Question 1

The nurse cares for a client with type I diabetes mellitus. Which action, by the nurse, best assesses the chronic complication of neuropathy?

Accepted Answer

Answer reason: Bedside assessment focuses on detecting diminished light touch, temperature, vibration, or monofilament sensation in distal digits, which directly evaluates this complication. Inspecting for ulcers screens for skin breakdown that results from neuropathy but does not assess the neurologic deficit itself. Orthostatic blood pressures assess autonomic neuropathy, but the question most directly targets peripheral sensory neuropathy assessment.

Question 2

The nurse is evaluating the effectiveness of antimicrobial therapy for a client diagnosed with infective endocarditis. The nurse determines that which finding is the least reliable indicator of effectiveness?

Accepted Answer

Answer reason: A murmur may persist despite effective antibiotics because it can result from residual structural valve damage or regurgitation that does not resolve with eradication of infection. In contrast, defervescence and especially sterilization of blood cultures more directly indicate antimicrobial success. Clear breath sounds can be supportive but are less specific than culture clearance; however, a murmur is particularly unreliable because it may remain unchanged even when therapy is working.

Question 3

In the early postoperative period, the nurse notes a bright red, 3" × 5" area of drainage on the client’s abdominal laparotomy dressing. What should be the nurse’s first action in response to this observation?

Accepted Answer

Answer reason: Bright red drainage early post-op can indicate active bleeding, so the priority is to rapidly assess for hemodynamic instability. Checking vital signs evaluates for early hypovolemia/shock (tachycardia, hypotension, decreasing oxygen saturation) and guides urgency of escalation. Changing the dressing can obscure the amount and rate of bleeding and delays assessment; the dressing should typically be reinforced/marked after assessment per protocol. Increasing IV fluids may be needed later, but it is not the first step before confirming instability and notifying the provider.

Question 4

Which of the following information would NOT be included in a client's pain history?

Accepted Answer

Answer reason: A pain history focuses on the subjective pain experience and its context, including quality, triggers, relieving factors, and the psychosocial meaning of the symptom. Vital signs are objective physiologic data collected during assessment, but they are not part of the historical narrative of pain and are unreliable as a primary indicator of pain severity. Affective responses and what the pain means to the client help characterize emotional and cognitive dimensions that shape coping and reporting. Prior alleviating measures are essential historical data because they guide what has or has not worked and inform the care plan.

Question 5

A client with a history of heart failure visits the clinic. He states, “I have not been feeling like my old self for about 2 weeks.” It would be MOST important for the nurse to ask which of the following questions?

Accepted Answer

Answer reason:  Worsening heart failure commonly causes orthopnea and paroxysmal nocturnal dyspnea due to fluid redistribution and pulmonary congestion when lying flat. Asking about sleeping position (e.g., needing extra pillows or sleeping in a chair) quickly screens for decompensation and guides urgency of evaluation and therapy. Peripheral edema can support volume overload but may be less sensitive and can appear later than nocturnal symptoms. Pleuritic chest pain is not a typical heart-failure symptom pattern and would point more toward alternate diagnoses such as pulmonary or pleural inflammation.

Question 6

The nurse performs a respiratory assessment on the client in for a yearly check up. What normal finding does the nurse expect to find on the client during the respiratory assessment?

Accepted Answer

Answer reason: Normal vesicular breath sounds heard over peripheral lung fields have a longer inspiratory phase than expiratory phase (I:E about 3:1), but the expiratory phase can be longer in the dependent lower lobes while remaining soft and without adventitious sounds. This option best reflects an expected I:E relationship in a healthy adult assessment when auscultating lower lobes. By contrast, normal inspiration is not typically twice as long as expiration between the scapulae, where bronchovesicular sounds have a more equal I:E ratio. Equal anterior-posterior and transverse chest diameters suggests barrel chest (e.g., COPD), not a normal finding, and tactile fremitus is not typically assessed as a discrete “normal” over the anterior sternum at a specific intercostal space.

Question 7

The nurse is performing a physical assessment on a patient with congestive heart failure (CHF). The nurse notes pitting edema and documents it as 2+ edema. Which of the following descriptions best defines 2+ edema?

Accepted Answer

Answer reason: A 2+ finding corresponds to a mild-to-moderate pit with a brief but noticeable delay in rebound, commonly around 10–15 seconds. Findings that are barely detectable with immediate rebound align with 1+ edema, while deeper pits with longer rebound times indicate more severe edema (3+ to 4+). In CHF, accurate grading helps trend fluid overload and evaluate response to diuretics and other therapies.

Question 8

A nurse notes a client’s respiratory rate is 24 breaths/min. on 3 L/min. of oxygen. The client reports shortness of breath. Which action does the nurse perform first?

Accepted Answer

Answer reason: Nursing priority follows ABCs, but the first action is to quickly assess the airway and breathing status to determine severity and the most appropriate immediate intervention. A focused respiratory assessment (work of breathing, lung sounds, SpO2 trend, mental status, ability to speak, accessory muscle use) identifies whether this is bronchospasm, fluid overload, atelectasis, or another cause. Automatically increasing oxygen without assessing can delay recognizing problems like worsening obstruction or impending fatigue and may not address the underlying issue. After assessment, the nurse can implement appropriate measures (e.g., administer ordered bronchodilator, titrate oxygen per protocol, and escalate/notify the provider based on findings).

Question 9

The nurse is testing the extraocular movements in a client to assess for muscle weakness in the eyes. The nurse should implement which assessment technique to assess for muscle weakness in the eye?

Accepted Answer

Answer reason: Extraocular muscle weakness is assessed by evaluating coordinated eye movements controlled by cranial nerves III, IV, and VI. Having the client follow an object through the six cardinal fields systematically tests each extraocular muscle for weakness, limitation, or nystagmus. Corneal reflex testing mainly evaluates CN V and VII and does not assess extraocular muscle strength. Snellen testing assesses visual acuity, and facial light-touch testing evaluates CN V sensory function, neither of which directly measures extraocular motor function.

Question 10

The nurse is closely monitoring the intake and output of an infant with heart failure who is receiving diuretic therapy. The nurse should use which most appropriate method to assess the urine output?

Accepted Answer

Answer reason: This method is noninvasive and provides objective data needed to evaluate diuretic response and fluid balance in heart failure. Urinary catheterization is invasive and increases infection risk, so it is not the most appropriate routine method. The other choices do not directly measure urine volume and therefore cannot provide precise output assessment.

Question 11

A school-aged client with cerebral palsy and a do not resuscitate status is treated for pneumonia at home. What is the home care nurse's first intervention when providing care?

Accepted Answer

Answer reason: Initial nursing care follows the assessment-first principle to establish current severity and detect urgent complications (e.g., increased work of breathing, hypoxia) before implementing interventions. Pneumonia in a child with cerebral palsy increases risk for ineffective airway clearance and rapid respiratory decline, so obtaining baseline findings (rate, effort, breath sounds, oxygenation, cough effectiveness) guides safe next steps. Treatments like nebulizers are implemented after confirming indications and prioritizing airway/breathing needs based on assessment findings. Documentation is essential but occurs after assessment, and reviewing prescriptions does not replace evaluating immediate physiologic status in the home setting.

Question 12

A nurse assesses the fetal monitor of a client in labor. Which observation is most concerning to the nurse?

Accepted Answer

Answer reason: Late decelerations (nadir after the peak of the contraction, occurring toward the end) reflect uteroplacental insufficiency and impaired fetal oxygenation, making them the most ominous tracing finding listed. This pattern indicates the fetus may be developing hypoxemia/acidemia, requiring prompt intrauterine resuscitation and escalation as needed. By contrast, decelerations that begin with the contraction are typically early decelerations from fetal head compression and are usually benign. Brief accelerations up to 60 seconds generally indicate adequate fetal oxygenation and intact neurologic responsiveness; a baseline of 164 bpm is mild tachycardia and can be less urgent unless persistent with other nonreassuring features.

Question 13

A nurse assesses a client with pneumonia for bronchophony. The nurse uses what procedure?

Accepted Answer

Answer reason: Bronchophony is assessed by having the patient speak clearly while the nurse auscultates lung fields to evaluate increased transmission of voice sounds through consolidated lung tissue. Pneumonia can cause consolidation, which makes spoken words sound louder and more distinct through the stethoscope than expected. Whispering assesses whispered pectoriloquy, and saying a long “E” assesses egophony, so those are different voice-transmission tests. Placing the palms on the chest wall while the client speaks evaluates tactile fremitus, which is palpation rather than auscultation.

Question 14

Which of the following is an example of data that should be validated?

Accepted Answer

Answer reason: Validation is required when assessment data are inconsistent, subjective, or don’t match objective findings, because decisions based on inaccurate cues can lead to inappropriate care. Feeling “feverish” is subjective and conflicts with an objectively normal oral temperature, so the nurse should recheck technique, consider other routes (e.g., tympanic/rectal), and reassess for other signs of infection. Laboratory and imaging reports are objective sources that generally do not require validation unless results are unexpected or don’t fit the clinical picture. A normal respiratory rate with clear breath sounds is internally consistent and does not suggest a need for validation.

Question 15

Kris with a history of chronic infection of the urinary system complains of urinary frequency and burning sensation. To figure out whether the current problem is of renal origin, the nurse should assess whether the client has discomfort or pain in the?

Accepted Answer

Answer reason: Bladder/urethral infections more often cause dysuria, frequency, and suprapubic discomfort rather than CVA tenderness. Assessing for CVA tenderness helps differentiate possible pyelonephritis or renal pathology from lower tract cystitis/urethritis. Findings limited to the urinary meatus or external genital discomfort suggest local irritation or urethral/vulvar causes, not renal origin.

Question 16

The nurse notes an isolated premature ventricular contraction (PVC) on the cardiac monitor of a client recovering from anesthesia. Which action should the nurse take?

Accepted Answer

Answer reason: An isolated PVC in a stable post-anesthesia client is commonly transient and can occur with stimulation, hypoxia, pain, or electrolyte shifts; the immediate nursing priority is ongoing assessment for frequency, patterns (e.g., runs), and hemodynamic impact. Monitoring allows the nurse to correlate the rhythm with vital signs, oxygenation, symptoms, and triggers and to intervene if ectopy becomes frequent or the client destabilizes. Defibrillation is reserved for shockable lethal rhythms (e.g., ventricular fibrillation/pulseless VT) rather than a single PVC. Antiarrhythmic therapy or urgent provider notification is typically indicated when PVCs are frequent/multifocal, occur in runs, or are accompanied by chest pain, hypotension, or worsening oxygenation.

Question 17

A client is brought to the emergency department with stroke symptoms that began 7 hours ago. A CT scan confirms the presence of an ischemic stroke. The client's current blood pressure is 202/108 mm Hg. Which nursing action is most appropriate?

Accepted Answer

Answer reason: With symptom onset at 7 hours, IV thrombolysis is not indicated, so immediate nursing priority is ongoing neurologic and hemodynamic assessment with accurate documentation and rapid communication of changes. Aggressively lowering blood pressure to 220/120) when not receiving reperfusion therapy. Antiseizure therapy is not given prophylactically unless seizures occur or are strongly suspected.

Question 18

The nurse is caring for a client who is 1 day postoperative extensive abdominal surgery for ovarian cancer. The client is receiving intravenous (IV) Ringer's lactate at 100 mL/hr and continual epidural morphine for pain control. The Foley catheter urine output has decreased to

Accepted Answer

Answer reason: Checking blood pressure, heart rate, temperature, and oxygenation determines whether this is an urgent perfusion problem requiring immediate escalation. Normal hemoglobin/hematocrit does not rule out early volume depletion or evolving blood loss, and urine output is a key end-organ perfusion indicator. Increasing IV fluids or calling the provider may be appropriate next steps, but assessment data are required first to guide safe, targeted intervention and urgency. A bladder scan can evaluate retention/obstruction, but unstable vital signs would take priority over troubleshooting catheter-related causes.

Question 19

The nurse is performing an assessment of a pregnant client who is at 28 weeks of gestation. The nurse measures the fundal height in centimeters and notes that the fundal height is 30 cm. How should the nurse interpret this finding?

Accepted Answer

Answer reason: Fundal height in centimeters typically approximates gestational age in weeks from about 20 to 36 weeks. A commonly accepted normal variation is within about 2 cm of the gestational age due to factors like maternal habitus, fetal position, and measurement technique. At 28 weeks, a fundal height of 30 cm is within this expected range. Measurements that are more than a small margin above or below would prompt evaluation for conditions such as polyhydramnios, macrosomia, oligohydramnios, or fetal growth restriction.

Question 20

The day care nurse is observing a 2-year-old child and suspects that the child may have strabismus. Which observation made by the nurse indicates the presence of this condition?

Accepted Answer

Answer reason: Strabismus is ocular misalignment that can cause diplopia or blurred vision and children often adopt compensatory head postures to optimize binocular vision and reduce symptoms. A persistent head tilt is a classic observational clue of an eye alignment problem rather than a hearing deficit. The hearing-focused findings (difficulty hearing, not responding when spoken to, turning head to hear) point to auditory impairment and do not specifically indicate ocular misalignment. Therefore the head tilt to see is the observation most consistent with strabismus and warrants referral for vision screening/ophthalmologic evaluation.

Question 21

The nurse reviews an arterial blood gas report for a client with chronic obstructive pulmonary disease (COPD). The results are as follows: pH 7.35; Pco2 62 (8.25 kPa); Po2 70 (9.31 kPa); HCO3 34 mEq/L (34 mmol/L). The nurse should first?

Accepted Answer

Answer reason: ABGs show chronic compensated respiratory acidosis: elevated PaCO2 with elevated HCO3 and a near-normal pH, which is typical for stable COPD rather than an acute decompensation. The priority is to correlate these values with the client’s current clinical status (respiratory rate/effort, SpO2, mental status, hemodynamics) to determine urgency and appropriate escalation. High-flow 100% oxygen is not the first action in COPD because it can worsen CO2 retention and should be titrated based on assessment and oxygenation targets. Intubation is reserved for signs of impending respiratory failure (e.g., worsening acidosis, severe distress, declining consciousness), which cannot be concluded from these compensated values alone.

Question 22

The nurse cares for a patient in Buck's traction. When assessing the patient what finding would indicate a complication?

Accepted Answer

Answer reason: Traction and limb immobilization can compromise distal neurovascular status, so assessment focuses on perfusion, sensation, and movement. A diminished pedal pulse suggests impaired arterial flow from swelling, excessive traction, or tight bandaging and is an urgent complication requiring prompt intervention. In contrast, brisk capillary refill indicates adequate peripheral perfusion and is reassuring. Discomfort can occur with traction and is not as specific for vascular compromise, while pin-site drainage is associated with skeletal traction rather than Buck’s skin traction.

Question 23

A clinic nurse is assessing the status of jaundice in a child with hepatitis. Which of the following anatomical areas will provide the best data regarding the presence of jaundice?

Accepted Answer

Answer reason: The tympanic membranes/ear canal mucosa provide a relatively uniform, non–sun-exposed surface where yellow discoloration can be detected early and more reliably. Areas like the abdomen or sacrum can be affected by skin tone, lighting, and pressure-related color changes, reducing assessment accuracy. Nail beds can show color changes but are less sensitive and can be confounded by peripheral perfusion and temperature.

Question 24

A nurse is performing an assessment of a client's peripheral vascular system. In which of the following locations should the nurse palpate the posterior tibial pulse?

Accepted Answer

Answer reason: The posterior tibial artery runs posterior to the medial malleolus, making this the correct landmark for palpation. The popliteal fossa corresponds to the popliteal pulse, the antecubital space to the brachial pulse, and the dorsum of the foot to the dorsalis pedis pulse. Choosing the correct site improves detection of impaired distal perfusion in peripheral vascular disease.

Question 25

A nurse is caring for a client who has acute respiratory distress syndrome (ARDS) exacerbation. The health care provider (HCP) initiates noninvasive positive airway pressure ventilation (NIPPV) with a bilevel positive airway pressure (BiPAP) device. The nurse reviews the client's medical history. Which of the following parameters is most important for the nurse to monitor frequently in this client?

Accepted Answer

Answer reason: Frequent mental-status checks help detect hypoxemia, hypercapnia, fatigue, and impending need for escalation to invasive ventilation before overt collapse occurs. In ARDS exacerbation, clinical deterioration can occur quickly despite noninvasive support, so bedside neurologic trends complement pulse oximetry and vital signs. By contrast, parameters like blood glucose or capillary refill are not the most direct or earliest markers of inadequate ventilation/oxygenation in this context.

Question 26

A 36-year-old primigravid client with a history of diabetes is admitted with preeclampsia. Which of the following actions should the nurse take FIRST?

Accepted Answer

Answer reason: In preeclampsia, the immediate nursing priority is early detection of worsening hypertension and end-organ compromise to prevent progression to stroke, eclampsia, placental abruption, and fetal compromise. Baseline and frequent blood pressure checks directly guide urgency of interventions (e.g., antihypertensives, magnesium sulfate, escalation of monitoring) and determine whether the situation is becoming an obstetric emergency. Low-dose aspirin and calcium are preventive measures used earlier in pregnancy for risk reduction and do not address acute stabilization on admission. Preparing for delivery may ultimately be required, but it is not the first step before assessing severity and maternal-fetal status.

Question 27

The nurse is planning care for a client being admitted with newly diagnosed quadriplegia (tetraplegia). Which intervention will the nurse prioritize?

Accepted Answer

Answer reason: Serial measurement of vital capacity and tidal volume provides an objective early warning of declining ventilatory reserve and the need for escalation (e.g., assisted cough, noninvasive support, or intubation). Turning and ROM are important for preventing pressure injury and contractures, but they do not address the most immediate life-threatening risk. Allowing expression of feelings supports coping, yet it is not prioritized over physiologic stability in an acute admission.

Question 28

The nurse admits an 81-year-old client with gastroenteritis. Admission vital signs are temperature 101 F (38.3 C), blood pressure 90/42 mm Hg, pulse 118/min, and respirations 32/min. Pulse oximetry shows 88%. The nurse suspects which of the following factors may be affecting accuracy of the pulse oximetry reading?

Accepted Answer

Answer reason: With low blood pressure (and likely vasoconstriction/poor perfusion in an ill older adult), the waveform can be weak, causing falsely low, erratic, or unreadable SpO2 values. In this client, 90/42 mm Hg strongly suggests compromised perfusion, making the pulse-ox reading less reliable. Fever and tachypnea do not typically interfere with the optical measurement itself, whereas low perfusion states are a classic cause of inaccuracy.

Question 29

A client with type 2 diabetes, coronary artery disease, and peripheral arterial disease developed hospital-acquired pneumonia (HAP) and has been receiving Intravenous (IV) antibiotics for 4 days. Which parameter monitored by the nurse best indicates the effectiveness of treatment?

Accepted Answer

Answer reason: A trending decrease toward normal in the WBC over several days of appropriate IV antibiotics indicates improving infection control and correlates with clinical recovery. Sputum color and lung sounds are less reliable because secretions can remain discolored and crackles may persist even as infection resolves. Oxygen saturation is important for current respiratory status but can be influenced by comorbid cardiopulmonary factors and supplemental oxygen, making it a less specific marker of antimicrobial response.

Question 30

The purpose of a health assessment is to?

Accepted Answer

Answer reason: This includes subjective data (symptoms, history, concerns) and objective data (vital signs, physical exam findings, observable measures) to identify actual or potential problems. Planning appropriate care and intervening occur after assessment, once data have been analyzed into nursing diagnoses and priorities. Evaluating whether interventions are effective is part of the evaluation phase, not the primary purpose of the initial health assessment.

Question 31

The RN is admitting a client with benign prostatic hyperplasia (BPH) to an acute care unit. The client describes an oral intake of about 1400 mL/day. What is the RN's priority concern?

Accepted Answer

Answer reason: In BPH, the immediate safety risk is urinary retention and its complications (bladder overdistention, postrenal acute kidney injury, and infection), so the first priority is assessing voiding effectiveness. A reported fluid intake amount alone does not establish whether the client is obstructed; output pattern (frequency, hesitancy, weak stream, incomplete emptying, nocturia, or inability to void) directly reflects the severity of obstruction. Assessment should precede teaching or interventions because increasing fluids could worsen discomfort and retention if outflow is impaired. Bowel pattern and short-term diet diary are secondary compared with evaluating the urinary system in a client admitted for BPH.

Question 32

An experienced LPN/LVN reports to the RN that a client's blood pressure and heart rate have decreased, and when his face was assessed, one side twitches. What action should the RN take at this time?

Accepted Answer

Answer reason: The immediate priority is to validate and trend abnormal vital signs because bradycardia and hypotension can signal acute physiologic deterioration requiring rapid intervention. An RN must first perform a focused reassessment to confirm accuracy (cuff size/technique, apical pulse, rhythm) and determine current stability before escalating care. The unilateral facial twitching can represent a new neurologic finding (e.g., focal seizure activity) but does not replace the need to verify circulation status first. Reviewing calcium is relevant only if hypocalcemia is suspected (e.g., tetany) and is not the fastest safety action in the presence of potentially unstable hemodynamics. A neurologic consult is not the initial step until immediate assessment data are obtained and urgent responses are initiated if indicated.

Question 33

A patient is receiving positive pressure mechanical ventilation and has a chest tube. When assessing the water seal chamber what do you expect to find?

Accepted Answer

Answer reason: With positive-pressure ventilation, the ventilator pushes air into the lungs, raising intrathoracic (pleural) pressure during inspiration. This reverses the usual “tidaling” pattern seen with spontaneous breathing, so the water level rises on inspiration and falls on expiration. Continuous bubbling would suggest an air leak rather than normal water-seal function. Observing expected tidaling helps confirm patency of the chest tube system and guides prompt detection of complications.

Question 34

The nurse is performing nasotracheal suctioning of a client. The nurse determines that the client is adequately tolerating the procedure if which observation is made?

Accepted Answer

Answer reason: A protective cough/gag response during nasotracheal suctioning indicates the airway reflexes are intact and the catheter is stimulating the tracheobronchial tree appropriately. This suggests the client is maintaining airway patency and neurologic responsiveness during the procedure. In contrast, cyanosis signals hypoxemia, and a marked heart-rate drop reflects vagal stimulation–induced bradycardia, both indicating poor tolerance requiring stopping suctioning and re-oxygenation. Bloody secretions suggest mucosal trauma from excessive suction pressure or technique and also indicate intolerance/complication.

Question 35

When examining a patient with abdominal pain the nurse in charge should assess?

Accepted Answer

Answer reason: Palpating the painful area first increases voluntary and involuntary muscle tension, which can make subsequent assessment inaccurate and more uncomfortable. Starting away from the site of pain allows comparison of normal versus abnormal findings and supports a more reliable exam. A common error is going directly to the painful area, which risks escalating discomfort and limiting cooperation.

Question 36

Which vital sign in a pediatric client is most important to report to the primary health care provider?

Accepted Answer

Answer reason: Pediatric vital signs must be interpreted by age-specific norms, and school-age children should not have persistent tachycardia at rest. A heart rate of 130/min in a 6-year-old is above the expected range and can indicate early compromise such as fever, dehydration, pain/anxiety, hypoxia, or shock, warranting provider notification and further evaluation. In contrast, a newborn heart rate around 140/min is within normal limits for neonates, and a 3-year-old respiratory rate of 28/min is typically acceptable for toddlers/preschoolers. A 12-year-old respiratory rate of 16/min is normal for an older child/adolescent.

Question 37

A patient recovers from orthopedic surgery with a cast on their leg. When the nurse assesses the patient what is the highest priority?

Accepted Answer

Answer reason: Neurovascular compromise is the most urgent cast-related risk after orthopedic surgery because impaired circulation can rapidly progress to ischemia and compartment syndrome. Assessing distal perfusion with capillary refill provides a quick, sensitive screen for inadequate arterial flow to the affected extremity. Abnormal findings (delayed refill, coolness, pallor, increasing pain) require immediate escalation and potential cast splitting/bivalving to prevent permanent damage. Skin breakdown is important but is typically less immediately limb-threatening than loss of perfusion. Bladder distension is a postoperative concern but does not supersede potential limb ischemia in this context.

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