Question 1

The nurse is planning care for a 14 year-old client returning from scoliosis corrective surgery. Which of the following actions should receive PRIORITY in the plan?

Accepted Answer

Answer reason: After scoliosis corrective (spinal) surgery, the priority is frequent neurovascular assessments to detect cord or nerve injury. Assessing movement and sensation of extremities addresses this risk. The other options are not immediate priorities in the first postoperative period.

Question 2

A client has been admitted with a fractured femur and has been placed in skeletal traction. Which of the following nursing interventions should receive PRIORITY?

Accepted Answer

Answer reason: After femur fracture in traction, the time-critical priority is frequent neurovascular checks to detect compartment syndrome or vascular compromise early. Alignment, pin-site care, and trapeze use are important but not as urgent.

Question 3

The nurse notes that a 2 year-old child recovering from a tonsillectomy has a temperature of 98.2 degrees F at 8:00 AM. At 10:00 AM the child's mother reports that the child "feels very warm" to touch. The FIRST action by the nurse should be to?

Accepted Answer

Answer reason: When a parent reports the child feels warm, the priority is to reassess and verify the temperature before offering fluids or administering medication.

Question 4

The nurse is providing instructions for a client with asthma. Which of the following should the client monitor on a daily basis?

Accepted Answer

Answer reason: Asthma patients should use a peak flow meter daily to track peak expiratory flow; declines often precede symptoms and guide management. Respiratory rate, pulse oximetry, and skin color are not recommended for routine daily self-monitoring.

Question 5

A client with anorexia is hospitalized on a medical unit due to electrolyte imbalance and cardiac dysrhythmias. Additional assessment findings that the nurse would expect to observe are?

Accepted Answer

Answer reason: Anorexia nervosa commonly presents with malnutrition signs such as brittle hair, fine lanugo, and amenorrhea due to hypoestrogenism. Option B aligns more with bulimia, and option C is incorrect because anorexia typically causes hypothermia, bradycardia, and decreased metabolic rate.

Question 6

Which data gives the most accurate information regarding an ESRD client's fluid status?

Accepted Answer

Answer reason: Daily weight most accurately reflects fluid volume changes in ESRD; a 1 kg change approximates 1 L of fluid. I&O and skin turgor are less reliable, and electrolytes do not directly indicate volume status.

Question 7

Which of the following is not a sign of thromboembolism?

Accepted Answer

Answer reason: Venous thromboembolism typically presents with swelling, redness, warmth, and edema of the affected limb. Coolness is more consistent with arterial insufficiency and is not a typical sign of thromboembolism.

Question 8

A 32-year-old man presents with itchy, red, thickened, scaly patches on his elbows and knees. Gentle scraping produces pinpoint bleeding. What is the most likely diagnosis?

Accepted Answer

Answer reason: Psoriasis vulgaris typically presents with sharply demarcated erythematous plaques covered by silvery scales. The Auspitz sign—pinpoint bleeding after scale removal—is a classic diagnostic finding.

Question 9

A patient presents with clubbing of the fingers. Which condition is *least* likely associated?

Accepted Answer

Answer reason: Clubbing is typically associated with chronic hypoxia (e.g., cyanotic heart disease), pulmonary disease (e.g., lung cancer), or systemic inflammatory disorders such as inflammatory bowel disease. Iron deficiency anemia does not cause clubbing.

Question 10

A newborn has a dark brown to black, irregular, thickened pigmented lesion covering part of the face and scalp. The lesion contains coarse hair and was present at birth. What is the diagnosis?

Accepted Answer

Answer reason: Congenital melanocytic nevi are large, pigmented, often hair-bearing lesions present at birth. Their dark color and irregular borders distinguish them from other lesions.

Question 11

A postoperative patient has not voided for 8 hours and reports lower abdominal discomfort. Which action should the nurse take first?

Accepted Answer

Answer reason: A bladder scan provides a rapid, noninvasive assessment of urinary retention, guiding whether catheterization or further interventions are required. Assessment must occur before notifying the provider or implementing treatment.

Question 12

A nurse is caring for a patient receiving oxygen via nasal cannula at 4 L/min. Which action is most essential to ensure safe and effective oxygen delivery?

Accepted Answer

Answer reason: Moisture, friction, and pressure from nasal cannula tubing commonly cause skin breakdown around the nares and ears. Early detection allows timely intervention to prevent irritation, ulceration, and infection. Petroleum products should never be used near oxygen due to fire risk.

Question 13

A newborn presents with a dark, thick, hair-bearing lesion present at birth. What is the most likely diagnosis?

Accepted Answer

Answer reason: Large, pigmented, irregular lesions containing coarse hair at birth are classic congenital melanocytic nevi. Their presence carries increased melanoma risk depending on size.

Question 14

What is common site for recording pulse rate?

Accepted Answer

Answer reason: The radial artery at the wrist is the most common site for measuring pulse in adults because it is superficial, easily accessible, and allows comfortable counting during routine vital sign assessment. The apical pulse is preferred when the peripheral pulse is irregular, in infants, or when giving certain cardiac medications. The brachial pulse is commonly used in infants and for blood pressure measurement, and the femoral pulse is reserved for central circulation assessment or emergencies.

Question 15

A 36-year-old patient has been diagnosed with scleroderma and has breathing difficulties, including wheezing and dry cough. Which of the following skin changes would the nurse also expect to see upon assessment of this patient?

Accepted Answer

Answer reason: Scleroderma (systemic sclerosis) causes excessive collagen deposition leading to skin fibrosis and induration. Typical findings include thick, stiff, and tight skin that may show hypo- or hyperpigmented patches. Pulmonary involvement can present with cough and wheezing, consistent with the scenario. Petechial rash, redundant skin folds, or moist cool skin are not characteristic of scleroderma.

Question 16

Which finding should the nurse observe first when a client arrives in the immediate postoperative period?

Accepted Answer

Answer reason: Immediate postoperative assessment prioritizes ABCs and perfusion. Observing the colour of the skin (pallor, cyanosis, mottling) gives rapid clues to oxygenation and circulation and can be done instantly on arrival. Tachycardia and hypertension are vital signs that require measurement, and oliguria is assessed over time via urine output. Therefore, the most immediate observable parameter listed is skin colour.

Question 17

A 5-year-old child with a suspected middle-ear infection screams as the nurse approaches with a tympanic thermometer. What should the nurse do?

Accepted Answer

Answer reason: Tympanic measurements can be uncomfortable in suspected otitis media and are unreliable if the child is distressed and resisting, leading to an improper seal. Using clear, age-appropriate communication and choosing a less invasive route like the axillary site improves cooperation and safety while still providing a usable temperature. Restraining the child is inappropriate and can escalate fear. Simply delaying does not address the painful route or accuracy concerns.

Question 18

The normal blood pressure is?

Accepted Answer

Answer reason: For adults, the standard reference blood pressure is approximately 120/80 mm Hg, with systolic

Question 19

Which pulse site is used during CPR?

Accepted Answer

Answer reason: During CPR, the carotid pulse is used because it is a central artery with strong perfusion even during low cardiac output states. Peripheral pulses such as radial or pedal may be absent during cardiac arrest, making the carotid the most reliable site.

Question 20

The fluid and electrolyte balance in a patient can be easily assessed by?

Accepted Answer

Answer reason: Urine output is the most immediate and reliable bedside indicator of fluid balance and renal perfusion; oliguria signals hypovolemia or renal dysfunction. Blood pressure and pulse can be influenced by many factors and are less specific for fluid-electrolyte status. Therefore, among the choices, urine output provides the easiest and most direct assessment.

Question 21

The adaptations of a client with complete heart block would most likely include?

Accepted Answer

Answer reason: Complete (third-degree) heart block causes atrioventricular dissociation with a ventricular escape rhythm, typically 20–40 bpm. The profound bradycardia reduces cardiac output and cerebral perfusion, producing syncope (Adams–Stokes attacks), dizziness, and fatigue. Therefore, syncope with a slow ventricular rate is most characteristic. The other option sets are nonspecific and less predictive of complete heart block.

Question 22

Normal urinary output is anywhere between?

Accepted Answer

Answer reason: For adults, expected urine output is about 0.5–1 mL/kg/hr, with oliguria defined as

Question 23

Normal systolic blood pressure in adults is?

Accepted Answer

Answer reason: In healthy adults, normal systolic blood pressure is typically around 120 mmHg, with an acceptable range of about 90–120 mmHg. Values below 90 mmHg may indicate hypotension, while sustained readings ≥140 mmHg suggest hypertension. Options 140–160 and 160–200 mmHg are hypertensive ranges, and 60–80 mmHg corresponds to normal diastolic pressures, not systolic.

Question 24

The sequence in examining the quadrants of the abdomen is?

Accepted Answer

Answer reason: Abdominal assessment is performed systematically, beginning in the right lower quadrant where bowel sounds are most consistently present near the ileocecal valve. From there, the examiner proceeds in a clockwise fashion: RLQ → RUQ → LUQ → LLQ. This pattern ensures all quadrants are assessed without omission and is commonly used for auscultation and subsequent palpation/percussion.

Question 25

Skin pinch test is done in case of...?

Accepted Answer

Answer reason: The skin pinch (turgor) test assesses the elasticity and return of the skin after being pinched. In dehydration or fluid volume deficit, skin turgor is reduced and the skin tents or returns slowly, indicating decreased interstitial fluid. Infection, hypothermia, and hypoglycemia do not primarily affect skin turgor in this way. Therefore, the test is used to evaluate dehydration.

Question 26

While auscultating a client's bowel sounds, the nurse notes a swooshing sound to the left of the umbilical area. What would be the nurse's priority action?

Accepted Answer

Answer reason: A swooshing sound over the abdomen is a vascular bruit, suggesting turbulent flow and possible abdominal aortic aneurysm or arterial stenosis. Palpation or percussion could precipitate rupture or dislodge plaque and should be avoided. The safest priority is to stop manipulating the abdomen and promptly notify the provider for further evaluation (e.g., ultrasound, vascular consult). Continue monitoring vital signs and abdominal findings while avoiding pressure on the area.

Question 27

The Glasgow Coma Scale is used to assess?

Accepted Answer

Answer reason: The Glasgow Coma Scale (GCS) quantifies a patient's level of consciousness based on eye opening, verbal response, and motor response. Scores help track neurologic status and detect deterioration, especially after head injury or in altered mental status. It does not measure pain, mobility, or nutritional status.

Question 28

Which of the following is a subjective sign?

Accepted Answer

Answer reason: Subjective signs (symptoms) are experiences reported by the patient that cannot be directly observed or measured by the clinician. A headache is perceived only by the patient and thus is subjective. Vomiting, fever, and cough are objective findings because they can be observed or measured (e.g., emesis, temperature, audible cough).

Question 29

The first sign of dehydration is?

Accepted Answer

Answer reason: Thirst is the earliest physiologic response to rising plasma osmolality, mediated by hypothalamic osmoreceptors, and is typically the first symptom people notice with mild dehydration. Fever and vomiting are potential causes or later accompanying findings rather than initial signs. Confusion occurs in more severe dehydration, especially in older adults. Therefore, thirst is the first sign.

Question 30

Fred is a 12-year-old boy diagnosed with pneumococcal pneumonia. Which of the following would Nurse Nica expect to assess?

Accepted Answer

Answer reason: Pneumococcal pneumonia commonly presents with high fever, productive cough, and pleuritic chest pain due to inflammation of the pleura. Mild cough and slight fever are atypical for pneumococcal pneumonia, which tends to be more acute and severe. Bulging fontanel is a sign seen in infants with increased intracranial pressure or meningitis, not expected in a 12-year-old with pneumonia. Therefore, chest pain is the most expected assessment finding.

Question 31

A patient with type 1 diabetes becomes confused, diaphoretic, and shaky. What is the nurse’s priority action?

Accepted Answer

Answer reason: Confusion, diaphoresis, and tremors in a patient with type 1 diabetes strongly suggest hypoglycemia. The priority is to assess by checking a rapid point-of-care blood glucose to confirm and guide immediate treatment. Administering insulin could worsen hypoglycemia, and calling the provider or starting an IV delays the critical assessment and treatment. If glucose is low, provide fast-acting carbohydrates or IV dextrose per protocol.

Question 32

The first techniques used examination the abdomen of a client is --------?

Accepted Answer

Answer reason: Abdominal assessment follows the sequence inspection, auscultation, percussion, and palpation. Inspection is performed first to observe contour, symmetry, and any visible abnormalities without altering bowel activity. Auscultation comes next to avoid stimulating peristalsis that percussion or palpation could cause. Therefore, the first technique is inspection.

Question 33

Temperature difference between the axillary and rectal route is ......?

Accepted Answer

Answer reason: Rectal temperatures typically read about 0.9°F (0.5°C) higher than oral, while axillary temperatures read about 0.9°F lower than oral. Therefore, rectal temperature is approximately 1.8°F higher than axillary, rounded to 2°F. This reflects that rectal measures core temperature, whereas axillary is more affected by ambient conditions.

Question 34

The nurse should use the diaphragm of the stethoscope to auscultate which of the following?

Accepted Answer

Answer reason: The diaphragm is designed to transmit higher-pitched sounds best, such as normal bowel sounds and many breath sounds. In contrast, low-pitched vascular sounds like carotid bruits and jugular venous hums are typically better heard with the bell using light pressure. While some murmurs may be high-pitched, many classic exam questions associate murmurs with bell use, whereas bowel sounds are reliably assessed with the diaphragm.

Question 35

The proper way to measure a patient's blood pressure is to?

Accepted Answer

Answer reason: Accurate blood pressure measurement requires an appropriately sized cuff; an undersized cuff can falsely elevate readings, while an oversized cuff can falsely lower them. Standard technique also includes measuring on a bare upper arm with the arm supported at heart level and the patient seated and rested, not standing. Wrist measurements are generally less reliable and more position-dependent than upper-arm measurements. Measuring over clothing can interfere with cuff compression and produce inaccurate values.

Question 36

One day after a coronary artery bypass (CABG), the nurse discovers a client sitting in a chair. The client is cold, pale and responds to loud verbal stimuli. Which of the following actions by the nurse is MOST appropriate?

Accepted Answer

Answer reason: A post-CABG client who is pale, cold, and only responsive to loud verbal stimuli suggests possible hypoperfusion or a cardiopulmonary complication (e.g., low cardiac output, dysrhythmia). The priority is immediate assessment of airway/breathing/circulation with focused cardiac assessment (vital signs, heart rhythm, perfusion, mental status) to identify the cause and guide urgent interventions. Oxygen and repositioning may be needed, but without assessment the nurse cannot determine the most urgent underlying problem or safely choose the next step. Reviewing prior sedatives delays evaluation of a potentially life-threatening deterioration.

Question 37

Which artery is used to measure Blood Pressure?

Accepted Answer

Answer reason: Standard noninvasive blood pressure measurement with a cuff and stethoscope is performed over the brachial artery in the antecubital fossa. This location provides a large, accessible artery that aligns well with upper-arm cuff placement and yields accurate Korotkoff sounds. Radial is commonly used to palpate a pulse, not for routine auscultatory BP measurement, and femoral/carotid are not used for routine cuff BP due to positioning and safety/accuracy considerations.

Question 38

The most accurate method of measuring core body temperature is?

Accepted Answer

Answer reason: Rectal temperature most closely reflects core body temperature because the rectum is less affected by ambient air and external cooling/heating compared with oral and axillary sites. Axillary readings are typically the least accurate and are more influenced by skin temperature. Oral readings can be affected by recent ingestion of hot/cold liquids and mouth breathing. Tympanic readings approximate core temperature but are technique- and ear-canal–dependent, making them less consistently accurate than rectal in basic clinical measurement.

Question 39

A patient is found to have a reddened area of skin with serum filled blister formation. The wound is staged as?

Accepted Answer

Answer reason: A reddened area of skin with a serum-filled blister indicates partial-thickness skin loss with exposed dermis, which is characteristic of a Stage II pressure injury. Stage I has intact skin with nonblanchable erythema only and no blistering. Stage III and IV involve full-thickness tissue loss, with Stage IV extending to muscle, tendon, or bone, which is not described here.

Question 40

The client arrives at the emergency department with complaints of low abdominal pain and hematuria. The client is a febrile. The nurse assesses the client to determine a history of?

Accepted Answer

Answer reason: Hematuria with fever suggests an infectious etiology in the urinary tract; assessing for a history of pyelonephritis helps identify prior upper UTI episodes and risk for recurrence or complications. Pyelonephritis commonly presents with systemic signs (fever/chills) along with urinary findings, and may include abdominal/flank pain. Glomerulonephritis more often presents with edema, hypertension, and tea-colored urine rather than acute febrile illness. Trauma and family history of renal cancer can be associated with hematuria, but they do not best explain the febrile presentation compared with infection.

Question 41

Which of the following blood pressure readings should be reported immediately to the physician?

Accepted Answer

Answer reason: A diastolic blood pressure of 98 mm Hg is abnormally elevated and indicates significant hypertension (especially concerning because diastolic ≥90 is high). Compared with the other options, this reading reflects the most clinically concerning abnormality that may require provider notification and possible treatment adjustment. The other readings are normal to mildly elevated and generally do not require immediate reporting in an otherwise stable adult without symptoms. Immediate reporting is prioritized for values that suggest increased risk of acute complications (e.g., stroke, end-organ strain) or represent a notable change from baseline.

Question 42

Which of the following techniques should the nurse use to assess a patient's cranial nerve II (optic nerve)?

Accepted Answer

Answer reason: Cranial nerve II (optic nerve) is responsible for vision, so assessing it focuses on visual function such as visual acuity (e.g., Snellen chart) and visual fields. Pupillary light response primarily evaluates cranial nerve III (oculomotor) as the efferent limb (with CN II as the afferent limb), so it is not the best single technique for CN II. The Romberg test assesses balance/proprioception (primarily dorsal columns/vestibular pathways), not the optic nerve. Facial symmetry evaluates cranial nerve VII (facial nerve).

Question 43

Which of the following is the primary indicator of adequate tissue perfusion?

Accepted Answer

Answer reason: Capillary refill is a direct bedside assessment of peripheral tissue perfusion, reflecting adequacy of microcirculatory blood flow and oxygen delivery to tissues. A brisk refill (typically

Question 44

A pregnant client at 36 weeks gestation reports decreased fetal movement. What should the nurse do first?

Accepted Answer

Answer reason: Decreased fetal movement requires prompt assessment, but the first nursing action is a simple, immediate intervention to optimize conditions for fetal activity before escalating care. Having the client rest (often left lateral) reduces maternal activity and can improve uteroplacental perfusion, which may increase perceived fetal movement and clarifies whether the decrease persists. If movement remains decreased after rest, the nurse should then proceed with fetal assessment such as a non-stress test and notify the obstetric provider based on findings. Checking vital signs is appropriate but does not directly address fetal status as effectively as initiating rest and then evaluating fetal response.

Question 45

A nurse is preparing a client for a Romberg test to evaluate balance. Which of the following statements should the nurse make?

Accepted Answer

Answer reason: The Romberg test assesses balance and proprioception by having the client stand with feet together and arms at the sides, then typically closing the eyes while the nurse observes for swaying or loss of balance. This positioning narrows the base of support and helps reveal sensory ataxia. The other options describe different assessments: tuning fork for hearing/vibration, plantar reflex (Babinski), and rapid finger-to-thumb movements for coordination.

Question 46

When a patient's nasogastric (NG) tube stops draining, what is the nurse's first action?

Accepted Answer

Answer reason: The first action when an NG tube stops draining is to assess for tube patency and safety by verifying tube placement, because migration or dislodgement can place the tube in the esophagus or respiratory tract and make further interventions unsafe. Flushing/instilling water can be inappropriate if the tube is malpositioned and may increase aspiration risk. Retracting the tube without verification can worsen malposition or cause mucosal injury. Clamping would not correct the problem and could contribute to gastric distention or vomiting.

Question 47

A 24-year-old female patient presents with dysuria, vaginal discharge, and lower abdominal pain. The nurse suspects chlamydia infection. Which of the following is the priority assessment for this patient?

Accepted Answer

Answer reason: With suspected chlamydia and pelvic symptoms, the priority assessment is a focused sexual history to identify STI exposure risks, guide appropriate screening (including for gonorrhea/HIV/syphilis), and determine need for partner notification and treatment. This information also helps assess risk for complications such as pelvic inflammatory disease and informs urgency of evaluation. While NAAT and pelvic exam are important diagnostic steps, obtaining key history is the first priority assessment to direct safe, targeted testing and management. Temperature and urinalysis may be helpful but are less specific to chlamydia and do not replace focused STI risk assessment.

Question 48

A nurse is performing an assessment of a client who is scheduled for cesarean delivery. Which assessment finding would indicate a need to contact the physician?

Accepted Answer

Answer reason: A fetal heart rate of 180 bpm represents fetal tachycardia (normal baseline typically 110–160 bpm) and can indicate fetal distress, maternal fever/infection, or hypoxia, requiring prompt provider notification before surgery. The other findings are not urgent abnormalities in a term pregnant client: WBC 12,000 can be a normal pregnancy leukocytosis, maternal pulse 85 bpm is within normal range, and hemoglobin 11.0 g/dL is borderline/expected mild dilutional anemia in pregnancy and is not an immediate pre-op emergency finding by itself.

Question 49

A nurse is performing a postpartum assessment on a client who delivered a baby 8 hours ago. The nurse assesses the client’s legs by checking the Homan’s sign and the client complains of pain. Which condition can a positive Homan’s sign indicate?

Accepted Answer

Answer reason: A positive Homan’s sign (calf pain with dorsiflexion of the foot) is classically associated with deep vein thrombosis (DVT). Postpartum clients are at increased risk for DVT due to hypercoagulability, venous stasis, and potential vascular injury around delivery. While Homan’s sign is neither sensitive nor specific and should not be used alone to diagnose DVT, among the options it most directly indicates DVT and warrants further evaluation (e.g., venous duplex ultrasound).

Question 50

What is the common site for recording pulse rate?

Accepted Answer

Answer reason: The radial pulse is the most commonly used site for routine pulse assessment because it is superficial, easy to palpate, and generally accessible without repositioning the client. Apical pulses are used when peripheral pulses are difficult to assess or when evaluating rate/rhythm more accurately (e.g., infants, dysrhythmias, before certain cardiac meds). Brachial pulses are commonly used for blood pressure measurement and in infants, while femoral pulses are assessed for central perfusion but are not the usual routine site. Therefore, the common site for recording pulse rate is the radial artery.

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