts are
inappropriate.
Correct Answer: C
Q3. A nurse obtains a blood pressure of 90/58 mmHg in a patient using a cuff that is
too small for the arm. Which statement is accurate?
A. The reading is falsely low
B. The reading is falsely elevated [CORRECT]
,2
C. The cuff size does not affect the reading
D. The reading is accurate and requires no re-assessment
Rationale: A cuff that is too small relative to the arm circumference produces a falsely
elevated blood pressure reading because the bladder must be inflated to a higher
pressure to occlude the brachial artery. A cuff that is too large produces falsely low
readings.
Correct Answer: B
Q4. A nurse is assessing a patient's respiratory rate. Which technique yields the most
accurate measurement?
A. Ask the patient to breathe deeply while watching the chest
B. Count respirations immediately after taking the radial pulse while holding the wrist
[CORRECT]
C. Place a hand on the patient's chest and count for 15 seconds
D. Tell the patient you are counting their breaths and watch for 30 seconds
Rationale: Respiratory rate is most accurately measured when the patient is unaware,
as awareness can alter breathing patterns; counting immediately after taking the
radial pulse while maintaining contact allows covert observation. Asking the patient
to breathe deeply or telling them you are counting will change their natural rate.
Correct Answer: B
Q5. A nurse is assessing pain in a 6-month-old infant who has had surgery. Which
pain assessment tool is most appropriate?
A. Numeric rating scale 0-10
B. Visual analog scale
C. FLACC scale [CORRECT]
D. McGill Pain Questionnaire
Rationale: The FLACC scale (Face, Legs, Activity, Cry, Consolability) is designed for
infants and young children who cannot verbally report pain. Numeric and visual
analog scales require cognitive ability to quantify pain, and the McGill Pain
Questionnaire is used for adults.
Correct Answer: C
Q6. A patient with COPD has a pulse oximetry reading of 88% on room air. Which
factor is most likely contributing to inaccurate SpO2 measurement?
, 3
A. The patient is breathing slowly
B. The patient has poor peripheral perfusion or nail polish [CORRECT]
C. The patient is hyperventilating
D. The probe is placed on the earlobe
Rationale: Pulse oximetry accuracy is affected by poor peripheral perfusion, nail
polish, artificial nails, dark skin pigment, carbon monoxide, and motion artifact. Slow
breathing and hyperventilation do not directly affect oximetry accuracy, and earlobe
placement is a valid alternative site.
Correct Answer: B
Q7. A nurse is caring for four patients. Using Maslow's hierarchy and the ABC
framework, which patient should the nurse assess first?
A. A patient requesting a warm blanket for comfort
B. A patient who needs assistance filling out a menu
C. A patient with a respiratory rate of 8 and oxygen saturation of 82% [CORRECT]
D. A patient asking for discharge paperwork
Rationale: The ABC framework and Maslow's hierarchy prioritize physiologic needs
(airway, breathing, circulation) over safety, love/belonging, esteem, and self-
actualization; a respiratory rate of 8 with SpO2 of 82% indicates life-threatening
respiratory compromise requiring immediate assessment.
Correct Answer: C
Q8. A nurse is caring for four patients. Which vital sign finding requires the nurse's
immediate attention?
A. A patient with a blood pressure of 118/76 mmHg
B. A patient with an oral temperature of 37.0°C (98.6°F)
C. A patient with a respiratory rate of 6 and pinpoint pupils [CORRECT]
D. A patient with an apical pulse of 82 beats per minute
Rationale: A respiratory rate of 6 with pinpoint pupils indicates possible opioid-
induced respiratory depression and impending respiratory arrest, requiring
immediate assessment and intervention. The other vital signs are within normal limits
and are not life-threatening.
Correct Answer: C
NUR155 FOUNDATIONS OF NURSING EXAM 2 ACTUAL
2026/2027 | Grade A | Galen College | Questions & Verified
Answers | Pass Guaranteed - A+ Graded
Section 1: Vital Signs & Physical Assessment (Q1-12)
Q1. A nurse is assessing a patient who had rectal surgery 4 hours ago and needs a
temperature measurement. Which route should the nurse avoid?
A. Oral
B. Axillary
C. Tympanic
D. Rectal [CORRECT]
Rationale: Rectal temperatures are contraindicated after rectal surgery, in patients
with diarrhea, bleeding disorders, or cardiac conditions because they can cause injury
or stimulate the vagus nerve. Oral, axillary, and tympanic routes are safe alternatives.
Correct Answer: D
Q2. A nurse is counting a patient's apical pulse and notes an irregular rhythm. Which
action is most appropriate?
A. Count the radial pulse for 30 seconds and multiply by 2
B. Count the apical pulse for 15 seconds and multiply by 4
C. Count the apical pulse for a full 60 seconds [CORRECT]
D. Count the carotid pulse for 30 seconds
Rationale: An apical pulse with an irregular rhythm must be counted for a full 60
seconds to ensure accuracy; shorter intervals can miss irregular beats. Radial and
carotid pulses are less accurate for irregular rhythms, and 15-second counts are
inappropriate.
Correct Answer: C
Q3. A nurse obtains a blood pressure of 90/58 mmHg in a patient using a cuff that is
too small for the arm. Which statement is accurate?
A. The reading is falsely low
B. The reading is falsely elevated [CORRECT]
,2
C. The cuff size does not affect the reading
D. The reading is accurate and requires no re-assessment
Rationale: A cuff that is too small relative to the arm circumference produces a falsely
elevated blood pressure reading because the bladder must be inflated to a higher
pressure to occlude the brachial artery. A cuff that is too large produces falsely low
readings.
Correct Answer: B
Q4. A nurse is assessing a patient's respiratory rate. Which technique yields the most
accurate measurement?
A. Ask the patient to breathe deeply while watching the chest
B. Count respirations immediately after taking the radial pulse while holding the wrist
[CORRECT]
C. Place a hand on the patient's chest and count for 15 seconds
D. Tell the patient you are counting their breaths and watch for 30 seconds
Rationale: Respiratory rate is most accurately measured when the patient is unaware,
as awareness can alter breathing patterns; counting immediately after taking the
radial pulse while maintaining contact allows covert observation. Asking the patient
to breathe deeply or telling them you are counting will change their natural rate.
Correct Answer: B
Q5. A nurse is assessing pain in a 6-month-old infant who has had surgery. Which
pain assessment tool is most appropriate?
A. Numeric rating scale 0-10
B. Visual analog scale
C. FLACC scale [CORRECT]
D. McGill Pain Questionnaire
Rationale: The FLACC scale (Face, Legs, Activity, Cry, Consolability) is designed for
infants and young children who cannot verbally report pain. Numeric and visual
analog scales require cognitive ability to quantify pain, and the McGill Pain
Questionnaire is used for adults.
Correct Answer: C
Q6. A patient with COPD has a pulse oximetry reading of 88% on room air. Which
factor is most likely contributing to inaccurate SpO2 measurement?
, 3
A. The patient is breathing slowly
B. The patient has poor peripheral perfusion or nail polish [CORRECT]
C. The patient is hyperventilating
D. The probe is placed on the earlobe
Rationale: Pulse oximetry accuracy is affected by poor peripheral perfusion, nail
polish, artificial nails, dark skin pigment, carbon monoxide, and motion artifact. Slow
breathing and hyperventilation do not directly affect oximetry accuracy, and earlobe
placement is a valid alternative site.
Correct Answer: B
Q7. A nurse is caring for four patients. Using Maslow's hierarchy and the ABC
framework, which patient should the nurse assess first?
A. A patient requesting a warm blanket for comfort
B. A patient who needs assistance filling out a menu
C. A patient with a respiratory rate of 8 and oxygen saturation of 82% [CORRECT]
D. A patient asking for discharge paperwork
Rationale: The ABC framework and Maslow's hierarchy prioritize physiologic needs
(airway, breathing, circulation) over safety, love/belonging, esteem, and self-
actualization; a respiratory rate of 8 with SpO2 of 82% indicates life-threatening
respiratory compromise requiring immediate assessment.
Correct Answer: C
Q8. A nurse is caring for four patients. Which vital sign finding requires the nurse's
immediate attention?
A. A patient with a blood pressure of 118/76 mmHg
B. A patient with an oral temperature of 37.0°C (98.6°F)
C. A patient with a respiratory rate of 6 and pinpoint pupils [CORRECT]
D. A patient with an apical pulse of 82 beats per minute
Rationale: A respiratory rate of 6 with pinpoint pupils indicates possible opioid-
induced respiratory depression and impending respiratory arrest, requiring
immediate assessment and intervention. The other vital signs are within normal limits
and are not life-threatening.
Correct Answer: C
