NR224 WEEK 2 EXAM: FUNDAMENTALS
OF VITAL SIGNS AND NURSING
PROCESS
1. A nurse is assessing a patient with a history of cardiac arrhythmia. Which method is most
accurate for determining the patient’s heart rate?
A. Palpating the radial pulse for 30 seconds and multiplying by two.
B. Using a pulse oximeter to monitor the peripheral pulse rate.
C. Auscultating the apical pulse for one full minute.
D. Palpating the carotid pulse for 15 seconds and multiplying by four.
Answer: C
Conceptual Explanation: For patients with irregular heart rhythms, an apical pulse must
be auscultated for a full 60 seconds to ensure accuracy, as peripheral pulses may not reflect
every ventricular contraction.
2. When assessing a patient for orthostatic hypotension, which finding would indicate a
positive result?
A. A decrease in systolic BP by 10 mmHg and an increase in heart rate by 5 bpm.
,B. An increase in diastolic BP by 5 mmHg upon standing.
C. A decrease in systolic BP of 20 mmHg or a decrease in diastolic BP of 10 mmHg within 3
minutes of standing.
D. A consistent blood pressure reading in both sitting and standing positions.
Answer: C
Conceptual Explanation: Orthostatic hypotension is defined as a drop in systolic BP of at
least 20 mmHg or a drop in diastolic BP of at least 10 mmHg when moving from a supine to
a standing position.
3. A nurse is preparing to measure a patient’s blood pressure. If the blood pressure cuff used
is too narrow for the patient’s arm, how will the reading be affected?
A. The blood pressure reading will be falsely low.
B. The systolic reading will be accurate, but the diastolic will be low.
C. The cuff size does not significantly impact the accuracy of the reading.
D. The blood pressure reading will be falsely high.
Answer: D
Conceptual Explanation: A cuff that is too small or too narrow will result in a falsely high
blood pressure reading because it requires more pressure to occlude the artery.
, 4. During a physical assessment, the nurse notes the patient is using accessory muscles to
breathe and has a respiratory rate of 28 breaths per minute. Which term best describes this
finding?
A. Tachypnea
B. Bradypnea
C. Eupnea
D. Apnea
Answer: A
Conceptual Explanation: Tachypnea is defined as a respiratory rate greater than 20
breaths per minute in an adult. The use of accessory muscles further indicates respiratory
distress.
5. A patient’s oral temperature is 102.2°F (39°C). Which phase of the fever is characterized by
shivering and the patient feeling cold?
A. The plateau phase
B. The flush phase
C. The chill phase (onset)
D. The crisis phase
Answer: C
OF VITAL SIGNS AND NURSING
PROCESS
1. A nurse is assessing a patient with a history of cardiac arrhythmia. Which method is most
accurate for determining the patient’s heart rate?
A. Palpating the radial pulse for 30 seconds and multiplying by two.
B. Using a pulse oximeter to monitor the peripheral pulse rate.
C. Auscultating the apical pulse for one full minute.
D. Palpating the carotid pulse for 15 seconds and multiplying by four.
Answer: C
Conceptual Explanation: For patients with irregular heart rhythms, an apical pulse must
be auscultated for a full 60 seconds to ensure accuracy, as peripheral pulses may not reflect
every ventricular contraction.
2. When assessing a patient for orthostatic hypotension, which finding would indicate a
positive result?
A. A decrease in systolic BP by 10 mmHg and an increase in heart rate by 5 bpm.
,B. An increase in diastolic BP by 5 mmHg upon standing.
C. A decrease in systolic BP of 20 mmHg or a decrease in diastolic BP of 10 mmHg within 3
minutes of standing.
D. A consistent blood pressure reading in both sitting and standing positions.
Answer: C
Conceptual Explanation: Orthostatic hypotension is defined as a drop in systolic BP of at
least 20 mmHg or a drop in diastolic BP of at least 10 mmHg when moving from a supine to
a standing position.
3. A nurse is preparing to measure a patient’s blood pressure. If the blood pressure cuff used
is too narrow for the patient’s arm, how will the reading be affected?
A. The blood pressure reading will be falsely low.
B. The systolic reading will be accurate, but the diastolic will be low.
C. The cuff size does not significantly impact the accuracy of the reading.
D. The blood pressure reading will be falsely high.
Answer: D
Conceptual Explanation: A cuff that is too small or too narrow will result in a falsely high
blood pressure reading because it requires more pressure to occlude the artery.
, 4. During a physical assessment, the nurse notes the patient is using accessory muscles to
breathe and has a respiratory rate of 28 breaths per minute. Which term best describes this
finding?
A. Tachypnea
B. Bradypnea
C. Eupnea
D. Apnea
Answer: A
Conceptual Explanation: Tachypnea is defined as a respiratory rate greater than 20
breaths per minute in an adult. The use of accessory muscles further indicates respiratory
distress.
5. A patient’s oral temperature is 102.2°F (39°C). Which phase of the fever is characterized by
shivering and the patient feeling cold?
A. The plateau phase
B. The flush phase
C. The chill phase (onset)
D. The crisis phase
Answer: C
