NR 224 Fundamentals of Nursing Week 3 Study Guide 2026
|Chamberlain College
1. When assessing a patient’s blood pressure, the nurse uses a cuff that is too
small for the patient’s arm. What effect will this have on the blood pressure
reading?
A. The reading will be falsely low
B. The reading will be falsely high
C. The reading will be accurate if the patient is supine
D. The diastolic reading will be low and systolic will be high
Answer: B
Rationale: Using a blood pressure cuff that is too small for the patient’s arm circumference
will result in a falsely high reading because the cuff must be inflated more to occlude the
artery.
2. In what order should the nurse perform the physical assessment techniques
for the abdomen?
A. Inspection, Palpation, Percussion, Auscultation
B. Inspection, Auscultation, Percussion, Palpation
C. Palpation, Percussion, Auscultation, Inspection
D. Auscultation, Inspection, Palpation, Percussion
Answer: B
Rationale: For the abdominal assessment, auscultation is performed before percussion
and palpation to prevent the stimulation of bowel sounds, which could lead to an
inaccurate assessment.
,3. The nurse is assessing a patient for orthostatic hypotension. Which finding
would indicate the presence of this condition?
A. A decrease in systolic BP by 10 mmHg when standing
B. An increase in heart rate by 5 beats per minute when sitting up
C. An increase in diastolic BP by 10 mmHg when moving from supine to standing
D. A decrease in systolic BP by 20 mmHg when moving from supine to standing
Answer: D
Rationale: 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 within 3 minutes of standing.
4. Which part of the hand is most sensitive and should be used by the nurse to
assess the patient’s skin temperature?
A. Dorsal surface
B. Fingertips
C. Palmar surface
D. Ulnar surface
Answer: A
Rationale: The dorsal surface (back) of the hand is the thinnest and most sensitive to
temperature variations.
5. A patient has a pulse rate of 120 beats per minute. How should the nurse
document this finding?
A. Bradycardia
B. Eupnea
C. Pulse deficit
D. Tachycardia
Answer: D
Rationale: Tachycardia is defined as an abnormally elevated heart rate, typically above
100 beats per minute in an adult.
, 6. The nurse is calculating a pulse deficit. Which method is correct?
A. Multiply the apical pulse by two
B. Add the radial pulse and the apical pulse together
C. Subtract the carotid pulse from the radial pulse
D. Subtract the radial pulse from the apical pulse
Answer: D
Rationale: A pulse deficit is the difference between the apical pulse and the radial pulse,
indicating that some heart contractions are not reaching the peripheral arteries.
7. While assessing a patient’s respirations, the nurse notes periods of deep
breathing alternating with periods of apnea. This pattern is known as:
A. Kussmaul respirations
B. Bradypnea
C. Tachypnea
D. Cheyne-Stokes respirations
Answer: D
Rationale: Cheyne-Stokes respirations are characterized by a rhythmic increase in rate
and depth followed by a decrease and then a period of apnea.
8. Which assessment finding is considered subjective data?
A. The patient’s blood pressure is 140/90 mmHg
B. The patient complains of a sharp pain in the chest
C. The nurse observes the patient grimacing
D. The patient’s skin is warm and dry to the touch
Answer: B
Rationale: Subjective data are the patient’s verbal descriptions of their health problems,
such as pain levels or feelings.
|Chamberlain College
1. When assessing a patient’s blood pressure, the nurse uses a cuff that is too
small for the patient’s arm. What effect will this have on the blood pressure
reading?
A. The reading will be falsely low
B. The reading will be falsely high
C. The reading will be accurate if the patient is supine
D. The diastolic reading will be low and systolic will be high
Answer: B
Rationale: Using a blood pressure cuff that is too small for the patient’s arm circumference
will result in a falsely high reading because the cuff must be inflated more to occlude the
artery.
2. In what order should the nurse perform the physical assessment techniques
for the abdomen?
A. Inspection, Palpation, Percussion, Auscultation
B. Inspection, Auscultation, Percussion, Palpation
C. Palpation, Percussion, Auscultation, Inspection
D. Auscultation, Inspection, Palpation, Percussion
Answer: B
Rationale: For the abdominal assessment, auscultation is performed before percussion
and palpation to prevent the stimulation of bowel sounds, which could lead to an
inaccurate assessment.
,3. The nurse is assessing a patient for orthostatic hypotension. Which finding
would indicate the presence of this condition?
A. A decrease in systolic BP by 10 mmHg when standing
B. An increase in heart rate by 5 beats per minute when sitting up
C. An increase in diastolic BP by 10 mmHg when moving from supine to standing
D. A decrease in systolic BP by 20 mmHg when moving from supine to standing
Answer: D
Rationale: 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 within 3 minutes of standing.
4. Which part of the hand is most sensitive and should be used by the nurse to
assess the patient’s skin temperature?
A. Dorsal surface
B. Fingertips
C. Palmar surface
D. Ulnar surface
Answer: A
Rationale: The dorsal surface (back) of the hand is the thinnest and most sensitive to
temperature variations.
5. A patient has a pulse rate of 120 beats per minute. How should the nurse
document this finding?
A. Bradycardia
B. Eupnea
C. Pulse deficit
D. Tachycardia
Answer: D
Rationale: Tachycardia is defined as an abnormally elevated heart rate, typically above
100 beats per minute in an adult.
, 6. The nurse is calculating a pulse deficit. Which method is correct?
A. Multiply the apical pulse by two
B. Add the radial pulse and the apical pulse together
C. Subtract the carotid pulse from the radial pulse
D. Subtract the radial pulse from the apical pulse
Answer: D
Rationale: A pulse deficit is the difference between the apical pulse and the radial pulse,
indicating that some heart contractions are not reaching the peripheral arteries.
7. While assessing a patient’s respirations, the nurse notes periods of deep
breathing alternating with periods of apnea. This pattern is known as:
A. Kussmaul respirations
B. Bradypnea
C. Tachypnea
D. Cheyne-Stokes respirations
Answer: D
Rationale: Cheyne-Stokes respirations are characterized by a rhythmic increase in rate
and depth followed by a decrease and then a period of apnea.
8. Which assessment finding is considered subjective data?
A. The patient’s blood pressure is 140/90 mmHg
B. The patient complains of a sharp pain in the chest
C. The nurse observes the patient grimacing
D. The patient’s skin is warm and dry to the touch
Answer: B
Rationale: Subjective data are the patient’s verbal descriptions of their health problems,
such as pain levels or feelings.
