Question 1

A 66 year-old client is admitted for mitral valve replacement surgery. The client has a history of mitral valve regurgitation and mitral stenosis since her teenage years. During the admission assessment, the nurse should ask the client if as a child she had?

Accepted Answer

Answer reason: Rheumatic fever can lead to rheumatic heart disease causing chronic mitral stenosis and regurgitation; a history of rheumatic fever in childhood is a key assessment question.

Question 2

In a client with mitral regurgitation the nurse would expect to see which of the following signs and symptoms?

Accepted Answer

Answer reason: Mitral regurgitation increases left atrial pressure and leads to pulmonary congestion, producing dyspnea on exertion. Anemia, infection, or MI-related crushing chest pain are not typical expected findings of isolated MR.

Question 3

A 74 year-old male is admitted due to inability to void. He has a history of an enlarged prostate and has not voided in 14 hours. When assessing for bladder distention, the BEST method for the nurse to use is to assess for?

Accepted Answer

Answer reason: A distended bladder presents as a palpable, rounded suprapubic fullness. Rebound tenderness suggests peritoneal irritation, LLQ dullness relates to bowel findings, and urinary discharge does not assess distention.

Question 4

While assessing a 1 month-old infant, which of the following findings should the nurse report IMMEDIATELY?

Accepted Answer

Answer reason: Grunting in an infant is a sign of respiratory distress and warrants immediate reporting. Abdominal and irregular respirations are normal patterns in young infants, and heart rate increases with crying is expected.

Question 5

A client who is 12 hour post-op becomes confused and complains of giant sharks swimming across the ceiling. Which assessment is necessary to adequately identify the source of this client's behavior?

Accepted Answer

Answer reason: Sudden postoperative confusion and hallucinations commonly indicate hypoxemia. The priority assessment to identify this cause is to check oxygenation with pulse oximetry.

Question 6

The nurse is performing a neurological assessment on a client post right CVA. Which of the following findings, if observed by the nurse, would warrant IMMEDIATE attention?

Accepted Answer

Answer reason: A declining level of consciousness signals acute neurologic deterioration (e.g., worsening stroke or increased ICP) and requires immediate intervention.

Question 7

The nurse is performing an assessment on a child who has been recently diagnosed with Cystic Fibrosis. Which of the following findings would the nurse anticipate?

Accepted Answer

Answer reason: In cystic fibrosis, thickened secretions obstruct airways early, leading to noisy respirations and a dry, nonproductive cough—an expected initial respiratory finding.

Question 8

What color should a nurse expect nasogastric tube drainage to be for about 12 to 24 hours after a subtotal gastrectomy?

Accepted Answer

Answer reason: Early postoperative NG drainage after gastric surgery is typically dark brown/coffee-ground from old blood for the first 12–24 hours; bright red suggests active bleeding and bile-green occurs later.

Question 9

Which of the following is used to assess the level of consciousness?

Accepted Answer

Answer reason: The Glasgow Coma Scale evaluates eye, verbal, and motor responses to quantify level of consciousness. Braden assesses pressure-injury risk, Apgar evaluates newborn status, and Snellen tests visual acuity.

Question 10

What is the first symptom that develops when a patient experiences cast compromise?

Accepted Answer

Answer reason: Early neurovascular compromise from a tight cast presents first with paresthesia (tingling). Cyanosis is a late sign, 'circulation' is not a symptom, and restlessness is nonspecific.

Question 11

Which vital sign is abnormal in a patient with temperature 37.0°C (98.6°F), heart rate 82, respiration rate 18, and blood pressure 130/94 mmHg?

Accepted Answer

Answer reason: All values are within normal adult ranges except the blood pressure; a diastolic of 94 mmHg is elevated (hypertension).

Question 12

When a patient supports his own arm while having his blood pressure taken, the following error can occur?

Accepted Answer

Answer reason: If the patient supports their own arm, isometric muscle contraction occurs, which falsely elevates the diastolic reading.

Question 13

All of the following are true of physical assessments except which one?

Accepted Answer

Answer reason: Physical assessments are typically systematic (head-to-toe) and may combine systems for each body area, with depth tailored to the patient’s condition. The sequence should be adapted as needed (e.g., painful areas last), so it is not unvarying; thus option A is the exception.

Question 14

A four-year-old is admitted with drooling and an inflamed epiglottis. During the assessment, the nurse would identify which of the following symptoms as indicative of an increase in respiratory distress?

Accepted Answer

Answer reason: An increased respiratory rate is a direct, early sign of worsening respiratory distress. Bradycardia is a late, pre-arrest sign; pallor and irritability are less specific.

Question 15

The nurse is observing a student nurse auscultate the lungs of a client. The nurse knows that the student nurse is correctly auscultating the right middle lobe (RML) if the stethoscope is placed in which of the following positions?

Accepted Answer

Answer reason: The right middle lobe is heard best on the right anterior chest between the 4th and 6th intercostal spaces; it does not extend to the posterior chest.

Question 16

When caring for a client with myasthenia gravis, an important nursing consideration would be to?

Accepted Answer

Answer reason: Myasthenia gravis causes skeletal muscle weakness that worsens with activity and later in the day. Assessing muscle groups toward the end of the day best reflects fatigability. Vertigo, ICP issues, and fluid-electrolyte imbalance are not primary concerns.

Question 17

Which artery is most commonly palpated for taking pulse?

Accepted Answer

Answer reason: The radial artery is superficial and easily accessible at the wrist, making it the standard site for routine pulse assessment.

Question 18

Which artery is usually palpated to get the pulse?

Accepted Answer

Answer reason: The radial artery at the wrist is the standard site to palpate a peripheral pulse in adults.

Question 19

How does a nurse assess the proper functioning of the laryngeal nerve after thyroidectomy?

Accepted Answer

Answer reason: The recurrent laryngeal nerve controls the vocal cords; post-thyroidectomy function is assessed by asking the patient to speak and evaluating voice quality/hoarseness.

Question 20

Examination of a patient with the help of a stethoscope is termed as?

Accepted Answer

Answer reason: Listening to internal body sounds with a stethoscope is called auscultation; percussion is tapping, palpation is feeling with hands, and precursor is not an exam technique.

Question 21

The nurse is caring for a patient admitted two days ago with a diagnosis of closed head injury. If the patient develops diabetes insipidus, the nurse would observe which of the following symptoms?

Accepted Answer

Answer reason: Central diabetes insipidus after head injury causes polyuria of very dilute urine (specific gravity

Question 22

A client has developed a low intestinal obstruction. The nurse would anticipate which of the following findings?

Accepted Answer

Answer reason: Low intestinal obstruction typically presents with progressive abdominal distention and nausea/vomiting (often later and feculent if distal). Diarrhea, rectal bleeding, or melena are not characteristic of mechanical low obstruction.

Question 23

When assessing orientation to person, place, and time for an elderly hospitalized client, which of the following principles should be understood by the nurse?

Accepted Answer

Answer reason: Hospitalization and unfamiliar surroundings can precipitate confusion/delirium in older adults. Short-term memory is typically less efficient than long-term in aging (1 false). Cognitive decline is not a normal part of aging (3 false). Older adults can learn; hospitalization may slow learning but not inherently reduce ability (4 not the best principle).

Question 24

A client with acquired immunodeficiency syndrome (AIDS) is admitted with a tentative diagnosis of late AIDS dementia complex. The nursing assessment is most likely to reveal which of the following?

Accepted Answer

Answer reason: Late AIDS dementia complex presents with global cognitive decline and confusion, including disorientation to person, place, and time. Hyperactive reflexes are not defining, peripheral neuropathy typically begins in the feet rather than the hands, and impaired concentration/memory loss are earlier signs.

Question 25

While assessing the vital signs in children, the nurse should know that the apical heart rate is preferred until the radial pulse can be accurately assessed at about?

Accepted Answer

Answer reason: In children under about 2 years old, peripheral pulses may be difficult to palpate reliably; therefore the apical pulse is preferred until around age 2.

Question 26

The nurse is performing an assessment of the motor function in a client with a head injury. The BEST technique is?

Accepted Answer

Answer reason: For neurologic motor assessment in an unresponsive head-injury patient, a central painful stimulus such as gentle supraorbital (eye orbit) pressure is preferred. It gives a reliable motor response and avoids tissue injury; sternal rub and random pinching are less appropriate.

Question 27

The nurse admits a two year-old child who has had a seizure. Which of the following statement by the child's parent would be important in determining the etiology of the seizure?

Accepted Answer

Answer reason: Infections such as otitis media can cause fever and trigger febrile seizures in toddlers, making an ear infection a key etiologic clue. The other statements are not typical causes.

Question 28

In assessing the healing of a client's wound during a home visit, which of the following is the BEST indicator of good healing?

Accepted Answer

Answer reason: Healthy granulation tissue appears red, indicating vascularization and progress toward healing. Green drainage suggests infection, white patches or eschar indicate nonviable tissue.

Question 29

The nurse is assessing a 4 year-old for possible developmental dysplasia of the right hip. Which of the following would the nurse expect to find?

Accepted Answer

Answer reason: In a walking 4-year-old with developmental dysplasia of the hip, classic infant signs like the Ortolani maneuver are absent; the typical finding is a waddling/Trendelenburg-type characteristic limp.

Question 30

The nurse is participating in a community health fair. As part of the assessments, the nurse should conduct a mental status examination when?

Accepted Answer

Answer reason: A mental status exam is part of the baseline neurologic assessment and should be included with every health assessment, not only when specific symptoms are present.

Question 31

In a child with suspected coarctation of the aorta, the nurse would expect to find?

Accepted Answer

Answer reason: Coarctation of the aorta causes increased pressure and perfusion to the upper extremities and decreased to the lower, producing bounding brachial/radial pulses and weak/absent femoral-pedal pulses.

Question 32

While assessing a 2 year-old child with a tentative diagnosis of Wilm's tumor, the nurse would be MOST concerned about the mother's report that?

Accepted Answer

Answer reason: Wilms tumor commonly presents as a rapidly enlarging abdominal mass; increasing abdominal girth (tight clothing at the waist) is an early, specific warning sign and most concerning compared to nonspecific findings like weight loss, decreased urine noted by parent, or food preferences.

Question 33

The nursing history for a newborn suspected of having pyloric stenosis would MOST likely reveal?

Accepted Answer

Answer reason: Hypertrophic pyloric stenosis classically presents in infants with progressively worsening, non-bilious vomiting that becomes projectile after feeds. Bile-stained emesis suggests obstruction distal to the pylorus; peristalsis is not absent; cyanosis is not typical.

Question 34

A client is admitted with the diagnosis of meningitis. Which of the following assessments would the nurse expect to find in assessing this client?

Accepted Answer

Answer reason: Meningeal irritation produces a positive Brudzinski sign: passive neck flexion causes involuntary flexion of the hips and knees. Other options are unrelated (e.g., rebound tenderness is a peritoneal sign).

Question 35

The nurse is caring for a client who has developed cardiac tamponade. Which of the following assessments would the nurse anticipate finding?

Accepted Answer

Answer reason: Cardiac tamponade increases intrapericardial pressure, impeding venous return and raising venous pressure, producing jugular venous distention. Tamponade typically causes narrowed (not widened) pulse pressure and tachycardia; a pleural friction rub reflects pleural/pericardial inflammation, not tamponade.

Question 36

Which nursing action is a PRIORITY as the plan of care is developed for a seven year-old child hospitalized for acute glomerulonephritis?

Accepted Answer

Answer reason: Acute glomerulonephritis commonly causes fluid retention and significant hypertension, which can lead to complications such as encephalopathy. Priority nursing action is close monitoring of blood pressure patterns. Edema and decreased (not increased) urine output are expected, but BP monitoring is the most urgent.

Question 37

The nurse auscultates bibasilar inspiratory crackles in a newly admitted 68 year-old client with a diagnosis of congestive heart disease. Which of the following symptoms is MOST likely to occur?

Accepted Answer

Answer reason: Bibasilar crackles indicate pulmonary congestion from heart failure; fluid overload commonly presents with dependent/peripheral edema. The other options are less specific to CHF.

Question 38

The nurse is performing an assessment on a child with severe airway obstruction. Which of the following would the nurse anticipate finding?

Accepted Answer

Answer reason: Severe airway obstruction in children increases work of breathing, producing marked intercostal/suprasternal retractions. Cyanosis is a late sign; chest pain is not typical; rapid shallow respirations are nonspecific.

Question 39

An ambulatory client reports edema during the day in his feet and ankles that disappears while sleeping at night. Which of the following is the most appropriate follow-up question for the nurse to ask?

Accepted Answer

Answer reason: Dependent edema in an ambulatory client suggests right-sided heart failure. The best follow-up is to assess for dyspnea on exertion, a common associated symptom, making option B the most appropriate.

Question 40

The nurse is planning care for a ten month-old infant with bacterial meningitis. Which of the following nursing measures would be appropriate for the nurse to do?

Accepted Answer

Answer reason: In infants with meningitis, frequent neurologic assessment is essential; measuring head circumference detects increased ICP and complications like hydrocephalus. Contact isolation is incorrect (needs droplet precautions), and added stimulation or active ROM is not prioritized.

Question 41

The nurse is performing a physical assessment on an infant with roseola. Which of the following characteristics of the skin lesions would the nurse expect to find?

Accepted Answer

Answer reason: Roseola (HHV-6) presents with a blanching rose-pink macular rash that begins on the trunk and may spread. Option A describes varicella, C describes erythema infectiosum, and D describes measles.

Question 42

The nurse is assessing a client in the emergency room. Which of the following statements suggests that the problem is acute angina?

Accepted Answer

Answer reason: Angina classically presents as deep, pressure-like substernal chest pain; it is not typically pleuritic, positional, or localized to the abdomen.

Question 43

The nurse is ready to begin an exam on a nine-month-old infant who is sitting quietly on his mother's lap. Which should the nurse do first?

Accepted Answer

Answer reason: When an infant is quiet, the nurse should auscultate heart and lung sounds first because subsequent maneuvers (ear exam, abdominal palpation, reflex checks) may upset the child and alter assessment findings.

Question 44

A mother brings her the clinic, complaining that the child seems to be The nurse expects to find which of the following on the initial history and physical assessment?

Accepted Answer

Answer reason: Among the listed choices, rash and restlessness are common early assessment findings in a child; the other options reflect more severe systemic illness or dehydration.

Question 45

A client is admitted to the emergency room following an acute asthma attack. Which of the following assessments would be expected by the nurse?

Accepted Answer

Answer reason: Acute asthma causes airway narrowing and air trapping, producing diffuse expiratory wheezes. Productive cough and fever suggest infection, and lack of relief from an inhalant is not an expected assessment finding.

Question 46

The nurse is caring for a client who was successfully resuscitated from a pulseless dysrhythmia. Which of the following assessments is CRITICAL for the nurse to include in the plan of care?

Accepted Answer

Answer reason: Post-resuscitation patients are at risk for decreased renal perfusion and pre-renal failure; hourly urine output is the most immediate, critical indicator of kidney perfusion and must be closely monitored.

Question 47

As the nurse interviews the parents of a child with asthma, it is a PRIORITY to ask about?

Accepted Answer

Answer reason: Animal dander from household pets is a common trigger for asthma exacerbations in children and is a priority assessment item. New furniture off-gassing and plants are less common triggers, and lead paint relates to toxicity, not asthma.

Question 48

A 3 year-old child is brought to the clinic by his grandmother to be seen for "scratching his bottom and wetting the bed at night." Based on these complaints, the nurse would INITIALLY assess for?

Accepted Answer

Answer reason: Perianal itching with nocturnal symptoms and bed-wetting in a preschooler is classic for Enterobius vermicularis infestation; the nurse should initially assess for pinworms (e.g., tape test).

Question 49

The nurse is assessing an eight month-old infant with a malfunctioning ventriculoperitoneal shunt. Which one of the following manifestations would the infant be MOST likely to exhibit?

Accepted Answer

Answer reason: A malfunctioning VP shunt causes increased intracranial pressure in infants; early signs include irritability and high‑pitched cry. A depressed fontanel suggests dehydration, not IICP; lethargy is later; a negative Moro is not typical.

Question 50

A client diagnosed with hepatitis C discusses his health history with the admitting nurse. The nurse should recognize which of the following as the MOST important data?

Accepted Answer

Answer reason: Hepatitis C is primarily transmitted via blood exposure; transfusions before routine HCV screening could lead to infection that manifests years later. Travel or raw shellfish are linked to hepatitis A, and sexual transmission of HCV is less common.

Train with a large NCLEX question bank and jump into a full exam-style simulator

System-Specific Assessments NCLEX Practice Test

Continue Learning