NURS 100 Week 4 Nursing Fundamentals Quiz 2026 |WCU
1. A nurse is measuring the blood pressure of a patient with a very large arm. If
the nurse uses a standard-sized cuff that is too small, how will the reading be
affected?
A. The blood pressure reading will be falsely low.
B. The blood pressure reading will be falsely high.
C. The diastolic pressure will be accurate, but systolic will be low.
D. The reading will be unaffected if the patient is sitting.
Answer: B
Rationale: A cuff that is too narrow or short for the limb will result in a falsely elevated
(high) blood pressure reading because it requires more pressure to occlude the artery.
2. When assessing an apical pulse, where should the nurse place the
stethoscope diaphragm?
A. Second intercostal space at the right sternal border.
B. Second intercostal space at the left sternal border.
C. Fifth intercostal space at the left midclavicular line.
D. Fourth intercostal space at the left midaxillary line.
Answer: C
Rationale: The apical pulse is best auscultated at the point of maximal impulse (PMI),
located at the 5th intercostal space at the midclavicular line.
,3. A patient has a radial pulse of 72 and an apical pulse of 84. What is the
calculated pulse deficit?
A. 156 bpm
B. 6 bpm
C. 12 bpm
D. 24 bpm
Answer: C
Rationale: The pulse deficit is the difference between the apical and radial pulse rates (84 -
72 = 12).
4. A nurse is assessing a patient’s respiratory pattern and notes periods of deep
breathing alternating with periods of apnea. This is documented as:
A. Kussmaul’s respirations
B. Bradypnea
C. Biot’s respirations
D. Cheyne-Stokes respirations
Answer: D
Rationale: Cheyne-Stokes respirations are characterized by a rhythmic increase in depth
followed by a decrease and then a period of apnea.
5. Which finding is an example of objective data?
A. The patient reports feeling dizzy.
B. The patient states their pain is a 5 out of 10.
C. The patient’s skin is warm and dry to the touch.
D. The patient’s spouse says the patient didn’t sleep well.
Answer: C
Rationale: Objective data is observable and measurable by the nurse, such as skin
temperature or physical findings.
, 6. Following a change-of-shift report, which patient should the nurse assess first
using the ABC (Airway, Breathing, Circulation) priority?
A. A patient with a respiratory rate of 28/min and oxygen saturation of 89%.
B. A patient reporting a pain level of 8/10 after abdominal surgery.
C. A patient who needs a dressing change for a clean wound.
D. A patient who has not voided for 6 hours.
Answer: A
Rationale: Respiratory distress and low oxygen saturation take priority over pain, hygiene,
or elimination issues according to the ABC framework.
7. The nurse is performing a physical assessment and uses the back (dorsum) of
the hand. What is the nurse likely assessing?
A. Vibration
B. Temperature
C. Skin turgor
D. Presence of masses
Answer: B
Rationale: The dorsum (back) of the hand is the most sensitive part for detecting skin
temperature.
8. A patient is at high risk for falls. Which intervention is the highest priority?
A. Keep all four side rails up at all times.
B. Turn off the lights so the patient can sleep.
C. Administer a sedative to prevent the patient from getting up.
D. Place the call bell within the patient’s reach.
Answer: D
Rationale: The call bell must always be within reach to allow the patient to ask for help;
using four side rails is often considered a restraint.
1. A nurse is measuring the blood pressure of a patient with a very large arm. If
the nurse uses a standard-sized cuff that is too small, how will the reading be
affected?
A. The blood pressure reading will be falsely low.
B. The blood pressure reading will be falsely high.
C. The diastolic pressure will be accurate, but systolic will be low.
D. The reading will be unaffected if the patient is sitting.
Answer: B
Rationale: A cuff that is too narrow or short for the limb will result in a falsely elevated
(high) blood pressure reading because it requires more pressure to occlude the artery.
2. When assessing an apical pulse, where should the nurse place the
stethoscope diaphragm?
A. Second intercostal space at the right sternal border.
B. Second intercostal space at the left sternal border.
C. Fifth intercostal space at the left midclavicular line.
D. Fourth intercostal space at the left midaxillary line.
Answer: C
Rationale: The apical pulse is best auscultated at the point of maximal impulse (PMI),
located at the 5th intercostal space at the midclavicular line.
,3. A patient has a radial pulse of 72 and an apical pulse of 84. What is the
calculated pulse deficit?
A. 156 bpm
B. 6 bpm
C. 12 bpm
D. 24 bpm
Answer: C
Rationale: The pulse deficit is the difference between the apical and radial pulse rates (84 -
72 = 12).
4. A nurse is assessing a patient’s respiratory pattern and notes periods of deep
breathing alternating with periods of apnea. This is documented as:
A. Kussmaul’s respirations
B. Bradypnea
C. Biot’s respirations
D. Cheyne-Stokes respirations
Answer: D
Rationale: Cheyne-Stokes respirations are characterized by a rhythmic increase in depth
followed by a decrease and then a period of apnea.
5. Which finding is an example of objective data?
A. The patient reports feeling dizzy.
B. The patient states their pain is a 5 out of 10.
C. The patient’s skin is warm and dry to the touch.
D. The patient’s spouse says the patient didn’t sleep well.
Answer: C
Rationale: Objective data is observable and measurable by the nurse, such as skin
temperature or physical findings.
, 6. Following a change-of-shift report, which patient should the nurse assess first
using the ABC (Airway, Breathing, Circulation) priority?
A. A patient with a respiratory rate of 28/min and oxygen saturation of 89%.
B. A patient reporting a pain level of 8/10 after abdominal surgery.
C. A patient who needs a dressing change for a clean wound.
D. A patient who has not voided for 6 hours.
Answer: A
Rationale: Respiratory distress and low oxygen saturation take priority over pain, hygiene,
or elimination issues according to the ABC framework.
7. The nurse is performing a physical assessment and uses the back (dorsum) of
the hand. What is the nurse likely assessing?
A. Vibration
B. Temperature
C. Skin turgor
D. Presence of masses
Answer: B
Rationale: The dorsum (back) of the hand is the most sensitive part for detecting skin
temperature.
8. A patient is at high risk for falls. Which intervention is the highest priority?
A. Keep all four side rails up at all times.
B. Turn off the lights so the patient can sleep.
C. Administer a sedative to prevent the patient from getting up.
D. Place the call bell within the patient’s reach.
Answer: D
Rationale: The call bell must always be within reach to allow the patient to ask for help;
using four side rails is often considered a restraint.
