Question 1

The nurse performing an assessment on a newly admitted client, notes a lesion on the client’s right heel that appears as a shallow open ulcer with a pink wound bed. The nurse will document this as a?

Accepted Answer

Answer reason: Pressure injury staging is based on depth and tissue loss. A shallow open ulcer with a pink/red wound bed indicates partial-thickness skin loss with exposed dermis, which defines Stage II. Stage I is intact skin with nonblanchable erythema, so an open ulcer would not fit. Stage III involves full-thickness skin loss with visible subcutaneous fat/granulation and often undermining, which is deeper than described. Unstageable requires obscuring slough/eschar so the depth cannot be determined, which is not present here.

Question 2

The nurse is reviewing the record of a client with a diagnosis of cirrhosis and notes that there is documentation of the presence of asterixis. How should the nurse assess for its presence?

Accepted Answer

Answer reason: Asterixis is a “flapping tremor” from impaired hepatic detoxification leading to hepatic encephalopathy, and it is elicited by testing for a brief loss of postural tone. The bedside assessment is to have the client extend the arms (typically with wrists dorsiflexed) and observe for irregular, nonrhythmic flapping movements at the wrists/hands. This directly assesses a neurologic sign of encephalopathy rather than fluid status. Measuring abdominal girth evaluates ascites, not neuromuscular instability from encephalopathy.

Question 3

During the postoperative period, the client who underwent a pelvic exenteration reports pain in the calf area. What action should the nurse take?

Accepted Answer

Answer reason: New postoperative calf pain raises concern for deep vein thrombosis, where early nursing priority is focused assessment for local signs of impaired venous return and inflammation. Assessing temperature, color, and size helps identify unilateral warmth, erythema, and swelling that support possible DVT and guides urgent escalation of care. Ambulation or massaging the calf could dislodge a clot and precipitate pulmonary embolism, creating an avoidable safety risk. Treating pain with an opioid without first assessing the extremity may mask a potentially life-threatening complication and delay timely intervention.

Question 4

A patient is admitted to the ER with the following signs and symptoms: very painful mid-epigastric pain felt in the back, elevated glucose, fever, and vomiting. During the head-to-toe assessment, you notice bluish discoloration around the belly button. As the nurse, you know this is called?

Accepted Answer

Answer reason: In the context of severe epigastric pain radiating to the back, fever, vomiting, and hyperglycemia, this supports severe/hemorrhagic pancreatitis. This named finding is specifically periumbilical discoloration, distinguishing it from flank ecchymosis, which would point to Grey-Turner’s sign. Recognizing this sign helps the nurse anticipate significant complications (e.g., shock) and need for urgent escalation and monitoring.

Question 5

The nurse assessing the vital signs of a 3-year-old child hospitalized with a diagnosis of croup notes that the respiratory rate is 28 breaths per minute. Based on this finding, which nursing action is appropriate?

Accepted Answer

Answer reason: A respiratory rate of 28/min in a 3-year-old falls within expected pediatric norms (about 20–30/min), so it is not, by itself, an abnormal finding requiring escalation. In a child with croup, interventions such as oxygen or urgent provider notification are driven by signs of respiratory distress or hypoxemia (e.g., low SpO2, retractions, cyanosis, altered mental status), which are not provided here. Because this is an expected value, the appropriate nursing action is to record it as part of routine vital-sign assessment. Reassessment in 15 minutes is not necessary solely for a normal rate unless other concerning clinical changes are present.

Question 6

A client contacts his home care nurse with complaints of nausea and abdominal pain. He has type 1 diabetes. The nurse should advise the client to do which of the following?

Accepted Answer

Answer reason: " Nausea and abdominal pain in a client with type 1 diabetes raise concern for worsening hyperglycemia and possible diabetic ketoacidosis, so frequent assessment is the safest immediate advice. Monitoring glucose at regular short intervals supports early recognition of deteriorating control and guides timely escalation of care and insulin adjustments per sick-day guidance. Holding insulin is dangerous in type 1 diabetes because absolute insulin deficiency can rapidly precipitate ketosis and acidosis. Increasing simple sugars or activity can further destabilize glucose and hydration status when the client may already be becoming ketotic or dehydrated.

Question 7

The nurse admits a client who fell off a 20-ft (6-m) ladder. On arrival in the emergency department, the client is arousable but lethargic. What is the nurse's priority action?

Accepted Answer

Answer reason: Lethargy after trauma raises concern for traumatic brain injury and potential increasing intracranial pressure, so establishing a baseline neurologic status immediately guides urgency of imaging, airway protection, and serial reassessments. This focused neurologic assessment is faster and more critical than a full head-to-toe exam, which can follow once immediate threats are identified. Pain and chronic history are important but do not supersede early identification of evolving neurologic compromise in a high-mechanism injury.

Question 8

The nurse prepares to complete an assessment of cranial nerves IX and X. Which supplies will the nurse obtain to complete the assessment?

Accepted Answer

Answer reason: Cranial nerves IX (glossopharyngeal) and X (vagus) are assessed by inspecting the oropharynx and evaluating swallowing and palate/uvula movement with phonation and the gag reflex when indicated. A light source and tongue blade allow visualization of the soft palate rise and uvula midline position while the client says “ah,” which screens for vagal dysfunction (e.g., hoarseness, dysphagia, asymmetric palatal elevation). A cotton ball is used for facial sensation (CN V), a tuning fork is for hearing/vibration tests (CN VIII), and an ophthalmoscope/Snellen chart are for optic/visual acuity assessment (CN II). This makes the tongue depressor and flashlight the most appropriate supplies for CN IX/X assessment.

Question 9

The nurse has finished suctioning the tracheostomy of a client. Which item should the nurse monitor to determine the effectiveness of the procedure?

Accepted Answer

Answer reason: The most direct bedside assessment of secretion clearance is auscultation for improved aeration (decreased rhonchi/coarse crackles) and more equal breath sounds after suctioning. Respiratory rate and pulse oximetry can improve, but they are indirect and may lag or be affected by other factors (pain, anxiety, oxygen delivery). Capillary refill reflects peripheral perfusion and does not evaluate airway clearance.

Question 10

The postpartum nurse is assessing a client who gave birth by cesarean section 5 hours ago and is requesting pain medication. The client appears restless, has a heart rate of 110/min, and admits to recent onset of anxiety. What priority action should the nurse take?

Accepted Answer

Answer reason: g., pulmonary embolism), and airway/breathing assessment takes priority. A pulse oximetry reading is a rapid, noninvasive way to screen for impaired oxygenation and guides urgency of escalation and further evaluation. Assessing for leg warmth/redness may support DVT suspicion but does not address immediate oxygenation status. Nonurgent comfort measures (relaxation techniques) and administering PRN analgesia should follow once physiologic instability and oxygenation have been assessed.

Question 11

A nurse suspects a patient's IV has infiltrated. What would be the next action?

Accepted Answer

Answer reason:  Infiltration occurs when IV fluid leaks into surrounding tissue, so the priority is to assess for classic local findings such as swelling/edema and coolness from nonvesicant fluid in the interstitium. Palpation around the insertion site helps confirm infiltration early and guides immediate actions like stopping the infusion and restarting the IV at a different site. Redness and warmth are more consistent with phlebitis or infection rather than infiltration. Increasing the infusion rate can worsen tissue injury by forcing more fluid into the tissue.

Question 12

It is 0700 and the nurse is caring for an 84-year-old client with dementia and a fractured hip. The client has been disoriented to time, place, and person since admission. The client moans frequently and grimaces when moving. He is prescribed morphine IV every 2 hours as needed for pain and was last medicated at 0530. He is scheduled for surgery at 1000 to repair the hip fracture, but the consent has not yet been signed. The client's spouse and child are to arrive at 0900. Which intervention should the nurse carry out first?

Accepted Answer

Answer reason: A focused morning assessment (pain level, neurovascular status of the affected extremity, vital signs, respiratory status given recent opioid use, and overall condition) determines whether urgent actions are needed before proceeding with other tasks. Pain medication may be appropriate, but it should follow assessment to confirm need, evaluate sedation/respiratory risk, and document response. Consent coordination and checklist completion are important but are not as time-critical as first assessing for complications (e.g., hypoxia, delirium progression, neurovascular compromise) that could affect safety and the surgical plan.

Question 13

A client with blunt head injury is admitted for observation, including hourly neurologic checks. At 01:00 AM, the client reports a headache; the nurse obtains a normal neurologic assessment and administers the PRN acetaminophen. At 02:00 AM, the client appears to be sleeping. Which action should the nurse take?

Accepted Answer

Answer reason: A client who appears to be sleeping still requires arousal and assessment of orientation/mental status because altered level of consciousness can be subtle and easily missed. Asking an orientation question provides a quick, sensitive check of cerebral function compared with simply observing breathing. Documenting presumed relief or deferring the assessment delays recognition of neurologic decline and is unsafe; checking paresthesia is less targeted than evaluating consciousness and orientation in this context.

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System-Specific Assessments Practice Test 28

System-Specific Assessments NCLEX Practice Test

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The nurse performing an assessment on a newly admitted client, notes a lesion on the client’s right heel that appears as a shallow open ulcer with a pink wound bed. The nurse will document this as a?

The nurse is reviewing the record of a client with a diagnosis of cirrhosis and notes that there is documentation of the presence of asterixis. How should the nurse assess for its presence?

During the postoperative period, the client who underwent a pelvic exenteration reports pain in the calf area. What action should the nurse take?

A patient is admitted to the ER with the following signs and symptoms: very painful mid-epigastric pain felt in the back, elevated glucose, fever, and vomiting. During the head-to-toe assessment, you notice bluish discoloration around the belly button. As the nurse, you know this is called?

The nurse assessing the vital signs of a 3-year-old child hospitalized with a diagnosis of croup notes that the respiratory rate is 28 breaths per minute. Based on this finding, which nursing action is appropriate?

A client contacts his home care nurse with complaints of nausea and abdominal pain. He has type 1 diabetes. The nurse should advise the client to do which of the following?

The nurse admits a client who fell off a 20-ft (6-m) ladder. On arrival in the emergency department, the client is arousable but lethargic. What is the nurse's priority action?

The nurse prepares to complete an assessment of cranial nerves IX and X. Which supplies will the nurse obtain to complete the assessment?

The nurse has finished suctioning the tracheostomy of a client. Which item should the nurse monitor to determine the effectiveness of the procedure?

The postpartum nurse is assessing a client who gave birth by cesarean section 5 hours ago and is requesting pain medication. The client appears restless, has a heart rate of 110/min, and admits to recent onset of anxiety. What priority action should the nurse take?

A nurse suspects a patient's IV has infiltrated. What would be the next action?

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