The nurse is assessing bowel sounds for a hospitalized client. The nurse has heard bowel
sounds in the right upper quadrant. What action should the nurse take next? - ANSWER
Note the character and frequency of bowel sounds
The nurse is performing a thoracic assessment on a client with chronic asthma and hyperin-
flation of the lungs. Which finding should be expected for this client? - ANSWER Barrel
chest
During inspection of a client's mouth and pharynx, the nurse places a tongue blade on the
back of the tongue which causes the client to gag. After removing the tongue blade, what
action should the nurse take? - ANSWER Document an intact gag reflex.
When teaching a client how to perform a monthly breast self-assessment, the nurse should
tell the client that it is most important to assess which part of the breast more closely for
changes? - ANSWER Upper outer quadrant.
The nurse is assessing a postmenopausal client who has a BMI of 32. The client has a chest
measurement of 42 inches, waist measurement of 45 inches, and hip measurement of 50
inches. What important message should the nurse explain to the client to promote health
promotion? - ANSWER A waist circumference is greater than 35 inches in women puts
you at higher risk for type 2 diabetes and heart disease."
The nurse performs a physical assessment on an older female client. Which change from the
prior exam may be an indication of osteoporosis? - ANSWER Height reduction of 1.5
inches.
1
,While conducting an interview to obtain a health history, the nurse notices that the client
pauses frequently and looks at the nurse expectantly. Which response is best for the nurse
to provide? - ANSWER Sit quietly to allow the client to respond comfortably.
A client is in the clinical for a yearly physical examination. Which action should the nurse
take when preparing to examine the client's abdomen? - ANSWER Ask the client to uri-
nate before beginning the examination.
Which respiratory condition should the nurse document after measuring a respiratory rate
of 8 breaths/minute? - ANSWER Bradypnea.
Which procedure should the nurse use to assessfor a pulse deficit? - ANSWER Measure
the apical pulse and compare it to the peripheral pulse.
*A pulse deficit is a palpable difference between the apical pulse at the point of maximal im-
pulse and the radial pulse palpated at the wrist.
A client has been diagnosed with bilateral lower lobe atelectasis. What percussion sound
should the nurse expect to hear when percussing over the client's lower lobes? - AN-
SWER Dull, thud-like.
The nurse is assessing a healthy young adult during an annual physical examination. Which
assessment technique should the nurse implement when palpating the abdominal aorta? -
ANSWER Deep palpation above and to the left of the umbilicus.
A client is being assessed upon admission to the medical-surgical unit. The nurse is preparing
to complete a head-to-toe assessment and will begin at the head of the client. Which tech-
nique should the nurse use to begin the assessment? - ANSWER Inspect the hair and
skin.
The nurse is conducting a family history as part of the assessment interview. Which action
should the nurse take to ensure that sufficient information about the client's blood relatives
2
, is obtained? - ANSWER Document at least 3 generations of the client's family medical his-
tory.
The nurse is testing the client's shoulders for range of motion. What should the nurse docu-
ment to record normal internal rotation? - ANSWER Range of 90 degrees when the hands
are placed at the small of the back.
A client presents with a rash along the occipital area of the hairline and reports intense itch-
ing. How should the nurse begin the objective part of the examination? - ANSWER In-
spect the scalp looking for nits.
The nurse is assessing a client's range of motion as the client bends the right knee up to the
chest while keeping the left leg straight, but is unable to keep the left thigh on the table. The
assessment is repeated for the left knee, and the client is unable to keep the right thigh on
the table. How should the nurse document this finding? - ANSWER A flexion deformity
referred to as a positive Thomas test.
During a skin asssessment, the nurse notes, round and discrete lesions that are dark red in
color and will not blanch. The lesions range from 1 to 3 mm in size. What is the first question
the nurse should ask the client? - ANSWER Have you notice any irregular bleeding
A client with progressive hearing loss appears distressed when the registered nurse (RN)
asks open-ended questions about the client's health history. Which forms of communication
should the RN use? - ANSWER Face the client so the client can see the RN's mouth.
Check if the client's hearing aides are working properly.
Reduce environmental noise surrounding the client.
A client states that she had a mastectomy of her left breast last year and now experiences
lymphedema. What should the nurse expect to find when examining the client? - AN-
SWER Swelling of the left arm and non-pitting edema.
3
sounds in the right upper quadrant. What action should the nurse take next? - ANSWER
Note the character and frequency of bowel sounds
The nurse is performing a thoracic assessment on a client with chronic asthma and hyperin-
flation of the lungs. Which finding should be expected for this client? - ANSWER Barrel
chest
During inspection of a client's mouth and pharynx, the nurse places a tongue blade on the
back of the tongue which causes the client to gag. After removing the tongue blade, what
action should the nurse take? - ANSWER Document an intact gag reflex.
When teaching a client how to perform a monthly breast self-assessment, the nurse should
tell the client that it is most important to assess which part of the breast more closely for
changes? - ANSWER Upper outer quadrant.
The nurse is assessing a postmenopausal client who has a BMI of 32. The client has a chest
measurement of 42 inches, waist measurement of 45 inches, and hip measurement of 50
inches. What important message should the nurse explain to the client to promote health
promotion? - ANSWER A waist circumference is greater than 35 inches in women puts
you at higher risk for type 2 diabetes and heart disease."
The nurse performs a physical assessment on an older female client. Which change from the
prior exam may be an indication of osteoporosis? - ANSWER Height reduction of 1.5
inches.
1
,While conducting an interview to obtain a health history, the nurse notices that the client
pauses frequently and looks at the nurse expectantly. Which response is best for the nurse
to provide? - ANSWER Sit quietly to allow the client to respond comfortably.
A client is in the clinical for a yearly physical examination. Which action should the nurse
take when preparing to examine the client's abdomen? - ANSWER Ask the client to uri-
nate before beginning the examination.
Which respiratory condition should the nurse document after measuring a respiratory rate
of 8 breaths/minute? - ANSWER Bradypnea.
Which procedure should the nurse use to assessfor a pulse deficit? - ANSWER Measure
the apical pulse and compare it to the peripheral pulse.
*A pulse deficit is a palpable difference between the apical pulse at the point of maximal im-
pulse and the radial pulse palpated at the wrist.
A client has been diagnosed with bilateral lower lobe atelectasis. What percussion sound
should the nurse expect to hear when percussing over the client's lower lobes? - AN-
SWER Dull, thud-like.
The nurse is assessing a healthy young adult during an annual physical examination. Which
assessment technique should the nurse implement when palpating the abdominal aorta? -
ANSWER Deep palpation above and to the left of the umbilicus.
A client is being assessed upon admission to the medical-surgical unit. The nurse is preparing
to complete a head-to-toe assessment and will begin at the head of the client. Which tech-
nique should the nurse use to begin the assessment? - ANSWER Inspect the hair and
skin.
The nurse is conducting a family history as part of the assessment interview. Which action
should the nurse take to ensure that sufficient information about the client's blood relatives
2
, is obtained? - ANSWER Document at least 3 generations of the client's family medical his-
tory.
The nurse is testing the client's shoulders for range of motion. What should the nurse docu-
ment to record normal internal rotation? - ANSWER Range of 90 degrees when the hands
are placed at the small of the back.
A client presents with a rash along the occipital area of the hairline and reports intense itch-
ing. How should the nurse begin the objective part of the examination? - ANSWER In-
spect the scalp looking for nits.
The nurse is assessing a client's range of motion as the client bends the right knee up to the
chest while keeping the left leg straight, but is unable to keep the left thigh on the table. The
assessment is repeated for the left knee, and the client is unable to keep the right thigh on
the table. How should the nurse document this finding? - ANSWER A flexion deformity
referred to as a positive Thomas test.
During a skin asssessment, the nurse notes, round and discrete lesions that are dark red in
color and will not blanch. The lesions range from 1 to 3 mm in size. What is the first question
the nurse should ask the client? - ANSWER Have you notice any irregular bleeding
A client with progressive hearing loss appears distressed when the registered nurse (RN)
asks open-ended questions about the client's health history. Which forms of communication
should the RN use? - ANSWER Face the client so the client can see the RN's mouth.
Check if the client's hearing aides are working properly.
Reduce environmental noise surrounding the client.
A client states that she had a mastectomy of her left breast last year and now experiences
lymphedema. What should the nurse expect to find when examining the client? - AN-
SWER Swelling of the left arm and non-pitting edema.
3
