College of Nursing
3 MAXE SDNUF
★ ★
N Department of Health Sciences
SCIENTIA · CURA · COMPASSIO
EST. 1908
Nursing Fundamentals — Examination 3
V I TA L S I G N S · 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 College of Nursing COURSE CODE NURS 1101
PROGRAM Bachelor of Science in Nursing (BSN) ACADEMIC YEAR
EXAM TITLE Nursing Fundamentals Exam 3 TOTAL QUESTIONS 130+ Questions
COURSE TITLE Nursing Fundamentals FORMAT Multiple Choice & Short Answer — Study
Guide
EXAMINATION INSTRUCTIONS
▸ This comprehensive study guide covers vital signs, physical assessment, mobility, sleep, and hygiene.
▸ Each question includes the correct answer and a clinical rationale for board review.
▸ Normal value ranges follow current clinical laboratory and nursing practice standards.
▸ Use this document for NCLEX preparation and nursing fundamentals mastery.
SECTION I — VITAL SIGNS: TEMPERATURE, PULSE, BP, RESPIRATIONS, Questions 1 –
O ₂ , PAIN 68
1. What are the six vital signs?
CORRECT ANSWER 1. Temperature, 2. Pulse (heart rate), 3. Blood pressure, 4. Respiratory rate, 5. Oxygen saturation, 6.
Pain level
RATIONALE Pain is now widely recognized as the "fifth vital sign," with oxygen saturation added as the sixth. These six
measurements provide a comprehensive snapshot of a patient's physiological status.
2. When do you assess vital signs?
CORRECT ANSWER On admission, based on policy and procedures, change in patient condition, loss of consciousness,
before/after invasive diagnostic procedures, before/after risky activities, before administering
medications
RATIONALE Vital signs are assessed at regular intervals per facility policy and whenever the patient's condition changes.
They establish a baseline on admission and help evaluate response to interventions.
3. What is the rule with nurses delegating vitals to LNAs?
CORRECT ANSWER Nurses can delegate the task of taking vitals to LNAs, but the nurse must interpret the results.
RATIONALE Delegation follows the principle that the task (data collection) can be delegated, but the interpretation and
clinical decision-making remain the responsibility of the registered nurse.
,4. What is the typical oral temperature range?
CORRECT ANSWER 97–99°F (36.1–37.2°C)
RATIONALE Oral temperature is the most commonly used route in adults. It is approximately 0.5–1°F lower than rectal
and slightly higher than axillary.
5. What is the typical rectal temperature range?
CORRECT ANSWER 99.6–100.3°F (37.6–37.9°C)
RATIONALE Rectal temperature is the most accurate reflection of core body temperature and is approximately 0.5–1°F
higher than oral temperature.
6. What is the typical axillary temperature range?
CORRECT ANSWER 97.6–99.4°F (36.4–37.4°C)
RATIONALE Axillary temperature is the least accurate route and is approximately 0.5–1°F lower than oral temperature. It
is used when other routes are contraindicated.
7. What is the typical tympanic temperature range?
CORRECT ANSWER 96–99.5°F (35.6–37.5°C)
RATIONALE Tympanic thermometers measure infrared heat from the tympanic membrane, providing a close
approximation of core temperature quickly and non-invasively.
8. What is the typical temporal temperature range?
CORRECT ANSWER 94–99°F (34.4–37.2°C)
RATIONALE Temporal artery thermometers scan the forehead and temporal artery. They are non-invasive, quick, and
well-tolerated, but may be affected by ambient temperature and diaphoresis.
9. What factors affect body temperature?
CORRECT ANSWER Circadian rhythms, age and sex, physical activity, state of health, environmental temperature,
sources of heat loss
RATIONALE Body temperature naturally fluctuates throughout the day (lowest in early morning, highest in late
afternoon). Infants and older adults have less efficient thermoregulation.
10. What is pyrexia?
CORRECT ANSWER A fever (high body temperature) greater than 100.4°F (38°C)
RATIONALE Pyrexia is the body's protective immune response to infection, inflammation, or tissue damage. The
hypothalamus raises the thermoregulatory set point in response to pyrogens.
11. What is hyperpyrexia?
CORRECT ANSWER Abnormally high body temperature greater than 106°F (41.1°C)
RATIONALE Hyperpyrexia is a medical emergency. At this temperature, cellular proteins denature, and the patient is at
risk for seizures, brain damage, and death. Aggressive cooling measures are required.
, 12. What is hypothermia?
CORRECT ANSWER A core body temperature lower than 95°F (35°C)
RATIONALE Hypothermia occurs when heat loss exceeds heat production. It can be accidental (environmental exposure)
or therapeutic (induced for certain surgical procedures). Rewarming must be done gradually.
13. What is pulse rate?
CORRECT ANSWER The number of contractions in the artery per minute
RATIONALE Pulse rate reflects the number of times the left ventricle contracts per minute. It is palpated at peripheral
artery sites where an artery lies close to the skin over a bone.
14. What is the normal pulse rate range?
CORRECT ANSWER 60–100 bpm
RATIONALE The normal adult resting heart rate is 60–100 beats per minute. Well-conditioned athletes may have resting
heart rates as low as 40–50 bpm.
15. What does parasympathetic stimulation do to the heart rate?
CORRECT ANSWER Decreases heart rate
RATIONALE The parasympathetic nervous system, via the vagus nerve, releases acetylcholine which slows SA node firing
and decreases heart rate. This is the "rest and digest" response.
16. What does sympathetic stimulation do to the heart rate?
CORRECT ANSWER Increases heart rate
RATIONALE The sympathetic nervous system releases norepinephrine, which increases SA node firing rate, AV
conduction velocity, and myocardial contractility — the "fight or flight" response.
17. What is tachycardia?
CORRECT ANSWER Heart rate >100 bpm
RATIONALE Tachycardia can be caused by exercise, fever, pain, anxiety, blood loss, dehydration, medications, or cardiac
conditions. Sustained tachycardia reduces ventricular filling time and cardiac output.
18. What is bradycardia?
CORRECT ANSWER Heart rate <60 bpm
RATIONALE Bradycardia may be normal in athletes but can indicate conduction problems, increased intracranial
pressure, hypothermia, or medication effects (e.g., beta-blockers, digoxin).
19. What are the different amplitudes/quality of a peripheral pulse?
CORRECT ANSWER Strong, weak, thready, bounding
RATIONALE Pulse amplitude reflects stroke volume and vascular resistance. A bounding pulse (3+) may indicate fluid
overload; a thready/weak pulse (1+) suggests decreased cardiac output or hypovolemia. Normal is 2+.
3 MAXE SDNUF
★ ★
N Department of Health Sciences
SCIENTIA · CURA · COMPASSIO
EST. 1908
Nursing Fundamentals — Examination 3
V I TA L S I G N S · 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 College of Nursing COURSE CODE NURS 1101
PROGRAM Bachelor of Science in Nursing (BSN) ACADEMIC YEAR
EXAM TITLE Nursing Fundamentals Exam 3 TOTAL QUESTIONS 130+ Questions
COURSE TITLE Nursing Fundamentals FORMAT Multiple Choice & Short Answer — Study
Guide
EXAMINATION INSTRUCTIONS
▸ This comprehensive study guide covers vital signs, physical assessment, mobility, sleep, and hygiene.
▸ Each question includes the correct answer and a clinical rationale for board review.
▸ Normal value ranges follow current clinical laboratory and nursing practice standards.
▸ Use this document for NCLEX preparation and nursing fundamentals mastery.
SECTION I — VITAL SIGNS: TEMPERATURE, PULSE, BP, RESPIRATIONS, Questions 1 –
O ₂ , PAIN 68
1. What are the six vital signs?
CORRECT ANSWER 1. Temperature, 2. Pulse (heart rate), 3. Blood pressure, 4. Respiratory rate, 5. Oxygen saturation, 6.
Pain level
RATIONALE Pain is now widely recognized as the "fifth vital sign," with oxygen saturation added as the sixth. These six
measurements provide a comprehensive snapshot of a patient's physiological status.
2. When do you assess vital signs?
CORRECT ANSWER On admission, based on policy and procedures, change in patient condition, loss of consciousness,
before/after invasive diagnostic procedures, before/after risky activities, before administering
medications
RATIONALE Vital signs are assessed at regular intervals per facility policy and whenever the patient's condition changes.
They establish a baseline on admission and help evaluate response to interventions.
3. What is the rule with nurses delegating vitals to LNAs?
CORRECT ANSWER Nurses can delegate the task of taking vitals to LNAs, but the nurse must interpret the results.
RATIONALE Delegation follows the principle that the task (data collection) can be delegated, but the interpretation and
clinical decision-making remain the responsibility of the registered nurse.
,4. What is the typical oral temperature range?
CORRECT ANSWER 97–99°F (36.1–37.2°C)
RATIONALE Oral temperature is the most commonly used route in adults. It is approximately 0.5–1°F lower than rectal
and slightly higher than axillary.
5. What is the typical rectal temperature range?
CORRECT ANSWER 99.6–100.3°F (37.6–37.9°C)
RATIONALE Rectal temperature is the most accurate reflection of core body temperature and is approximately 0.5–1°F
higher than oral temperature.
6. What is the typical axillary temperature range?
CORRECT ANSWER 97.6–99.4°F (36.4–37.4°C)
RATIONALE Axillary temperature is the least accurate route and is approximately 0.5–1°F lower than oral temperature. It
is used when other routes are contraindicated.
7. What is the typical tympanic temperature range?
CORRECT ANSWER 96–99.5°F (35.6–37.5°C)
RATIONALE Tympanic thermometers measure infrared heat from the tympanic membrane, providing a close
approximation of core temperature quickly and non-invasively.
8. What is the typical temporal temperature range?
CORRECT ANSWER 94–99°F (34.4–37.2°C)
RATIONALE Temporal artery thermometers scan the forehead and temporal artery. They are non-invasive, quick, and
well-tolerated, but may be affected by ambient temperature and diaphoresis.
9. What factors affect body temperature?
CORRECT ANSWER Circadian rhythms, age and sex, physical activity, state of health, environmental temperature,
sources of heat loss
RATIONALE Body temperature naturally fluctuates throughout the day (lowest in early morning, highest in late
afternoon). Infants and older adults have less efficient thermoregulation.
10. What is pyrexia?
CORRECT ANSWER A fever (high body temperature) greater than 100.4°F (38°C)
RATIONALE Pyrexia is the body's protective immune response to infection, inflammation, or tissue damage. The
hypothalamus raises the thermoregulatory set point in response to pyrogens.
11. What is hyperpyrexia?
CORRECT ANSWER Abnormally high body temperature greater than 106°F (41.1°C)
RATIONALE Hyperpyrexia is a medical emergency. At this temperature, cellular proteins denature, and the patient is at
risk for seizures, brain damage, and death. Aggressive cooling measures are required.
, 12. What is hypothermia?
CORRECT ANSWER A core body temperature lower than 95°F (35°C)
RATIONALE Hypothermia occurs when heat loss exceeds heat production. It can be accidental (environmental exposure)
or therapeutic (induced for certain surgical procedures). Rewarming must be done gradually.
13. What is pulse rate?
CORRECT ANSWER The number of contractions in the artery per minute
RATIONALE Pulse rate reflects the number of times the left ventricle contracts per minute. It is palpated at peripheral
artery sites where an artery lies close to the skin over a bone.
14. What is the normal pulse rate range?
CORRECT ANSWER 60–100 bpm
RATIONALE The normal adult resting heart rate is 60–100 beats per minute. Well-conditioned athletes may have resting
heart rates as low as 40–50 bpm.
15. What does parasympathetic stimulation do to the heart rate?
CORRECT ANSWER Decreases heart rate
RATIONALE The parasympathetic nervous system, via the vagus nerve, releases acetylcholine which slows SA node firing
and decreases heart rate. This is the "rest and digest" response.
16. What does sympathetic stimulation do to the heart rate?
CORRECT ANSWER Increases heart rate
RATIONALE The sympathetic nervous system releases norepinephrine, which increases SA node firing rate, AV
conduction velocity, and myocardial contractility — the "fight or flight" response.
17. What is tachycardia?
CORRECT ANSWER Heart rate >100 bpm
RATIONALE Tachycardia can be caused by exercise, fever, pain, anxiety, blood loss, dehydration, medications, or cardiac
conditions. Sustained tachycardia reduces ventricular filling time and cardiac output.
18. What is bradycardia?
CORRECT ANSWER Heart rate <60 bpm
RATIONALE Bradycardia may be normal in athletes but can indicate conduction problems, increased intracranial
pressure, hypothermia, or medication effects (e.g., beta-blockers, digoxin).
19. What are the different amplitudes/quality of a peripheral pulse?
CORRECT ANSWER Strong, weak, thready, bounding
RATIONALE Pulse amplitude reflects stroke volume and vascular resistance. A bounding pulse (3+) may indicate fluid
overload; a thready/weak pulse (1+) suggests decreased cardiac output or hypovolemia. Normal is 2+.
