NR224 WEEK 2: FUNDAMENTALS OF
NURSING - PHYSICAL ASSESSMENT
AND VITAL SIGNS
1. When assessing a patient’s blood pressure, the nurse uses a cuff that is too narrow for the
patient’s arm circumference. Which of the following results is most likely to occur?
A. A false-low systolic reading
B. The reading will be unaffected if the patient is supine
C. An accurate reading but a false-low diastolic reading
D. A false-high systolic reading
Answer: D
Conceptual Explanation: If a blood pressure cuff is too small (too narrow) for the
extremity, it will result in a false-high reading because the pressure required to occlude the
artery is overestimated.
2. The nurse is performing a physical assessment on a patient’s abdomen. In which order
should the nurse perform the assessment techniques?
A. Inspection, Auscultation, Percussion, Palpation
,B. Auscultation, Inspection, Palpation, Percussion
C. Inspection, Palpation, Percussion, Auscultation
D. Percussion, Auscultation, Inspection, Palpation
Answer: A
Conceptual Explanation: For abdominal assessment, auscultation is performed before
percussion and palpation to avoid stimulating bowel sounds, which would lead to an
inaccurate assessment.
3. A patient’s radial pulse is found to be irregular. What is the most appropriate action for the
nurse to take next?
A. Assess the carotid pulse for 30 seconds
B. Wait 15 minutes and recheck the radial pulse
C. Document the findings and notify the provider immediately
D. Measure the apical pulse for one full minute
Answer: D
Conceptual Explanation: If a peripheral pulse is irregular, the nurse should assess the
apical pulse for 60 seconds to obtain a more accurate measurement of the heart rate and
rhythm.
, 4. During a respiratory assessment, the nurse notes a patient is breathing at a rate of 8
breaths per minute. This finding is documented as:
A. Tachypnea
B. Eupnea
C. Bradypnea
D. Apnea
Answer: C
Conceptual Explanation: Bradypnea is defined as a regular respiratory rate of less than
12 breaths per minute in an adult.
5. Which part of the hand is most sensitive and should be used by the nurse to assess skin
temperature during palpation?
A. Palmar surface
B. Finger pads
C. Ulnar surface
D. Dorsum (back) of the hand
Answer: D
Conceptual Explanation: The dorsum or back of the hand is the most sensitive area for
assessing temperature because the skin is thinner there than on the palms.
NURSING - PHYSICAL ASSESSMENT
AND VITAL SIGNS
1. When assessing a patient’s blood pressure, the nurse uses a cuff that is too narrow for the
patient’s arm circumference. Which of the following results is most likely to occur?
A. A false-low systolic reading
B. The reading will be unaffected if the patient is supine
C. An accurate reading but a false-low diastolic reading
D. A false-high systolic reading
Answer: D
Conceptual Explanation: If a blood pressure cuff is too small (too narrow) for the
extremity, it will result in a false-high reading because the pressure required to occlude the
artery is overestimated.
2. The nurse is performing a physical assessment on a patient’s abdomen. In which order
should the nurse perform the assessment techniques?
A. Inspection, Auscultation, Percussion, Palpation
,B. Auscultation, Inspection, Palpation, Percussion
C. Inspection, Palpation, Percussion, Auscultation
D. Percussion, Auscultation, Inspection, Palpation
Answer: A
Conceptual Explanation: For abdominal assessment, auscultation is performed before
percussion and palpation to avoid stimulating bowel sounds, which would lead to an
inaccurate assessment.
3. A patient’s radial pulse is found to be irregular. What is the most appropriate action for the
nurse to take next?
A. Assess the carotid pulse for 30 seconds
B. Wait 15 minutes and recheck the radial pulse
C. Document the findings and notify the provider immediately
D. Measure the apical pulse for one full minute
Answer: D
Conceptual Explanation: If a peripheral pulse is irregular, the nurse should assess the
apical pulse for 60 seconds to obtain a more accurate measurement of the heart rate and
rhythm.
, 4. During a respiratory assessment, the nurse notes a patient is breathing at a rate of 8
breaths per minute. This finding is documented as:
A. Tachypnea
B. Eupnea
C. Bradypnea
D. Apnea
Answer: C
Conceptual Explanation: Bradypnea is defined as a regular respiratory rate of less than
12 breaths per minute in an adult.
5. Which part of the hand is most sensitive and should be used by the nurse to assess skin
temperature during palpation?
A. Palmar surface
B. Finger pads
C. Ulnar surface
D. Dorsum (back) of the hand
Answer: D
Conceptual Explanation: The dorsum or back of the hand is the most sensitive area for
assessing temperature because the skin is thinner there than on the palms.
