NU131 EXAM 2 ACTUAL EXAM 2026/2027 |
Complete Q&A with Detailed Rationales |
Nursing and Healthcare I | Verified A+ | Pass
Guaranteed - A+ Graded
Module 1: Vital Signs & General Survey (12 Questions)
Q1: The nurse is assessing an adult patient's blood pressure using a manual cuff. The first Korotkoff
sound appears at 132 mmHg. The sound disappears at 78 mmHg. The nurse should document this
reading as:
A. 132/78 [CORRECT]
B. 78/132
C. 132 with a palpable systolic
D. 140/80 corrected
Correct Answer: A
Rationale: The first Korotkoff sound (phase I) represents systolic blood pressure. The disappearance of
sound (phase V) represents diastolic blood pressure in adults. Accurate BP documentation is critical for
treatment decisions and trending.
Q2: The nurse obtains an oral temperature of 99.8°F (37.7°C) on a patient who reports feeling warm.
The patient's baseline temperature is 98.2°F (36.8°C). What is the most appropriate nursing action?
A. Administer acetaminophen immediately
B. Recheck the temperature rectally for accuracy
C. Document the finding and assess for other signs of infection [CORRECT]
D. Apply a cooling blanket
Correct Answer: C
Rationale: Low-grade fever (99.6–100.3°F oral) may indicate early infection or inflammation. Fever is a
defense mechanism. The nurse should first document and perform a focused assessment before
notifying the provider.
,Q3: A nurse is assessing a 72-year-old patient and notes a radial pulse of 54 beats per minute. The
patient is alert, oriented, and asymptomatic. What is the nurse's priority action?
A. Prepare for emergency cardiac pacing
B. Document the finding and continue monitoring [CORRECT]
C. Administer atropine per standing orders
D. Increase IV fluid rate immediately
Correct Answer: B
Rationale: Bradycardia (pulse <60 bpm) in older adults may be a normal variant if the patient is
asymptomatic. Accurate documentation and ongoing monitoring allow detection of changes that would
require intervention.
Q4: The nurse is counting respirations on a patient who is aware of being observed. To obtain the most
accurate rate, the nurse should:
A. Ask the patient to breathe normally while looking at the chest
B. Count respirations immediately after taking the radial pulse while still holding the wrist [CORRECT]
C. Place a hand on the patient's chest to feel breaths
D. Inform the patient that breathing rate will be counted
Correct Answer: B
Rationale: Patients often alter their breathing pattern when aware it is being assessed. Counting
respirations while appearing to take the pulse minimizes patient awareness and yields a more accurate
rate.
Q5: A nurse obtains a blood pressure of 88/52 mmHg on a patient whose baseline is 124/78 mmHg. The
patient reports dizziness and lightheadedness. What is the priority nursing action?
A. Encourage the patient to stand slowly
B. Place the patient in supine position with legs elevated and notify the provider [CORRECT]
C. Recheck the BP in 30 minutes
D. Administer a prescribed antihypertensive
Correct Answer: B
, Rationale: Hypotension with symptoms indicates inadequate tissue perfusion. The Trendelenburg
position promotes venous return to the heart, and immediate provider notification is required for
potential fluid resuscitation or medication adjustment.
Q6: A patient has an oxygen saturation of 91% on room air. The nurse applies a nasal cannula at 2 L/min,
and after 15 minutes the SpO₂ is 94%. What is the nurse's next best action?
A. Increase oxygen to 4 L/min to achieve 98%
B. Document the response and continue monitoring [CORRECT]
C. Switch to a non-rebreather mask immediately
D. Notify the provider of treatment failure
Correct Answer: B
Rationale: A nasal cannula at 1–6 L/min delivers 24–44% oxygen. An SpO₂ of 94% is within the
acceptable range (≥92%). Documentation of the patient's response validates the intervention and
supports ongoing clinical decision-making.
Q7: The nurse is using a tympanic thermometer on a 3-year-old child. To ensure accuracy, the nurse
should:
A. Pull the pinna straight back and up
B. Pull the pinna straight down and back [CORRECT]
C. Insert the probe deeply into the ear canal
D. Use the same ear for all measurements
Correct Answer: B
Rationale: In children under 3 years, the ear canal runs more horizontally; pulling down and back
straightens the canal. In adults, the pinna is pulled up and back. Proper technique prevents trauma and
ensures accurate readings.
Q8: A patient reports pain rated 8/10 in the right lower quadrant. The nurse observes guarding and
facial grimacing. Which action demonstrates the most accurate pain assessment?
A. Document "patient states pain is 8/10" only
B. Reassess using only a nonverbal pain scale
C. Document the numeric rating, location, quality, and observed behaviors [CORRECT]
D. Ask the patient to rate pain again after distraction
Complete Q&A with Detailed Rationales |
Nursing and Healthcare I | Verified A+ | Pass
Guaranteed - A+ Graded
Module 1: Vital Signs & General Survey (12 Questions)
Q1: The nurse is assessing an adult patient's blood pressure using a manual cuff. The first Korotkoff
sound appears at 132 mmHg. The sound disappears at 78 mmHg. The nurse should document this
reading as:
A. 132/78 [CORRECT]
B. 78/132
C. 132 with a palpable systolic
D. 140/80 corrected
Correct Answer: A
Rationale: The first Korotkoff sound (phase I) represents systolic blood pressure. The disappearance of
sound (phase V) represents diastolic blood pressure in adults. Accurate BP documentation is critical for
treatment decisions and trending.
Q2: The nurse obtains an oral temperature of 99.8°F (37.7°C) on a patient who reports feeling warm.
The patient's baseline temperature is 98.2°F (36.8°C). What is the most appropriate nursing action?
A. Administer acetaminophen immediately
B. Recheck the temperature rectally for accuracy
C. Document the finding and assess for other signs of infection [CORRECT]
D. Apply a cooling blanket
Correct Answer: C
Rationale: Low-grade fever (99.6–100.3°F oral) may indicate early infection or inflammation. Fever is a
defense mechanism. The nurse should first document and perform a focused assessment before
notifying the provider.
,Q3: A nurse is assessing a 72-year-old patient and notes a radial pulse of 54 beats per minute. The
patient is alert, oriented, and asymptomatic. What is the nurse's priority action?
A. Prepare for emergency cardiac pacing
B. Document the finding and continue monitoring [CORRECT]
C. Administer atropine per standing orders
D. Increase IV fluid rate immediately
Correct Answer: B
Rationale: Bradycardia (pulse <60 bpm) in older adults may be a normal variant if the patient is
asymptomatic. Accurate documentation and ongoing monitoring allow detection of changes that would
require intervention.
Q4: The nurse is counting respirations on a patient who is aware of being observed. To obtain the most
accurate rate, the nurse should:
A. Ask the patient to breathe normally while looking at the chest
B. Count respirations immediately after taking the radial pulse while still holding the wrist [CORRECT]
C. Place a hand on the patient's chest to feel breaths
D. Inform the patient that breathing rate will be counted
Correct Answer: B
Rationale: Patients often alter their breathing pattern when aware it is being assessed. Counting
respirations while appearing to take the pulse minimizes patient awareness and yields a more accurate
rate.
Q5: A nurse obtains a blood pressure of 88/52 mmHg on a patient whose baseline is 124/78 mmHg. The
patient reports dizziness and lightheadedness. What is the priority nursing action?
A. Encourage the patient to stand slowly
B. Place the patient in supine position with legs elevated and notify the provider [CORRECT]
C. Recheck the BP in 30 minutes
D. Administer a prescribed antihypertensive
Correct Answer: B
, Rationale: Hypotension with symptoms indicates inadequate tissue perfusion. The Trendelenburg
position promotes venous return to the heart, and immediate provider notification is required for
potential fluid resuscitation or medication adjustment.
Q6: A patient has an oxygen saturation of 91% on room air. The nurse applies a nasal cannula at 2 L/min,
and after 15 minutes the SpO₂ is 94%. What is the nurse's next best action?
A. Increase oxygen to 4 L/min to achieve 98%
B. Document the response and continue monitoring [CORRECT]
C. Switch to a non-rebreather mask immediately
D. Notify the provider of treatment failure
Correct Answer: B
Rationale: A nasal cannula at 1–6 L/min delivers 24–44% oxygen. An SpO₂ of 94% is within the
acceptable range (≥92%). Documentation of the patient's response validates the intervention and
supports ongoing clinical decision-making.
Q7: The nurse is using a tympanic thermometer on a 3-year-old child. To ensure accuracy, the nurse
should:
A. Pull the pinna straight back and up
B. Pull the pinna straight down and back [CORRECT]
C. Insert the probe deeply into the ear canal
D. Use the same ear for all measurements
Correct Answer: B
Rationale: In children under 3 years, the ear canal runs more horizontally; pulling down and back
straightens the canal. In adults, the pinna is pulled up and back. Proper technique prevents trauma and
ensures accurate readings.
Q8: A patient reports pain rated 8/10 in the right lower quadrant. The nurse observes guarding and
facial grimacing. Which action demonstrates the most accurate pain assessment?
A. Document "patient states pain is 8/10" only
B. Reassess using only a nonverbal pain scale
C. Document the numeric rating, location, quality, and observed behaviors [CORRECT]
D. Ask the patient to rate pain again after distraction
