BSN 205 UPDATED 2026 EXAM SCRIPT QUESTIONS AND
SOLUTIONS SCORED A+
✔✔thermometers (and corresponding route) would be most accurate for monitoring
rapid changes in core body temperature? - ✔✔Oral electronic thermometer
Temporal artery thermometer
✔✔How far should a rectal thermometer be inserted in an adult? - ✔✔1.5 in (3.8 cm)
✔✔How far should a rectal thermometer be inserted in a child? - ✔✔0.5 in (1.3 cm)
✔✔In what direction should the nurse pull the pinna of the adult when taking a tympanic
temperature? - ✔✔Backward, up, and out
✔✔At the end of the clinical day, the nursing instructor notices that a student nurse has
documented a resident having a temperature of 99.8° F (37.7° C) and that the student
administered a flu shot. What should the student nurse have done? - ✔✔Held the flu
vaccine; notify supervisor or instructor of increase in temperature.
✔✔A temperature reading obtained at noon will likely be ________ the 6 PM reading. -
✔✔lower than
✔✔Because older adults often maintain a ________ body temperature, a temperature
within an acceptable range in an adult may reflect a fever in an older adult. - ✔✔lower
✔✔A young adult has been admitted to the hospital with a fever of unknown origin.
Intravenous (IV) fluids have been started, and the patient is feeling much better. You
are going to take the patient's temperature. Which of the following would be the best
thermometer selection? - ✔✔An electronic thermometer with a blue probe end
✔✔The patient's temperature is 102.2 ºF (39 ºC). What action should you take? -
✔✔Administer an antipyretic as ordered.
✔✔Before taking the patient's temperature, the patient tells you they just drank some
ice water. What is your best action? - ✔✔Request that the patient refrain from eating or
drinking until you return in 20 minutes to assess their oral temperature
✔✔The skill of radial pulse measurement can or can not be delegated to NAP. - ✔✔can
✔✔If the patient is to receive a medication that requires an apical pulse before
administration, it should or should not be delegated to NAP. - ✔✔should not
,✔✔NAP should be instructed to report any abnormalities that should be ________ by
the nurse. - ✔✔confirmed
✔✔You enter the patient's room to take routine vital signs. You see that the patient has
just finished exercising with physical therapy. What is your best action? - ✔✔Wait 5 to
10 minutes before assessing the pulse.
✔✔When measuring an irregular radial pulse, you must: - ✔✔Consider reassessing the
patient using the apical site.
Count the rate over 60 seconds/1 full minute.
✔✔2nd right ICS - ✔✔aortic valve area
✔✔2nd left ICS - ✔✔pulmonic valve area
✔✔3rd left ICS - ✔✔Erb's point
✔✔Left lower sternal border - ✔✔tricuspid valve area
✔✔5th ICS/left MCL - ✔✔PMI point of maximal impulse
✔✔A patient has an irregular, thready pulse. You decide to have a nursing assistant
help you obtain the pulse deficit. You auscultate the apical pulse while the NAP
measures the radial pulse simultaneously. The results are: apical pulse 88, radial pulse
74. The pulse deficit is? - ✔✔14
✔✔The student nurse caring for an elderly patient with heart failure determines the
patient's pulse is irregular. The student asks a peer to help determine whether there is a
pulse deficit. The student who took the apical pulse obtained a rate of 56 and irregular.
The student who took the radial pulse obtained a rate of 72 and irregular. How could
this best be explained? - ✔✔There was an error made in obtaining the pulse rates. It
would be impossible to have a faster rate at the radial site than at the apical site;
therefore, an error must have occurred.
✔✔The students locate the point of maximal impulse and reassess the patient's apical
pulse before administering a cardiac medication. They agree the patient's pulse is
irregular. How should the apical pulse be measured? - ✔✔Take the patient's apical
pulse for 1 full minute.
✔✔Where will you best be able to auscultate the patient's apical pulse? - ✔✔The 5th
ICS/left MCL
✔✔Diffusion - ✔✔movement of O2 and CO2 between the alveoli and the red blood
cells.
, ✔✔Ventilation - ✔✔mechanical movement of gases into and out of the lungs.
✔✔Perfusion - ✔✔distribution of red blood cells to and from the pulmonary capillaries.
✔✔Hemoglobin (males) - ✔✔14-18 g/dL
✔✔pH - ✔✔7.35-7.45
✔✔Hemoglobin (females) - ✔✔12-16 g/dL
✔✔PaCO2 - ✔✔35-45 mmHg
✔✔________ pressure is the minimal pressure exerted against the arterial wall at all
times. - ✔✔Diastolic
✔✔________ pressure is the peak pressure that occurs during contraction of the heart's
ventricles. - ✔✔Systolic
✔✔The difference between systolic and diastolic pressure is called the ________ -
✔✔pulse pressure
✔✔T/F Hypertension is having a BP of greater than 140/90 mm Hg on two separate
occasions. - ✔✔True
✔✔T/F A diagnosis of hypertension can be made on one reading if the BP is
significantly elevated above 140/90. - ✔✔False
✔✔T/F Hypotension is generally considered present when the SBP falls to 100 mm Hg
or below. - ✔✔False, its below 90
✔✔T/F If you are unable to roll up the patient's sleeve far enough, you may place your
stethoscope over clothing to assess blood pressure. - ✔✔False
✔✔When would you expect the patient's BP to be lowest? - ✔✔In the early morning
✔✔Why might a child's respirations be shallow? - ✔✔acute pain
✔✔An 80-year-old patient with rheumatoid arthritis is being admitted for a procedure
where injections will be placed in her back to relieve pain. She reports having fallen less
than 1 year ago on icy steps to her house. She is alert and oriented and occasionally
uses a cane. She has never smoked, but takes an antihypertensive medication for her
blood pressure. Is this patient at risk for a fall? Yes or no? - ✔✔Yes
SOLUTIONS SCORED A+
✔✔thermometers (and corresponding route) would be most accurate for monitoring
rapid changes in core body temperature? - ✔✔Oral electronic thermometer
Temporal artery thermometer
✔✔How far should a rectal thermometer be inserted in an adult? - ✔✔1.5 in (3.8 cm)
✔✔How far should a rectal thermometer be inserted in a child? - ✔✔0.5 in (1.3 cm)
✔✔In what direction should the nurse pull the pinna of the adult when taking a tympanic
temperature? - ✔✔Backward, up, and out
✔✔At the end of the clinical day, the nursing instructor notices that a student nurse has
documented a resident having a temperature of 99.8° F (37.7° C) and that the student
administered a flu shot. What should the student nurse have done? - ✔✔Held the flu
vaccine; notify supervisor or instructor of increase in temperature.
✔✔A temperature reading obtained at noon will likely be ________ the 6 PM reading. -
✔✔lower than
✔✔Because older adults often maintain a ________ body temperature, a temperature
within an acceptable range in an adult may reflect a fever in an older adult. - ✔✔lower
✔✔A young adult has been admitted to the hospital with a fever of unknown origin.
Intravenous (IV) fluids have been started, and the patient is feeling much better. You
are going to take the patient's temperature. Which of the following would be the best
thermometer selection? - ✔✔An electronic thermometer with a blue probe end
✔✔The patient's temperature is 102.2 ºF (39 ºC). What action should you take? -
✔✔Administer an antipyretic as ordered.
✔✔Before taking the patient's temperature, the patient tells you they just drank some
ice water. What is your best action? - ✔✔Request that the patient refrain from eating or
drinking until you return in 20 minutes to assess their oral temperature
✔✔The skill of radial pulse measurement can or can not be delegated to NAP. - ✔✔can
✔✔If the patient is to receive a medication that requires an apical pulse before
administration, it should or should not be delegated to NAP. - ✔✔should not
,✔✔NAP should be instructed to report any abnormalities that should be ________ by
the nurse. - ✔✔confirmed
✔✔You enter the patient's room to take routine vital signs. You see that the patient has
just finished exercising with physical therapy. What is your best action? - ✔✔Wait 5 to
10 minutes before assessing the pulse.
✔✔When measuring an irregular radial pulse, you must: - ✔✔Consider reassessing the
patient using the apical site.
Count the rate over 60 seconds/1 full minute.
✔✔2nd right ICS - ✔✔aortic valve area
✔✔2nd left ICS - ✔✔pulmonic valve area
✔✔3rd left ICS - ✔✔Erb's point
✔✔Left lower sternal border - ✔✔tricuspid valve area
✔✔5th ICS/left MCL - ✔✔PMI point of maximal impulse
✔✔A patient has an irregular, thready pulse. You decide to have a nursing assistant
help you obtain the pulse deficit. You auscultate the apical pulse while the NAP
measures the radial pulse simultaneously. The results are: apical pulse 88, radial pulse
74. The pulse deficit is? - ✔✔14
✔✔The student nurse caring for an elderly patient with heart failure determines the
patient's pulse is irregular. The student asks a peer to help determine whether there is a
pulse deficit. The student who took the apical pulse obtained a rate of 56 and irregular.
The student who took the radial pulse obtained a rate of 72 and irregular. How could
this best be explained? - ✔✔There was an error made in obtaining the pulse rates. It
would be impossible to have a faster rate at the radial site than at the apical site;
therefore, an error must have occurred.
✔✔The students locate the point of maximal impulse and reassess the patient's apical
pulse before administering a cardiac medication. They agree the patient's pulse is
irregular. How should the apical pulse be measured? - ✔✔Take the patient's apical
pulse for 1 full minute.
✔✔Where will you best be able to auscultate the patient's apical pulse? - ✔✔The 5th
ICS/left MCL
✔✔Diffusion - ✔✔movement of O2 and CO2 between the alveoli and the red blood
cells.
, ✔✔Ventilation - ✔✔mechanical movement of gases into and out of the lungs.
✔✔Perfusion - ✔✔distribution of red blood cells to and from the pulmonary capillaries.
✔✔Hemoglobin (males) - ✔✔14-18 g/dL
✔✔pH - ✔✔7.35-7.45
✔✔Hemoglobin (females) - ✔✔12-16 g/dL
✔✔PaCO2 - ✔✔35-45 mmHg
✔✔________ pressure is the minimal pressure exerted against the arterial wall at all
times. - ✔✔Diastolic
✔✔________ pressure is the peak pressure that occurs during contraction of the heart's
ventricles. - ✔✔Systolic
✔✔The difference between systolic and diastolic pressure is called the ________ -
✔✔pulse pressure
✔✔T/F Hypertension is having a BP of greater than 140/90 mm Hg on two separate
occasions. - ✔✔True
✔✔T/F A diagnosis of hypertension can be made on one reading if the BP is
significantly elevated above 140/90. - ✔✔False
✔✔T/F Hypotension is generally considered present when the SBP falls to 100 mm Hg
or below. - ✔✔False, its below 90
✔✔T/F If you are unable to roll up the patient's sleeve far enough, you may place your
stethoscope over clothing to assess blood pressure. - ✔✔False
✔✔When would you expect the patient's BP to be lowest? - ✔✔In the early morning
✔✔Why might a child's respirations be shallow? - ✔✔acute pain
✔✔An 80-year-old patient with rheumatoid arthritis is being admitted for a procedure
where injections will be placed in her back to relieve pain. She reports having fallen less
than 1 year ago on icy steps to her house. She is alert and oriented and occasionally
uses a cane. She has never smoked, but takes an antihypertensive medication for her
blood pressure. Is this patient at risk for a fall? Yes or no? - ✔✔Yes
