NUR155 FOUNDATIONS OF NURSING EXAM 2 REVIEW
2026/2027 | 100% Correct | Galen College | Questions &
Verified Answers | Pass Guaranteed - A+ Graded
Section 1: Vital Signs Assessment & Interpretation (Q1-14)
Question 1
A nurse assesses a healthy adult patient. Which vital sign set falls within normal
parameters?
A. HR 55, RR 22, BP 138/88, Temp 37.2°C (99.0°F)
B. HR 72, RR 16, BP 118/76, Temp 36.8°C (98.2°F)
C. HR 105, RR 10, BP 142/92, Temp 35.6°C (96.0°F)
D. HR 88, RR 24, BP 128/82, Temp 38.5°C (101.3°F)
Correct Answer: B. HR 72, RR 16, BP 118/76, Temp 36.8°C (98.2°F) [CORRECT]
Rationale: Normal adult vital signs: HR 60-100 bpm, RR 12-20 breaths/min, BP
<120/80 mmHg, temp 36-38°C (96.8-100.4°F). Option A has bradycardia (55) and
tachypnea (22). Option C has tachycardia (105), bradypnea (10), and hypertension.
Option D has tachypnea (24) and fever. REVIEW TIP: Memorize normal ranges as your
baseline—every abnormal finding requires investigation.
Question 2
A nurse obtains an apical pulse on a patient with atrial fibrillation. Which technique is
most appropriate?
A. Count for 15 seconds and multiply by 4
B. Count for 30 seconds and multiply by 2
C. Count for 1 full minute
D. Palpate the radial pulse simultaneously
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Correct Answer: C. Count for 1 full minute [CORRECT]
Rationale: Apical pulse must be counted for 1 full minute in patients with irregular
rhythms (atrial fibrillation, frequent ectopy) because the irregularity makes short-
interval counting inaccurate; radial pulse may not detect all beats in irregular
rhythms. REVIEW TIP: "Irregular = 1 minute"—always count apical pulse for 60
seconds when the rhythm is irregular.
Question 3
A patient has a blood pressure of 156/94 mmHg on two separate occasions.
According to current guidelines, which classification applies?
A. Normal blood pressure
B. Elevated blood pressure
C. Stage 1 hypertension
D. Stage 2 hypertension
Correct Answer: C. Stage 1 hypertension [CORRECT]
Rationale: Stage 1 hypertension is defined as systolic 130-139 or diastolic 80-89; this
patient's BP of 156/94 actually meets Stage 2 criteria (≥140/90). Wait—let me
recalculate: 156/94 = Stage 2 (systolic ≥140 OR diastolic ≥90). The question should
reflect accurate staging.
Question 3 (Revised)
A patient has a blood pressure of 136/86 mmHg on two separate occasions.
According to current guidelines, which classification applies?
A. Normal blood pressure
B. Elevated blood pressure
C. Stage 1 hypertension
D. Stage 2 hypertension
Correct Answer: C. Stage 1 hypertension [CORRECT]
Rationale: Stage 1 hypertension is systolic 130-139 or diastolic 80-89; this patient's
136/86 falls within Stage 1. Normal is <120/80. Elevated is 120-129 and <80. Stage 2
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is ≥140 or ≥90. REVIEW TIP: Remember the threshold dropped in 2017—130/80 is
now Stage 1, not "prehypertension."
Question 4
A nurse uses a blood pressure cuff that is too small for the patient's arm. Which
result will occur?
A. Falsely low blood pressure reading
B. Falsely high blood pressure reading
C. No effect on the blood pressure reading
D. Inability to obtain a reading
Correct Answer: B. Falsely high blood pressure reading [CORRECT]
Rationale: A cuff that is too small requires higher pressure to occlude the brachial
artery, resulting in a falsely elevated reading; the bladder should encircle 80% of the
arm circumference. A cuff too large gives falsely low readings. REVIEW TIP: "Small
cuff = Small arm needs more pressure = Higher reading" or remember Goldilocks:
too small = too high, too big = too low.
Question 5
A patient's arm is positioned below heart level during blood pressure measurement.
Which effect on the reading will occur?
A. Falsely low reading
B. Falsely high reading
C. No effect on the reading
D. Erratic, unreliable reading
Correct Answer: B. Falsely high reading [CORRECT]
Rationale: When the arm is below heart level, hydrostatic pressure increases the
column of blood in the arm, resulting in a falsely elevated BP reading; the arm should
be supported at heart level. Above heart level would cause falsely low readings.
, 4
REVIEW TIP: "Arm down = pressure up"—gravity increases the fluid column when the
limb is dependent.
Question 6
A nurse assesses a patient and documents Cheyne-Stokes respirations. Which pattern
is described?
A. Deep, rapid breathing compensating for metabolic acidosis
B. Cyclical waxing and waning of depth with periods of apnea
C. Irregular periods of apnea with variable depth breathing
D. Prolonged inspiration with pauses
Correct Answer: B. Cyclical waxing and waning of depth with periods of apnea
[CORRECT]
Rationale: Cheyne-Stokes respiration is characterized by regular cycles of
progressively deepening and quickening breaths followed by gradual shallowing and
slowing, ending in apnea; it is seen in heart failure, brain injury, and severe illness.
Kussmaul is deep, rapid breathing. Biot has irregular apneic periods without the
crescendo-decrescendo pattern. Apneustic breathing has prolonged inspirations.
REVIEW TIP: "Cheyne-Stokes = Coming and Going" (waxing and waning).
Question 7
A patient with diabetic ketoacidosis has deep, rapid respirations. Which respiratory
pattern is documented?
A. Cheyne-Stokes respiration
B. Kussmaul respiration
C. Biot respiration
D. Bradypnea
Correct Answer: B. Kussmaul respiration [CORRECT]