1. 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?
A. Resonant
B. Tympanic
C. Hyperresonant
D. Dull, thud-like
Rationale: Dullness is typically heard over areas of increased density such as
consolidation or atelectasis. The collapsed alveoli in atelectasis replace air with fluid or
tissue, producing a thud-like sound upon percussion. Recognizing dullness helps
differentiate normal lung fields from pathologic conditions.
2. Aclient 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. Which
technique should the nurse use first?
A. Inspect the hair and skin
B. Palpate the scalp
C. Auscultate for bruits
D. Percuss the frontal sinuses
Rationale: Inspection is always the first step in a physical assessment. By visually
examining hair and skin, the nurse gathers objective data such as texture, lesions,
infestations, or discoloration before moving on to palpation, percussion, or
auscultation.
,3. During a physical exam of a healthy young adult, the nurse is palpating the
abdominal aorta. Which technique should the nurse implement?
A. Light palpation along the midline
B. Deep palpation above and to the left of the umbilicus
C. Percussion over the epigastrium
D. Auscultation before palpation
Rationale: Deep palpation allows the nurse to assess the size, pulsation, and possible
aneurysms of the abdominal aorta. It should be performed above and slightly left of
the umbilicus. Palpation too lightly may miss abnormalities, and auscultation is done
prior for bruits if indicated.
4. When conducting a family history as part of the assessment, which action ensures
sufficient information is obtained?
A. Ask about the client’s siblings only
B. Focus on the maternal side
C. Document at least 3 generations of the client’s family medical history
D. Record only first-degree relatives’ illnesses
Rationale: Collecting three generations provides a comprehensive view of hereditary
conditions and patterns, which can identify risks for cardiovascular, metabolic, or
genetic diseases. Limiting to siblings or first-degree relatives may miss important
trends.
5. The nurse is testing a client’s shoulders for range of motion. What should the nurse
document as normal internal rotation?
,A. 45 degrees with hands on the side
B. 60 degrees with arms abducted
C. 90 degrees when hands are placed at the small of the back
D. 120 degrees with elbows extended
Rationale: Normal shoulder internal rotation is 90 degrees when the hands are
placed behind the back. This is assessed by having the client reach toward the lumbar
spine. Documenting accurate range of motion is essential for baseline and follow-up
comparison.
6. A client presents with a rash along the occipital hairline and reports intense itching.
How should the nurse begin the objective assessment?
A. Palpate the scalp for tenderness
B. Inspect the scalp looking for nits
C. Obtain a culture before examination
D. Apply topical medication before assessment
Rationale: Inspection is the first step in identifying scalp infestations such as lice.
Looking for nits or lice guides treatment and prevents unnecessary discomfort.
Palpation or interventions should follow inspection.
7. The nurse is assessing a client’s range of motion as the client bends the right knee
to the chest while keeping the left leg straight, but the left thigh lifts off the table.
Repeated on the left knee, the right thigh lifts. How should the nurse document this?
A. Flexion deformity referred to as a positive Thomas test
B. Limited abduction
C. Hyperextension of the opposite leg
D. Normal hip flexibility
Rationale: The Thomas test identifies hip flexion contractures. If the opposite thigh
lifts off the table, this indicates a flexion deformity. Documenting positive Thomas
tests aids in planning interventions or further musculoskeletal evaluation.
, 8. During a skin assessment, the nurse notes round, discrete, dark red lesions that do
not blanch, measuring 1-3 mm. What is the first question the nurse should ask?
A. Have you experienced any itching?
B. Have you noticed any irregular bleeding?
C. Have you recently traveled?
D. Have you applied new skin products?
Rationale: Non-blanching lesions may indicate purpura or bleeding under the skin.
Asking about bleeding helps differentiate between benign rashes and serious
hematologic conditions. Early detection is critical for patient safety.
9. A client with progressive hearing loss appears distressed when asked open-ended
health questions. Which forms of communication should the RN use?
A. Face the client so they can see the RN’s mouth, check hearing aids,
reduce environmental noise
B. Speak louder and faster
C. Avoid visual cues to prevent distraction
D. Use medical jargon to simplify questions
Rationale: Clients with hearing loss benefit from visual cues, functional hearing aids,
and reduced background noise. Effective communication ensures accurate assessment
and patient comfort.
10. A client who had a left mastectomy last year now experiences lymphedema. What
should the nurse expect to find?
sound should the nurse expect to hear when percussing over the client’s lower lobes?
A. Resonant
B. Tympanic
C. Hyperresonant
D. Dull, thud-like
Rationale: Dullness is typically heard over areas of increased density such as
consolidation or atelectasis. The collapsed alveoli in atelectasis replace air with fluid or
tissue, producing a thud-like sound upon percussion. Recognizing dullness helps
differentiate normal lung fields from pathologic conditions.
2. Aclient 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. Which
technique should the nurse use first?
A. Inspect the hair and skin
B. Palpate the scalp
C. Auscultate for bruits
D. Percuss the frontal sinuses
Rationale: Inspection is always the first step in a physical assessment. By visually
examining hair and skin, the nurse gathers objective data such as texture, lesions,
infestations, or discoloration before moving on to palpation, percussion, or
auscultation.
,3. During a physical exam of a healthy young adult, the nurse is palpating the
abdominal aorta. Which technique should the nurse implement?
A. Light palpation along the midline
B. Deep palpation above and to the left of the umbilicus
C. Percussion over the epigastrium
D. Auscultation before palpation
Rationale: Deep palpation allows the nurse to assess the size, pulsation, and possible
aneurysms of the abdominal aorta. It should be performed above and slightly left of
the umbilicus. Palpation too lightly may miss abnormalities, and auscultation is done
prior for bruits if indicated.
4. When conducting a family history as part of the assessment, which action ensures
sufficient information is obtained?
A. Ask about the client’s siblings only
B. Focus on the maternal side
C. Document at least 3 generations of the client’s family medical history
D. Record only first-degree relatives’ illnesses
Rationale: Collecting three generations provides a comprehensive view of hereditary
conditions and patterns, which can identify risks for cardiovascular, metabolic, or
genetic diseases. Limiting to siblings or first-degree relatives may miss important
trends.
5. The nurse is testing a client’s shoulders for range of motion. What should the nurse
document as normal internal rotation?
,A. 45 degrees with hands on the side
B. 60 degrees with arms abducted
C. 90 degrees when hands are placed at the small of the back
D. 120 degrees with elbows extended
Rationale: Normal shoulder internal rotation is 90 degrees when the hands are
placed behind the back. This is assessed by having the client reach toward the lumbar
spine. Documenting accurate range of motion is essential for baseline and follow-up
comparison.
6. A client presents with a rash along the occipital hairline and reports intense itching.
How should the nurse begin the objective assessment?
A. Palpate the scalp for tenderness
B. Inspect the scalp looking for nits
C. Obtain a culture before examination
D. Apply topical medication before assessment
Rationale: Inspection is the first step in identifying scalp infestations such as lice.
Looking for nits or lice guides treatment and prevents unnecessary discomfort.
Palpation or interventions should follow inspection.
7. The nurse is assessing a client’s range of motion as the client bends the right knee
to the chest while keeping the left leg straight, but the left thigh lifts off the table.
Repeated on the left knee, the right thigh lifts. How should the nurse document this?
A. Flexion deformity referred to as a positive Thomas test
B. Limited abduction
C. Hyperextension of the opposite leg
D. Normal hip flexibility
Rationale: The Thomas test identifies hip flexion contractures. If the opposite thigh
lifts off the table, this indicates a flexion deformity. Documenting positive Thomas
tests aids in planning interventions or further musculoskeletal evaluation.
, 8. During a skin assessment, the nurse notes round, discrete, dark red lesions that do
not blanch, measuring 1-3 mm. What is the first question the nurse should ask?
A. Have you experienced any itching?
B. Have you noticed any irregular bleeding?
C. Have you recently traveled?
D. Have you applied new skin products?
Rationale: Non-blanching lesions may indicate purpura or bleeding under the skin.
Asking about bleeding helps differentiate between benign rashes and serious
hematologic conditions. Early detection is critical for patient safety.
9. A client with progressive hearing loss appears distressed when asked open-ended
health questions. Which forms of communication should the RN use?
A. Face the client so they can see the RN’s mouth, check hearing aids,
reduce environmental noise
B. Speak louder and faster
C. Avoid visual cues to prevent distraction
D. Use medical jargon to simplify questions
Rationale: Clients with hearing loss benefit from visual cues, functional hearing aids,
and reduced background noise. Effective communication ensures accurate assessment
and patient comfort.
10. A client who had a left mastectomy last year now experiences lymphedema. What
should the nurse expect to find?
