Question 1

What is the first action the nurse should perform when providing care for a client diagnosed with pre-renal acute kidney injury?

Accepted Answer

Answer reason: Pre-renal AKI results from decreased renal perfusion, commonly due to hypotension or hypovolemia. The priority first action is to assess blood pressure to evaluate perfusion and guide urgent interventions. The other options are not immediate priorities and may address different causes (e.g., post-renal obstruction) or longer-term monitoring.

Question 2

Which of the following will the nurse observe in the client in the ictal phase of a generalized tonic-clonic seizure?

Accepted Answer

Answer reason: Generalized tonic-clonic seizures present with sudden loss of consciousness followed by tonic stiffening and clonic violent muscle contractions. Other options describe focal motor (Jacksonian), absence, or complex partial seizures.

Question 3

Which respiratory finding should the nurse expect when assessing a client who has suffered a fractured rib?

Accepted Answer

Answer reason: Rib fractures cause pleuritic chest pain that worsens with inspiration, leading to splinting and shallow breaths. Paradoxical respirations indicate flail chest, not a simple rib fracture; deep respirations are not expected.

Question 4

Which assessment finding indicates that the respiratory condition of a 3-day-old preterm neonate with respiratory distress syndrome (RDS) is improving?

Accepted Answer

Answer reason: Improvement in RDS is reflected by decreasing tachypnea toward normal. A respiratory rate trending down to 60–70/min suggests stabilization, whereas edema or a new systolic murmur indicate complications; urine output does not directly reflect respiratory status.

Question 5

What is the appropriate nursing action when an isolated premature ventricular contraction (PVC) is noted on the cardiac monitor of a client recovering from anesthesia?

Accepted Answer

Answer reason: Occasional isolated PVCs in a client recovering from anesthesia are common due to transient hypoxia, stress, or catecholamine release. If the PVCs are infrequent and the client is asymptomatic, the appropriate nursing action is to continue monitoring while assessing for potential contributing factors (e.g., electrolyte imbalance, hypoxia). Intervention or medication is indicated only if PVCs are frequent, multifocal, or symptomatic.

Question 6

What is the nurse's priority action when hearing swooshing bowel sounds to the left of the umbilical area?

Accepted Answer

Answer reason: A “swooshing” or “bruit-like” sound over the abdomen indicates turbulent blood flow, commonly from an abdominal aortic aneurysm. Palpation or percussion could cause rupture and must be avoided. The nurse should stop the assessment and immediately notify the primary healthcare provider for further diagnostic evaluation.

Question 7

Most accurate pulse site of assess arrhythmia in children?

Accepted Answer

Answer reason: In children, arrhythmias are best detected by auscultating the apical pulse for a full minute; peripheral sites like radial, carotid, or brachial are less reliable.

Question 8

What condition is associated with bruising behind the ear?

Accepted Answer

Answer reason: Bruising behind the ear is Battle's sign, which is classically associated with a basilar skull fracture.

Question 9

Which sign is most indicative of meningitis?

Accepted Answer

Answer reason: Brudzinski's sign is a classic meningeal sign where neck flexion causes hip/knee flexion, indicating meningeal irritation. Nausea, cough, and headache are nonspecific.

Question 10

Which of the following is a sign of deep vein thrombosis (DVT)?

Accepted Answer

Answer reason: DVT commonly presents with unilateral leg swelling, pain, warmth, and erythema. Bradycardia, rapid weight loss, and increased urine output are not typical signs of DVT.

Question 11

A nursing student auscultating the breath sounds of a client is observed by the nurse. The nurse should intervene if the nursing student performs which action?

Accepted Answer

Answer reason: Correct respiratory auscultation uses the diaphragm, places it on bare skin, and has the client sit up and breathe slowly and deeply through the mouth. Asking the client to lie on the sides is incorrect; the client should ideally be upright.

Question 12

A patient is having abdomen pain. You assess them and find that they have a positive murphy's sign. What is this indicative of?

Accepted Answer

Answer reason: A positive Murphy's sign—arrest of inspiration with RUQ palpation—indicates acute gallbladder inflammation, i.e., cholecystitis.

Question 13

When measuring pulse, it is important to pay attention to?

Accepted Answer

Answer reason: Pulse assessment includes rate (beats per minute), rhythm, and strength/force; therefore all listed aspects are important.

Question 14

Objective data might include?

Accepted Answer

Answer reason: Objective data are measurable and observable findings; vital sign measurements like blood pressure are objective. Chest pain and dizziness are subjective complaints reported by the patient.

Question 15

Which of the following is an early indicator of deterioration in a client with increased intracranial pressure (ICP)?

Accepted Answer

Answer reason: Early signs of increased ICP are subtle changes in mental status and LOC. Widened pulse pressure, bradycardia, and a fixed dilated pupil are late signs of deterioration (Cushing's triad and herniation).

Question 16

A client is at risk for increased intracranial pressure (ICP). Which of the following would be the priority for the nurse to monitor?

Accepted Answer

Answer reason: Unequal pupils indicate cranial nerve III compression and rising ICP. In increased ICP, Cushing’s response shows increased (not decreased) systolic BP and bradycardia; tachycardia and hypothermia are not typical indicators.

Question 17

Based on Leopold's maneuver findings of breech presentation and fetal back at the right side of the mother, in which location can you hear the fetal heartbeat (PMI)?

Accepted Answer

Answer reason: PMI is best heard over the fetal back. In breech presentation it is above the umbilicus; with the back on the mother’s right side, it is in the right upper quadrant.

Question 18

Which ECG rhythm is characterized by a polymorphic ventricular tachycardia with a twisting QRS complex around the isoelectric line?

Accepted Answer

Answer reason: Torsades de pointes is a polymorphic ventricular tachycardia with QRS complexes that appear to twist around the isoelectric line. The other options do not show this pattern.

Question 19

A patient is admitted with shortness of breath, so the nurse immediately listens to his breath sounds. Which type of assessment is the nurse performing?

Accepted Answer

Answer reason: The nurse targets assessment to the patient’s presenting problem (shortness of breath) by auscultating breath sounds, which is a focused physical assessment rather than comprehensive or ongoing.

Question 20

The nurse performs an assessment of a newly admitted patient. The nurse understands that this admission assessment is conducted primarily to?

Accepted Answer

Answer reason: The primary purpose of an admission assessment is to collect comprehensive baseline data to guide care planning. Screening for fall risk, checking skin, and building rapport are components but not the main objective.

Question 21

In assessing the abdomen, Which of the following is the correct sequence of the physical assessment?

Accepted Answer

Answer reason: For abdominal assessment the sequence is IAPP—inspect first, then auscultate before percussion and palpation to avoid altering bowel sounds.

Question 22

A client at risk for increased intracranial pressure (ICP) requires priority monitoring of which sign?

Accepted Answer

Answer reason: Anisocoria indicates cranial nerve III compression and rising ICP/possible herniation, making it a priority sign to monitor. ICP typically causes increased systolic BP with bradycardia (Cushing triad), not decreasing SBP or tachycardia; temperature often increases rather than decreases.

Question 23

Which findings does the nurse anticipate on physical examination of a client with epididymitis?

Accepted Answer

Answer reason: Epididymitis presents with acute scrotal pain and swelling of the epididymis, often with fever and systemic symptoms like nausea and vomiting. Diarrhea and ecchymosis are not typical findings, and testicular torsion is a different condition.

Question 24

Which respiratory finding indicates that a client being treated for an asthma attack is worsening?

Accepted Answer

Answer reason: Diminished or absent breath sounds indicate minimal air movement (silent chest), a sign of severe airflow obstruction and impending respiratory failure in asthma—worse than loud wheezing.

Question 25

How should a resting pulse of 58 beats per minute in an adult patient be interpreted?

Accepted Answer

Answer reason: Normal adult resting HR is 60–100 bpm; 58 bpm is below 60 and indicates bradycardia. It is not automatically emergent unless symptomatic.

Question 26

Which pain assessment scale is shown with faces ranging from 'No Hurt' to 'Worst'?

Accepted Answer

Answer reason: The faces scale labeled from 'No Hurt' to 'Worst' is the Wong-Baker FACES Pain Rating Scale.

Question 27

The nurse is assessing the deep tendon reflexes of a client with preeclampsia. Which method is used to elicit the biceps reflex?

Accepted Answer

Answer reason: Biceps reflex is elicited by placing a thumb over the biceps tendon in the antecubital fossa and striking the thumb with the reflex hammer. The other options describe triceps, patellar, and brachioradialis reflex techniques.

Question 28

What should the nurse assess for in a client in the postictal phase of a generalized tonic-clonic seizure?

Accepted Answer

Answer reason: After a generalized tonic-clonic seizure, the postictal phase commonly includes drowsiness and confusion. Inability to move (Todd’s paralysis) is not routine, paresthesia is not typical, and hypotension is uncommon.

Question 29

What is the correct sequence of steps in a nursing physical assessment?

Accepted Answer

Answer reason: The standard sequence for most physical assessments is IPPA: inspection, then palpation, percussion, and auscultation. (Abdominal exams are the notable exception.).

Question 30

What position should the nurse place the head of the bed to obtain the most accurate reading of jugular vein distension?

Accepted Answer

Answer reason: Jugular venous pressure is best assessed with the head of bed elevated about 30–45 degrees; flatter exaggerates and more upright obscures the jugular pulsation.

Question 31

Which instrument is used to assess vibratory sensation during a neurological examination?

Accepted Answer

Answer reason: Vibratory sensation is tested by placing a vibrating tuning fork on bony prominences; the other instruments are not used for sensory testing.

Question 32

What is the Glasgow Coma Scale (GCS) eye opening score when the patient opens eyes to speech?

Accepted Answer

Answer reason: GCS eye opening scores: 4 spontaneous, 3 to speech, 2 to pain, 1 none; therefore to speech equals 3.

Question 33

What phase of the nursing process is being implemented when the nurse takes the client's vital signs after a walk-in client presents with abdominal pain and diarrhea?

Accepted Answer

Answer reason: Taking vital signs is data collection, which corresponds to the Assessment phase of the nursing process.

Question 34

Which of the following is an example of subjective data?

Accepted Answer

Answer reason: Subjective data are the client’s feelings or perceptions; pain is whatever the patient says it is. Blood pressure, temperature, and lab results are objective measurable data.

Question 35

What is the correct sequence for abdominal assessment?

Accepted Answer

Answer reason: For the abdomen, auscultation is performed before percussion and palpation to avoid altering bowel sounds. Option B is the only choice that places auscultation before both, making it the best answer among the options provided.

Question 36

How should a nurse interpret a blood pressure reading of 150/95 mmHg?

Accepted Answer

Answer reason: Per ACC/AHA guidelines, stage 2 hypertension is systolic ≥140 mmHg or diastolic ≥90 mmHg; 150/95 meets both thresholds.

Question 37

The nurse assesses the client's pedal pulses as having a pulse volume of 1 on a scale of 0 to 3. Based on this assessment finding, it would be important for the nurse to also assess the?

Accepted Answer

Answer reason: A weak, thready pedal pulse (1+) may indicate decreased stroke volume and hypotension; checking the blood pressure is the priority to evaluate hemodynamic stability and perfusion.

Question 38

What is the proper order in physical assessment of the abdomen?

Accepted Answer

Answer reason: For abdominal assessment, auscultation is performed before percussion and palpation to avoid altering bowel sounds; the correct sequence is inspection, auscultation, percussion, palpation.

Question 39

Which examination uses a stethoscope?

Accepted Answer

Answer reason: Auscultation is listening to internal body sounds with a stethoscope; percussion involves tapping, palpation uses touch, and vibration is not a primary exam technique.

Question 40

As the nurse takes a history of a 3 year-old with neuroblastoma, what comments by the parents require follow-up and are consistent with the diagnosis?

Accepted Answer

Answer reason: Neuroblastoma commonly presents with an abdominal mass and increasing abdominal girth; parents noticing clothes tighter across the abdomen suggests this. The other options are nonspecific or less characteristic.

Question 41

An 80 year-old client was admitted with a diagnosis of possible cerebral vascular accident. Blood pressure has ranged from 180/110 to 160/100. Over the past several hours, the nurse noted increasing lethargy. Which of the following assessments should the nurse report IMMEDIATELY to the physician?

Accepted Answer

Answer reason: New or worsening slurred speech in a suspected stroke with increasing lethargy signifies acute neurologic deterioration or intracranial bleeding and requires immediate reporting. Incontinence, muscle weakness, or a rapid pulse are less specific and not as urgent in this context.

Question 42

Which of the following manifestations observed by the school nurse confirms the presence of pediculosis capitis in students?

Accepted Answer

Answer reason: Pediculosis capitis is confirmed by seeing nits—white, oval eggs firmly attached to hair shafts. Pruritus or flakes can be dandruff; patterned occipital hair loss is not typical.

Question 43

A client with a fracture of the radius had a plaster cast applied two days ago. The client complains of constant pain and swelling of the fingers. The FIRST action of the nurse should be?

Accepted Answer

Answer reason: With a recent cast and reports of constant pain and finger swelling, the priority is a neurovascular assessment to detect compromised perfusion/compartment syndrome; check capillary refill first. Removing the cast is not the nurse’s first step, warm soaks can worsen swelling, and keeping the arm no higher than heart level is inappropriate.

Question 44

A client is two days post operative. The vital signs are: BP - 120/70, HR - 110, RR - 26, and Temperature - 100.4 degrees F (38 degrees C). The client suddenly becomes profoundly short of breath, skin color is gray. Which assessment would have alerted the nurse FIRST to the client's change in condition?

Accepted Answer

Answer reason: Tachypnea is the earliest and most sensitive indicator of hypoxia; respiratory rate rises before changes in heart rate, blood pressure, or temperature.

Question 45

A 43-year-old African American male is admitted with sickle cell anemia. The nurse plans to assess circulation in the lower extremities every 2 hours. Which of the following outcome criteria would the nurse use?

Accepted Answer

Answer reason: Capillary refill under 3 seconds is a direct measure of peripheral perfusion to the lower extremities. The other options assess temperature, motor function, or sensation, not circulation.

Question 46

The client with suspected meningitis is admitted to the unit. The doctor is performing an assessment to determine meningeal irritation and spinal nerve root inflammation. A positive Kernig’s sign is charted if the nurse notes?

Accepted Answer

Answer reason: Kernig’s sign is tested by flexing the hip and knee and then attempting to extend the knee; pain or resistance indicates meningeal irritation. Among the options, the finding describing pain associated with hip and knee flexion best corresponds to a positive Kernig’s sign.

Question 47

The nurse has identified what appears to be ventricular tachycardia on the cardiac monitor of a client being evaluated for possible myocardial infarction. The FIRST action the nurse would perform is to?

Accepted Answer

Answer reason: Before initiating any emergency intervention, the nurse must quickly assess the client to confirm if the rhythm is producing a pulse and adequate perfusion. If pulseless, CPR and defibrillation follow.

Question 48

Burger's test is used to assess the adequacy of the arterial supply to the _________?

Accepted Answer

Answer reason: Buerger's test evaluates peripheral arterial insufficiency by observing elevation pallor and dependent rubor of the lower limb; it is used for lower extremity arterial supply.

Question 49

What does a peripheral neurological examination consist of?

Accepted Answer

Answer reason: A peripheral neurologic assessment includes evaluation of gait, reflexes, and motor power with sensation; therefore, all listed components are included.

Question 50

Aspects of timing as a characteristic of a patient's chief complaint are?

Accepted Answer

Answer reason: Timing in symptom analysis focuses on when symptoms occur, how long they last, and how often they occur—i.e., onset, duration, and frequency. The other options describe quality, location, or context.

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