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    Exam Review

    1. Which action by a nurse demonstrates correct use of electronic health records (EHR) to protect client confidentiality?
      A)Printing lab results to review later at the nurse's station
      B)Logging off the computer after completing documentation
      C)Allowing a student nurse to use the nurse's login for EHR access
      D)Discussing client lab values at the nurse's station near visitors
    2. A client reports pain in the lower right abdomen. The nurse uses their fingertips to gently press on the area to assess for tenderness and guarding. Which assessment technique is being used?
      A)Auscultation
      B)Palpation
      C)Inspection
      D)Percussion
    3. During a client interview, the nurse asks, "Why didn't you take your medication as prescribed?" What is the most likely impact of this question on the client?
      A)The client will feel supported and understood by the nurse.
      B)The client may feel defensive and less likely to share information.
      C)The client will feel encouraged to explain their reasoning.
      D)The client will feel empowered to make better decisions in the future.
    4. A nurse is caring for a client whose cultural beliefs prohibit certain foods. The client is on a hospital diet. What should the nurse do first?
      A)Refuse to provide the restricted foods
      B)Explain that the client must follow the standard hospital diet
      C)Ask the client to ignore their cultural beliefs while in the hospital
      D)Document the client's cultural preferences and consult the dietary team
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    Exam Review

    1. A nurse is preparing to examine a client's tympanic membrane. Which instrument should the nurse use to perform this assessment?
      A)Stethoscope
      B)Otoscope
      C)Sphygmomanometer
      D)Reflex hammer
    2. A nurse is reviewing the chart of an adult client recently diagnosed with hypertension. Which of the following blood pressure readings is most consistent with this diagnosis?
      A)110/70 mm Hg
      B)118/78 mm Hg
      C)146/92 mm Hg
      D)124/84 mm Hg
    3. During a physical assessment which question best evaluates a client's self-care abilities?
      A)"Who helps you when you are feeling ill?"
      B)"Do you feel confident managing your health conditions?"
      C)"Do you have difficulty coping with stress?"
      D)"Are you able to bathe, dress, and feed yourself without assistance?"
    4. Which finding is best assessed through palpation?
      A)Skin temperature
      B)Tympany and dullness
      C)Skin color
      D)Breath sounds
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    Exam Review

    1. A nurse assesses a client's radial pulse at 54 beats per minute with an irregular rhythm. What action should the nurse take next?
      A)Use an electronic blood pressure monitor
      B)Notify the provider of bradycardia
      C)Reassess the pulse in one hour
      D)Apically auscultate the pulse for one minute
    2. A nurse is preparing to interview a client to obtain a health history. Which actions should the nurse take to promote effective communication and accurate data collection? (Select all that apply)(SATA)
      A)Interrupt the client if they are unable to stay focused on health history questions
      B)Use therapeutic silence when the client pauses
      C)Maintain a nonjudgmental attitude throughout the conversation
      D)Begin by asking closed-ended questions about the client's medical history
      E)Sit at eye level with the client during the interview
    3. Which of the following best defines culture in the context of healthcare?
      A)Culture is the language spoken by a particular community.
      B)Culture is the technological advancement level of a society.
      C)Culture refers to the genetic makeup of a patient
      D)Culture is a set of beliefs, values, and practices shared by a group of people.
    4. Which of the following can be classified as open-ended questioning?
      A)"Do you get around okay at home?"
      B)"Are you feeling any pain right now?"
      C)"Can you tell me about your home environment?"
      D)"How many times per day do you use your inhaler?"
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    Exam Review

    1. A nurse prepares to use a penlight during a physical assessment. Which assessment is the nurse performing?
      A)Pupillary response
      B)Tactile fremitus
      C)Percussion
      D)Range of motion
    2. Select the best description of "Review of Systems" as part of the health history.
      A)Recording of the objective findings of the practitioner
      B)Evaluation of the past and present health state of each body system
      C)Statement that describes the overall health state of the patient
      D)Documentation of the problem as described by the patient
    3. A nurse is obtaining vital signs on a client in a clinic. The client's oxygen saturation (SpO2) is 93% on room air while the client is talking during the assessment. Which action should the nurse take next?
      A)Apply supplemental oxygen via nasal cannula
      B)Document the finding as an abnormal assessment result
      C)Notify the healthcare provider of the low oxygen level
      D)Ask the client to stop talking and recheck the oxygen saturation
    4. Which of the following is an example of objective data?
      A)The client reports a 7/10 pain in the abdomen
      B)The client's heart rate is 112 beats per minute
      C)The client states, "I feel dizzy when standing up"
      D)The client says, "I feel anxious about my upcoming surgery"
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    Exam Review

    1. A nurse is performing the general survey of a client during a routine physical assessment. Which of the following findings related to the client's physical appearance should the nurse further investigate?
      A)The client's facial expression appears flat and unchanging throughout the interview
      B)The client appears stated age, has even skin tone, and symmetrical facial features
      C)The client's clothing is clean and appropriate for the weather
      D)The client's body movements are smooth and coordinated
    2. A nurse assesses a client's vital signs and documents the following: temperature 98.6°F (37°C), heart rate 72 beats/min, respiratory rate 8 breaths/min and blood pressure 124/80 mmHg. Which action should the nurse take?
      A)Report the heart rate immediately to the provider
      B)Document the findings as within expected range
      C)Ask if the client feels lightheaded or dizzy
      D)Recheck the respiratory rate in 30 minutes
    3. A nurse is assessing a client for orthostatic hypotension. Which actions should the nurse take during the assessment? (Select all that apply)(SATA)
      A)Measure blood pressure while client is lying, sitting, and standing
      B)Record any drop in systolic BP of 20 mmHg or more
      C)Provide water before the test
      D)Ask the client to walk during the test
      E)Wait 1-2 minutes between each position change
    4. During a physical assessment the nurse observes that the client's skin is warm, dry, and slightly flushed. This type of information is considered
      A)Subjective data
      B)Reported data
      C)Objective data
      D)Emotional data
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    Exam Review

    1. The nurse is preparing to perform an initial assessment on an older adult client who is hard of hearing and speaks limited English, which of the following actions should the nurse take to promote therapeutic communication? (Select all that apply)(SATA)
      A)Ensure the room is quiet and free from distractions.
      B)Play soft music to promote a relaxing environment.
      C)Obtain a licensed interpreter to assist with communication.
      D)Ask the client's family to interpret to promote comfort.
      E)Observe the client's nonverbal communication such as posture and facial expressions.
    2. A nursing student is assessing a client's vital signs, which method is most accurate for measuring body temperature?
      A)Rectal
      B)Axillary
      C)Tympanic
      D)Oral
    3. As the nurse enters the client's room, which is the first priority to assess?
      A)Listen to bowel sounds with a stethoscope
      B)Ask the client to describe their pain
      C)Measure blood pressure, heart rate, and oxygen saturation
      D)Observe the client for signs of respiratory distress or discomfort
    4. A nurse is performing general inspection and measuring vital signs on a client during a routine physical exam. Which of the following actions should the nurse take to ensure an accurate assessment? (Select all that apply)(SATA)
      A)Use an appropriately sized cuff.
      B)Ensure the client has been seated and rested for at least 5 minutes before measuring blood pressure.
      C)Count respirations for 30 seconds and multiply by 2, even if the pattern is irregular.
      D)Document the client's appearance, posture, and breathing pattern during general inspection.
      E)Position the client's arm above heart level while measuring blood pressure.
      F)Remove clothing that interferes with cuff placement prior to taking the blood pressure.
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