NCLEX RN - Basic Physical Assessment

The nurse is assessing a client's respiratory status. Which assessment data indicate a problem?

28 breaths/min and audible

A nurse is teaching a client about the importance of increasing fluids when experiencing the early stages of dehydration. Which statement by the client would express understanding?

"I should drink more water when feeling thirsty or becoming irritable."

Students in a health class are discussing birth control and prevention of sexually transmitted disease. The school nurse would know that teaching has been effective if the students make which statement?

"Responsible sex involves using condoms and spermicides for protection and birth control."

A nurse is caring for a client after internal fixation of a compound fracture in the tibia. The nurse finds that the client has not had dinner, seems restless, and is tossing on the bed. What is the most appropriate response by the nurse?

"Tell me what you are feeling."

The nurse enters the hospital room and finds the client unresponsive to verbal stimulation. What would be the next action by the nurse?

Apply physical stimulation.

When collecting a health history on a child, what is important for the nurse to assess regarding the child's allergies? Select all that apply.

-allergies to items other than medications, such as foods and animals -allergies to any medications -severity of the allergy -reaction to the allergen

The nurse is conducting an admission interview with a client and is assessing for risk factors related to the client's safety. The nurse should include which targeted assessments? Select all that apply.

-suicide or self-harm ideation -recent use of substances of abuse -allergic reactions or adverse drug reactions

Which statement heard during shift report identifies an important priority for action?

A postoperative client's pulse has been increasing, and the blood pressure is decreasing.

The nurse is caring for a client who has become unresponsive. The blood pressure is 80/40 mm Hg, and SpO2 is 90% on 50% face mask. What should the nurse do next?

Call the rapid response team.

A cloth chest restraint has been presecribed for a client who is restless and combative due to alcohol intoxication. What is an appropriate nursing intervention for this client?

Check the extremities for circulation based on hospital protocols.

At 8 a.m. (0800), a nurse assesses a client who is scheduled for surgery at 10 a.m. (1000). During the assessment, the nurse detects dyspnea, a nonproductive cough, and back pain. What would the nurse do next?

Immediately notify the healthcare provider of these findings.

The nurse is caring for a postoperative client who has not voided since before surgery. Which is the nurse's most appropriate action?

Palpate for the bladder above the symphysis pubis.

After a laminectomy, a client has a palpable bladder and reports lower abdominal discomfort with voiding 60 to 80 mL of urine every 4 hours. The vital signs are BP 110/88 mm Hg, HR 86 bpm, and RR of 20 breaths/min. What is the best nursing intervention?

Perform a bladder scan, and obtain an order for urinary catheterization.

Which is a priority nursing assessment of a reddened heel in a bed-ridden client?

Test for blanching to the affected area.

A client from Mexico has bacterial pneumonia and has a temperature of 102°F (39°C). The client has been treating the infection by drinking milk. How should the nurse interpret the client's method of self-treatment?

The client is using the hot disease concept.

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?

The lump is round and movable.

A nurse observes a student auscultating a client's lungs. Which action by the student indicates a need for further instruction on respiratory assessment skills?

The student places the stethoscope over the posterior chest and only listens during inspiration.

A client, age 75, is admitted to the hospital. Because of the client's age, how should the nurse modify the client's assessment?

allowing extra time for the assessment

The nurse is caring for a client experiencing acute abdominal pain. What is the first action by the nurse?

auscultation of all four quadrants using a stethoscope

The nurse is observing a nursing student palpating a client's maxillary sinuses. The nurse observes that the student has correctly palpated the client's maxillary sinuses when the student palpates which area?

below the client's cheekbones

A client is 12 hours post abdominal inguinal hernia repair done under general anesthesia. The practitioner orders to progress diet as tolerated. Which tray should the nurse choose for this client?

broth, gelatin cubes, and tea

A nurse is assessing a client at the beginning of the shift. Which signs of hypoxia would alert the nurse to take further action?

increased pulse rate, oxygen saturation of 88%, and circumoral cyanosis

The nurse is monitoring a client during moderate sedation. The client is laying on the gurney with eyes closed and opens the eyes and moans when the nurse touches the shoulder, but not when the nurse says the client's name. The nurse charts the client responds to what type of stimuli?

tactile

A client has just been transferred to the postanesthesia recovery room following a laparotomy. The nurse has completed assessing vital signs. What other important initial assessments would the nurse make?

level of consciousness, pain level, and wound dressing

When assessing a dark-skinned client for cyanosis, what area of the body will best reveal cyanosis?

oral mucous membranes

A nurse is caring for a client during barbiturate therapy. The client receiving this drug should be evaluated for which condition?

physical dependence

A nurse correctly identifies which items as belonging to the dorsal cavity?

vertebral canal

The nurse is caring for an infant who is retaining fluid. How will the nurse assess for urine output?

weighing the diaper before and after micturition

The nurse receives morning lab work after shift hand-off. Based on the analysis of lab values, which client would the nurse assess first?

a client diagnosed with renal disease and a serum potassium level of 6.1 mEq/dL (6.1 mmol/L) who has limited output

A nurse assesses the client's pulse as weak and thready in both lower extremities. How would the nurse best document this finding?

pulse amplitude +1 bilateral lower extremities

The nurse notices redness, swelling, and induration at a surgical wound site. What is the nurse's next action?

Assess the client's temperature.

A client with Parkinson disease who is scheduled for physiotherapy is experiencing nausea and weakness. What is the most appropriate action by the nurse?

Assess the nausea and weakness, and call physiotherapy to cancel or reschedule the appointment.

When assessing a client diagnosed with third spacing, a nurse should expect to assess manifestation?

decreased blood pressure

A client tells a nurse that about a rash on the back and right flank. The nurse observes elevated, round, blisterlike lesions filled with clear fluid. When documenting the findings, what medical term would the nurse use to describe these lesions?

vesicles

A nurse is observing a unlicensed assistive personnel (UAP) measure a client's blood pressure. Which action by the UAP would be evaluated as correct?

wrapping the cuff around the limb, with the bladder covering three-quarters of the limb circumference

Why should an infant be quiet and seated in an upright position when the nurse assesses the fontanels?

Lying down and crying can cause the fontanels to bulge.