Question 1

A nurse is caring for a 4-year-old with a fever, rash, redness, swelling of the hands and feet, and cervical lymphadenopathy. The primary healthcare provider (PHCP) suspects Kawasaki disease. Which assessment should be performed to support the diagnosis of Kawasaki disease?

Accepted Answer

Answer reason: Kawasaki disease is an acute childhood vasculitis diagnosed largely by characteristic clinical findings on focused assessment. Oral mucous membrane changes (eg, erythematous cracked lips, “strawberry” tongue, diffuse oropharyngeal erythema) are one of the classic diagnostic criteria that directly support the suspected diagnosis. In contrast, checking capillary refill or measuring blood pressure are general perfusion/vital sign assessments and are not specific diagnostic features. Although cardiac assessment is important due to risk of coronary artery involvement, it supports complication screening rather than being a key criterion to establish the diagnosis at bedside.

Question 2

The nurse observes that an older adult client with a urinary tract infection (UTI) suddenly becomes agitated. Which immediate action is best?

Accepted Answer

Answer reason: Sudden agitation in an older adult with a UTI can be an early sign of systemic deterioration such as fever, hypoxia, hypotension, or evolving sepsis/delirium, so rapid physiologic assessment is the priority. Obtaining vital signs is the fastest way to identify instability and determine whether urgent escalation is needed. Calling the provider may be appropriate after assessment, but it delays identifying immediately treatable threats. Giving a benzodiazepine risks worsening delirium and respiratory depression and can mask a change in status; comfort measures like a blanket do not address potential life-threatening causes.

Question 3

The nurse in the postanesthesia care unit (PACU) is caring for a client that has just received an arteriovenous (AV) fistula in the left upper extremity. Which assessment finding would be expected?

Accepted Answer

Answer reason:  A newly created AV fistula should have evidence of patency and high-flow turbulence at the anastomosis. Auscultation typically reveals a bruit (rushing sound) and palpation reveals a thrill, indicating adequate blood flow through the access. Findings such as a pale/cool hand or numbness/tingling suggest distal ischemia (steal syndrome) or impaired perfusion and are not expected. Frank sanguineous drainage suggests bleeding or hematoma risk and warrants evaluation rather than being a normal expected finding.

Question 4

While assessing orientation, the patient correctly states his name and the year, but cannot identify where he is or why he is there. How should the nurse chart the patient’s orientation?

Accepted Answer

Answer reason: Here, the patient knows his name (person) and the year (time) but cannot state where he is (place) or why he is there (situation). That means he is oriented to 2 out of 4 spheres. This documentation communicates a focused neuro/mental status finding that helps trend changes and prompt further assessment of delirium, intoxication, or neurologic decline.

Question 5

A parent of a child with a moderate head injury asks the nurse, "How will you know if my child is getting worse?" The nurse should tell the parents that best indicator of the child's brain function is?

Accepted Answer

Answer reason: Level of consciousness is the most sensitive and earliest indicator of changes in cerebral function because it reflects overall cortical and brainstem integrity. In a worsening head injury with rising intracranial pressure, subtle deterioration in arousal, orientation, or responsiveness often occurs before late findings like vital sign changes. Pupil reaction and motor strength are important focal neurologic checks, but they may remain normal until compression/herniation affects specific pathways. Therefore, frequent reassessment of consciousness (e.g., GCS/behavioral responsiveness) best detects early neurologic decline.

Question 6

A 3-month-old infant with a heart rate of 220 beats per minute is diagnosed with supraventricular tachycardia (SVT). Which intervention should the nurse implement first?

Accepted Answer

Answer reason: Capillary refill is a rapid bedside indicator of systemic perfusion that helps identify shock or decompensation requiring urgent escalation (e.g., cardioversion in unstable SVT). A heart rate of 220 in a 3-month-old can quickly compromise cardiac output due to reduced ventricular filling time, so circulation assessment is critical first. Preparing an ice pack relates to a vagal maneuver (diving reflex) that may be appropriate for stable SVT, but perfusion must be assessed first to ensure it is safe to proceed. Looking for causes may be useful later but does not address immediate risk.

Question 7

A 57-year-old arrives to the clinic with a complaint of chest pain. What question is not helpful in determining the severity of the diagnosis?

Accepted Answer

Answer reason:  Severity assessment of chest pain focuses on characterizing the pain and identifying features suggestive of ischemia or other emergent causes. Asking about activity at onset helps assess exertional angina and hemodynamic stress triggers, while describing the pain captures quality, radiation, and associated symptoms that correlate with acuity. Cardiac history informs baseline risk and raises suspicion for acute coronary syndrome when combined with current symptoms. Prior aspirin use may affect immediate management decisions but does not reliably quantify how severe or dangerous the underlying condition is.

Question 8

The nurse reviews the vital signs of a client admitted to the medical-surgical unit. The unlicensed assistive personnel (UAP) obtained the client's blood pressure from the client's leg. The nurse should expect which change in blood pressure?

Accepted Answer

Answer reason: Blood pressure readings vary by anatomic site due to differences in arterial distance from the heart and peripheral amplification of the pulse pressure in larger, more distal arteries. When measured in the lower extremity (eg, popliteal artery with a thigh cuff), systolic pressure is typically higher than the brachial systolic pressure by about 10–40 mm Hg, while diastolic pressure is usually similar. Therefore a higher systolic value is an expected physiologic finding rather than an error by the UAP. Options suggesting a lower systolic or major diastolic change do not match normal extremity-to-extremity variation and would be more concerning for pathology or technique issues.

Question 9

The nurse assesses a client after a renal arteriogram. The nurse palpates the right groin access site. The client then reports right calf pain. Which action does the nurse take first?

Accepted Answer

Answer reason: After a femoral/groin arterial access procedure, new ipsilateral calf pain can signal compromised distal arterial flow from thrombosis, embolus, arterial spasm, or an enlarging hematoma compressing the vessel. The nursing priority is to immediately evaluate circulation in the affected limb (pulses, capillary refill, skin temperature/color, sensation/movement) to identify acute limb ischemia early. Treating pain first could mask a time-sensitive vascular complication and delay escalation of care. Vital signs are important but do not directly assess limb-threatening perfusion, and dorsiflexion targets DVT screening and is not a reliable or prioritized post-arteriogram assessment compared with distal neurovascular checks.

Question 10

Which clinical finding indicates a sign of illness in the newborn?

Accepted Answer

Answer reason: An axillary temperature greater than 38°C (100.4°F) Fever in a newborn is a high-risk finding because neonates can have serious bacterial or viral infection with minimal other symptoms and can deteriorate quickly. A temperature at or above 38°C (100.4°F) meets the standard threshold that warrants prompt clinical evaluation and often a sepsis workup depending on age and presentation. In contrast, a yellow scaly scalp lesion is consistent with cradle cap, which is common and typically benign. Small regurgitation after feeds and multiple soft stools per day can also be normal neonatal patterns depending on feeding type and age.

Question 11

The nurse is caring for a client who had an endovascular repair of an abdominal aortic aneurysm 2 hours ago. Which of the following would be a priority for the nurse to include in the plan of care?

Accepted Answer

Answer reason: After endovascular AAA repair, the most immediate, limb-threatening complication is compromised distal perfusion from thrombus/embolization or arterial occlusion at/near the femoral access or graft. Frequent neurovascular checks (pedal pulses, limb temperature, color, cap refill, sensation/movement) detect acute ischemia early, when rapid intervention can prevent tissue loss. Urine output and renal labs are important because contrast and hemodynamic changes can affect kidney function, but they are typically less time-critical than recognizing an acutely ischemic extremity. Monitoring temperature and WBC targets infection, which is generally not the first priority within 2 hours post-op compared with ensuring adequate distal circulation.

Question 12

The nurse cares for a client immediately following a shoulder reduction procedure with moderate sedation. The nurse assesses the client as restless and irritable. The nurse should take which priority action?

Accepted Answer

Answer reason: After moderate sedation, the priority assessment is airway and breathing because hypoventilation and hypoxemia can present early as restlessness and irritability. Pulse oximetry provides an immediate, objective measure of oxygenation and helps identify respiratory compromise requiring prompt intervention. Pain can also cause agitation, but it is addressed after life-threatening causes are ruled out. Lung sounds and GCS are useful follow-up assessments, but they are less rapid indicators of acute sedation-related hypoxemia than oxygen saturation.

Question 13

The nurse performs a physical assessment on a client and observes the client demonstrate palmar flexion while obtaining the blood pressure. The nurse should take which action?

Accepted Answer

Answer reason: The appropriate nursing action is to prompt evaluation for underlying causes and associated electrolyte abnormalities, including hypomagnesemia, which can suppress PTH activity and produce refractory hypocalcemia. Checking magnesium helps guide correction and prevent persistent symptoms and complications such as tetany and dysrhythmias. Options focused on alternate BP sites, orthostatic vitals, or glucose do not address the likely electrolyte-driven etiology suggested by this specific finding.

Question 14

The nurse in a birthing room is monitoring a client with dysfunctional labor for signs of fetal or maternal compromise. Which assessment finding should alert the nurse to a compromise?

Accepted Answer

Answer reason: In dysfunctional labor, prolonged or ineffective labor can contribute to stress and reduced oxygen reserve, making continuous fetal assessment critical. This finding requires prompt nursing actions (e.g., intrauterine resuscitation measures and notifying the provider) because it can precede fetal decompensation. By contrast, coordinated contractions and progressive cervical change are reassuring signs of effective labor progress, and maternal fatigue alone is not a direct marker of fetal compromise.

Question 15

A child visits the clinic for a 6-week checkup after a tonsillectomy and adenoidectomy. In addition to assessing hearing, the nurse should include an assessment of the child's?

Accepted Answer

Answer reason: Swallowing assessment screens for residual pain-related dysphagia, dehydration risk, or scarring/velopharyngeal dysfunction that can alter safe oral intake. Speech assessment evaluates resonance and articulation changes (e.g., hypernasality) that can occur if velopharyngeal closure is affected after adenoid removal. Smell and taste are not the primary functional concerns after this procedure and are less directly linked to clinically important post-op sequelae at 6 weeks.

Question 16

The nurse is auscultating the apical pulse over the PMI (point of maximum impact). Which heart sounds would be audible?

Accepted Answer

Answer reason: S1 is produced by closure of the mitral and tricuspid valves and is typically loudest at the apex. S2 is produced by closure of the aortic and pulmonic valves and can still be heard at the apex even though it is usually louder at the base. Extra sounds (S3 or S4) may be heard at the apex in specific clinical conditions, but they are not expected as the standard audible pair when assessing the apical pulse.

Question 17

Which of the following temperatures is considered a core body temperature?

Accepted Answer

Answer reason: The rectal route closely approximates the temperature of the body’s core due to proximity to internal organs and reduced heat loss compared with surface sites. Axillary and oral measurements are more influenced by environmental temperature, mouth breathing, recent intake, and peripheral perfusion. Temporal artery readings are noninvasive but can be less reliable in some clinical contexts because technique and skin conditions affect accuracy.

Question 18

The nurse assesses a patient’s pulse and finds it to be bounding. How should this be documented?

Accepted Answer

Answer reason: A bounding pulse reflects an abnormally strong, forceful pulse consistent with hyperdynamic circulation (e.g., fever, anxiety, anemia, hyperthyroidism, or aortic regurgitation). Therefore it should be charted at the highest intensity on this scale. In contrast, 0 would indicate no palpable pulse, which is the opposite of bounding.

Question 19

The nurse is receiving a handoff report regarding a client admitted to the medical-surgical unit for the past 24 hours after a fall at home. Assessment reveals easy bruising, jaundice, and cachexia. The client is complaining of 7/10 abdominal pain. Upon palpation, the nurse notes a round and hard abdomen. What blood panel would the nurse prioritize in obtaining?

Accepted Answer

Answer reason: Jaundice, easy bruising (impaired clotting factor synthesis), cachexia, and a distended firm abdomen (possible ascites/hepatomegaly) most directly point to hepatobiliary pathology and require targeted liver assessment. A liver panel with transaminases helps identify hepatocellular damage and supports rapid escalation of care if significant injury is present. While a CBC can detect anemia/bleeding and a BMP assesses electrolytes/renal function, they are less specific to the most likely organ system driving these hallmark findings. Cardiac markers are not indicated by the presentation and would not address the most urgent suspected process.

Question 20

A client had oral surgery following a motor vehicle accident. The nurse assessing the client finds the skin flushed and warm. Which of the following would be the best method to take the client's body temperature?

Accepted Answer

Answer reason: A noninvasive site that avoids the operative area is preferred for safety and feasibility while still allowing timely screening for fever. The axillary method is appropriate when oral measurement is contraindicated, especially in clients with facial or oral trauma/surgery. Rectal temperatures are more invasive and carry additional risks (e.g., mucosal injury, bleeding, vagal stimulation) without being necessary here, and an arterial line is not a standard or appropriate method for routine temperature measurement.

Question 21

When assessing a four-month-old male infant, the nurse correctly evaluates his heart rate by performing which of the following actions?

Accepted Answer

Answer reason: Infant heart rates are often irregular and rapid, so the most accurate method is to assess the apical pulse rather than relying on peripheral pulses. Counting for a full 60 seconds reduces error from respiratory sinus arrhythmia and brief pauses common in infants. The apical impulse in infants is best assessed by auscultation at the left sternal border around the 4th intercostal space. Peripheral sites like the radial pulse can be difficult to palpate reliably at this age, and shorter count intervals increase inaccuracy.

Question 22

The nurse is assessing a client who complained of palpitations and shortness of breath. The cardiac monitor shows an irregular rhythm at 140 beats per minute with no discernible P waves. The nurse recognizes the patient is in which cardiac rhythm?

Accepted Answer

Answer reason: An irregularly irregular rhythm with absent discernible P waves indicates chaotic atrial depolarization with variable AV conduction. The ventricular rate of ~140 bpm is consistent with atrial fibrillation with rapid ventricular response, which commonly presents with palpitations and dyspnea from reduced cardiac output. Junctional rhythms are typically regular and slower (often 40–60) with absent or inverted P waves rather than no discernible P waves. First-degree AV block shows a prolonged PR interval with visible P waves, and idioventricular rhythms are usually wide-complex and bradycardic.

Question 23

The nurse is evaluating the outcome on a number of therapies for a client. Three days prior, the client was admitted for an acute exacerbation of heart failure. The client developed pulmonary edema, hypoxia, and fatigue. Based upon the following therapies (See exhibit), which of the following clinical signs and symptoms indicates improvement? Exhibit Oxygen 2L nasal cannula Furosemide 40mg BID Digoxin 0.5mg qday?

Accepted Answer

Answer reason: A PaO2 around 80 mmHg is within the expected normal range for many adults and indicates resolution of hypoxemia compared with the admission problem. Subjective reports can be influenced by fatigue/anxiety and are less reliable as an outcome measure than arterial oxygenation. Persistent basilar crackles suggest ongoing alveolar/interstitial fluid rather than improvement, and endocarditis is not the primary issue being treated here.

Question 24

The nurse is caring for a client who has diabetic ketoacidosis (DKA). Which of the following would indicate the client is achieving the treatment goals?

Accepted Answer

Answer reason: A MAP around 65 mmHg or higher generally indicates adequate organ perfusion, so 71 mmHg suggests hemodynamic improvement consistent with resuscitation goals. The potassium value shown is hypokalemic and is unsafe with insulin therapy because insulin drives potassium intracellularly, increasing arrhythmia risk. The glucose and pH values remain abnormal (still hyperglycemic and acidemic), so they do not best indicate resolution compared with improved perfusion.

Question 25

The nurse is caring for a client who had a chest tube inserted two days ago for a pneumothorax. Which assessment finding indicates that the procedure has produced its desired effect?

Accepted Answer

Answer reason: The goal of chest tube therapy for pneumothorax is re-expansion of the affected lung and restoration of normal ventilation. Bilaterally clear breath sounds indicate improved lung expansion and air movement, consistent with resolution of the pneumothorax. Rapid bubbling in the suction chamber suggests an air leak or excessive suction, not clinical resolution. Crepitus at the site reflects subcutaneous emphysema from air tracking into tissues and is a complication rather than the desired effect, while consolidation on x-ray points toward pneumonia/atelectasis rather than pneumothorax improvement.

Question 26

The nurse is performing a neurological assessment on a client post right CVA. Which finding, if observed by the nurse, would warrant immediate attention?

Accepted Answer

Answer reason: This change can precede airway compromise and indicates impaired cerebral perfusion, making it a time-sensitive threat to life and brain tissue. In contrast, sensory changes and bladder dysfunction are common post-stroke deficits but are typically not as immediately life-threatening unless accompanied by other signs of deterioration. Immediate attention focuses on urgent reassessment, vital signs/glucose check, and notifying the provider/rapid response to prevent secondary brain injury.

Question 27

Which of the following would indicate that an infant with a tracheoesophageal fistula (TEF) needs suctioning?

Accepted Answer

Answer reason: Retractions are an immediate, observable sign of respiratory distress suggesting the airway needs to be cleared to improve ventilation. Suctioning is an appropriate nursing action when increased work of breathing indicates secretions are compromising airway patency. Tachypnea can be a later, nonspecific response to many stressors, whereas retractions more directly indicate obstructed or difficult breathing. Decreased activity is also nonspecific and does not directly signal secretion accumulation requiring suction.

Question 28

Which of the following is not a component of the FLACC pain scale?

Accepted Answer

Answer reason: The domains are Face, Legs, Activity, Cry, and Consolability, each scored to estimate pain severity. Oxygen requirement reflects respiratory support/oxygenation status and is not part of behavioral pain assessment criteria in FLACC. A common confusion is with other clinical scoring systems that incorporate oxygen needs, but FLACC strictly focuses on observable behaviors.

Question 29

Which of the following is not a component of a pain assessment?

Accepted Answer

Answer reason: g., OPQRST) focusing on the patient’s subjective report: onset, provocative/palliative factors, quality, region/radiation, severity, and timing. These elements characterize the pain experience and guide targeted interventions and reassessment. Vital signs may change with acute pain (tachycardia, hypertension), but they are nonspecific and can be normal despite significant pain, so they are not considered a core component of pain assessment. Relying on physiologic data can lead to under-treatment, whereas OPQRST components capture the clinically relevant features of pain.

Question 30

Which age group has an expected pulse range of 100-160 bpm?

Accepted Answer

Answer reason: A resting pulse of 100–160 bpm aligns with expected norms in infancy, especially in the first year of life. Adults and adolescents typically have much lower resting ranges (often ~60–100 bpm), so this range would suggest tachycardia for them. Children can have higher rates than adults, but the upper bound of 160 bpm is most consistent with infants rather than older children.

Question 31

The nurse is providing care for a 1-day-old infant experiencing tachypnea, tachycardia, and bounding pulses. Which additional client finding makes the nurse suspect the client has a patent ductus arteriosus?

Accepted Answer

Answer reason: Turbulent flow across the duct commonly generates a characteristic murmur (often continuous, but it may be appreciated as systolic early on), making a murmur a key additional assessment finding. Episodic cyanosis suggests a right-to-left shunt lesion (eg, tetralogy of Fallot) rather than PDA. Higher arm than leg blood pressure points to coarctation of the aorta, and unilateral diminished breath sounds indicates a pulmonary problem like pneumothorax or atelectasis.

Question 32

A client has a head injury. Which sign is the most sensitive indicator of increased intracranial pressure?

Accepted Answer

Answer reason: Early rising intracranial pressure most reliably affects cerebral perfusion and cortical function first, making subtle mental status changes the earliest and most sensitive finding. New confusion, restlessness, lethargy, or a falling Glasgow Coma Scale can occur before brainstem signs appear. Pupillary changes and Cushing responses (hypertension with bradycardia) are typically later findings suggesting worsening pressure and possible herniation risk. Therefore, frequent neurologic checks emphasizing mentation/LOC best detect evolving increased ICP.

Question 33

When caring for a newborn several house after birth, you assess his respiratory rate. in a normal newborn this would be?

Accepted Answer

Answer reason: A rate in this range is considered expected in the first hours to days of life, often with periodic breathing that remains without signs of distress. The other ranges listed are typical for older pediatric or adult patients and would represent abnormally low respirations (bradypnea) in a newborn. In practice, the count should be taken for a full minute and interpreted alongside work of breathing, color, and oxygenation.

Question 34

A nurse test a newborn's nervous functioning by stroking the sole of the baby's in an inverted "J" curve from the heel upward. the baby responds by having his toes. which reflex has just been demonstrated?

Accepted Answer

Answer reason: Stroking the lateral sole from heel upward and across the ball of the foot (inverted “J”) normally produces toe fanning/extension in newborns due to immature corticospinal tract inhibition. This is expected in infants and typically disappears by about 12 months; persistence beyond that can suggest upper motor neuron dysfunction. Rooting involves turning the head toward cheek stimulation, Moro is a startle response with arm extension/abduction, and extrusion is tongue thrust with oral stimulation.

Question 35

A 2-year-old male presents to the clinic for an annual visit. The nurse practitioner knows that to examine the child’s tympanic membrane, the nurse practitioner will do which of the following?

Accepted Answer

Answer reason: This maneuver aligns the canal to allow a clear, atraumatic view of the tympanic membrane. Pulling up and back is the adult technique and can worsen visualization in toddlers. Not pulling the pinna commonly leaves the canal partially collapsed or curved, limiting the view and increasing discomfort.

Question 36

The nurse is speaking with an 89-year-old patient admitted for atrial fibrillation. As you are conversing with him, his speech suddenly is mumbled and incoherent. What is the best action for the nurse to take next?

Accepted Answer

Answer reason: Sudden onset of mumbled, incoherent speech in an older adult with atrial fibrillation is a time-sensitive red flag for acute stroke/TIA from thromboembolism. The nurse’s immediate priority is to rapidly assess neurologic status (e.g., level of consciousness, cranial nerves, motor strength, pupillary response, and an NIHSS-focused screen) and establish last-known-well to guide emergent treatment eligibility. This targeted assessment provides actionable data needed to activate the stroke pathway and communicate precise findings to the team without delaying care. Simply checking blood pressure/telemetry is incomplete for a focal neurologic deficit, and calling the provider without first assessing delays critical baseline neuro findings that drive urgent decisions.

Question 37

A client in the intensive care unit is diagnosed with cardiogenic shock after experiencing a myocardial infarction. The physician places a femoral arterial line for continuous blood pressure monitoring. A nurse educator is witnessing the staff nurse set up the arterial line system. Which of the following actions if witnessed would require further education by the nurse educator?

Accepted Answer

Answer reason: Leveling at the femoral insertion site will mis-zero the system and can falsely elevate or lower readings depending on patient position, leading to inappropriate titration of vasoactive therapy. A square wave (fast-flush) test is an appropriate way to assess damping and dynamic response of the system. Using normal saline for the pressurized flush solution and maintaining a sterile occlusive dressing at the insertion site are standard, correct setup/infection-prevention actions.

Question 38

The nurse is caring for a patient recovering from cardiac catheterization via the right femoral artery. The nurse notes stable vitals one hour after the procedure but cannot palpate the patient’s right pedal pulse. Which action would be the nurse’s highest priority?

Accepted Answer

Answer reason: After femoral arterial catheterization, loss of a distal pedal pulse suggests possible arterial spasm, thrombus/embolus, or occlusion, so rapid verification of distal perfusion is the priority. A Doppler assessment is the most sensitive immediate bedside method to confirm whether any arterial flow is present when the pulse is not palpable, guiding urgency of escalation. Capillary refill is less reliable and can remain deceptively normal early despite compromised arterial flow. The provider should be notified promptly if Doppler confirms absent/markedly diminished flow or if other ischemic signs (pain, pallor, paresthesia, paralysis, coolness) are present, but confirming the finding comes first.

Question 39

While caring for a client who requires a mechanical ventilator for breathing, the high-pressure alarm goes off on the ventilator. What is the first action the nurse should perform?

Accepted Answer

Answer reason: The priority is to assess the patient first to determine whether the alarm reflects an immediate life-threatening ventilation problem (airway obstruction, bronchospasm, biting the tube, secretions, decreased lung compliance) versus a ventilator/equipment issue. A rapid patient assessment (work of breathing, chest rise, breath sounds, SpO2, vital signs, level of consciousness) guides the next intervention and prevents delays in treating hypoxia. Immediate disconnection and bagging is indicated if the patient is in distress or cannot be effectively ventilated, but doing it automatically may be unnecessary and risks loss of PEEP/oxygenation. Calling respiratory therapy or resetting the alarm does not address the patient’s current oxygenation/ventilation status and may dangerously delay care.

Question 40

When assessing an adult patient’s far vision, how far should they be positioned from the Snellen chart?

Accepted Answer

Answer reason: This setup allows the line read to be interpreted correctly as a 20/x acuity measurement. Using shorter or longer distances without an appropriately scaled chart can systematically overestimate or underestimate acuity and reduce test reliability. Therefore, positioning the adult at the calibrated distance ensures accurate, comparable results for screening and monitoring vision changes.

Question 41

While assessing a patient’s skin the nurse notes an elevated fluid-filled lesion measuring 3 cm in diameter. The nurse correctly identifies this as which type of skin lesion?

Accepted Answer

Answer reason: A diameter of 3 cm clearly exceeds the typical cutoff (>1 cm) for a bulla. A macule is flat and nonpalpable, so it cannot describe an elevated fluid-filled finding. A nodule is solid and deeper, not fluid-filled, making it inconsistent with the assessment description.

Question 42

How should the nurse document the respiratory rate of an adult patient breathing 8 times per minute?

Accepted Answer

Answer reason: The correct documentation term for a decreased respiratory rate is bradypnea. Apnea would indicate absence of breathing rather than a slowed rate. Eupnea refers to normal, unlabored breathing, and tachypnea refers to an increased respiratory rate.

Question 43

When percussing over a hollow organ, which finding should the nurse expect to hear?

Accepted Answer

Answer reason: A hollow organ (e.g., stomach or bowel) normally contains air, so the expected percussion note is drumlike. Dullness is more consistent with solid organs (like liver) or fluid accumulation, and flatness suggests very dense tissue such as bone or a large muscle. Resonance is the normal sound over healthy lung fields rather than hollow abdominal viscera.

Question 44

When assessing a patient's mouth, the nurse notes that the tonsils take up 60% of the oropharynx. How should this be documented?

Accepted Answer

Answer reason: A finding of about 50–75% obstruction corresponds to a grade of 3+, indicating markedly enlarged tonsils that may narrow the airway. Grades 1+ and 2+ represent smaller enlargements with less space occupied, while 4+ indicates “kissing” tonsils with near-complete obstruction. Therefore, 60% of the oropharynx is best documented as 3+.

Question 45

The nurse is preparing to document normal deep tendon reflexes. How should this be documented?

Accepted Answer

Answer reason: A 2+ reflex indicates a normal, average reflex response that is neither diminished nor hyperactive. Lower values (0–1+) suggest decreased or absent reflexes, which can occur with peripheral neuropathy or lower motor neuron dysfunction. Higher values (3+–4+) indicate brisk to clonus-level hyperreflexia, more consistent with upper motor neuron involvement.

Question 46

A client is admitted to a medical-surgical unit for a urinary tract infection. The client is confused and has a history of Alzheimer’s. Prior to performing a neurological examination, the nurse should do which of the following?

Accepted Answer

Answer reason: Accurate neurologic assessment depends on the patient’s ability to attend, follow simple commands, and respond consistently. In Alzheimer’s disease and acute confusion (which can be worsened by a UTI), excess noise and visual stimuli increase agitation and reduce cooperation, making findings less reliable. Reducing environmental distractions promotes focus and decreases delirium-like behaviors, improving the quality of the exam and patient safety. Waiting for family is not required to obtain baseline neuro data and may delay needed assessment, while clustering extra tasks can fatigue the patient and further impair performance.

Question 47

A nurse is caring for a client who is diagnosed with CVA (stroke). To achieve the desired outcome, which is the best nursing intervention to be included in the plan of care?

Accepted Answer

Answer reason: In acute stroke care, frequent focused neurologic assessment is essential to detect deterioration from rising intracranial pressure, hemorrhagic conversion, or expanding edema. Pupillary size, symmetry, and reactivity are high-yield indicators of brainstem function and can change quickly with worsening cerebral perfusion. This intervention provides actionable data for rapid escalation (e.g., notifying the provider/rapid response) and helps evaluate response to therapies. By contrast, keeping a client in one position for an entire shift increases risk for complications (skin breakdown, aspiration, atelectasis) and does not address neurologic monitoring needs.

Question 48

A 32-year-old G4P2 is 37 and 5/7 weeks gestation with premature rupture of membranes. She has been ruptured 23 hours and the nurse is preparing to administer antibiotics. The last thirty minutes, the nurse has noticed a decrease in fetal heart rate with a baseline of 115 with moderate variability and no accelerations or decelerations noted. The nurse interprets this finding as?

Accepted Answer

Answer reason: A baseline of 115 bpm is within the normal fetal heart rate range (110–160), so this is not bradycardia. The absence of accelerations alone is not diagnostic of hypoxia or acidemia; it can occur with fetal sleep cycles and may warrant continued observation or stimulation rather than emergent escalation. Metabolic acidemia is more consistent with persistent minimal/absent variability and/or recurrent late decelerations, which are not present here.

Question 49

A nurse is assigned to care for a client who reportedly has no special skincare needs. However, upon assessment, the nurse observes reddened areas over bony prominences. What action should the nurse take?

Accepted Answer

Answer reason: Nonblanchable or persistent erythema over bony prominences can indicate early pressure injury risk and requires prompt, targeted assessment to determine severity, contributing factors, and need for preventive interventions. A focused skin integrity assessment includes evaluating blanching, temperature, moisture, pain, skin breakdown, and risk factors (e.g., immobility, poor nutrition, incontinence) to guide an appropriate care plan. Simply documenting and continuing routine care fails to address potential for rapid progression to skin breakdown. Topical antibiotics are not indicated without signs of infection or an open lesion, and this finding does not warrant an “emergency” assessment unless accompanied by acute instability.

Question 50

The nurse is instructing the parents of a child with asthma about a peak flow meter. Which statement, if made by the parents, would indicate effective teaching?

Accepted Answer

Answer reason: Peak expiratory flow monitoring is a respiratory assessment used to quantify airway obstruction and track asthma control over time. Proper technique includes performing three forceful exhalations and documenting the best (highest) value because it most closely reflects the child’s maximal effort and true peak flow capacity. Recording an average could underestimate function if one attempt is submaximal, potentially leading to unnecessary escalation of therapy. A common error is inhaling through the device; the peak flow meter requires a quick, hard exhalation after a full inspiration, typically in an upright position.

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