NURS 103: Vital Signs & Basic Assessment Skills (2026/2027 Update)
WCU
1. When assessing a patient’s blood pressure, the nurse notes that the cuff used
is too narrow for the patient’s arm circumference. Which result should the
nurse expect?
A. The blood pressure reading will be falsely low.
B. The diastolic reading will be accurate, but the systolic will be low.
C. The blood pressure reading will be falsely high.
D. The reading will be unaffected by the cuff size.
Answer: C
Rationale: A cuff that is too narrow or small for the arm prevents the even distribution of
pressure, requiring more pressure to occlude the artery, resulting in a false-high reading.
2. A nurse is measuring a pulse deficit on a patient with atrial fibrillation. Which
technique is correct?
A. One nurse measures the apical pulse for 15 seconds and the radial pulse for 15 seconds.
B. One nurse measures the radial pulse for 30 seconds and doubles it, then does the same for the apical.
C. Two nurses measure the apical and radial pulses simultaneously for 60 seconds.
D. Two nurses measure the carotid and radial pulses simultaneously for 30 seconds.
Answer: C
Rationale: To accurately determine a pulse deficit, two clinicians must count the apical and
radial pulses simultaneously for one full minute. The difference between the apical and
radial rates is the deficit.
,3. Which physiological mechanism is primarily responsible for the heat
production in the body?
A. Evaporation from the skin surface.
B. Decreased muscle activity.
C. Vasodilation of peripheral blood vessels.
D. Basal metabolic rate (BMR).
Answer: D
Rationale: The basal metabolic rate (BMR) is the primary source of heat production in the
body, representing the energy required to maintain essential physiological functions at
rest.
4. A patient has a respiratory rate of 28 breaths per minute, and the breaths are
shallow. How should the nurse 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, often characterized by rapid, shallow breathing.
5. The nurse is assessing the temperature of a 4-year-old child using a tympanic
thermometer. How should the nurse position the ear?
A. Pull the pinna up and back.
B. Push the tragus forward.
C. Pull the pinna straight back.
D. Pull the pinna down and back.
Answer: D
, Rationale: For children under 3 years of age, the pinna is pulled down and back. For adults
and children older than 3, it is pulled up and back to straighten the ear canal.
6. Which part of the brain acts as the body’s ‘thermostat’ to regulate
temperature?
A. Hypothalamus
B. Thalamus
C. Medulla oblongata
D. Cerebellum
Answer: A
Rationale: The hypothalamus regulates body temperature by sensing changes in blood
temperature and receiving input from thermoreceptors in the skin.
7. A nurse is performing a physical assessment and uses the dorsum (back) of
the hand. Which characteristic is the nurse primarily assessing?
A. Skin moisture
B. Presence of edema
C. Skin temperature
D. Vibration or fremitus
Answer: C
Rationale: The dorsum (back) of the hand is the thinnest part of the hand and is most
sensitive to temperature variations.
8. A patient presents with a core body temperature of 105.8°F (41°C). Which
term best describes this condition?
A. Pyrexia
B. Hyperpyrexia
C. Hypothermia
D. Normal febrile state
Answer: B
WCU
1. When assessing a patient’s blood pressure, the nurse notes that the cuff used
is too narrow for the patient’s arm circumference. Which result should the
nurse expect?
A. The blood pressure reading will be falsely low.
B. The diastolic reading will be accurate, but the systolic will be low.
C. The blood pressure reading will be falsely high.
D. The reading will be unaffected by the cuff size.
Answer: C
Rationale: A cuff that is too narrow or small for the arm prevents the even distribution of
pressure, requiring more pressure to occlude the artery, resulting in a false-high reading.
2. A nurse is measuring a pulse deficit on a patient with atrial fibrillation. Which
technique is correct?
A. One nurse measures the apical pulse for 15 seconds and the radial pulse for 15 seconds.
B. One nurse measures the radial pulse for 30 seconds and doubles it, then does the same for the apical.
C. Two nurses measure the apical and radial pulses simultaneously for 60 seconds.
D. Two nurses measure the carotid and radial pulses simultaneously for 30 seconds.
Answer: C
Rationale: To accurately determine a pulse deficit, two clinicians must count the apical and
radial pulses simultaneously for one full minute. The difference between the apical and
radial rates is the deficit.
,3. Which physiological mechanism is primarily responsible for the heat
production in the body?
A. Evaporation from the skin surface.
B. Decreased muscle activity.
C. Vasodilation of peripheral blood vessels.
D. Basal metabolic rate (BMR).
Answer: D
Rationale: The basal metabolic rate (BMR) is the primary source of heat production in the
body, representing the energy required to maintain essential physiological functions at
rest.
4. A patient has a respiratory rate of 28 breaths per minute, and the breaths are
shallow. How should the nurse 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, often characterized by rapid, shallow breathing.
5. The nurse is assessing the temperature of a 4-year-old child using a tympanic
thermometer. How should the nurse position the ear?
A. Pull the pinna up and back.
B. Push the tragus forward.
C. Pull the pinna straight back.
D. Pull the pinna down and back.
Answer: D
, Rationale: For children under 3 years of age, the pinna is pulled down and back. For adults
and children older than 3, it is pulled up and back to straighten the ear canal.
6. Which part of the brain acts as the body’s ‘thermostat’ to regulate
temperature?
A. Hypothalamus
B. Thalamus
C. Medulla oblongata
D. Cerebellum
Answer: A
Rationale: The hypothalamus regulates body temperature by sensing changes in blood
temperature and receiving input from thermoreceptors in the skin.
7. A nurse is performing a physical assessment and uses the dorsum (back) of
the hand. Which characteristic is the nurse primarily assessing?
A. Skin moisture
B. Presence of edema
C. Skin temperature
D. Vibration or fremitus
Answer: C
Rationale: The dorsum (back) of the hand is the thinnest part of the hand and is most
sensitive to temperature variations.
8. A patient presents with a core body temperature of 105.8°F (41°C). Which
term best describes this condition?
A. Pyrexia
B. Hyperpyrexia
C. Hypothermia
D. Normal febrile state
Answer: B
