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1.	A client comes to the clinic for a routine checkup. To assess the client's gag reflex, the nurse should use which method?

A.	Place a tongue blade on the front of the tongue and ask the client to say "ah."

B.	Place a tongue blade lightly on the posterior aspect of the tongue.

C.	Place a tongue blade on the middle of the tongue and ask the client to cough.

D.	Place a tongue blade on the uvula.

2.	Hyperactive bowel sounds can result from all of the following except:

A.

hunger.

B.	paralytic ileus.

C.	intestinal obstruction.

D.

diarrhea.

3.	The nurse conducts a test for the Romberg's sign. What is the correct procedure for this test?

A.	Have the client stand with feet together and arms at the sides and try to balance, first with eyes open and then with eyes closed.

B.	Instruct the client to walk across the room on the heels and to return walking on the toes.

C.	Ask the client to touch the thumb of one hand to each finger on that hand and then repeat this action using the other hand.

D.	Instruct the client to lie on the back and slowly slide the heel down the shin of the opposite leg, from the knee to ankle.

4.	When examining a client with abdominal pain, the nurse should assess:

A.	any quadrant first.

B.	the symptomatic quadrant first.

C.	the symptomatic quadrant last.

D.	the symptomatic quadrant either second or third.

5.	An 82-year-old client is admitted to the hospital with a diagnosis of pneumonia. The nurse learns that the client lives alone and hasn't been eating or drinking. When assessing him for dehydration, the nurse would expect to find:

A.	distended neck veins.

B.	hypothermia.

C.	hypertension.

D.	tachycardia.

6.	Why shouldn't the nurse palpate both carotid arteries at one time?

A.	The pulse can't be assessed accurately unless the arteries are palpated one at a time.

B.	It may cause transient hypertension.

C.	It may cause severe bradycardia.

D.	It may cause severe tachycardia.

7.	A client undergoes a total abdominal hysterectomy. When assessing the client 10 hours later, the nurse identifies which finding as an early sign of shock?

A.	Restlessness

B.	Pale, warm, dry skin

C.	Heart rate of 110 beats/minute

D.	Urine output of 30 ml/hour

8.	The nurse determines that a client has 20/40 vision. Which statement about this client's vision is true?

A.	The client can read the entire vision chart at 40′ (12 m).

B.	The client can read from 20′ (6 m) what a person with normal vision can read at 40′.

C.	The client can read the vision chart from 20′ with the right eye and from 40′ with the left eye.

D.	The client can read at 30′ (9 m) what a person with normal vision can read at 40′.

9.	A pediatric nurse is asked to work temporarily (float) in the intensive care unit (ICU) because there are few clients in the pediatric unit. The nurse has never worked in ICU and has no critical care experience. Which action is most appropriate for this nurse?

A.	Refuse to float to ICU.

B.	Notify the nursing supervisor that she feels unqualified and untrained for the assignment.

C.	Go to ICU and take a total client assignment; ask the critical care nurses for assistance when necessary.

D.	Go to ICU, tell the ICU nurses she has never worked in ICU, and let the nurses decide what tasks she can perform.

10.

A client who recently immigrated to the United States from Korea is hospitalized with second- and third-degree burns. He speaks little English and has been lying quietly in bed. Ten hours after his admission, the nurse conducts a serial assessment and asks him whether he's in pain. He smiles and shakes his head vigorously back and forth. Which nursing action would be most appropriate at this time?

A.	Documenting that the client is resting quietly and denies pain

B.	Calling a family member to obtain information about the client

C.	Giving the client the prescribed as-needed pain medication

D.	Checking vital signs and assessing for nonverbal indications of pain

11.	The nurse is assessing a client's pulse. Which pulse feature should the nurse document?

A.	Timing in the cycle

B.

Amplitude

C.

Pitch

D.

Intensity

12.	A client with fever, weight loss, and watery diarrhea is being admitted to the facility. While assessing the client, a nurse inspects the client's abdomen and notices that it's slightly concave. Additional assessment should proceed in which order?

A.	Auscultation, percussion, and palpation

B.	Palpation, percussion, and auscultation

C.	Percussion, palpation, and auscultation

D.	Palpation, auscultation, and percussion

13.	A mother comes to the clinic with her 5-year-old son who's complaining of a fever and sore throat. The nurse documents the client's tonsils as 3+. This means they're:

A.	barely visible outside the tonsillar pillar.

B.	halfway between the tonsillar pillar and the uvula.

C.	touching the uvula.

D.	touching each other.

14.	A 76-year-old client with no debilitating conditions belongs to which geriatric population?

A.

Young-old

B.	Middle-old

C.

Old-old

D.	Frail elderly

15.	Before a transesophageal echocardiogram, a client is given an oral topical anesthetic spray. Upon return from the procedure, the nurse observes that the client has no active gag reflex. In response, the nurse should

A.	insert an oral airway.

B.	withhold food and fluids.

C.	position the client on his side.

D.	introduce a nasogastric (NG) tube.

16.	To evaluate a client's cerebellar function, the nurse should ask:

A.	"Do you have any problems with balance?"

B.	"Do you have any difficulty speaking?"

C.	"Do you have any trouble swallowing food or fluids?"

D.	"Have you noticed any changes in muscle strength?"

17.	During the physical examination, the nurse uses various techniques to assess structures, organs, and body systems. Which technique allows the nurse to feel for vibration and locate body structures?

A.	Auscultation

B.	Inspection

C.

Palpation

D.	Percussion

18.	Which of the following factors are major components of a client's general background drug history?

A.	Allergies and socioeconomic status

B.	Urine output and allergies

C.	Gastric reflex and age

D.	Bowel habits and allergies

19.	The nurse is teaching a client who will be discharged soon how to change a sterile dressing on the right leg. During the teaching session, the nurse notices redness, swelling, and induration at the wound site. What do these signs suggest?

A.

Infection

B.	Dehiscence

C.	Hemorrhage

D.	Evisceration

20.	Vasodilation or vasoconstriction produced by an external cause will interfere with an accurate assessment of a client with peripheral vascular disease (PVD). Therefore, the nurse should:

A.	keep the client warm.

B.	maintain room temperature at 78° F (25.6° C).

C.	keep the client uncovered.

D.	match the room temperature with the client's body temperature.

21.	The nurse reviews the arterial blood gas (ABG) values of a client admitted with pneumonia: pH, 7.51; PaCO2, 28 mm Hg; PaO2, 70 mm Hg; and HCO3–, 24 mEq/L. What do these values indicate?

A.	Metabolic acidosis

B.	Metabolic alkalosis

C.	Respiratory acidosis

D.	Respiratory alkalosis

22.	A client has lymphedema in both arms and the nurse must measure blood pressure using a thigh cuff. In reference to the client's baseline arm blood pressure, the nurse should expect the thigh to have a:

A.	higher systolic blood pressure reading.

B.	higher diastolic blood pressure reading.

C.	lower systolic blood pressure reading.

D.	lower diastolic blood pressure reading.

23.	When a nurse enters the client's room, the client complains that she's spitting up blood when she coughs. The nurse takes a quick health history that includes:

A.	the history of the present problem, medications, review of systems, and recent major operations.

B.	the history of the present problem, allergies, medications, and recent major operations.

C.	the history of the present problem, medications, family history, psychosocial history, and review of systems.

D.	the history of the present problem, allergies, medications, review of systems, and recent major operations.

24.	To evaluate a client's reason for seeking care, the nurse performs deep palpation. The purpose of deep palpation is to assess which of the following?

A.	Skin turgor

B.

Hydration

C.

Organs

D.	Temperature

25.	During a physical examination, the nurse asks a client to hold the breath briefly, and then uses a stethoscope to auscultate over the carotid arteries. Which finding is normal when auscultating over these arteries?

A.	No sounds heard over either carotid artery

B.	Faint swishing sounds heard over both carotid arteries

C.	Throbbing pulsations heard bilaterally

D.	Louder sounds heard over the right carotid artery than over the left carotid artery

26.	The nurse is assessing a client's abdomen. Which examination technique should the nurse use first?

A.	Auscultation

B.	Inspection

C.	Percussion

D.

Palpation

27.	During assessment, the nurse auscultates for a client's breath sounds. Auscultation produces which type of data?

A.	Subjective

B.

Objective

C.	Secondary source

D.

Medical

28.	The nurse is obtaining the health history of a client whose background differs from the nurse's. To develop culturally acceptable strategies for nursing care, the nurse should assess which client factor?

A.	Marital status

B.	Cultural influences

C.	Financial resources

D.	Community involvement

29.	The nurse is monitoring a client for adverse reactions during barbiturate therapy. What is the major disadvantage of barbiturate use?

A.	Prolonged half-life

B.	Prolonged half-life

C.	Potential for drug dependence

D.	Potential for hepatotoxicity

30.	The ear canal of an infant or young child:

A.	slants upward.

B.	slants downward.

C.	is horizontal.

D.	slants backward.

31.	To evaluate a client's posterior tibial pulse, where should the nurse palpate?

A.	Medially in the antecubital space

B.	Midway between the superior iliac spine and symphysis pubis

C.	On the inner aspect of the ankle, below the medial malleolus

D.	Along the top of the foot, over the instep

32.	The nurse measures a client's temperature at 102° F. What is the equivalent Centigrade temperature?

A.

39° C

B.

47° C

C.

38.9° C

D.

40.1° C

33.	The nurse is assessing a client who may be in the early stages of dehydration. Early manifestations of dehydration include:

A.	coma or seizures.

B.	sunken eyeballs and poor skin turgor.

C.	increased heart rate with hypotension.

D.	thirst or confusion.

34.	Which of the following sentences correctly describes the anatomic position?

A.	The body is supine.

B.	Arms are elevated at shoulder level.

C.	Palms are turned forward.

D.	The body is facing backward.

35.	The 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 took small steps at a rate of 40 to 50 per minute.

B.	The client reported feeling dizzy and weak and perspired profusely.

C.	The client's head was down, gaze was cast down, and toes were pointed outward.

D.	The client's pulse and respiratory rates increased moderately during ambulation.

36.	A client comes to the clinic for diagnostic allergy testing. Why is intradermal injection used for such testing?

A.	Intradermal injection is less painful.

B.	Intradermal drugs are easier to administer.

C.	Intradermal drugs diffuse more rapidly.

D.	Intradermal drugs diffuse more slowly.

37.	When should the nurse check a client for rebound tenderness?

A.	Near the beginning of the examination

B.	Before doing anything else

C.	Anytime during the examination

D.	At the end of the examination

38.	When assessing the facial lacerations of a middle-aged client admitted to the facility 1 week ago, the nurse observes scabs around the lacerations. Scabs indicate which phase of wound healing?

A.	Contraction

B.	Fibrinoplastic

C.

Lag

D.	Inflammation

39.	A client has just undergone bronchoscopy. Which nursing assessment is most important at this time?

A.	Level of consciousness (LOC)

B.

Memory

C.	Personality changes

D.	Intellectual ability

40.	The nurse plans to obtain client information from a primary source. Which is a primary information source?

A.	A family member

B.	The physician

C.	The client

D.	Previous medical records

41.	The nurse measures a client's apical pulse rate and compares it with the radial pulse rate. The differential between these two pulses is called:

A.	the pulse pressure.

B.	the pulse deficit.

C.	the pulse rhythm.

D.	pulsus regularis.

42.	To assess the effectiveness of cardiac compressions during adult cardiopulmonary resuscitation (CPR), the nurse should palpate which pulse site?

A.

Radial

B.

Apical

C.

Carotid

D.

Brachial

43.	When obtaining a client's history, the nurse develops a genogram. What is the purpose of developing a genogram?

A.	To identify genetic and familial health problems

B.	To identify previously undetected diseases and disorders

C.	To identify the client's reason for seeking care

D.	To identify the client's chronic health problems

44.	The nurse is examining a client with suspected peritonitis. How does the nurse elicit rebound tenderness?

A.	Pressing the affected area firmly with one hand, releasing pressure quickly, and noting any tenderness on release

B.	Using light palpation, noting any tenderness over an area

C.	Using deep ballottement, noting any tenderness over an area

D.	Pressing firmly with one hand, releasing pressure while maintaining fingertip contact with the skin, and noting tenderness on release

45.	Which statement regarding heart sounds is correct?

A.	S1 and S2 sound equally loud over the entire cardiac area.

B.	S1 and S2 sound fainter at the apex.

C.	S1 and S2 sound fainter at the base.

D.	S1 is loudest at the apex, and S2 is loudest at the base.

46.	Which pulse should the nurse palpate during rapid assessment of an unconscious adult?

A.

Radial

B.

Brachial

C.

Femoral

D.

Carotid

47.	When percussing a client's chest, the nurse should identify which sound as a normal finding?

A.	Hyperresonance

B.

Tympany

C.

Resonance

D.

Dullness

48.	Which plane divides the body longitudinally into anterior and posterior regions?

A.	Frontal plane

B.	Sagittal plane

C.	Midsagittal plane

D.	Transverse plane

49.	The nurse uses a stethoscope to auscultate a client's chest. Which statement about a stethoscope with a bell and diaphragm is true?

A.	The bell detects high-pitched sounds best.

B.	The diaphragm detects high-pitched sounds best.

C.	The bell detects thrills best.

D.	The diaphragm detects low-pitched sounds best.

50.	Why should an infant be quiet and seated upright when the nurse assesses his fontanels?

A.	The mother will have less trouble holding a quiet, upright infant.

B.	Lying down can cause the fontanels to recede, making assessment more difficult.

C.	The infant can breathe more easily when sitting up.

D.	Lying down and crying can cause the fontanels to bulge.

51.	The nurse correctly identifies which items as belonging to the dorsal cavity?

A.	Mediastinum

B.

Mouth

C.	Vertebral canal

D.	Reproductive organs

52.	When routinely evaluating a geriatric client for any atypical signs or symptoms, the nurse should remember that:

A.	aging can reduce the body's ability to regulate body temperature.

B.	aging can increase pain perception.

C.	anesthesia usually causes psychotic behavior postoperatively in a geriatric client.

D.	the risk of developing emphysema is highest in elderly people.

53.	The nurse prepares to assess a client who has just been admitted to the health care facility. During assessment, the nurse performs which activity?

A.	Collects data

B.	Formulates nursing diagnoses

C.	Develops a care plan

D.	Writes client outcomes

54.	When assessing a client with cellulitis of the right leg, which of the following would the nurse expect to find?

A.	Painful skin that is swollen and pale in color

B.	Cold, red skin

C.	Small, localized blackened area of skin

D.	Red, swollen skin with inflammation spreading to surrounding tissues

55.	Why should the nurse inspect first and then auscultate when performing an assessment of a pediatric client?

A.	Because the nurse's touch may calm the child

B.	Because the child may cry as the assessment proceeds, making auscultation difficult

C.	Because the nurse's touch may frighten the child

D.	Because the nurse's hand or stethoscope may feel cold, making the child recoil

56.	The nurse is assessing a client's abdomen. Which finding should the nurse report as abnormal?

A.	Dullness over the liver

B.	Bowel sounds occurring every 10 seconds

C.	Shifting dullness over the abdomen

D.	Vascular sounds heard over the renal arteries

57.	A client reports abdominal pain. Which action would aid the nurse's investigation of this complaint?

A.	Using deep palpation

B.	Assessing the painful area last

C.	Assessing the painful area first

D.	Checking for warmth in the painful area

58.	The nurse prepares to palpate a client's maxillary sinuses. For this procedure, where should the nurse place the hands?

A.	On the bridge of the nose

B.	Below the eyebrows

C.	Below the cheekbones

D.	Over the temporal area

59.	The nurse is performing a preoperative assessment. Which statement by the client would alert the nurse to the presence of risk factors for postoperative complications?

A.	"I haven't been able to eat anything solid for the past 2 days."

B.	"I've never had surgery before."

C.	"I had an operation 2 years ago, and I don't want to have another one."

D.	"I've cut my smoking down from two packs to one pack a day."

60.	A client complains of abdominal pain. To elicit as much information about the pain as possible, the nurse should ask:

A.	"Are you having pain?"

B.	"Is the pain constant?"

C.	"Is the pain sharp?"

D.	"What does the pain feel like?"

61.	Tachycardia can result from:

A.	vagal stimulation.

B.	vomiting, anger, or suctioning.

C.	fear, pain, or anger.

D.	stress, pain, or vomiting.

62.	The nurse is assessing an elderly client. When performing the assessment, the nurse should consider that one normal aging change is:

A.	cloudy vision.

B.	incontinence.

C.	diminished reflexes.

D.

tremors.

63.	When performing an abdominal assessment, the nurse should follow which examination sequence?

A.	Inspection, auscultation, percussion, and palpation

B.	Inspection, auscultation, palpation, and percussion

C.	Inspection, percussion, palpation, and auscultation

D.	Inspection, palpation, percussion, and auscultation

64.	The nurse is evaluating a client's auditory function. To compare air conduction to bone conduction, the nurse should conduct which test?

A.	Whispered voice test

B.	Weber's test

C.	Watch tick test

D.	Rinne test

65.	The nurse is assessing a 47-year-old client who has come to the physician's office for his annual physical. One of the first physical signs of aging is:

A.	having more frequent aches and pains.

B.	failing eyesight, especially close vision.

C.	increasing loss of muscle tone.

D.	accepting limitations while developing assets.

66.	To help assess a client's cerebral function, the nurse should ask:

A.	"Have you noticed a change in your memory?"

B.	"Have you noticed a change in your muscle strength?"

C.	"Have you had any coordination problems?"

D.	"Have you had any problems with your eyes?"

67.	The nurse is assessing tactile fremitus in a client with pneumonia. For this examination, the nurse should use the:

A.	fingertips.

B.	ulnar surface of the hand.

C.	dorsal surface of the hand.

D.	finger pads.

68.	The nurse must assess a client's splinted extremity for neurovascular damage. What should she do?

A.	Assess extremities, ensuring that the extremity with the splint feels cooler than the unsplinted extremities

B.	Move the client's fingers or toes to test movement

C.	Compare the capillary refill of each extremity, making sure it's the same bilaterally

D.	Be aware that edema and pulse checks aren't part of the neurovascular assessment

69.	When palpating a client's body to detect warmth, the nurse should use which part of the hand?

A.	Fingertips

B.	Finger pads

C.	Back (dorsal surface)

D.	Ulnar surface

70.	A 60-year old client reports to the nurse that he has a rash on his back and right flank. The nurse observes elevated, round, blisterlike lesions that are filled with clear fluid. When documenting the findings, what medical term should the nurse use to describe these lesions?

A.

Pustules

B.

Papule

C.

Plaque

D.

Vesicles

71.	When determining appropriate nursing interventions for a client with a medical diagnosis, the nurse is using which of the following?

A.	Developmental anatomy

B.	Applied anatomy

C.	Regional anatomy

D.	Descriptive anatomy

72.	The nurse is assessing a client who has a rash on his chest and upper arms. Which questions should the nurse ask in order to gain further information about the client's rash?

A.	"When did the rash start?"

B.	"Are you allergic to any medications, foods, or pollen?"

C.	"How old are you?"

D.	"What have you been using to treat the rash?"

E.	"Have you recently traveled outside the country?"

F.	"Do you smoke cigarettes or drink alcohol?"

73.	At 8 a.m., the nurse assesses a client who's scheduled for surgery at 10 a.m. During the assessment, the nurse detects dyspnea, a nonproductive cough, and back pain. What should the nurse do next?

A.	Check to see that the chest X-ray was done yesterday as ordered.

B.	Check the serum electrolyte levels and complete blood count (CBC).

C.	Notify the physician immediately of these findings.

D.	Sign the preoperative checklist for this client.

74.	When palpating the bladder of an adult client, the nurse should identify which finding as normal?

A.	A soft, smooth bladder

B.	A hard, rough bladder

C.	A nonpalpable bladder

D.	A palpable bladder located 3" to 5" (7.5 to 12.7 cm) above the symphysis pubis

75.	The nurse is caring for a client who has suffered a severe stroke. During routine assessment, the nurse notices Cheyne-Stokes respirations. Cheyne-Stokes respirations are:

A.	progressively deeper breaths followed by shallower breaths with apneic periods.

B.	rapid, deep breaths with abrupt pauses between each breath.

C.	rapid, deep breaths and irregular breathing without pauses.

D.	shallow breaths with an increased respiratory rate.

76.	The nurse is assessing a postoperative client. Which of the following should the nurse document as subjective data?

A.	Vital signs

B.	Laboratory test results

C.	Client's description of pain

D.	Electrocardiographic (ECG) waveforms

77.	When auscultating a client's chest, the nurse assesses a second heart sound (S2). This sound results from:

A.	opening of the mitral and tricuspid valves.

B.	closing of the mitral and tricuspid valves.

C.	opening of the aortic and pulmonic valves.

D.	closing of the aortic and pulmonic valves.

78.	The nurse is auscultating a client's chest. How can the nurse differentiate a pleural friction rub from other abnormal breath sounds?

A.	A rub occurs during expiration only and produces a light, popping, musical noise.

B.	A rub occurs during inspiration only and may be heard anywhere.

C.	A rub occurs during both inspiration and expiration and produces a squeaking or grating sound.

D.	A rub occurs during inspiration only and clears with coughing.

79.	To avoid recording an erroneously low systolic blood pressure because of failure to recognize an auscultatory gap, the nurse should:

A.	have the client lie down while taking his blood pressure.

B.	inflate the cuff to at least 200 mm Hg.

C.	take blood pressure readings in both arms.

D.	inflate the cuff at least another 30 mm Hg after the radial pulse becomes unpalpable.

80.	A client, age 75, is admitted to the facility. Because of the client's age, the nurse should modify the assessment by:

A.	shortening it.

B.	talking in a loud voice.

C.	addressing the client by the first name.

D.	allowing extra time for the assessment.

81.	Two days after undergoing a total abdominal hysterectomy, a client complains of left calf pain, and venography reveals deep vein thrombosis (DVT). When assessing this client, the nurse is most likely to detect:

A.	pallor and coolness of the left foot.

B.	a decrease in the left pedal pulse.

C.	loss of hair on the lower portion of the left leg.

D.	left calf circumference 1" (2.5 cm) larger than the right.

82.	After suctioning a tracheostomy tube, the nurse assesses the client to determine the effectiveness of the suctioning. Which findings indicate that the airway is now patent?

A.	A respiratory rate of 24 breaths/minute with accessory muscle use

B.	Effective breathing at a rate of 16 breaths/minute through the established airway

C.	Increased pulse rate, rapid respirations, and cyanosis of the skin and nail beds

D.	Restlessness, pallor, increased pulse and respiratory rates, and bubbling breath sounds

83.	The nurse must assess skin turgor of an elderly client. When evaluating skin turgor, the nurse should remember that:

A.	overhydration causes the skin to tent.

B.	dehydration causes the skin to appear edematous and spongy.

C.	inelastic skin turgor is a normal part of aging.

D.	normal skin turgor is moist and boggy.

84.	The nurse prepares to perform light palpation. How is light palpation performed?

A.	By indenting the skin ½" to ¾" (1.3 to 1.9 cm)

B.	By indenting the skin 1" to 2" (2.5 to 5 cm)

C.	By indenting the skin 1", using both hands

D.	By indenting the skin 1" and then releasing the pressure quickly

85.	When inspecting a client's skin, the nurse finds a vesicle on the client's arm. Which description applies to a vesicle?

A.	Flat, nonpalpable, and colored

B.	Solid, elevated, and circumscribed

C.	Circumscribed, elevated, and filled with serous fluid

D.	Elevated, pus-filled, and circumscribed

86.	The nurse prepares to auscultate a client's carotid arteries for bruits. For this procedure, the nurse should:

A.	have the client inhale during auscultation.

B.	palpate the radial artery during auscultation.

C.	use the bell of the stethoscope.

D.	use the diaphragm of the stethoscope.

87.	The nurse prepares to measure a client's blood pressure. What is the correct procedure for measuring blood pressure?

A.	Wrapping the cuff around the limb, with the uninflated bladder covering about one-fourth of the limb circumference

B.	Measuring the arm about 2" (5 cm) above the antecubital space

C.	Wrapping the cuff around the limb, with the uninflated bladder covering about three-quarters of the limb circumference

D.	Using a bladder that is 6" (15 cm) long.

88.	When testing a client's pupils for accommodation, the nurse should interpret which findings as normal?

A.	Constriction and divergence

B.	Dilation and convergence

C.	Constriction and convergence

D.	Dilation and divergence

89.	The nurse can auscultate for heart sounds more easily if the client is:

A.

supine.

B.	on his right side.

C.	holding his breath.

D.	leaning forward.