NR 224 Fundamentals of Nursing - Week 4 Study Guide 2026
|Chamberlain College
1. Which site is considered the most accurate for measuring a patient’s core
body temperature?
A. Axillary
B. Rectal
C. Oral
D. Temporal artery
Answer: B
Rationale: Rectal temperatures are considered the gold standard for core temperature
measurement because they are least affected by environmental factors.
2. When assessing a patient’s blood pressure, the nurse uses a cuff that is too
narrow for the patient’s arm. What effect will this have on the reading?
A. The reading will be unaffected
B. The reading will be falsely low
C. The reading will be falsely high
D. The diastolic reading will be low and systolic high
Answer: C
Rationale: A cuff that is too small or narrow results in a falsely high blood pressure
reading because it requires more pressure to occlude the artery.
,3. A nurse is caring for a patient with a respiratory rate of 24 breaths per
minute. Which term should the nurse use to document this finding?
A. Bradypnea
B. Eupnea
C. Apnea
D. Tachypnea
Answer: D
Rationale: Tachypnea is defined as a respiratory rate greater than 20 breaths per minute
in an adult.
4. The nurse is assessing a client’s radial pulse and notes that the rhythm is
irregular. What is the next appropriate action by the nurse?
A. Assess the apical pulse for one full minute
B. Document the finding and continue the assessment
C. Wait 10 minutes and retake the radial pulse
D. Notify the healthcare provider immediately
Answer: A
Rationale: If a peripheral pulse is irregular, the nurse should assess the apical pulse for a
full 60 seconds to obtain an accurate heart rate and rhythm.
5. A patient’s blood pressure is 140/90 mmHg. What is the pulse pressure for
this patient?
A. 140 mmHg
B. 90 mmHg
C. 50 mmHg
D. 230 mmHg
Answer: C
Rationale: Pulse pressure is the difference between the systolic and diastolic blood
pressure (140 - 90 = 50).
, 6. Which of the following patients is at the highest risk for orthostatic
hypotension?
A. A 25-year-old athlete
B. A pregnant woman in her first trimester
C. A patient with a high sodium diet
D. A patient on prolonged bed rest
Answer: D
Rationale: Prolonged bed rest leads to decreased vascular tone, making the patient more
susceptible to a drop in blood pressure when changing positions.
7. The nurse is preparing to measure a patient’s oxygen saturation using a pulse
oximeter. Which factor could lead to an inaccurate low reading?
A. Increased hemoglobin levels
B. Hypertension
C. Fever
D. Dark fingernail polish
Answer: D
Rationale: Dark nail polish can interfere with the light transmission of the pulse oximeter
sensor, leading to an inaccurate or low reading.
8. What is the first step the nurse should take when a fire is discovered in a
patient’s room?
A. Rescue and remove the patient
B. Extinguish the fire
C. Activate the fire alarm
D. Close the door to confine the fire
Answer: A
Rationale: Following the RACE acronym (Rescue, Alarm, Confine, Extinguish), the priority
is always to rescue and protect patients in immediate danger.
|Chamberlain College
1. Which site is considered the most accurate for measuring a patient’s core
body temperature?
A. Axillary
B. Rectal
C. Oral
D. Temporal artery
Answer: B
Rationale: Rectal temperatures are considered the gold standard for core temperature
measurement because they are least affected by environmental factors.
2. When assessing a patient’s blood pressure, the nurse uses a cuff that is too
narrow for the patient’s arm. What effect will this have on the reading?
A. The reading will be unaffected
B. The reading will be falsely low
C. The reading will be falsely high
D. The diastolic reading will be low and systolic high
Answer: C
Rationale: A cuff that is too small or narrow results in a falsely high blood pressure
reading because it requires more pressure to occlude the artery.
,3. A nurse is caring for a patient with a respiratory rate of 24 breaths per
minute. Which term should the nurse use to document this finding?
A. Bradypnea
B. Eupnea
C. Apnea
D. Tachypnea
Answer: D
Rationale: Tachypnea is defined as a respiratory rate greater than 20 breaths per minute
in an adult.
4. The nurse is assessing a client’s radial pulse and notes that the rhythm is
irregular. What is the next appropriate action by the nurse?
A. Assess the apical pulse for one full minute
B. Document the finding and continue the assessment
C. Wait 10 minutes and retake the radial pulse
D. Notify the healthcare provider immediately
Answer: A
Rationale: If a peripheral pulse is irregular, the nurse should assess the apical pulse for a
full 60 seconds to obtain an accurate heart rate and rhythm.
5. A patient’s blood pressure is 140/90 mmHg. What is the pulse pressure for
this patient?
A. 140 mmHg
B. 90 mmHg
C. 50 mmHg
D. 230 mmHg
Answer: C
Rationale: Pulse pressure is the difference between the systolic and diastolic blood
pressure (140 - 90 = 50).
, 6. Which of the following patients is at the highest risk for orthostatic
hypotension?
A. A 25-year-old athlete
B. A pregnant woman in her first trimester
C. A patient with a high sodium diet
D. A patient on prolonged bed rest
Answer: D
Rationale: Prolonged bed rest leads to decreased vascular tone, making the patient more
susceptible to a drop in blood pressure when changing positions.
7. The nurse is preparing to measure a patient’s oxygen saturation using a pulse
oximeter. Which factor could lead to an inaccurate low reading?
A. Increased hemoglobin levels
B. Hypertension
C. Fever
D. Dark fingernail polish
Answer: D
Rationale: Dark nail polish can interfere with the light transmission of the pulse oximeter
sensor, leading to an inaccurate or low reading.
8. What is the first step the nurse should take when a fire is discovered in a
patient’s room?
A. Rescue and remove the patient
B. Extinguish the fire
C. Activate the fire alarm
D. Close the door to confine the fire
Answer: A
Rationale: Following the RACE acronym (Rescue, Alarm, Confine, Extinguish), the priority
is always to rescue and protect patients in immediate danger.
