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NUR 209 Final Exam Medical Surgical
Nursing II Test Bank with Verified
Answers and Detailed Rationales Grade A
1. What is normal blood pressure?
Correct Answer: 120/80
Rationale:
1. Normal blood pressure is defined as less than 120/80 mm Hg.
2. Systolic (top number) is the pressure during ventricular contraction.
3. Diastolic (bottom number) is the pressure during ventricular relaxation.
2. What is normal pulse rate?
Correct Answer: 60-100 beats per minute
Rationale:
1. Normal adult resting heart rate is 60-100 beats per minute.
2. Well-conditioned athletes may have rates as low as 40-60.
3. Bradycardia is <60; tachycardia is >100.
3. What is normal respiratory rate?
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Correct Answer: 12-20 breaths per minute
Rationale:
1. Normal adult respiratory rate is 12-20 breaths per minute.
2. Tachypnea is >20 breaths per minute.
3. Bradypnea is <12 breaths per minute.
4. What is normal body temperature?
Correct Answer: 98.6°F or 37°C
Rationale:
1. Normal core body temperature is approximately 98.6°F (37°C).
2. Normal range is 97°F to 99°F (36.1°C to 37.2°C).
3. Fever is typically >100.4°F (38°C).
5. True or false: Older adults may have a naturally lower body
temperature.
Correct Answer: True
Rationale:
1. Older adults often have baseline temperatures of 95-97°F.
2. This is due to decreased metabolic rate and thermoregulatory efficiency.
3. A "normal" temperature in an older adult may not reach 98.6°F.
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6. What are indications for measuring vital signs?
Correct Answer: Change in health status, before or after
medications/interventions affecting vital signs, transfer to another unit,
routine orders, before or after procedures.
Rationale:
1. Vital signs detect changes in patient condition (deterioration or
improvement).
2. Monitor before and after medications that affect cardiovascular or
respiratory status.
3. Routine vital signs are ordered by frequency (e.g., every 4 hours, daily).
7. True or false: Older adults may not exhibit a fever with infections.
Correct Answer: True
Rationale:
1. Older adults have blunted febrile response due to decreased immune function.
2. Infection may present with confusion, falls, or anorexia instead of fever.
3. A "normal" temperature in an older adult may still indicate infection.
8. What are nursing interventions for fever?
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Correct Answer: Decrease activity, increase fluids, assess skin, measure
intake and output, provide oral hygiene, ensure the patient and their
bed is dry, monitor labs.
Rationale:
1. Decreasing activity reduces metabolic heat production.
2. Increased fluids prevent dehydration from insensible losses.
3. Monitor I&O to assess hydration status.
4. Dry linens and skin prevent chills from evaporative cooling.
9. What are signs of fever?
Correct Answer: Loss of appetite, headache, thirst, flushed face, fatigue,
muscle aches, diaphoresis, chills, increased pulse, increased
respirations.
Rationale:
1. Chills and diaphoresis occur during fever cycles (rigors, flush, defervescence).
2. Tachycardia and tachypnea result from increased metabolic demand.
3. Headache and myalgia are common systemic symptoms.
10. True or false: Any thermometer can be used rectally.
Correct Answer: False
NUR 209 Final Exam Medical Surgical
Nursing II Test Bank with Verified
Answers and Detailed Rationales Grade A
1. What is normal blood pressure?
Correct Answer: 120/80
Rationale:
1. Normal blood pressure is defined as less than 120/80 mm Hg.
2. Systolic (top number) is the pressure during ventricular contraction.
3. Diastolic (bottom number) is the pressure during ventricular relaxation.
2. What is normal pulse rate?
Correct Answer: 60-100 beats per minute
Rationale:
1. Normal adult resting heart rate is 60-100 beats per minute.
2. Well-conditioned athletes may have rates as low as 40-60.
3. Bradycardia is <60; tachycardia is >100.
3. What is normal respiratory rate?
,2|Page
Correct Answer: 12-20 breaths per minute
Rationale:
1. Normal adult respiratory rate is 12-20 breaths per minute.
2. Tachypnea is >20 breaths per minute.
3. Bradypnea is <12 breaths per minute.
4. What is normal body temperature?
Correct Answer: 98.6°F or 37°C
Rationale:
1. Normal core body temperature is approximately 98.6°F (37°C).
2. Normal range is 97°F to 99°F (36.1°C to 37.2°C).
3. Fever is typically >100.4°F (38°C).
5. True or false: Older adults may have a naturally lower body
temperature.
Correct Answer: True
Rationale:
1. Older adults often have baseline temperatures of 95-97°F.
2. This is due to decreased metabolic rate and thermoregulatory efficiency.
3. A "normal" temperature in an older adult may not reach 98.6°F.
,3|Page
6. What are indications for measuring vital signs?
Correct Answer: Change in health status, before or after
medications/interventions affecting vital signs, transfer to another unit,
routine orders, before or after procedures.
Rationale:
1. Vital signs detect changes in patient condition (deterioration or
improvement).
2. Monitor before and after medications that affect cardiovascular or
respiratory status.
3. Routine vital signs are ordered by frequency (e.g., every 4 hours, daily).
7. True or false: Older adults may not exhibit a fever with infections.
Correct Answer: True
Rationale:
1. Older adults have blunted febrile response due to decreased immune function.
2. Infection may present with confusion, falls, or anorexia instead of fever.
3. A "normal" temperature in an older adult may still indicate infection.
8. What are nursing interventions for fever?
, 4|Page
Correct Answer: Decrease activity, increase fluids, assess skin, measure
intake and output, provide oral hygiene, ensure the patient and their
bed is dry, monitor labs.
Rationale:
1. Decreasing activity reduces metabolic heat production.
2. Increased fluids prevent dehydration from insensible losses.
3. Monitor I&O to assess hydration status.
4. Dry linens and skin prevent chills from evaporative cooling.
9. What are signs of fever?
Correct Answer: Loss of appetite, headache, thirst, flushed face, fatigue,
muscle aches, diaphoresis, chills, increased pulse, increased
respirations.
Rationale:
1. Chills and diaphoresis occur during fever cycles (rigors, flush, defervescence).
2. Tachycardia and tachypnea result from increased metabolic demand.
3. Headache and myalgia are common systemic symptoms.
10. True or false: Any thermometer can be used rectally.
Correct Answer: False
