Practice questions

When assessing a client for possible oral cancer, the nurse should most closely inspect which area? A) Area under the tongue B) Along the gum line C) Hard palate D) Buccal mucosa

A) Area under the tongue

The nurse is assessing the skin condition and color of an African American client. What would the nurse document as an abnormal finding? A) Ashen gray skin color B) Lack of visible pores C) Light to medium dark brown skin D) Evenly distributed color

A) Ashen gray skin color

During an assessment, the nurse determines that a client sees more than one primary care provider and has obtained prescriptions from each provider. Which method would be most appropriate to determine a client's current medication regimen? A) Ask the client to bring all the medications and supplements to an interview. B) Ask the caregiver whether the client is taking prescribed medications. C) Ask the client about the use of any over-the-counter medications. D) Ask the client to identify which medications taken every day.

A) Ask the client to bring all the medications and supplements to an interview.

When assessing the temperature of the feet of an older client with diabetes, the nurse would use which part of the hand to obtain the most accurate assessment data? A) Dorsal surface B) Fingerpad surface C) Ulnar surface D) Palmar surface

A) Dorsal surface

A nurse has completed an assessment of a client's lymph nodes. What data would the nurse document as an abnormal finding? A) Tender B) Diameter: 0.75 cm C) Discrete D) Mobile

A) Tender

During an eye assessment, the nurse is testing a client's visual acuity using a Snellen chart. In order to prepare the client for this component of assessment, what instruction should the nurse provide? A) "Hold this chart and start to read out the letters after covering one of your eyes." B) "Cover one of your eyes and then read out the letters on the chart, starting from the top." C) "Please stand at a comfortable distance from the chart and I'll get you to read each letter." D) "I'm going to ask you to slowly walk forward until the last line of the chart become clear."

B) "Cover one of your eyes and then read out the letters on the chart, starting from the top."

Which client situation would the nurse interpret as requiring an emergency assessment? A) A client needing an employment physical B) A client who overdosed on acetaminophen C) A distraught client who wants a pregnancy test D) A pediatric client with severe sunburn

B) A client who overdosed on acetaminophen

The nurse collects vital signs on a hospital client who has recently been experiencing pain. Which finding would indicate the client is currently experiencing pain? A) Blood pressure of 120/70 mm Hg B) Heart rate of 110 beats/min C) Respiratory rate of 18 breaths/min D) Temperature of 37.3°C (99.1°F)

B) Heart rate of 110 beats/min

When describing the importance of documenting initial assessment data to a group of new nurses, what would the nurse emphasize as the primary reason? A) It satisfies legal standards established by health care organizations and institutions. B) It becomes the foundation for the entire nursing process. C) Incorrect conclusions may be made without documentation of the nurse's opinions. D) Health care institutions have established policies regarding documentation.

B) It becomes the foundation for the entire nursing process.

A community health nurse is planning a health promotion campaign that will focus on cancer prevention. Which educational intervention should the nurse select in order to most influence participants' risks of head and neck cancers? A) Teaching about monthly self-examination B) Teaching about genetic screening C) A smoking cessation program D) A nutritional health program

C) A smoking cessation program

A client tells the clinic nurse that she has sought care because she has been experiencing excessive tearing of her eyes. Which assessment should the nurse next perform? A) Perform the eye positions test. B) Test pupillary reaction to light. C) Assess the nasolacrimal sac. D) Inspect the palpebral conjunctiva.

C) Assess the nasolacrimal sac.

A client has presented to the emergency department (ED) with complaints of abdominal pain. Which member of the care team would most likely be responsible for collecting the subjective data on the client during the initial comprehensive assessment? A) Diagnostic technician B) Gastroenterologist C) ED nurse D) Admissions clerk

C) ED nurse

A nurse is preparing to assess a client who is new to the clinic. When beginning the collection of the client database, which of the following actions should the nurse prioritize? A) Making clinical inferences B) Identifying potential health problems C) Establishing a trusting relationship D) Determining the client's strengths

C) Establishing a trusting relationship

A nurse is performing an otoscopic examination of a client's right tympanic membrane. At which location would the nurse document seeing the cone of light if it were in the appropriate place? A) In the 7 o'clock position B) In the upper left quadrant C) In the 5 o'clock position D) In the center of the membrane

C) In the 5 o'clock position

A nurse in the emergency department assesses a client's pupillary reaction and observes pinpoint pupils. The nurse interprets this finding as suggesting which of the following? A) Macular degeneration B) Recent peripheral nervous system injury C) Narcotic use D) Recent eye trauma

C) Narcotic use

A nurse is reviewing a colleague's documentation of a client assessment. The nurse reads that the client's radial pulse was 2+. How should the nurse interpret this assessment finding? A) The client's radial pulse could not be manually occluded. B) The client's radial pulse occluded easily. C) The client's radial pulse occluded with moderate pressure. D) The client's radial pulse occluded with very firm pressure.

C) The client's radial pulse occluded with moderate pressure.

A nurse is completing the intake assessment of an older adult who has just relocated to a long-term care facility. Which nursing action would be most important to ensure accurate data when gathering the resident's information? A) Determining client needs B) Documenting the data C) Validating the data D) Identifying client support systems

C) Validating the data

Which of the following would be most important for the nurse to do when assessing a client's blood pressure? A) Hold the client's arm slightly flexed with palm down. B) Deflate the cuff about 5 mm Hg per second. C) Palpate the pulsations of the ulnar artery. D) Inflate the cuff 30 mm Hg above where the radial pulse disappears.

D) Inflate the cuff 30 mm Hg above where the radial pulse disappears.

A client presents to an ambulatory clinic with purulent, bloody drainage of the ear. What would the nurse assess first? A) Palpate the client's tragus. B) Perform hearing assessments. C) Assess the client's tympanic membrane. D) Inspect the client's external ear canal.

D) Inspect the client's external ear canal.