NR 302 Health Assessment I: Vital Signs & Pain Assessment 2026
|Chamberlain College
1. A nurse is assessing a patient’s radial pulse and notes that the rhythm is
irregular. What is the most appropriate next action?
A. Assess the apical pulse for one full minute.
B. Document the finding and reassess in 4 hours.
C. Ask another nurse to verify the radial pulse.
D. Notify the healthcare provider immediately.
Answer: A
Rationale: When a peripheral pulse is irregular, the nurse should assess the apical pulse
for 60 seconds to obtain a more accurate heart rate and identify potential deficits.
2. When measuring a patient’s blood pressure, the nurse uses a cuff that is too
narrow for the patient’s arm. What effect will this have on the reading?
A. The blood pressure reading will be falsely high.
B. The blood pressure reading will be falsely low.
C. The reading will be accurate if the patient is sitting up.
D. Only the diastolic pressure will be affected.
Answer: A
Rationale: Using a blood pressure cuff that is too small or narrow results in a falsely high
reading because the cuff must be inflated to a higher pressure to occlude the artery.
,3. The nurse is assessing the ‘P’ in the PQRST mnemonic for a patient in pain.
Which question should the nurse ask?
A. ‘What does the pain feel like?’
B. ‘What makes the pain better or worse?’
C. ‘Where exactly is the pain located?’
D. ‘How would you rate your pain on a scale of 0 to 10?’
Answer: B
Rationale: In the PQRST mnemonic, ‘P’ stands for Provocation or Palliative factors, asking
what triggers the pain or what relieves it.
4. Which temperature route is generally considered the most accurate
representation of core body temperature?
A. Axillary
B. Rectal
C. Oral
D. Tympanic
Answer: B
Rationale: Rectal temperatures are considered the gold standard for core temperature
measurement because they are least influenced by external environment factors.
5. A patient’s respiratory rate is 24 breaths per minute. Which term should the
nurse use to document this finding?
A. Eupnea
B. Bradypnea
C. Apnea
D. Tachypnea
Answer: D
Rationale: Tachypnea is defined as a respiratory rate greater than 20 breaths per minute
in an adult.
, 6. The nurse notes that a patient has an ‘auscultatory gap.’ What does this mean
for the blood pressure measurement?
A. The patient has a very low pulse pressure.
B. There is a period where Korotkoff sounds disappear during deflation.
C. The systolic pressure is higher than 200 mmHg.
D. The heart rate is too fast to hear the sounds clearly.
Answer: B
Rationale: An auscultatory gap is a silent interval between the first and second Korotkoff
sounds, which can lead to an underestimation of systolic pressure if not identified.
7. Which of the following is an objective sign of pain?
A. The patient reporting a score of 8/10.
B. The patient describing the pain as ‘burning.’
C. Increased heart rate and blood pressure.
D. The patient stating the pain started two days ago.
Answer: C
Rationale: Objective signs are observable and measurable, such as vital sign changes
(tachycardia, hypertension) or guarding behaviors. Self-reporting is subjective.
8. The nurse is assessing a 4-year-old child for pain. Which pain scale is most
appropriate to use?
A. Numeric Rating Scale (0-10)
B. Visual Analog Scale
C. Wong-Baker FACES Scale
D. FLACC Scale
Answer: C
Rationale: The Wong-Baker FACES Scale is designed for children as young as 3 years old,
as they can point to the face that best represents their level of pain.
|Chamberlain College
1. A nurse is assessing a patient’s radial pulse and notes that the rhythm is
irregular. What is the most appropriate next action?
A. Assess the apical pulse for one full minute.
B. Document the finding and reassess in 4 hours.
C. Ask another nurse to verify the radial pulse.
D. Notify the healthcare provider immediately.
Answer: A
Rationale: When a peripheral pulse is irregular, the nurse should assess the apical pulse
for 60 seconds to obtain a more accurate heart rate and identify potential deficits.
2. When measuring a patient’s blood pressure, the nurse uses a cuff that is too
narrow for the patient’s arm. What effect will this have on the reading?
A. The blood pressure reading will be falsely high.
B. The blood pressure reading will be falsely low.
C. The reading will be accurate if the patient is sitting up.
D. Only the diastolic pressure will be affected.
Answer: A
Rationale: Using a blood pressure cuff that is too small or narrow results in a falsely high
reading because the cuff must be inflated to a higher pressure to occlude the artery.
,3. The nurse is assessing the ‘P’ in the PQRST mnemonic for a patient in pain.
Which question should the nurse ask?
A. ‘What does the pain feel like?’
B. ‘What makes the pain better or worse?’
C. ‘Where exactly is the pain located?’
D. ‘How would you rate your pain on a scale of 0 to 10?’
Answer: B
Rationale: In the PQRST mnemonic, ‘P’ stands for Provocation or Palliative factors, asking
what triggers the pain or what relieves it.
4. Which temperature route is generally considered the most accurate
representation of core body temperature?
A. Axillary
B. Rectal
C. Oral
D. Tympanic
Answer: B
Rationale: Rectal temperatures are considered the gold standard for core temperature
measurement because they are least influenced by external environment factors.
5. A patient’s respiratory rate is 24 breaths per minute. Which term should the
nurse use to document this finding?
A. Eupnea
B. Bradypnea
C. Apnea
D. Tachypnea
Answer: D
Rationale: Tachypnea is defined as a respiratory rate greater than 20 breaths per minute
in an adult.
, 6. The nurse notes that a patient has an ‘auscultatory gap.’ What does this mean
for the blood pressure measurement?
A. The patient has a very low pulse pressure.
B. There is a period where Korotkoff sounds disappear during deflation.
C. The systolic pressure is higher than 200 mmHg.
D. The heart rate is too fast to hear the sounds clearly.
Answer: B
Rationale: An auscultatory gap is a silent interval between the first and second Korotkoff
sounds, which can lead to an underestimation of systolic pressure if not identified.
7. Which of the following is an objective sign of pain?
A. The patient reporting a score of 8/10.
B. The patient describing the pain as ‘burning.’
C. Increased heart rate and blood pressure.
D. The patient stating the pain started two days ago.
Answer: C
Rationale: Objective signs are observable and measurable, such as vital sign changes
(tachycardia, hypertension) or guarding behaviors. Self-reporting is subjective.
8. The nurse is assessing a 4-year-old child for pain. Which pain scale is most
appropriate to use?
A. Numeric Rating Scale (0-10)
B. Visual Analog Scale
C. Wong-Baker FACES Scale
D. FLACC Scale
Answer: C
Rationale: The Wong-Baker FACES Scale is designed for children as young as 3 years old,
as they can point to the face that best represents their level of pain.
