Basic Physical Assessment NCLEX Questions
The nurse is caring for a client with possible immune deficiency. Which subjective data would be most indicative? a) "I sneeze and have watery eyes throughout the spring and summer." b) "I have had a sore on my leg that just won't heal." c) "I get up every morning with a stuffy nose and sore throat." d) "Just as I get over a virus, it seems that I get another."
"Just as I get over a virus, it seems that I get another."
During the physical examination, which assessment technique best determines the presence of respiratory fremitus? a) Percussion b) Auscultation c) Palpation d) Inspection
A Palpation Explanation: Respiratory fremitus is felt when the nurse places hands on the client's back and palpates for presence of vibrations or fremitus during respiratory effort. During palpation, a nurse touches a client's body to feel for vibrations and pulsations, to locate body structures, and to assess such characteristics as size, texture, temperature, tenderness, and mobility. During auscultation, the nurse uses a stethoscope to listen for sounds. During inspection, the nurse uses her critical observation skills. During percussion, she taps the client's body sharply with her fingers or hands to elicit sounds
The nurse is conducting a health history of a child. The mother states that the client continually has a cold all winter with a runny nose, is not doing well in school, and is itching all the time. The nurse suspects the child has which of the following? a) Allergies b) Sinusitis c) Ringworm d) Fifth disease
Allergies
Which factors are major components of a client's general background history? a) Bowel habits and allergies b) Gastric reflex and the client's age c) Allergies and socioeconomic status d) Urine output and allergies
Allergies and socioeconomic status
A client with Parkinson's disease who is scheduled for physiotherapy is experiencing nausea and weakness. What is the most appropriate action by the nurse? a) Administer an antiemetic to reduce the nausea and send to physiotherapy. b) Assess the nausea and weakness and call physiotherapy to cancel or reschedule the appointment. c) Notify the dietician to change the diet to clear fluids and cancel physiotherapy until the client's strength resumes. d) Ask the dietician to visit regarding food preferences and recommend that the physician order sleeping pills.
Assess the nausea and weakness and call physiotherapy to cancel or reschedule the appointment.
A nurse is assessing a client using light palpation. How does a nurse perform light palpation? a) By indenting the client's skin ½″ to ¾″ (1.3 to 1.9 cm) b) By indenting the client's skin 1″, using both hands c) By indenting the client's skin 1″ to 2″ (2.5 to 5 cm) d) By indenting the client's skin 1″ and then releasing the pressure quickly
By indenting the client's skin ½″ to ¾″ (1.3 to 1.9 cm)
A client is admitted to the hospital with aspiration pneumonia secondary to progression of Parkinson's disease. Which assessment finding should the nurse anticipate? a) Muscle flaccidity of the lower extremities b) Pleasant and smiling demeanor c) Coughing when drinking liquids d) Tremors in the fingers that increase with purposeful movement
Coughing when drinking liquids
A client is admitted to the hospital with aspiration pneumonia secondary to progression of Parkinson's disease. Which assessment finding should the nurse anticipate? a) Pleasant and smiling demeanor b) Tremors in the fingers that increase with purposeful movement c) Muscle flaccidity of the lower extremities d) Coughing when drinking liquids
Coughing when drinking liquids
A client who is found unresponsive has arterial blood gases drawn and the results indicate the following: pH is 7.12, Pco2 is 90 mm Hg, and HCO3 is 22 mEq/L. The nurse interprets the results as indicating which condition?
Respiratory Acidosis, compensated
In a care conference, the social worker is asking if a psychosocial assessment has been completed. Which areas would the nurse report on as part of this assessment? a) Rest and sleep patterns, activity and exercise patterns, and coping and stress tolerance b) Breathing patterns, circulation patterns, and responses to hospitalization c) Health habits, family relationships, affect, and thought patterns d) General survey results, eating habits, and ability to perform activities of daily living
Health habits, family relationships, affect, and thought patterns
Which component of a client's medical record is the major source of subjective data about the client's health status? a) Health history b) Radiologic findings c) Physical findings d) Laboratory test results
Health history
The nurse is preparing a client for a cardiac catheterization. Which of the following client statements would the nurse need to report to the healthcare provider immediately? a) "I am allergic to penicillin and midazolam (Versed)." b) "I am very claustrophobic in small spaces." c) "I have not been able to eat since yesterday." d) "I took my metformin this morning."
I took my metformin this morning
The nurse reviews the arterial blood gas results of a client and notes the following: pH 7.45, Pco2 of 30 mm Hg, and HCO3 of 20 mEq/L. The nurse analyzes these results as indicating which condition?
Respiratory alkalosis, compensated
A client presents to the emergency room with abdominal pain and upper gastrointestinal bleeding. The client is sweating and appears to be in moderate distress. Which nursing action would be a priority at this time? a) Insert an NG tube and connect to suction. b) Obtain vital signs. c) Document history of the symptoms. d) Assess bowel sounds and abdominal tenderness
Obtain Vital Signs
Why should the nurse avoid palpating both carotid arteries at one time? a) The nurse can't assess the pulse accurately unless she palpates the arteries one at a time. b) Palpating both arteries at one time may cause severe tachycardia. c) Palpating both arteries at one time may cause transient hypertension. d) Palpating both arteries at one time may cause severe bradycardia.
Palpating both arteries at one time may cause severe bradycardia.
When taking a client's vital signs on the first postoperative day, the unlicensed assistive personnel (UAP) reports to the nurse that the oral temperature is 100° F (37.8° C). After encouraging the client to use the incentive spirometer, the nurse should delegate which activity to the UAP? a) Continue to monitor the client's temperature. b) Place a hyperthermia blanket on the client's bed. c) Apply an ice cap to a client's forehead. d) Bathe the client with cool water.
Place a hyperthermia blanket on the client's bed.
What are important nursing responsibilities when a referral to other health team members has been made for a client? a) Ensuring that the physician reports the level of functioning of the client b) Recommending that each health team member independently completes his or her own assessment and then consults with each other c) Sharing assessment information and information on the client's capability and level of participation in meeting activities of daily living d) Recommending that each member read the history and nurse's notes to understand the client's progress
Sharing assessment information and information on the client's capability and level of participation in meeting activities of daily living
A client had a total abdominal hysterectomy 10 hours ago. Knowing that sepsis is a potential complication of the surgery, the nurse will monitor for which early assessment change? a) Urine output of 20 ml/hour b) Difficulty breathing c) Abrupt change in mental status d) Temperature of 101.8° F (38.8° C)
Temperature of 101.8° F (38.8° C)
A nurse is helping a client ambulate for the first time after 3 days of bed rest. Which observation by the nurse suggests that the client tolerated the activity without distress? a) The client reported feeling dizzy and weak and perspired profusely. b) The client's pulse and respiratory rate returned to baseline 1 hour after activity. c) The client's pulse and respiratory rates increased moderately during ambulation. d) The client's head was down, gaze was cast down, and toes were pointed outward.
The client's pulse and respiratory rates increased moderately during ambulation.
An elderly client admitted with new-onset confusion, headache, and bounding pulse has been drinking copious amounts of water and voiding frequently. The nurse reviews the laboratory results (see accompanying chart). Which of the abnormal lab values is consistent with the client's symptoms? a) serum osmolality b) serum sodium c) urine specific gravity d) platelet count
Urine output of 90 mL of dark, concentrated urine for the past 6 hours
The nurse is assessing an older adult's skin. The assessment will involve inspecting the skin for color, pigmentation, and vascularity. The critical component in the nurse's assessment is noting the: a) appearance of age-related wrinkles. b) changes from the normal expected findings. c) similarities from one side to the other. d) skin turgor.
changes from the normal expected findings.
A client has had hoarseness for more than 2 weeks. The nurse should: a) instruct the client to gargle with salt water at home. b) instruct the client to take a throat analgesic. c) assess the client for dysphagia. d) refer the client to a health care provider (HCP) for a prescription for an antibiotic.
assess the client for dysphagia
When assessing an adolescent for scoliosis, what should the nurse ask the client to do? a) Lie flat on the floor and extend the legs straight from the trunk. b) Sit in a chair while lifting the feet and legs to a right angle with the trunk. c) Stand against a wall while pressing the length of the back against the wall. d) Bend forward at the waist with arms hanging freely.
bend forward at the waist with arms hanging freely
The nurse in the postanesthesia care unit notes that one of the client's pupils is larger than the other. The nurse should: a) administer oxygen. b) check the client's baseline data. c) rate the client on the Glasgow Coma Scale. d) call the surgeon.
check the clients baseline
The nurse is assessing the lower extremities of the client with peripheral artery disease (PVD). Which findings are expected? Select all that apply. a) hairy legs b) coolness c) pink skin d) mottled skin e) moist skin
coolness mottled skin
When assessing an elderly client, the nurse expects to find various aging-related physiologic changes. These changes include: a) increased coronary artery blood flow. b) decreased posterior thoracic curve. c) decreased peripheral resistance. d) delayed gastric emptying.
delayed gastric emptying
On the second day after surgery, the nurse assesses an elderly client and finds the following: • blood pressure, 148/92 mm Hg; heart rate, 98 bpm; respirations 32 breaths/min • O2 saturation of 88 on 4 L/min of oxygen administered by nasal cannula • breath sounds are coarse and wet bilaterally with a loose, productive cough • client voided 100 mL very dark, concentrated urine during the last 4 hours • bilateral pitting pedal edema Using the SBAR method to notify the health care provider (HCP) of current assessment findings, the nurse should recommend that the HCP write a prescription for a(n): a) diuretic medication. b) additional fluid intake. c) increased oxygen liter flow rate. d) antihypertensive medication.
diuretic medication
While preparing to examine a 6-week-old infant's scrotal sac and testes for possible undescended testes, which would be most important for the nurse to do? a) Tap lightly on the left inguinal ring. b) Give the infant a pacifier. c) Check the diaper for recent urination. d) Ensure that the room is kept warm.
ensure the room is kept warm
A client in the postanesthesia care unit is being actively rewarmed with an external warming device. How often should the nurse monitor the client's body temperature? a) every 20 minutes b) every 10 minutes c) every 5 minutes d) every 15 minutes
every 15 minutes
A nurse is assessing a client's abdomen after abdominal surgery. Place the assessment techniques in the order in which the nurse should conduct them
inspection auscultation percussion palpation
A client who is found unresponsive has arterial blood gases drawn and the results indicate the following: pH is 7.12, Pco2 is 90 mm Hg, and HCO3 is 22 mEq/L. The nurse interprets the results as indicating which condition? Ph 7.24 paco2 35 hco3- 15
metabolic acidosis
The nurse is caring for a postoperative client who has not voided since before surgery. Which is the nurse's most appropriate action? a) Request an order to insert a Foley catheter b) Palpate for the bladder above the symphysis pubis c) Initiate hourly intake and output measurement d) Force fluids to encourage voiding
palpate the bladder above the symphysis pubis
The nurse is caring for a client who has just had an upper GI endoscopy. The client's vital signs must be taken every 30 minutes for 2 hours after the procedure. The nurse assigns an unlicensed assistive personnel (UAP) to take the vital signs. One hour later, the UAP reports the client, who was previously afebrile, has developed a temperature of 101.8° F (38.8° C). The nurse should: a) tell the assistant to change thermometers and retake the temperature. b) promptly assess the client for potential perforation. c) plan to give the client acetaminophen to lower the temperature. d) ask the assistant to bathe the client with tepid water.
promptly assess the client for potential perforation.
The nurse is assessing a client's activity tolerance. Which report from a treadmill test indicates an abnormal response? a) pulse rate within 6 bpm of resting pulse after 3 minutes of rest b) pulse rate increased by 20 bpm immediately after the activity c) respiratory rate decreased by 5 breaths/minute d) diastolic blood pressure increased by 7 mm Hg
respiratory rate decreased by 5 breaths/minute
A client arrives at a public health clinic worried that she has breast cancer after finding a lump in her breast. When assessing the breast, which assessment finding provides an indication that the lump is more typical of fibrocystic breast disease? a) The lump is firm and nonmovable. b) The lump is round and movable. c) One breast is larger than the other. d) Nipple retractions are noted.
the lump is round and movable
When examining a client who has abdominal pain, a nurse should assess: a) the symptomatic quadrant first. b) any quadrant first. c) the symptomatic quadrant last. d) the symptomatic quadrant either second or third.
the symptomatic quadrant last
The nurse is unable to palpate the client's left pedal pulses. What should the nurse do first? a) Inspect the lower left extremity. b) Use a Doppler ultrasound device. c) Auscultate the pulses with a stethoscope. d) Call the health care provider (HCP).
use a doppler ultrasound device
When inspecting a client's skin, a nurse finds a circumscribed elevated area filled with serous fluid. What term should the nurse use to document this finding? a) Macule b) Pustule c) Vesicle d) Papule
vesicle
A nurse is assessing a client who has a rash on the chest and upper arms. Which questions would the nurse ask in order to gain further information about the client's rash? Select all that apply. a) "Are you allergic to any medications, foods, or pollen?" b) "How old are you?" c) "Do you smoke cigarettes or drink alcohol?" d) "Have you recently traveled outside the country?" e) "What have you been using to treat the rash?" f) "When did the rash start?"
• "Are you allergic to any medications, foods, or pollen?" • "Have you recently traveled outside the country?" • "What have you been using to treat the rash?" • "When did the rash start?"
Which of the following nursing assessment findings in a client with septic shock would require immediate intervention? a) Client experiencing polydipsia b) Urine output of 90 mL of dark, concentrated urine for the past 6 hours c) Fluctuation of temperature d) Confusion when listening to explanations of procedures
• "When did the rash start?" • "Are you allergic to any medications, foods, or pollen?" • "What have you been using to treat the rash?" • "Have you recently traveled outside the country?"
To interpret the results of blood pressure screenings in children over three years of age, the nurse compares the results to percentiles for systolic and diastolic blood pressure based on what factors? Select all that apply. a) occipital frontal circumference (OFC) b) weight c) age d) body mass index (BMI) e) gender f) height
• age • gender • height
A client has been pronounced brain dead. Which findings should the nurse document? Select all that apply. a) decerebrate posturing b) blink reflex c) deep tendon reflexes d) nonreactive dilated pupils e) absent corneal reflex
• nonreactive dilated pupils • deep tendon reflexes • absent corneal reflex
When a client with cirrhosis is medically stabilized, the nurse further explores the alcohol intake. About which important aspects would the nurse ask? a) Whether the client understands that the bleeding is a direct result of the alcoholism and that it means permanent damage has occurred b) Amount of alcohol intake, physical symptoms indicating abuse, and whether the client is in denial c) Amount and pattern of alcohol intake, influence on employment, and influence on relationships d) Whether there is a history of delirium tremens, and how it has influenced the decision regarding alcohol intake
Amount and pattern of alcohol intake, influence on employment, and influence on relationships
A nurse is caring for a client who is exhibiting signs and symptoms characteristic of a myocardial infarction (MI). Which statement describes priorities the nurse should establish while performing the physical assessment? a) Assess the client's level of pain, and administer prescribed analgesics. b) Prepare the client for pulmonary artery catheterization. c) Ensure that the client's family is kept informed of his status. d) Assess the client's level of anxiety, and provide emotional support.
Assess the client's level of pain, and administer prescribed analgesics.
A nurse is performing a preoperative assessment. Which client statement should alert her to the presence of risk factors for postoperative complications? a) "I've cut my smoking down from two packs to one pack per day." b) "I haven't been able to eat anything solid for the past 2 days." c) "I've never had surgery before." d) "I had an operation 2 years ago, and I don't want to have another one."
I've cut my smoking down from two packs to one pack per day
A community health nurse is planning to address the physical needs of older adults living in their homes. What primary areas would be included in this discussion? a) Importance of frequent physician visits and access to health care resources b) Importance of exercise, balanced nutrition, mobility and safety needs c) Assessment of mobility patterns and ways to prevent joint deterioration and falls d) Social support systems and ways to prevent hearing and visual deficits
A client in the postanesthesia care unit is being actively rewarmed with an external warming device. How often should the nurse monitor the client's body temperature? a) every 20 minutes b) every 10 minutes c) every 5 minutes d) every 15 minutes
