All Free Fundamentals of Nursing MCQs with Answers

Every Fundamentals of Nursing question in the bank, across all chapters, each with the correct answer and a written explanation. Free and unlimited, with no account needed.

500 questions · page 22 of 25

Moderate
  • A. Assess pain, anxiety and recent activity
  • B. Apply oxygen immediately at a high flow rate
  • C. Ask the patient to hold the breath briefly
  • D. Document tachypnoea without reassessment

Explanation: Tachypnoea can result from anxiety, pain, fever, activity or respiratory disease, so the nurse should assess likely causes and associated…

Correct answer: Assess pain, anxiety and recent activity
Moderate
  • A. Check the probe position and repeat the reading
  • B. Start emergency resuscitation measures
  • C. Document the lower value without comparison
  • D. Ask the patient to breathe into a paper bag

Explanation: A new mild change should be verified by checking probe placement, circulation and the patient’s clinical condition.

Correct answer: Check the probe position and repeat the reading
  • A. Pain is present only when vital signs change
  • B. The patient’s self-report is the primary pain measure
  • C. A normal pulse rules out serious pain
  • D. The nurse should use facial expression instead of the rating

Explanation: Pain is subjective, and the patient’s self-report is the most reliable measure when the patient can communicate.

Correct answer: The patient’s self-report is the primary pain measure
  • A. Encourage the patient to walk to reduce weakness
  • B. Reassess later because the systolic pressure is above 90
  • C. Report possible circulatory compromise immediately
  • D. Give an oral antipyretic and wait for the next observation

Explanation: The narrow pulse pressure, tachycardia, cool skin and weakness suggest possible plasma leakage and circulatory compromise in dengue.

Correct answer: Report possible circulatory compromise immediately
  • A. 118/76 mmHg
  • B. 138/88 mmHg
  • C. 156/94 mmHg
  • D. sitio 176/102 mmHg

Explanation: A resting reading of 118/76 mmHg is within the commonly expected adult range.

Correct answer: 118/76 mmHg
  • A. Over the fifth intercostal space at the midclavicular line
  • B. Over the second intercostal space at the right sternal border
  • C. Over the sixth intercostal space at the midaxillary line
  • D. Over the third intercostal space at the left sternal border

Explanation: The adult apical pulse is heard at the fifth intercostal space on the left midclavicular line.

Correct answer: Over the fifth intercostal space at the midclavicular line
  • A. Pull the pinna upward and backward before inserting the probe
  • B. Pull the pinna downward and backward before inserting the probe
  • C. Place the probe under the tongue and ask the patient to close the mouth
  • D. Place the probe against the centre of the forehead for several seconds

Explanation: For an adult, the pinna is gently pulled upward and backward to straighten the ear canal before the tympanic probe is positioned.

Correct answer: Pull the pinna upward and backward before inserting the probe
Moderate
  • A. Use a validated behavioural pain assessment scale
  • B. Assume the patient has no pain because vital signs are stable
  • C. Ask the family to estimate the patient’s pain score
  • D. Wait until the patient can speak before giving prescribed analgesia

Explanation: A validated behavioural scale can assess pain through facial expression, body movement and response to care when self-report is not…

Correct answer: Use a validated behavioural pain assessment scale
  • A. Assess the airway and breathing while calling for urgent help
  • B. Allow the patient to sleep and reassess after one hour
  • C. Give the next prescribed opioid dose to prevent withdrawal
  • D. Offer oral fluids and place the patient in a sitting position

Explanation: A respiratory rate of 8 with reduced consciousness suggests opioid-related respiratory depression, so airway and breathing take priority.

Correct answer: Assess the airway and breathing while calling for urgent help
Hard
  • A. Support the hand, check probe placement and repeat the reading
  • B. Immediately document severe hypoxaemia without further assessment
  • C. Increase oxygen to a high flow rate without checking the reading
  • D. Remove the probe permanently because movement makes it unreliable

Explanation: Movement can create motion artefact and produce an unreliable pulse oximeter reading.

Correct answer: Support the hand, check probe placement and repeat the reading
  • A. Allow the patient to rest and cool before measuring orally
  • B. Measure immediately because exercise does not affect temperature
  • C. Give a hot drink before measuring to stabilise the reading
  • D. Place the thermometer in the axilla while the patient is exercising

Explanation: Exercise can temporarily raise body temperature, so the patient should rest and cool before an oral measurement.

Correct answer: Allow the patient to rest and cool before measuring orally
Moderate
  • A. Record the response to activity and continue routine observation
  • B. Report an emergency tachycardia despite the normal resting pulse
  • C. Administer a prescribed cardiac drug without reassessing the patient
  • D. Restrict all movement because any exertional pulse rise is abnormal

Explanation: A temporary pulse increase with activity that returns toward the patient’s baseline after rest can be a normal physiological response.

Correct answer: Record the response to activity and continue routine observation
  • A. Count the apical and radial pulses simultaneously for one full minute
  • B. Count the radial pulse for 15 seconds and multiply the result by four
  • C. Count the carotid pulse for 30 seconds while the patient talks
  • D. Estimate the heart rate from the patient’s blood pressure monitor

Explanation: Simultaneous one-minute apical and radial counts show whether every cardiac contraction produces a peripheral pulse.

Correct answer: Count the apical and radial pulses simultaneously for one full minute
  • A. 142/86 mmHg
  • B. 86/142 mmHg
  • C. 142/142 mmHg
  • D. 86/86 mmHg

Explanation: The first Korotkoff sound represents systolic pressure, and the disappearance of the sounds represents diastolic pressure.

Correct answer: 142/86 mmHg
  • A. 35.2°C
  • B. 36.8°C
  • C. 38.4°C
  • D. 39.1°C

Explanation: A resting adult oral temperature is commonly about 36°C to 38°C, although it varies with time and measurement method.

Correct answer: 36.8°C
  • A. Place the probe over clothing and hold the arm loosely
  • B. Place the probe in a dry axilla and hold the arm against the chest
  • C. Place the probe on the centre of the upper arm and support the elbow
  • D. Place the probe below the shoulder blade and ask the patient to lie still

Explanation: The probe should contact the skin in the deepest part of a dry axilla, with the arm held firmly against the chest.

Correct answer: Place the probe in a dry axilla and hold the arm against the chest
Hard
  • A. Document the reading as severe hypoxaemia
  • B. Remove the sensor and stop monitoring the patient
  • C. Warm the hand and repeat the reading on a suitable site
  • D. Administer a sedative to reduce possible anxiety

Explanation: Nail polish and poor peripheral perfusion can interfere with pulse oximeter accuracy.

Correct answer: Warm the hand and repeat the reading on a suitable site
  • A. Wait until oxygen saturation falls before taking action
  • B. Reassess the patient and report the concerning trend
  • C. Record the new rate as expected after routine activity
  • D. Ask the patient to hold the breath during reassessment

Explanation: A rising respiratory rate and increasingly shallow breathing may be an early sign of deterioration, even when oxygen saturation is still…

Correct answer: Reassess the patient and report the concerning trend
  • A. Recent quiet sleep
  • B. Recent strenuous exercise
  • C. Correctly sized cuff placement
  • D. Supported arm at heart level

Explanation: Exercise temporarily increases cardiac output and can raise blood pressure.

Correct answer: Recent strenuous exercise
Moderate
  • A. Diagnose hypertension from this single reading
  • B. Repeat the measurement after quiet rest
  • C. Give an antihypertensive medicine immediately
  • D. Measure the pressure over the patient’s clothing

Explanation: Talking can raise or alter a blood pressure reading, so the nurse should allow the patient to rest quietly and repeat the measurement…

Correct answer: Repeat the measurement after quiet rest