, SET 1
1. A nurse is assessing a client who reports sudden-onset chest pain that
becomes worse with deep inspiration and lying flat but is slightly relieved
when sitting forward. During the cardiovascular assessment, the nurse places
the diaphragm of the stethoscope at the left sternal border and hears a high-
pitched scratching sound occurring during both systole and diastole. The nurse
recognizes that this finding is associated with inflammation of the pericardial
sac. Which of the following heart sounds should the nurse document?
A. Audible Click
B. Murmur
C. Third heart sound
D. Pericardial friction rub
Correct Answer: D. Pericardial friction rub
Rationale: A pericardial friction rub is a high-pitched, scratchy, grating sound heard
best with the diaphragm of the stethoscope along the left sternal border. It is a classic
finding of pericarditis and commonly occurs when inflamed pericardial layers rub
against each other during both systole and diastole. Prompt recognition helps
facilitate early diagnosis and treatment of pericardial inflammation while preventing
complications such as cardiac tamponade.
2. A nurse is obtaining the blood pressure of a client whose upper extremities
cannot be used because of bilateral injuries. The nurse prepares to measure
the blood pressure in the client's lower extremity and wants to ensure that the
technique provides the most accurate reading. Which of the following actions
should the nurse take?
A. Auscultate for the blood pressure at the dorsalis pedis artery.
B. Measure the blood pressure with the client sitting on the side of the bed.
,C. Place the cuff 7.6 cm (3 in) above the popliteal artery.
D. Place the bladder of the cuff over the posterior aspect of the thigh.
Correct Answer: D. Place the bladder of the cuff over the posterior aspect of the
thigh.
Rationale: When obtaining a thigh blood pressure, the cuff bladder should be
centered over the posterior aspect of the thigh so it lies directly over the femoral
artery. Proper cuff placement ensures accurate compression of the artery and
reliable blood pressure measurements, while incorrect positioning may result in
inaccurate or falsely elevated readings.
3. A charge nurse is teaching a group of newly licensed nurses the current
guidelines for performing adult cardiopulmonary resuscitation (CPR). During
the class, the charge nurse presents a scenario involving an adult client who
suddenly collapses and appears motionless. Before initiating any additional
interventions, the nurses must identify the first appropriate action. Which of
the following actions should the charge nurse teach as the initial response in
CPR?
A. Call for assistance.
B. Begin chest compressions.
C. Confirm unresponsiveness.
D. Give rescue breaths.
Correct Answer: C. Confirm unresponsiveness.
Rationale: Confirming that the client is unresponsive is the first step in the adult
Basic Life Support (BLS) sequence because it establishes the need for emergency
intervention. Once unresponsiveness is verified, the nurse activates the emergency
response system, assesses breathing and pulse, and promptly begins chest
compressions if indicated to maximize survival.
4. A nurse is preparing a hospitalized client for transport to the radiology
department for a chest x-ray. Before the transporter arrives, the nurse
, completes the required safety checks to ensure the correct client receives the
prescribed diagnostic procedure. Which of the following actions should the
nurse take first?
A. Explain the x-ray procedure to the client.
B. Help the client into a wheelchair before the transporter arrives.
C. Ask if the client has any questions.
D. Identify the client using two identifiers.
Correct Answer: D. Identify the client using two identifiers.
Rationale: Correct client identification using two approved identifiers is the
highest priority before any diagnostic test or procedure because it prevents wrong-
patient errors and promotes client safety. Verifying identity before transport ensures
that all subsequent interventions, including education and preparation, are
performed for the correct individual.
5. A nurse is caring for a school-age child who is recovering after a tonsillectomy.
The child reports throat pain and is reluctant to swallow fluids because of
discomfort. The nurse plans postoperative interventions to promote comfort,
reduce complications, and encourage recovery. Which of the following actions
should the nurse take?
A. Encourage the child to cough frequently to clear congestion from anesthesia.
B. Place a heating pad at the child's neck for comfort.
C. Administer analgesics to the child on a routine schedule throughout the day and
night.
D. Provide the child with ice cream when oral intake is initiated.
Correct Answer: C. Administer analgesics to the child on a routine schedule
throughout the day and night.
Rationale: Scheduled administration of analgesics maintains consistent pain
control, allowing the child to swallow fluids more comfortably and decreasing the risk
of dehydration. Effective pain management also promotes healing, reduces anxiety
1. A nurse is assessing a client who reports sudden-onset chest pain that
becomes worse with deep inspiration and lying flat but is slightly relieved
when sitting forward. During the cardiovascular assessment, the nurse places
the diaphragm of the stethoscope at the left sternal border and hears a high-
pitched scratching sound occurring during both systole and diastole. The nurse
recognizes that this finding is associated with inflammation of the pericardial
sac. Which of the following heart sounds should the nurse document?
A. Audible Click
B. Murmur
C. Third heart sound
D. Pericardial friction rub
Correct Answer: D. Pericardial friction rub
Rationale: A pericardial friction rub is a high-pitched, scratchy, grating sound heard
best with the diaphragm of the stethoscope along the left sternal border. It is a classic
finding of pericarditis and commonly occurs when inflamed pericardial layers rub
against each other during both systole and diastole. Prompt recognition helps
facilitate early diagnosis and treatment of pericardial inflammation while preventing
complications such as cardiac tamponade.
2. A nurse is obtaining the blood pressure of a client whose upper extremities
cannot be used because of bilateral injuries. The nurse prepares to measure
the blood pressure in the client's lower extremity and wants to ensure that the
technique provides the most accurate reading. Which of the following actions
should the nurse take?
A. Auscultate for the blood pressure at the dorsalis pedis artery.
B. Measure the blood pressure with the client sitting on the side of the bed.
,C. Place the cuff 7.6 cm (3 in) above the popliteal artery.
D. Place the bladder of the cuff over the posterior aspect of the thigh.
Correct Answer: D. Place the bladder of the cuff over the posterior aspect of the
thigh.
Rationale: When obtaining a thigh blood pressure, the cuff bladder should be
centered over the posterior aspect of the thigh so it lies directly over the femoral
artery. Proper cuff placement ensures accurate compression of the artery and
reliable blood pressure measurements, while incorrect positioning may result in
inaccurate or falsely elevated readings.
3. A charge nurse is teaching a group of newly licensed nurses the current
guidelines for performing adult cardiopulmonary resuscitation (CPR). During
the class, the charge nurse presents a scenario involving an adult client who
suddenly collapses and appears motionless. Before initiating any additional
interventions, the nurses must identify the first appropriate action. Which of
the following actions should the charge nurse teach as the initial response in
CPR?
A. Call for assistance.
B. Begin chest compressions.
C. Confirm unresponsiveness.
D. Give rescue breaths.
Correct Answer: C. Confirm unresponsiveness.
Rationale: Confirming that the client is unresponsive is the first step in the adult
Basic Life Support (BLS) sequence because it establishes the need for emergency
intervention. Once unresponsiveness is verified, the nurse activates the emergency
response system, assesses breathing and pulse, and promptly begins chest
compressions if indicated to maximize survival.
4. A nurse is preparing a hospitalized client for transport to the radiology
department for a chest x-ray. Before the transporter arrives, the nurse
, completes the required safety checks to ensure the correct client receives the
prescribed diagnostic procedure. Which of the following actions should the
nurse take first?
A. Explain the x-ray procedure to the client.
B. Help the client into a wheelchair before the transporter arrives.
C. Ask if the client has any questions.
D. Identify the client using two identifiers.
Correct Answer: D. Identify the client using two identifiers.
Rationale: Correct client identification using two approved identifiers is the
highest priority before any diagnostic test or procedure because it prevents wrong-
patient errors and promotes client safety. Verifying identity before transport ensures
that all subsequent interventions, including education and preparation, are
performed for the correct individual.
5. A nurse is caring for a school-age child who is recovering after a tonsillectomy.
The child reports throat pain and is reluctant to swallow fluids because of
discomfort. The nurse plans postoperative interventions to promote comfort,
reduce complications, and encourage recovery. Which of the following actions
should the nurse take?
A. Encourage the child to cough frequently to clear congestion from anesthesia.
B. Place a heating pad at the child's neck for comfort.
C. Administer analgesics to the child on a routine schedule throughout the day and
night.
D. Provide the child with ice cream when oral intake is initiated.
Correct Answer: C. Administer analgesics to the child on a routine schedule
throughout the day and night.
Rationale: Scheduled administration of analgesics maintains consistent pain
control, allowing the child to swallow fluids more comfortably and decreasing the risk
of dehydration. Effective pain management also promotes healing, reduces anxiety
