NR-224 Comprehensive Fundamentals Examination: Vital Signs,
Physical Assessment, Hygiene, Mobility, Safety, Infection Control,
Patient-Centered Care, Clinical Judgment, and Ethical-Legal
Aspects in Diverse Healthcare Settings
150 Multiple-Choice Questions with Correct Answers and Rationales
Section 1: Vital Signs (Questions 1–25)
1. A nurse assesses a patient’s blood pressure as 148/92 mm Hg. The patient asks, “Is that bad?” Which response is
most accurate?
• A) “It’s perfect for your age.”
• B) “Your systolic is high, but diastolic is normal.”
• C) “It falls within the prehypertension category.”
• D) “This indicates stage 1 hypertension.”
Correct Answer: D – According to ACC/AHA guidelines, stage 1 hypertension is 130–139/80–89 mm Hg or higher.
148/92 meets this criteria.
2. A post-operative patient’s temperature is 96.8°F (36.0°C) axillary. What should the nurse do first?
• A) Apply a warming blanket
• B) Recheck using a rectal thermometer
• C) Assess the patient’s shivering and skin color
• D) Document as normal post-op finding
Correct Answer: C – Hypothermia requires assessment of the patient’s clinical status (shivering, pallor, mental
status) before intervention.
3. Which pulse characteristic is most concerning in a patient with a history of transient ischemic attacks?
• A) 2+ bounding
• B) Irregular rhythm with pulse deficit
• C) Rate of 58 bpm in an athlete
• D) Symmetrical radial pulses
Correct Answer: B – Irregular rhythm with pulse deficit (difference between apical and radial) suggests atrial
fibrillation, a stroke risk factor.
4. A nurse is unable to palpate a patient’s dorsalis pedis pulse. What is the best next action?
• A) Document “absent”
• B) Use a Doppler ultrasound device
• C) Notify the provider immediately
• D) Elevate the leg to improve flow
Correct Answer: B – Doppler is used to auscultate non-palpable pulses. Immediate provider notification is
premature without further assessment.
,5. Which respiratory rate in an adult sleeping patient requires immediate reassessment?
• A) 10 breaths/minute
• B) 14 breaths/minute
• C) 18 breaths/minute
• D) 24 breaths/minute
Correct Answer: D – Tachypnea (>20 in resting adult) may indicate pain, hypoxia, or metabolic acidosis. 24 is
abnormal during sleep.
6. A patient’s oxygen saturation is 88% on room air. The nurse notes the patient is anxious and has clubbing of fingers.
What should the nurse do first?
• A) Apply oxygen at 2 L/min via nasal cannula
• B) Reposition the pulse oximeter probe
• C) Obtain an ABG sample
• D) Elevate head of bed to 90 degrees
Correct Answer: A – SpO2 <90% indicates hypoxemia. First action is supplemental oxygen while preparing for
further assessment.
7. A manual blood pressure reading is 110/70. The nurse then uses an electronic cuff that reads 160/90. What action is
most appropriate?
• A) Document the electronic reading
• B) Repeat manual reading on opposite arm
• C) Assume patient became anxious
• D) Calibrate the electronic device
Correct Answer: B – Discrepancy >10 mm Hg requires verification. Repeat manual measurement on other arm to
rule out error or arm difference.
8. The nurse assesses a patient’s temperature 1 hour after administering IV acetaminophen for fever of 102.2°F (39°C).
Current temp is 101.5°F (38.6°C). What action is correct?
• A) Administer another dose now
• B) Document slight improvement
• C) Apply cooling blankets
• D) Notify provider of no response
Correct Answer: B – A decrease of 0.7°F in 1 hour is appropriate response. Fever curve shows gradual reduction.
9. Which finding during vital sign assessment requires an immediate call to the rapid response team?
• A) HR 110, RR 24, BP 100/70 in post-exercise
• B) HR 45, BP 88/50, patient confused
• C) Temp 100.4°F (38°C), HR 100
• D) SpO2 92% on 2L O2, RR 20
Correct Answer: B – Symptomatic bradycardia with hypotension and altered mental status meets rapid response
criteria.
10. A nurse assesses orthostatic vital signs. After lying supine for 5 minutes, HR=72, BP=118/76. Upon standing, HR=98,
BP=102/68. Which interpretation is correct?
, • A) Normal response
• B) Orthostatic hypotension
• C) Postural tachycardia without hypotension
• D) Equipment error
Correct Answer: B – Orthostatic hypotension defined by drop in SBP ≥20 or DBP ≥10, with rise in HR >15
(compensatory).
11. A patient’s radial pulse is 88 and irregular. The apical pulse is 104. What is the pulse deficit?
• A) 0
• B) 16
• C) 88
• D) 104
Correct Answer: B – Pulse deficit = apical rate – radial rate = 104 – 88 = 16. Indicates weak contractions not
reaching periphery.
12. Which technique ensures accurate non-invasive blood pressure measurement in an obese patient?
• A) Use a standard adult cuff
• B) Use a large adult or thigh cuff
• C) Apply cuff to forearm
• D) Use wrist monitor only
Correct Answer: B – Cuff bladder should encircle 80% of arm circumference. Obese patients require larger cuff to
avoid falsely high readings.
13. A patient with COPD has an SpO2 of 88% on 2L oxygen. The nurse increases to 3L, and SpO2 rises to 92%. One hour
later, the patient is lethargic. What is the most likely cause?
• A) Oxygen-induced hypoventilation
• B) Normal sleep onset
• C) Hypercapnia from reduced hypoxic drive
• D) Carbon monoxide poisoning
Correct Answer: C – COPD patients may retain CO2; excessive O2 reduces hypoxic drive, causing hypoventilation
and CO2 narcosis.
14. A febrile child is shivering. The nurse should:
• A) Apply a cooling blanket immediately
• B) Remove blankets to reduce temperature
• C) Provide warm blankets and comfort
• D) Administer an antipyretic rectally
Correct Answer: C – Shivering raises metabolic heat. Warm blankets reduce discomfort and shivering before
antipyretics take effect.
15. The nurse is unable to obtain a blood pressure reading using auscultation. Which alternative method is most
reliable?
• A) Palpatory method
• B) Automated oscillometric device
Physical Assessment, Hygiene, Mobility, Safety, Infection Control,
Patient-Centered Care, Clinical Judgment, and Ethical-Legal
Aspects in Diverse Healthcare Settings
150 Multiple-Choice Questions with Correct Answers and Rationales
Section 1: Vital Signs (Questions 1–25)
1. A nurse assesses a patient’s blood pressure as 148/92 mm Hg. The patient asks, “Is that bad?” Which response is
most accurate?
• A) “It’s perfect for your age.”
• B) “Your systolic is high, but diastolic is normal.”
• C) “It falls within the prehypertension category.”
• D) “This indicates stage 1 hypertension.”
Correct Answer: D – According to ACC/AHA guidelines, stage 1 hypertension is 130–139/80–89 mm Hg or higher.
148/92 meets this criteria.
2. A post-operative patient’s temperature is 96.8°F (36.0°C) axillary. What should the nurse do first?
• A) Apply a warming blanket
• B) Recheck using a rectal thermometer
• C) Assess the patient’s shivering and skin color
• D) Document as normal post-op finding
Correct Answer: C – Hypothermia requires assessment of the patient’s clinical status (shivering, pallor, mental
status) before intervention.
3. Which pulse characteristic is most concerning in a patient with a history of transient ischemic attacks?
• A) 2+ bounding
• B) Irregular rhythm with pulse deficit
• C) Rate of 58 bpm in an athlete
• D) Symmetrical radial pulses
Correct Answer: B – Irregular rhythm with pulse deficit (difference between apical and radial) suggests atrial
fibrillation, a stroke risk factor.
4. A nurse is unable to palpate a patient’s dorsalis pedis pulse. What is the best next action?
• A) Document “absent”
• B) Use a Doppler ultrasound device
• C) Notify the provider immediately
• D) Elevate the leg to improve flow
Correct Answer: B – Doppler is used to auscultate non-palpable pulses. Immediate provider notification is
premature without further assessment.
,5. Which respiratory rate in an adult sleeping patient requires immediate reassessment?
• A) 10 breaths/minute
• B) 14 breaths/minute
• C) 18 breaths/minute
• D) 24 breaths/minute
Correct Answer: D – Tachypnea (>20 in resting adult) may indicate pain, hypoxia, or metabolic acidosis. 24 is
abnormal during sleep.
6. A patient’s oxygen saturation is 88% on room air. The nurse notes the patient is anxious and has clubbing of fingers.
What should the nurse do first?
• A) Apply oxygen at 2 L/min via nasal cannula
• B) Reposition the pulse oximeter probe
• C) Obtain an ABG sample
• D) Elevate head of bed to 90 degrees
Correct Answer: A – SpO2 <90% indicates hypoxemia. First action is supplemental oxygen while preparing for
further assessment.
7. A manual blood pressure reading is 110/70. The nurse then uses an electronic cuff that reads 160/90. What action is
most appropriate?
• A) Document the electronic reading
• B) Repeat manual reading on opposite arm
• C) Assume patient became anxious
• D) Calibrate the electronic device
Correct Answer: B – Discrepancy >10 mm Hg requires verification. Repeat manual measurement on other arm to
rule out error or arm difference.
8. The nurse assesses a patient’s temperature 1 hour after administering IV acetaminophen for fever of 102.2°F (39°C).
Current temp is 101.5°F (38.6°C). What action is correct?
• A) Administer another dose now
• B) Document slight improvement
• C) Apply cooling blankets
• D) Notify provider of no response
Correct Answer: B – A decrease of 0.7°F in 1 hour is appropriate response. Fever curve shows gradual reduction.
9. Which finding during vital sign assessment requires an immediate call to the rapid response team?
• A) HR 110, RR 24, BP 100/70 in post-exercise
• B) HR 45, BP 88/50, patient confused
• C) Temp 100.4°F (38°C), HR 100
• D) SpO2 92% on 2L O2, RR 20
Correct Answer: B – Symptomatic bradycardia with hypotension and altered mental status meets rapid response
criteria.
10. A nurse assesses orthostatic vital signs. After lying supine for 5 minutes, HR=72, BP=118/76. Upon standing, HR=98,
BP=102/68. Which interpretation is correct?
, • A) Normal response
• B) Orthostatic hypotension
• C) Postural tachycardia without hypotension
• D) Equipment error
Correct Answer: B – Orthostatic hypotension defined by drop in SBP ≥20 or DBP ≥10, with rise in HR >15
(compensatory).
11. A patient’s radial pulse is 88 and irregular. The apical pulse is 104. What is the pulse deficit?
• A) 0
• B) 16
• C) 88
• D) 104
Correct Answer: B – Pulse deficit = apical rate – radial rate = 104 – 88 = 16. Indicates weak contractions not
reaching periphery.
12. Which technique ensures accurate non-invasive blood pressure measurement in an obese patient?
• A) Use a standard adult cuff
• B) Use a large adult or thigh cuff
• C) Apply cuff to forearm
• D) Use wrist monitor only
Correct Answer: B – Cuff bladder should encircle 80% of arm circumference. Obese patients require larger cuff to
avoid falsely high readings.
13. A patient with COPD has an SpO2 of 88% on 2L oxygen. The nurse increases to 3L, and SpO2 rises to 92%. One hour
later, the patient is lethargic. What is the most likely cause?
• A) Oxygen-induced hypoventilation
• B) Normal sleep onset
• C) Hypercapnia from reduced hypoxic drive
• D) Carbon monoxide poisoning
Correct Answer: C – COPD patients may retain CO2; excessive O2 reduces hypoxic drive, causing hypoventilation
and CO2 narcosis.
14. A febrile child is shivering. The nurse should:
• A) Apply a cooling blanket immediately
• B) Remove blankets to reduce temperature
• C) Provide warm blankets and comfort
• D) Administer an antipyretic rectally
Correct Answer: C – Shivering raises metabolic heat. Warm blankets reduce discomfort and shivering before
antipyretics take effect.
15. The nurse is unable to obtain a blood pressure reading using auscultation. Which alternative method is most
reliable?
• A) Palpatory method
• B) Automated oscillometric device
