WorksheetsHealth Assessment Practice Test 1
Total questions: 119
Worksheet time: 1hrs 2mins
Name
Class
Date
1.
A nurse is beginning an admission assessment on a 74-year-old client in an assisted living facility. The client is clean, sitting upright in a chair, and speaking clearly. The nurse notes a strong odor of cigarette smoke on the client’s clothing. Which of the following should the nurse identify as the most concerning finding at this time?
a)
The client is seated rather than lying in bed
b)
The client is alert and able to answer questions
c)
The presence of a strong tobacco odor on clothing
d)
The client’s speech is clear and coherent
2.
A nurse is preparing to interview a client who speaks limited English and is accompanied by an adult child who offers to translate. Which of the following actions should the nurse take first?
a)
Ask the family member to translate medical terminology carefully
b)
Request a trained medical interpreter
c)
Proceed with the interview using simple yes-or-no questions
d)
Provide written discharge instructions in English
3.
A nurse is assessing vital signs on a postoperative client. The client’s respiratory rate is 10/min, heart rate is 96/min, blood pressure is 128/76 mm Hg, and oxygen saturation is 97% on room air. Which finding should the nurse address first?
a)
Heart rate of 96/min
b)
Respiratory rate of 10/min
c)
Blood pressure of 128/76 mm Hg
d)
Oxygen saturation of 97%
4.
A nurse is planning to assess a client’s abdomen during a focused assessment. Which of the following actions should the nurse perform first?
a)
Palpate all four quadrants for tenderness
b)
Inspect the abdomen for contour and symmetry
c)
Percuss the abdomen for tympany
d)
Auscultate bowel sounds in each quadrant
5.
A nurse is collecting a health history from a client who reports chest discomfort that began earlier in the day. Which of the following questions is most appropriate to ask first?
a)
“Have you taken anything to relieve the discomfort?”
b)
“Can you describe what the discomfort feels like?”
c)
“Does anyone in your family have heart disease?”
d)
“How severe is the discomfort on a scale from 0 to 10?”
6.
A nurse is determining which tasks may be delegated to unlicensed assistive personnel (UAP). Which tasks are appropriate to delegate? (Select all that apply.)
a)
Obtaining routine vital signs
b)
Assisting a client with toileting
c)
Evaluating a client’s response to pain medication
d)
Teaching a client how to use an incentive spirometer
7.
A nurse is interviewing a client who states, “I haven’t felt like myself since my spouse died last year.” Which of the following responses demonstrates therapeutic communication?
a)
“At least you had many good years together.”
b)
“Can you tell me more about how this has been affecting you?”
c)
“Time usually helps people feel better.”
d)
“You should try to stay busy to distract yourself.”
8.
A nurse is assessing nutritional status in an older adult client. Which of the following findings places the client at highest risk for malnutrition?
a)
Body mass index of 27
b)
Unintentional weight loss over the past 2 months
c)
Preference for a vegetarian diet
d)
Occasional constipation
9.
A nurse is caring for a client who becomes dizzy when standing up from a seated position. Which assessment should the nurse perform next?
a)
Measure the client’s blood glucose level
b)
Obtain orthostatic blood pressure measurements
c)
Ask the client about fluid intake for the day
d)
Assist the client to ambulate in the hallway
10.
A nurse is preparing to obtain a health history from a new client in an urgent care clinic. The client’s chart has not been started yet. Which of the following should the nurse obtain first?
a)
Review of systems
b)
Biographical data
c)
Past surgical history
d)
Family history
11.
A nurse is beginning an interview with a client who says, “I came in because my stomach has been acting up.” Which of the following questions is the best broad opening?
a)
“Is your pain sharp or dull?”
b)
“Did you eat anything greasy today?”
c)
“Tell me more about what you mean by ‘acting up.’”
d)
“Have you had nausea or vomiting?”
12.
A nurse is performing a focused abdominal assessment on a client who reports nausea and bloating. Which order should the nurse use?
a)
Inspection → Palpation → Percussion → Auscultation
b)
Palpation → Percussion → Auscultation → Inspection
c)
Inspection → Auscultation → Percussion → Palpation
d)
Auscultation → Inspection → Palpation → Percussion
13.
A nurse is auscultating a client’s heart sounds and suspects a low-pitched murmur. Which part of the stethoscope should the nurse use?
a)
Diaphragm
b)
Bell
c)
Earpieces
d)
Tubing
14.
A nurse is caring for a client who is incontinent of liquid stool. While changing the linens, stool splashes onto the nurse’s forearm. Which actions should the nurse take? (Select all that apply.)
a)
Remove gloves
b)
Perform hand hygiene
c)
Clean the exposed skin
d)
Continue care and wash hands later
15.
A nurse obtains the following vital signs on a client who is anxious about an upcoming procedure: T 98.4°F (36.9°C), HR 112/min, RR 20/min, BP 146/84 mm Hg. The client’s hands are shaking and they keep asking, “Am I going to be okay?” Which finding is the nurse’s priority to address?
a)
Blood pressure of 146/84 mm Hg
b)
Heart rate of 112/min
c)
Respiratory rate of 20/min
d)
Shaking hands
16.
A nurse is rechecking a client’s blood pressure. The client has an IV in the left forearm and a dialysis shunt in the right arm. Which site should the nurse use?
a)
Left upper arm
b)
Right upper arm
c)
Thigh using the popliteal artery
d)
Left forearm over the IV site
17.
A nurse is determining which assessment findings are subjective data. Which findings should the nurse classify as subjective? (Select all that apply.)
a)
“It feels like a burning pain that shoots down my leg.”
b)
Blood pressure drops from 128/76 to 104/60 when standing
c)
“I feel dizzy when I stand up.”
d)
Grimacing during palpation
18.
A nurse is caring for a client who says, “My culture doesn’t allow pork, and I fast on certain holy days.” Which action best supports culturally competent care?
a)
Encourage the client to follow the hospital diet to speed healing
b)
Ask the provider to prescribe a high-calorie supplement immediately
c)
Ask the client which foods and meal times are acceptable and notify dietary services
d)
Document that the client is noncompliant with the recommended diet
19.
A nurse is performing a general survey on a client in the emergency department. Which observation is part of the general survey?
a)
Percussing for kidney tenderness
b)
Checking capillary refill in all extremities
c)
Noting posture, grooming, and signs of distress on first contact
d)
Measuring abdominal circumference with a tape measure
20.
A nurse is caring for a client who reports feeling weak and dizzy when standing. The nurse notes a blood pressure drop of 22 mm Hg systolic within 2 minutes of standing. Which finding should the nurse document?
a)
Tachycardia
b)
Bradycardia
c)
Orthostatic hypotension
d)
Hypotension at rest
21.
A nurse is conducting a comprehensive assessment on a client admitted to a medical-surgical unit. Which situation best indicates the need for a comprehensive rather than a focused assessment?
a)
A client returns for a blood pressure recheck
b)
A client is admitted for the first time to the unit
c)
A client reports new pain at an IV site
d)
A client requests help with sleep
22.
A nurse is preparing to take an oral temperature on a client. Which finding requires the nurse to choose a different method?
a)
The client smoked 30 minutes ago
b)
The client has dentures
c)
The client drank hot coffee 5 minutes ago
d)
The client is receiving oxygen via nasal cannula
23.
A nurse is evaluating whether a pain-management intervention was effective. Which action demonstrates the evaluation phase of the nursing process?
a)
Administering a prescribed analgesic
b)
Asking the client to rate pain before medication
c)
Asking the client to rate pain after the intervention
d)
Documenting the client’s pain history
24.
A nurse is assessing the integumentary system of an older adult client. Which finding should the nurse recognize as abnormal?
a)
Thinning of the epidermis
b)
Non-blanching redness over the sacrum
c)
Decreased skin elasticity
d)
Dry skin on the lower legs
25.
A nurse is caring for a client who appears anxious and avoids eye contact during the interview. Which nursing action best supports therapeutic communication?
a)
Proceed quickly to complete the interview
b)
Ask only closed-ended questions
c)
Use a calm tone and allow time for responses
d)
Redirect the client to stay on topic
26.
A nurse is reviewing the health history of a client. Which information belongs in the chief complaint?
a)
“History of hypertension for 10 years”
b)
“Sharp abdominal pain that started this morning”
c)
“Appendectomy at age 22”
d)
“Father died of heart disease”
27.
A nurse is determining priorities for care on a busy unit. Which client should the nurse assess first?
a)
A client requesting pain medication for chronic back pain
b)
A client waiting for discharge instructions
c)
A client with new-onset shortness of breath
d)
A client who missed breakfast
28.
A nurse is teaching a group of clients about preventing seasonal influenza. Which activity is an example of primary prevention?
a)
Screening older adults for early flu symptoms
b)
Administering influenza vaccinations
c)
Providing pulmonary rehabilitation after illness
d)
Teaching medication management after hospitalization
29.
A nurse is assessing a client who reports fatigue and poor appetite over the past month. Which additional finding most strongly supports a concern for malnutrition?
a)
BMI of 28
b)
Loose-fitting clothes compared to last visit
c)
Reports drinking coffee daily
d)
Sleeps 6 hours per night
30.
A nurse is initiating contact with a client for a scheduled health history interview. Which action best demonstrates an appropriate nurse introduction?
a)
“I’m your nurse today. Let’s get started.”
b)
“I need to ask you some questions for your chart.”
c)
“My name is Jordan, I’m your nurse, and I’ll be asking questions for about 20 minutes.”
d)
“I’ll try to be quick since you’re probably tired.”
31.
A nurse is determining which assessment data require immediate follow-up. Which finding should the nurse prioritize?
a)
BMI of 31
b)
New confusion noted during the interview
c)
Chronic knee pain rated 4/10
d)
Report of occasional heartburn
32.
A nurse is assessing respirations on a resting adult client and counts 22 breaths per minute. How should the nurse document this finding?
a)
Bradypnea
b)
Tachypnea
c)
Dyspnea
d)
Normal respiration
33.
A nurse is reviewing a client’s chart prior to assessment. Which information is considered a patient resource used in health assessment?
a)
The nurse’s clinical experience
b)
Current staffing assignments
c)
Previous diagnostic test results
d)
Unit policy manuals
34.
A nurse is caring for a client who has type 2 diabetes and attends a class on healthy meal planning to prevent complications. This activity is an example of which level of prevention?
a)
Primary
b)
Tertiary
c)
Secondary
d)
None of the above
35.
A nurse is performing a general survey on a client. Which observation is most important for identifying immediate instability?
a)
Clothing style
b)
Posture
c)
Level of consciousness
d)
Grooming
36.
A nurse is using critical thinking while assessing a client. Which action best reflects this process?
a)
Following a checklist exactly as written
b)
Comparing current findings to expected norms
c)
Completing documentation quickly
d)
Asking only closed-ended questions
37.
A nurse is reviewing the vital signs of a client who reports feeling lightheaded. Which finding should the nurse recognize as bradycardia?
a)
Heart rate of 88/min
b)
Heart rate of 54/min
c)
Respiratory rate of 10/min
d)
Blood pressure of 96/60 mm Hg
38.
A nurse is assessing a client who reports a sudden onset of chest tightness. Which nursing action reflects appropriate prioritization?
a)
Ask about family history of heart disease
b)
Assess airway, breathing, and circulation
c)
Obtain a detailed pain history
d)
Document the client’s medication list
39.
A nurse is preparing to auscultate lung sounds on an adult client. Where should the nurse place the stethoscope to assess posterior lung fields?
a)
Over the sternum
b)
At the midclavicular line
c)
Below the scapulae, comparing side to side
d)
Directly over the spine
40.
A nurse is caring for a client who states, “I don’t think this treatment is helping at all.” Which response demonstrates clarification?
a)
“You shouldn’t feel discouraged.”
b)
“What makes you feel that the treatment isn’t helping?”
c)
“Many clients feel that way at first.”
d)
“Let’s focus on finishing your medications.”
41.
A nurse is determining whether assessment data are subjective or objective. Which finding is objective?
a)
Reports dizziness when standing
b)
Blood pressure drops from 128/76 to 104/60 when standing
c)
States pain is throbbing
d)
Describes nausea after meals
42.
A nurse is assessing a client’s BMI. Which BMI value is classified as obese?
a)
22.4
b)
24.8
c)
27.1
d)
31.2
43.
A nurse is assisting an older adult client with ambulation after bed rest. Which actions promote client safety? (Select all that apply.)
a)
Use a gait belt
b)
Ensure the client wears nonskid footwear
c)
Encourage the client to move quickly
d)
Walk slightly behind and to the side of the client
44.
A nurse is collecting health history data. Which information belongs in the past medical history section?
a)
“My father has diabetes.”
b)
“I was hospitalized for pneumonia 3 years ago.”
c)
“I have had nausea since yesterday.”
d)
“I feel short of breath today.”
45.
A nurse is evaluating a client after providing nonpharmacological pain relief. Which outcome indicates the intervention was effective?
a)
The client requests stronger medication
b)
The client appears relaxed and reports decreased pain
c)
The client is sleeping but pain was not reassessed
d)
The client avoids moving the affected area
46.
Which client factors increase the risk for malnutrition? (Select all that apply.)
a)
Poor dentition
b)
Older adult living alone
c)
Unintentional weight loss
d)
Low socioeconomic status
47.
A nurse is beginning an admission interview with a client. Which information should the nurse collect during the introductory phase of the interview?
a)
Detailed past medical history
b)
The client’s comfort level and readiness to participate
c)
A complete review of systems
d)
Family medical history
48.
A nurse is assessing a client’s respiratory status. Which finding should the nurse document as bradypnea?
a)
Respiratory rate of 18/min
b)
Respiratory rate of 14/min
c)
Respiratory rate of 10/min
d)
Respiratory rate of 22/min
49.
A nurse is caring for a client who appears disheveled and has poor hygiene. Which interpretation is most appropriate?
a)
The client is being noncompliant
b)
The client lacks understanding of self-care
c)
The finding may indicate an underlying physical or mental health concern
d)
The finding is expected in hospitalized clients
50.
A nurse is prioritizing care for four clients. Which client should be seen first?
a)
A client requesting assistance to the bathroom
b)
A client with audible wheezing and use of accessory muscles
c)
A client waiting for scheduled medications
d)
A client asking questions about discharge paperwork
51.
A nurse is reviewing which tasks may be delegated to unlicensed assistive personnel (UAP). Which task should NOT be delegated?
a)
Assisting with feeding
b)
Measuring intake and output
c)
Evaluating a client’s response to treatment
d)
Obtaining routine vital signs
52.
A nurse is caring for a client who states, “I don’t want to take this medication anymore.” Which response best demonstrates therapeutic communication?
a)
“You need to take it as prescribed.”
b)
“Can you tell me what concerns you have about the medication?”
c)
“Stopping the medication could make you worse.”
d)
“Your provider knows what’s best for you.”
53.
A nurse is performing an assessment on a client who reports shortness of breath. Which finding should the nurse recognize as tachycardia?
a)
Heart rate of 58/min
b)
Heart rate of 76/min
c)
Heart rate of 112/min
d)
Heart rate of 90/min
54.
A nurse is obtaining vital signs on a client who just walked back from the bathroom. Which action is most appropriate?
a)
Document the findings immediately
b)
Allow the client to rest before measuring vital signs
c)
Measure vital signs while the client is standing
d)
Ask the client to hold their breath during measurement
55.
A nurse is reviewing assessment data on a client. Which finding should be identified as overnutrition?
a)
BMI of 18.9
b)
BMI of 22.5
c)
BMI of 24.7
d)
BMI of 32.1
56.
A nurse is preparing to assess bowel sounds. Which action is appropriate?
a)
Palpate the abdomen before auscultation
b)
Percuss all four quadrants before listening
c)
Place the diaphragm lightly on the abdomen
d)
Ask the client to take deep breaths during assessment
57.
A nurse is collecting a health history from a client who repeatedly provides vague answers. Which technique should the nurse use to obtain more specific information?
a)
Summarizing
b)
Clarifying
c)
Giving advice
d)
Changing the subject
58.
A nurse is reviewing the chart of a client admitted for pneumonia. Which information should be classified as subjective data?
a)
Temperature of 101.8°F (38.8°C)
b)
“I feel exhausted and can’t catch my breath.”
c)
Oxygen saturation of 90%
d)
Crackles heard in both lung bases
59.
A nurse is caring for a postoperative client at risk for falls. Which interventions are least restrictive and appropriate? (Select all that apply.)
a)
Place the bed in the lowest position
b)
Ensure the call light is within reach
c)
Apply wrist restraints
d)
Assign a one-to-one sitter
60.
A nurse is evaluating a client’s response to a pain management plan. Which finding indicates improvement?
a)
Client remains guarded when moving
b)
Client reports improved ability to perform activities
c)
Client requests additional medication
d)
Client avoids using the affected extremity
61.
A nurse is assessing a client’s health history. Which information belongs in the review of systems?
a)
“I had surgery five years ago.”
b)
“My mother has asthma.”
c)
“I’ve had shortness of breath when climbing stairs.”
d)
“I live alone.”
62.
A nurse is preparing to delegate care activities. Which task may the nurse assign to unlicensed assistive personnel (UAP)?
a)
Teaching incentive spirometer use
b)
Assisting the client with toileting
c)
Assessing pain levels
d)
Interpreting vital sign trends
63.
A nurse is reviewing laboratory and assessment data on a client. Which finding should the nurse identify as most concerning?
a)
BMI of 25
b)
Heart rate of 98/min
c)
New onset confusion noted during assessment
d)
Blood pressure of 132/84 mm Hg
64.
A nurse is preparing to perform a physical assessment on a client’s abdomen. Which position should the nurse place the client in?
a)
Lateral
b)
Sims’
c)
Supine with knees slightly flexed
d)
Lithotomy
65.
A nurse is interviewing a client who states, “I’m worried this pain means something serious.” Which response demonstrates empathy?
a)
“There’s no need to worry right now.”
b)
“It sounds like this pain is really concerning for you.”
c)
“Pain doesn’t always mean something serious.”
d)
“The tests will tell us what’s going on.”
66.
A nurse is caring for a client who has limited mobility and poor appetite. Which assessment finding further increases the risk for malnutrition?
a)
BMI of 26
b)
Difficulty chewing due to missing teeth
c)
Reports eating three meals daily
d)
Mild constipation
67.
A nurse is identifying which data are objective. Which finding is objective?
a)
“I feel dizzy when I stand up.”
b)
Blood pressure of 88/54 mm Hg
c)
“My stomach hurts after I eat.”
d)
“I feel anxious today.”
68.
A nurse is reviewing care priorities. Which situation best reflects secondary prevention?
a)
Teaching healthy eating habits to adolescents
b)
Screening adults for hypertension
c)
Providing rehabilitation after a stroke
d)
Administering pain medication for chronic arthritis
69.
A nurse is caring for a client who reports difficulty hearing. Which intervention should the nurse use when communicating?
a)
Speak loudly and slowly
b)
Stand behind the client
c)
Face the client and speak clearly
d)
Exaggerate mouth movements
70.
Which activities are examples of primary prevention? (Select all that apply.)
a)
Administering influenza vaccinations
b)
Teaching healthy lifestyle habits
c)
Screening adults for hypertension
d)
Providing rehabilitation after a stroke
71.
A nurse is reviewing assessment findings on a client who reports feeling “off balance” when standing. Which additional assessment best helps determine priority concerns?
a)
Ask about daily caffeine intake
b)
Measure blood pressure and heart rate in lying, sitting, and standing positions
c)
Review the client’s family history
d)
Assess the client’s diet over the past week
72.
A nurse is preparing to take a client’s blood pressure. Which situation requires the nurse to avoid using the left arm?
a)
The client is right-hand dominant
b)
The client has arthritis in the left wrist
c)
The client has a dialysis access in the left arm
d)
The client reports mild shoulder pain
73.
A nurse is conducting a health history interview. Which question best reflects the use of an open-ended question?
a)
“Do you have nausea?”
b)
“Is the pain sharp?”
c)
“What changes have you noticed in your health recently?”
d)
“Does the pain occur after meals?”
74.
A nurse is caring for a client who recently had a stroke and is attending physical therapy to regain mobility. This intervention represents which level of prevention?
a)
Primary
b)
Secondary
c)
Tertiary
d)
Health promotion
75.
A nurse is preparing to delegate care for a stable client. Which task must the nurse perform personally?
a)
Assisting the client to the bathroom
b)
Obtaining a blood glucose reading
c)
Interpreting abnormal assessment findings
d)
Recording intake and output
76.
A nurse is performing a general survey on a newly admitted client. Which observation is most important to note immediately?
a)
Clothing cleanliness
b)
Body mass
c)
Signs of acute distress
d)
Hair condition
77.
A nurse is caring for a client who states, “I don’t understand why this keeps happening to me.” Which response best supports therapeutic communication?
a)
“Everything happens for a reason.”
b)
“You’ll feel better once treatment starts.”
c)
“Can you tell me more about what’s been hardest for you?”
d)
“Let’s focus on what we can fix right now.”
78.
A nurse is reassessing a client after an intervention. Which finding best indicates the intervention was effective?
a)
The intervention was completed on time
b)
The client thanks the nurse
c)
The client’s symptoms have improved
d)
The provider is notified of the intervention
79.
A nurse is caring for a client with dementia who repeatedly attempts to get out of bed without assistance. The nurse places the bed in the lowest position, ensures the call light is within reach, and frequently checks on the client. Which QSEN competency is the nurse primarily demonstrating?
a)
Patient-centered care
b)
Safety
c)
Teamwork and collaboration
d)
Quality improvement
80.
A nurse notices that medication administration errors have increased on the unit during shift change. The nurse reports the trend to the charge nurse and participates in developing a standardized handoff process to reduce errors. Which QSEN competency is being applied?
a)
Safety
b)
Patient-centered care
c)
Quality improvement
d)
Evidence-based practice
81.
A nurse is caring for a client who presents with vague symptoms that do not clearly point to a diagnosis. The nurse reflects on the available data, considers multiple possible explanations, and prioritizes which problem needs to be addressed first. Which cognitive skill is the nurse primarily using?
a)
Nursing assessment
b)
Critical thinking
c)
Intuitive thinking
d)
Implementation
82.
A nurse systematically collects subjective and objective data, organizes findings, and identifies normal versus abnormal results before planning care. Which cognitive process is the nurse performing?
a)
Nursing assessment
b)
Clinical judgment
c)
Intuitive thinking
d)
Evaluation
83.
A nurse analyzes assessment findings, interprets their significance, and decides whether to take action or modify the plan of care. Which cognitive skill is being demonstrated?
a)
Critical thinking
b)
Nursing process
c)
Clinical judgment
d)
Intuitive thinking
84.
A nurse is assessing a client who presents to the emergency department with shortness of breath. Which finding should the nurse identify as a pertinent positive?
a)
The client denies chest pain
b)
Oxygen saturation is 88% on room air
c)
Use of accessory muscles during breathing
d)
The client reports no history of asthma
85.
A nurse is completing a focused respiratory assessment on a client with suspected pneumonia. Which finding is a pertinent negative?
a)
Crackles heard in the right lower lobe
b)
Productive cough with yellow sputum
c)
The client denies shortness of breath at rest
d)
Temperature of 101.6°F (38.7°C)
86.
A nurse is collecting a pain history from a client who reports abdominal discomfort. Which of the following nurse questions best assesses the “R” in OLDCARTS?
a)
“When did the pain first start?”
b)
“Can you describe what the pain feels like?”
c)
“Does the pain move anywhere else?”
d)
“What makes the pain better or worse?”
87.
A nurse is using the BATHE technique while interviewing a client who appears overwhelmed by a recent diagnosis. Which nurse question best reflects the “E” (Empathy) component of BATHE?
a)
“What has been going on in your life recently?”
b)
“How is this situation affecting your daily routine?”
c)
“What do you think might help you cope with this?”
d)
“That sounds really stressful for you.”
88.
A nurse is completing an intake assessment for a client who presents with anxiety and frequent unexplained injuries. The nurse decides to use the HITS screening tool. Which nurse action is most appropriate when administering this tool?
a)
Ask the questions in the presence of the client’s partner
b)
Rephrase the questions to make them less direct
c)
Ask the questions privately using a standardized format
d)
Use the tool only if physical abuse is already confirmed
89.
A nurse is assessing cognitive function in an older adult client who reports increasing forgetfulness. Which situation best indicates the use of the TICS screening tool?
a)
A client with expressive aphasia after a stroke
b)
A client who is illiterate and cannot read written materials
c)
A client being assessed over the telephone for cognitive changes
d)
A client who is experiencing acute confusion after surgery
90.
A nurse is assessing a client who reports, “I just don’t feel like eating anymore.” The client has unintentionally lost 10 lb over the past month and denies nausea or difficulty swallowing. Which term should the nurse use to document this finding?
a)
Anorexia
b)
Ageusia
c)
Dysgeusia
d)
Cachexia
91.
A nurse is completing a health history for a client who states, “I can’t taste anything at all, no matter what I eat.” Which term best describes this symptom?
a)
Anorexia
b)
Ageusia
c)
Dysgeusia
d)
Hypogeusia
92.
A nurse is assessing a client undergoing chemotherapy who reports, “Everything tastes metallic and off, even foods I usually like.” Which term should the nurse use to document this complaint?
a)
Anorexia
b)
Ageusia
c)
Dysgeusia
d)
Aphagia
93.
A nurse is caring for a client who has HIV and requires assistance with bathing. Which type of precautions should the nurse use?
a)
Standard precautions
b)
Contact precautions
c)
Droplet precautions
d)
Airborne precautions
94.
A nurse is preparing to enter the room of a client diagnosed with Clostridioides difficile (C. diff). Which precautions should the nurse implement?
a)
Standard precautions only
b)
Contact precautions
c)
Droplet precautions
d)
Airborne precautions
95.
A nurse is caring for a client diagnosed with influenza. Which precautions are required to prevent transmission?
a)
Standard precautions only
b)
Contact precautions
c)
Droplet precautions
d)
Airborne precautions
96.
A nurse is assigned to care for a client with suspected pulmonary tuberculosis. Which action is required to follow appropriate precautions?
a)
Wear a surgical mask when within 6 feet of the client
b)
Place the client in a private room with the door open
c)
Use an N95 respirator and place the client in a negative-pressure room
d)
Wear gloves only when providing direct care
97.
A nurse is performing an abdominal assessment on a client who reports mild discomfort. Which type of palpation should the nurse use first?
a)
Deep palpation to assess underlying organs
b)
Light palpation to assess surface tenderness
c)
Bimanual palpation to assess organ size
d)
Moderate palpation to assess muscle tone
98.
A nurse is assessing a client’s abdomen for an enlarged liver. Which palpation technique is most appropriate?
a)
Light palpation using fingertips only
b)
Moderate palpation to assess muscle resistance
c)
Deep palpation to assess underlying organs
d)
Superficial palpation using the palm
99.
A nurse is obtaining vital signs for a client during a clinic visit. Which statement by the client requires the nurse to delay the assessment to ensure accurate results?
a)
“I walked here from the parking lot.”
b)
“I just smoked a cigarette a few minutes ago.”
c)
“I feel a little anxious today.”
d)
“I didn’t sleep well last night.”
100.
A nurse is preparing to obtain a tympanic temperature for an adult client. Which action should the nurse take to ensure an accurate reading?
a)
Pull the pinna downward and back before inserting the probe
b)
Pull the pinna upward and back to straighten the ear canal
c)
Insert the probe deeply until resistance is felt
d)
Aim the probe toward the top of the ear canal
101.
A nurse is assessing a client and notes that the apical pulse is 96/min while the radial pulse is 78/min. How should the nurse document this finding?
a)
Bradycardia
b)
Tachycardia
c)
Pulse deficit
d)
Orthostatic hypotension
102.
A nurse is providing health promotion education to a community group that includes non-Hispanic African American adults. Which intervention best reflects culturally responsive nursing care related to hypertension?
a)
Advising all participants to follow the same standardized diet plan
b)
Explaining that hypertension affects all populations equally
c)
Encouraging routine blood pressure screening and early identification
d)
Teaching management strategies only after a diagnosis is made
103.
A nurse obtains a blood pressure reading of 158/92 mm Hg on a client during an admission assessment. Which action should the nurse take next to ensure accurate documentation?
a)
Document the initial reading as the client’s blood pressure
b)
Retake the blood pressure immediately in the same arm
c)
Wait about 2 minutes, retake the blood pressure in the opposite arm, and document the higher reading
d)
Notify the provider before repeating the measurement
104.
A client reports a deep, aching abdominal pain that is difficult to localize and associated with nausea. Which type of pain is most likely present?
a)
Somatic pain
b)
Visceral pain
c)
Cutaneous pain
d)
Neuropathic pain
105.
A client describes burning and tingling pain following nerve damage after surgery. Which type of pain should the nurse document?
a)
Somatic pain
b)
Visceral pain
c)
Neuropathic pain
d)
Colicky pain
106.
A client reports sharp pain on the skin after a minor burn to the forearm. Which type of pain is this?
a)
Cutaneous pain
b)
Visceral pain
c)
Referred pain
d)
Phantom limb pain
107.
A client with a history of kidney stones reports intermittent, cramping abdominal pain that comes in waves. Which type of pain does this describe?
a)
Visceral pain
b)
Colicky pain
c)
Neuropathic pain
d)
Radiating pain
108.
A client reports lower back pain that travels down the left leg. Which pain pattern is the nurse assessing?
a)
Referred pain
b)
Radiating pain
c)
Somatic pain
d)
Cutaneous pain
109.
A client experiencing a myocardial infarction reports pain in the left shoulder and jaw. Which type of pain is this?
a)
Radiating pain
b)
Referred pain
c)
Visceral pain
d)
Neuropathic pain
110.
A client weighs 198 lb and is 65 in tall. What is the client’s BMI? (Round to the nearest)
(a)
111.
A nurse is discussing a client’s condition at the nurses’ station. Which actions comply with HIPAA? (Select all that apply.)
a)
Speaking quietly and limiting information
b)
Discuss the clients diagnosis with a coworker not involved in their care
c)
Logging out of the computer before leaving the work station
d)
Sharing information with only those authorized
112.
A provider prescribes amoxicillin 900 mg per day PO in divided doses every 12 hours.
The medication available is amoxicillin oral suspension 400 mg/5 mL.
How many mL should the nurse administer per dose?
(Round to the nearest tenth.)
(a)
113.
A nurse is caring for a client admitted with pneumonia. Which finding represents a secondary issue requiring follow-up?
a)
Fever of 101 degrees F
b)
Decrease of oral intake and signs of dehydration
c)
Productive cough
d)
Fatigue
114.
A nurse is assessing a client with a history of heart failure. Which findings should the nurse expect? (Select all that apply.)
a)
Crackles in lung bases
b)
Peripheral edema
c)
Weight gain over a short period
d)
Bradycardia
115.
A nurse is assessing a client with COPD. Which findings are consistent with this condition? (Select all that apply.)
a)
Barrel shaped chest
b)
Use of accessory muscles
c)
Prolonged expiration
d)
Bradypnea
116.
A nurse is assessing a client who reports chest pain. The nurse uses the OPQRST pain assessment framework. Which questions are appropriate for the nurse to ask? (Select all that apply.)
a)
“What were you doing when the pain started?”
b)
“Can you describe what the pain feels like?”
c)
“On a scale from 0-10, how intense is the pain?”
d)
“What you ever had surgery for this condition?”
e)
“Does the pain travel anywhere else in your body?”
117.
A nurse performs a general survey on an older adult client. Which findings related to gait should the nurse recognize as abnormal? (Select all that apply.)
a)
Shuffling steps
b)
Uneven stride length
c)
Upright posture
d)
Uses arms to maintain balance while walking
118.
A nurse is assessing range of motion (ROM) in a client’s shoulder. Which action demonstrates assessment of active ROM?
a)
The nurse moves the client’s arm through the range of motion
b)
The nurse asks the client to raise the arm without assistance
c)
The nurse supports the arm while moving it
d)
The nurse measures joint movement with a goinometer
119.
A nurse is beginning a health history interview with a new client. Which information should the nurse collect as biographical data? (Select all that apply.)
a)
Age
b)
Date of Birth
c)
Source of the health history
d)
Preferred language
e)
History of present illness
100 %
