Question 1

This is the sound of a normal lung?

Accepted Answer

Answer reason: On percussion, a normally aerated lung produces a resonant sound. Hyperresonance occurs with excess air (e.g., emphysema or pneumothorax), dullness with consolidation or over an organ, and flatness over bone or muscle.

Question 2

A score of 4 for a reflex means that it is ________?

Accepted Answer

Answer reason: Deep tendon reflex scale: 0 absent, 1+ diminished, 2+ average/normal, 3+ brisker than average, 4+ hyperactive (often with clonus). Therefore, a score of 4 indicates hyperactive reflexes.

Question 3

When assessing temperature, which portion of the hand is most sensitive?

Accepted Answer

Answer reason: The dorsal (back) surface of the hand has more temperature receptors and is best for assessing skin temperature. Finger pads are used for fine discrimination, and the ulnar and palmar surfaces are better for vibration.

Question 4

When using percussion to assess a patient, dullness is normally found in which location?

Accepted Answer

Answer reason: Percussion over solid organs, like the liver, produces dullness. Normal lungs are resonant; muscle and bone are flat, and a gastric air bubble is tympanic.

Question 5

An example of direct (immediate) auscultation is?

Accepted Answer

Answer reason: Direct (immediate) auscultation is listening to sounds audible to the ear without an instrument, such as wheezing. The other options use devices and represent indirect (mediate) auscultation.

Question 6

How long should the rectal thermometer be inserted into the client's anus?

Accepted Answer

Answer reason: For rectal temperature, insert the probe about 1 to 1.5 inches in adults and about 0.5 to 1 inch in infants and children. Depths of 2 inches or more are unsafe. Thus, 0.5 to 1.5 inches represents the safe insertion range.

Question 7

On a Fahrenheit glass thermometer, how many degrees do the short lines indicate?

Accepted Answer

Answer reason: Clinical Fahrenheit thermometers have small divisions of 0.2°F between whole-degree marks, allowing readings to the nearest 0.2°F.

Question 8

When gathering baseline information on a client, the nurse will check blood pressure in both arms to detect deficits. There should be no more than how many mm Hg difference between the two?

Accepted Answer

Answer reason: An inter-arm systolic blood pressure difference greater than about 10 mmHg can indicate vascular disease (e.g., subclavian stenosis). An acceptable difference is no more than 10 mmHg.

Question 9

If you count nine respirations in 30 seconds, you would report?

Accepted Answer

Answer reason: Respirations counted over 30 seconds are doubled to obtain the per-minute rate: 9 × 2 = 18 breaths per minute.

Question 10

How many minutes should be allowed to pass if the client has engaged in strenuous activity, smoked, or ingested caffeine before taking his/her BP?

Accepted Answer

Answer reason: Exercise, smoking, and caffeine acutely elevate blood pressure via sympathetic stimulation; guidelines recommend waiting at least 30 minutes before measuring BP to avoid a falsely high reading.

Question 11

How many minutes are allowed to pass before making a re-reading after the first one?

Accepted Answer

Answer reason: When rechecking blood pressure, at least one minute should pass between readings to allow circulation to recover and avoid venous congestion that can skew results.

Question 12

Identify the length of time over which a pulse should be taken?

Accepted Answer

Answer reason: For accuracy when assessing pulse rate and rhythm, the nurse counts for a full minute (60 seconds) to best detect irregularities.

Question 13

How long should the thermometer stay in the client's axilla?

Accepted Answer

Answer reason: With a glass thermometer, the axillary site takes about 7–10 minutes to reach an accurate reading; standard teaching is 7 minutes.

Question 14

During a routine physical examination, a firm mass is palpated in the right breast of a 35-year-old woman. Which of the following findings or aspects of the client's history would suggest breast cancer rather than fibrocystic disease?

Accepted Answer

Answer reason: Early menarche increases lifetime estrogen exposure and is a recognized risk factor for breast cancer. Fibrocystic disease typically shows cyclic changes in lump size and tenderness; increased vascularity and anovulatory cycles do not specifically indicate malignancy.

Question 15

A client is admitted with newly diagnosed Hodgkin's disease. Which of the following would the nurse expect the client to report?

Accepted Answer

Answer reason: Hodgkin lymphoma commonly presents with B symptoms—fever, drenching night sweats, and weight loss—while the lymph nodes are typically painless. Weight gain and headache are not typical.

Question 16

Which of the following diastolic blood pressure readings is abnormal and should be reported to the doctor?

Accepted Answer

Answer reason: Normal adult diastolic BP is about 60–80 mm Hg. A diastolic value of 97 mm Hg is abnormally high and indicates hypertension, requiring provider notification.

Question 17

Rhina, who has Meniere's disease, said that her environment is moving. Which of the following is a valid assessment? 1. Rhina is giving objective data 2. Rhina is giving subjective data 3. The source of the data is primary 4. The source of the data is secondary?

Accepted Answer

Answer reason: The client’s statement that “the environment is moving” reflects a personal sensation (vertigo) that cannot be directly measured by the nurse; thus, it is subjective data. Because it comes directly from the client, the data source is primary.

Question 18

The nurse is assessing the integumentary system of a dark-skinned individual. Which area would most likely show a skin cancer lesion?

Accepted Answer

Answer reason: In dark-skinned individuals, skin cancers—especially acral lentiginous melanoma—are more likely on acral, non–sun-exposed sites such as the palms, soles, and nail beds, rather than sun-exposed areas like the face or arms.

Question 19

A client with a gastrointestinal bleed has an NG tube on low continuous wall suction. Which technique is the correct procedure for the nurse to use when assessing bowel sounds?

Accepted Answer

Answer reason: To accurately assess bowel sounds with an NG tube on suction, the suction must be stopped or the tube clamped to avoid transmission of suction noise; then auscultate with a stethoscope.

Question 20

The nurse is caring for a client with scalding burns across the face, neck, the upper half of the anterior chest, and the entire right arm. Using the rule of nines, estimate the percentage of the body burned?

Accepted Answer

Answer reason: Adult rule of nines: anterior head/neck = 4.5%, anterior chest (upper half of trunk) = 9%, entire arm = 9%. Total 4.5 + 9 + 9 = 22.5% ≈ 23%.

Question 21

The nurse is caring for a child with a diagnosis of possible hydrocephalus. Which assessment data in the admission history would be most objective?

Accepted Answer

Answer reason: Objective data are measurable observations. Head circumference is a direct, quantifiable measurement relevant to hydrocephalus, whereas anorexia and vomiting are subjective symptoms and temperature is a general vital sign not specific to the history of hydrocephalus.

Question 22

The nurse is caring for a client with cirrhosis of the liver. Which is the best method to determine whether the client has ascites?

Accepted Answer

Answer reason: Measuring abdominal girth daily provides an objective way to monitor fluid accumulation and evaluate ascites progression.

Question 23

The nurse is caring for a client scheduled for surgical repair of an abdominal aortic aneurysm. Which assessment is most crucial during the preoperative period?

Accepted Answer

Answer reason: Baseline identification of peripheral pulses is critical before AAA repair, to allow postoperative comparison and early detection of impaired lower-extremity perfusion or graft complications. The other assessments are not as immediately vital to vascular outcomes.

Question 24

The nurse is completing the admission of a client with possible esophageal cancer. Which finding would not be common for this diagnosis?

Accepted Answer

Answer reason: Typical signs of esophageal cancer include progressive dysphagia, halitosis due to food stasis, weight loss, and sometimes persistent hiccups due to nerve or diaphragmatic irritation. Diarrhea is not a common manifestation of esophageal pathology, making it the least likely finding.

Question 25

The nurse is caring for a client with a closed-head injury. Fluid is noted leaking from the ear. The nurse's first action will be to?

Accepted Answer

Answer reason: Clear otorrhea after a head injury may be cerebrospinal fluid. The priority is assessment—verify CSF by testing for glucose or the halo sign—before notifying the provider. Do not irrigate, and do not apply an occlusive dressing, which can increase ICP or the risk of infection.

Question 26

The nurse has inserted an NG tube for enteral feedings. Which assessment result is the best indicator of the tube's placement in the stomach?

Accepted Answer

Answer reason: Gastric contents are typically acidic (pH ≤ 5) and may appear green; checking the pH of the aspirate is the most reliable bedside indicator of gastric placement. Air bolus auscultation and bubbling tests are unreliable, and tan mucus suggests respiratory secretions.

Question 27

The nurse assesses a client who is complaining of a headache. When the nurse shines a light on the frontal and maxillary sinuses, the light does not penetrate the tissues. What is the best interpretation of this finding?

Accepted Answer

Answer reason: Transillumination of air-filled sinuses normally allows light to pass through and produce a glow. Failure of light to penetrate suggests the sinus is opaque, most commonly due to fluid or pus.

Question 28

The nurse is assessing a client for tactile fremitus. Which client is most likely to exhibit a decrease in tactile fremitus? A client with?

Accepted Answer

Answer reason: Tactile fremitus decreases when transmission of vibrations through lung tissue is reduced, such as with hyperinflation and increased air in the lungs seen in emphysema. Consolidation (e.g., pneumonia or some cases of TB) typically increases fremitus.

Question 29

The nurse is evaluating cerebral perfusion outcomes for a client with a subdural hematoma. Which of the following does the nurse evaluate as a favorable outcome for this client?

Accepted Answer

Answer reason: Adequate oxygenation (PaO2 ~98 mmHg) supports cerebral perfusion and reduces secondary brain injury. Increased lethargy, sluggish pupils, and fever indicate neurological decline or increased metabolic demand/ICP, not favorable outcomes.

Question 30

When inspecting the abdomen, which of the following is not done?

Accepted Answer

Answer reason: For abdominal assessment, the client should void first and assume a dorsal recumbent position, with knees flexed and hips externally rotated, to relax the abdominal muscles. Straightening the knees tenses the abdomen, so it is not done.

Question 31

Which of the following is the most common symptom of myocardial infarction (MI)?

Accepted Answer

Answer reason: The hallmark and most common symptom of acute MI is chest pain or pressure due to myocardial ischemia; dyspnea, palpitations, and edema can occur, but are less common primary presentations.

Question 32

A nurse is making rounds, taking vital signs. Which of the following vital signs is abnormal?

Accepted Answer

Answer reason: For an adolescent, normal HR is ~60–100 bpm, RR is 12–20, and BP averages near 110/65. The set in option B shows tachycardia and a low diastolic pressure (105/50), making it the abnormal set compared with age norms.

Question 33

Considered the most accessible and convenient method for taking temperatures?

Accepted Answer

Answer reason: The oral route is typically the most accessible and convenient for measuring temperature in cooperative adults; the rectal route is more invasive, the tympanic route requires specific equipment, and the axillary route is less accurate.

Question 34

What can you expect from Marianne, who is currently in the onset stage of a fever?

Accepted Answer

Answer reason: At fever onset, the hypothalamic set point rises, causing vasoconstriction and shivering. The skin appears pale and feels cool. Hot, flushed skin and increased thirst occur during the hot phase; convulsions are a possible complication, not typical at onset.

Question 35

If a person has a blue cast on their nail beds and feels cold to the touch, we say they have?

Accepted Answer

Answer reason: Cyanotic nail beds and cool skin indicate decreased peripheral oxygenation and blood flow, consistent with poor perfusion; the other options describe pulse characteristics not suggested by these findings.

Question 36

Which of the following is NOT a contraindication to taking an oral temperature?

Accepted Answer

Answer reason: A nasogastric tube passes through the nose and does not interfere with placing a thermometer under the tongue. Dyspnea (often mouth breathing) and active nausea or vomiting increase the risk and are contraindications; a quadriplegic patient may be unable to keep the thermometer in place or follow commands safely.

Question 37

A client with congestive heart failure has crackling lung sounds bilaterally at the bases. How should you document this finding?

Accepted Answer

Answer reason: Crackling lung sounds are termed crackles (rales) and are commonly heard with pulmonary edema in CHF. Rhonchi are coarse, low-pitched sounds; wheezes are musical; atelectasis is a condition, not a descriptive lung sound.

Question 38

Which of the following is incorrect in assessing a client's BP?

Accepted Answer

Answer reason: Proper BP technique is to inflate the cuff rapidly to 20–30 mmHg above the estimated systolic and then deflate it slowly at about 2–3 mmHg per second. Saying to inflate slowly is incorrect. Reading the upper meniscus at eye level and recognizing Korotkoff sounds are correct, and thigh (popliteal) systolic pressure can be 10–40 mmHg higher than brachial, making 160/80 potentially normal for a leg reading.

Question 39

A client who has experienced prolonged exposure to the cold has been admitted to the hospital. Which method of taking a temperature would be most appropriate for this client?

Accepted Answer

Answer reason: After prolonged cold exposure, a core temperature measurement is needed. Electronic rectal measurement best reflects core temperature, while axillary, oral, and tympanic readings can be inaccurate due to peripheral vasoconstriction or environmental factors.

Question 40

Earliest manifestation of inadequate oxygenation?

Accepted Answer

Answer reason: Restlessness and anxiety are early neurobehavioral signs of hypoxia before later findings such as cyanosis or hypotension develop.

Question 41

The sequence for examining the quadrants of the abdomen is?

Accepted Answer

Answer reason: Begin auscultation in the right lower quadrant at the ileocecal valve, where bowel sounds are usually present; then proceed clockwise: RLQ → RUQ → LUQ → LLQ.

Question 42

In assessing the client’s chest, which position best shows chest expansion as well as its movements?

Accepted Answer

Answer reason: The sitting position allows the best visualization and palpation of symmetrical chest expansion and respiratory movements; prone, side-lying, and supine positions limit observation.

Question 43

Which of the following is true about the auscultation of blood pressure?

Accepted Answer

Answer reason: Korotkoff sounds are low-pitched; they are best heard with the bell of the stethoscope. Saying they are high-frequency is false, and the pulse-grading statements are unrelated/incorrect (+1 is weak, not normal; +4 is bounding).

Question 44

Which arm is preferable for taking BP?

Accepted Answer

Answer reason: Use the right arm as the standard site for blood pressure measurement unless contraindicated. Avoid arms with devices or IVs, or the hemiplegic limb after a CVA. Therefore, the right arm is preferred, and options A, B, and D are inappropriate.

Question 45

If a person's heart doesn't always beat hard enough to produce a wave of blood, their pulse would be?

Accepted Answer

Answer reason: If some cardiac contractions are too weak to create a palpable arterial wave, peripheral beats will be dropped, making the pulse rhythm irregular. A thready pulse is consistently weak, and a bounding pulse is strong.

Question 46

Temperatures are not taken orally when a patient is receiving oxygen?

Accepted Answer

Answer reason: Oral temperatures are avoided in patients on oxygen therapy—especially with masks—because oxygen flow can cool the oral mucosa and produce inaccurate readings, and removing the mask may compromise oxygenation. Use another route (e.g., tympanic or axillary).

Question 47

A client is admitted with symptoms of vertigo and syncope. Diagnostic tests indicate left subclavian artery obstruction. What additional findings would the nurse expect?

Accepted Answer

Answer reason: Subclavian artery obstruction (subclavian steal) reduces perfusion to the affected upper extremity, producing diminished pulses and a notable inter-arm pulse/BP difference. Thus, a marked radial pulse difference is expected; the other options are not typical hallmarks.

Question 48

A client with pancreatitis has been transferred to the intensive care unit. The nurse assesses a pulmonary arterial wedge pressure (PAWP) of 14 mmHg. Based on this finding, the nurse would want to further assess for?

Accepted Answer

Answer reason: Normal PAWP is about 4–12 mmHg; a value of 14 indicates elevated left-sided filling pressures and risk of pulmonary congestion. The nurse should assess for crackles/rales. Hypotension and dry mucous membranes suggest low preload; chest pain is not specifically indicated by elevated PAWP.

Question 49

A client returns from surgery after an open reduction of a femur fracture. There is a small bloodstain on the cast. Four hours later, the nurse observes that the stain has doubled in size. What is the best action for the nurse to take?

Accepted Answer

Answer reason: Marking and dating the drainage on the cast allows objective monitoring of bleeding progression without unnecessary interventions. Cutting a window is inappropriate, and calling the provider is premature if bleeding appears minimal. Documentation should include the cast marking and nurse's notes.

Question 50

Which set of vital signs would best indicate increased intracranial pressure?

Accepted Answer

Answer reason: Increased intracranial pressure presents with Cushing’s response: hypertension with widened pulse pressure and bradycardia, often with elevated temperature. Option A shows markedly widened pulse pressure (180/70), bradycardia (50), and fever, best indicating increased ICP.

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