Nursing Fundamentals
3 MAXE
NF Foundations of Professional Nursing Practice
CARING · COMPETENCE · COMPASSION
FUNDAMENTALS
Nursing Fundamentals — Exam 3
B R A D E N S C A L E , W O U N D S , V I TA L S I G N S , PA I N , P H YS I C A L A SS E SS M E N T, M O B I L I TY, S L E E P &
H YG I E N E
INSTITUTION Nursing Fundamentals Program COURSE CODE NURS 101 — Fundamentals
PROGRAM Associate / Bachelor of Science in Nursing ACADEMIC YEAR
EXAM TITLE Exam 3 — Fundamentals of Nursing TOTAL QUESTIONS 100+ Questions (Complete)
COURSE TITLE Fundamentals of Nursing FORMAT Multiple Choice — Select the Single Best
Answer
EXAMINATION INSTRUCTIONS
▸ Select the single best answer for each question.
▸ All questions from the provided study material are included with correct answers and clinical rationales.
BRADEN, WOUNDS, VITALS, PAIN, ASSESSMENT, MOBILITY, SLEEP & Questions 1 –
HYGIENE 100+
1. The Braden Scale measures which six factors?
A. Temperature, pulse, respirations, blood pressure, pain, oxygen saturation.
B. Sensory perception, moisture, activity, mobility, nutrition, friction/shear.
C. Orientation, memory, attention, language, visuospatial, executive function.
D. Inspection, palpation, percussion, auscultation, olfaction, general survey.
CORRECT ANSWER B — The Braden Scale assesses pressure injury risk using six subscales. Lower scores = higher risk (≤18
= at risk; ≤9 = very high risk).
RATIONALE Each category scored 1-4 (friction/shear 1-3). Total range: 6-23. Interventions based on risk level:
repositioning q2h, pressure-reducing surfaces, moisture management, nutritional support.
2. Types of wound dressings include all EXCEPT:
A. Absorbent, alginates, antimicrobials, and collagens.
B. Foams, gauze, hydrocolloids, and hydrogels.
C. Antibiotic ointment tubes — these are medications, not dressings.
D. Skin sealants/moisture barriers and transparent films.
CORRECT ANSWER C — Antibiotic ointment is a topical medication, not a dressing category. Dressings include absorbent,
alginate, antimicrobial, collagen, foam, gauze, hydrocolloid, hydrogel, moisture barriers, and
transparent films.
RATIONALE Wound care interventions: cleaning/irrigating/debriding wounds, drainage devices, appropriate dressing
selection, infection control, securing dressings, wound immobilizers, hot/cold therapy, safety measures.
, 3. The six vital signs are:
A. Height, weight, BMI, waist circumference, vision, hearing.
B. Temperature, pulse (heart rate), blood pressure, respiratory rate, oxygen saturation, pain level.
C. LOC, orientation, pupil response, motor function, sensory function, reflexes.
D. Skin color, temperature, moisture, turgor, capillary refill, edema.
CORRECT ANSWER B — The six vital signs: temperature, pulse, BP, RR, SpO₂, and pain (the "5th vital sign" added to the
original four).
RATIONALE Assess vitals on admission, per policy, with change in condition, LOC change, before/after invasive
procedures, risky activities, and before certain medications. Nurses can delegate measurement to LNAs but
must interpret results.
4. Typical oral temperature range is:
A. 96-98°F.
B. 97-99°F.
C. 98-100°F.
D. 99-101°F.
CORRECT ANSWER B — Oral: 97-99°F. Rectal: 99.6-100.3°F. Axillary: 97.6-99.4°F. Tympanic: 96-99.5°F. Temporal: 94-99°F.
Rectal is ~1°F higher than oral; axillary is ~1°F lower.
RATIONALE Factors affecting body temp: circadian rhythms, age/sex, physical activity, health state, environmental temp,
heat loss sources. Pyrexia = >100.4°F. Hyperpyrexia = >106°F. Hypothermia = <95°F.
5. Normal adult pulse rate range is:
A. 40-60 bpm.
B. 60-100 bpm.
C. 80-120 bpm.
D. 100-140 bpm.
CORRECT ANSWER B — Normal HR = 60-100 bpm. Tachycardia >100; Bradycardia <60. Parasympathetic stimulation ↓HR;
sympathetic ↑HR.
RATIONALE Pulse amplitudes: strong, weak, thready, bounding. Apical pulse is most accurate — auscultate at 5th-6th
intercostal space. Factors affecting pulse: age, activity, food, stress, fever, disease, blood loss, position,
medications.
6. Average blood pressure is:
A. 100/60.
B. 120/80.
C. 140/90.
D. 160/100.
CORRECT ANSWER B — Normal BP ~120/80. Systolic = peak pressure during ventricular contraction. Diastolic = minimum
pressure during cardiac rest.
RATIONALE Elevated: 120-129/<80. HTN Stage 1: 130-139/80-89. HTN Stage 2: ≥140/≥90. Hypertensive crisis: ≥180/≥120.
Hypotension: ≤100/≤60. Orthostatic hypotension = BP drop with position change.
3 MAXE
NF Foundations of Professional Nursing Practice
CARING · COMPETENCE · COMPASSION
FUNDAMENTALS
Nursing Fundamentals — Exam 3
B R A D E N S C A L E , W O U N D S , V I TA L S I G N S , PA I N , P H YS I C A L A SS E SS M E N T, M O B I L I TY, S L E E P &
H YG I E N E
INSTITUTION Nursing Fundamentals Program COURSE CODE NURS 101 — Fundamentals
PROGRAM Associate / Bachelor of Science in Nursing ACADEMIC YEAR
EXAM TITLE Exam 3 — Fundamentals of Nursing TOTAL QUESTIONS 100+ Questions (Complete)
COURSE TITLE Fundamentals of Nursing FORMAT Multiple Choice — Select the Single Best
Answer
EXAMINATION INSTRUCTIONS
▸ Select the single best answer for each question.
▸ All questions from the provided study material are included with correct answers and clinical rationales.
BRADEN, WOUNDS, VITALS, PAIN, ASSESSMENT, MOBILITY, SLEEP & Questions 1 –
HYGIENE 100+
1. The Braden Scale measures which six factors?
A. Temperature, pulse, respirations, blood pressure, pain, oxygen saturation.
B. Sensory perception, moisture, activity, mobility, nutrition, friction/shear.
C. Orientation, memory, attention, language, visuospatial, executive function.
D. Inspection, palpation, percussion, auscultation, olfaction, general survey.
CORRECT ANSWER B — The Braden Scale assesses pressure injury risk using six subscales. Lower scores = higher risk (≤18
= at risk; ≤9 = very high risk).
RATIONALE Each category scored 1-4 (friction/shear 1-3). Total range: 6-23. Interventions based on risk level:
repositioning q2h, pressure-reducing surfaces, moisture management, nutritional support.
2. Types of wound dressings include all EXCEPT:
A. Absorbent, alginates, antimicrobials, and collagens.
B. Foams, gauze, hydrocolloids, and hydrogels.
C. Antibiotic ointment tubes — these are medications, not dressings.
D. Skin sealants/moisture barriers and transparent films.
CORRECT ANSWER C — Antibiotic ointment is a topical medication, not a dressing category. Dressings include absorbent,
alginate, antimicrobial, collagen, foam, gauze, hydrocolloid, hydrogel, moisture barriers, and
transparent films.
RATIONALE Wound care interventions: cleaning/irrigating/debriding wounds, drainage devices, appropriate dressing
selection, infection control, securing dressings, wound immobilizers, hot/cold therapy, safety measures.
, 3. The six vital signs are:
A. Height, weight, BMI, waist circumference, vision, hearing.
B. Temperature, pulse (heart rate), blood pressure, respiratory rate, oxygen saturation, pain level.
C. LOC, orientation, pupil response, motor function, sensory function, reflexes.
D. Skin color, temperature, moisture, turgor, capillary refill, edema.
CORRECT ANSWER B — The six vital signs: temperature, pulse, BP, RR, SpO₂, and pain (the "5th vital sign" added to the
original four).
RATIONALE Assess vitals on admission, per policy, with change in condition, LOC change, before/after invasive
procedures, risky activities, and before certain medications. Nurses can delegate measurement to LNAs but
must interpret results.
4. Typical oral temperature range is:
A. 96-98°F.
B. 97-99°F.
C. 98-100°F.
D. 99-101°F.
CORRECT ANSWER B — Oral: 97-99°F. Rectal: 99.6-100.3°F. Axillary: 97.6-99.4°F. Tympanic: 96-99.5°F. Temporal: 94-99°F.
Rectal is ~1°F higher than oral; axillary is ~1°F lower.
RATIONALE Factors affecting body temp: circadian rhythms, age/sex, physical activity, health state, environmental temp,
heat loss sources. Pyrexia = >100.4°F. Hyperpyrexia = >106°F. Hypothermia = <95°F.
5. Normal adult pulse rate range is:
A. 40-60 bpm.
B. 60-100 bpm.
C. 80-120 bpm.
D. 100-140 bpm.
CORRECT ANSWER B — Normal HR = 60-100 bpm. Tachycardia >100; Bradycardia <60. Parasympathetic stimulation ↓HR;
sympathetic ↑HR.
RATIONALE Pulse amplitudes: strong, weak, thready, bounding. Apical pulse is most accurate — auscultate at 5th-6th
intercostal space. Factors affecting pulse: age, activity, food, stress, fever, disease, blood loss, position,
medications.
6. Average blood pressure is:
A. 100/60.
B. 120/80.
C. 140/90.
D. 160/100.
CORRECT ANSWER B — Normal BP ~120/80. Systolic = peak pressure during ventricular contraction. Diastolic = minimum
pressure during cardiac rest.
RATIONALE Elevated: 120-129/<80. HTN Stage 1: 130-139/80-89. HTN Stage 2: ≥140/≥90. Hypertensive crisis: ≥180/≥120.
Hypotension: ≤100/≤60. Orthostatic hypotension = BP drop with position change.
