Explained Rationales | 2026 Latest Update | Instant Download PDF 200
Questions 1–200
1. Which of the following is an example of subjective data?
A) Blood pressure 120/80 mmHg
B) Heart rate 72 bpm
C) Patient reports severe headache
D) Skin is warm and dry
Answer C: Patient reports severe headache
Rationale: Subjective data is information reported by the patient and cannot
be directly measured.
2. The nurse is performing a physical assessment on a newly admitted
patient. Which assessment should be performed first?
,A) Palpation
B) Percussion
C) Inspection
D) Auscultation
Answer C: Inspection
Rationale: Inspection is always performed first during a physical examination.
3. During an abdominal assessment, in which order should the nurse
perform the techniques?
A) Palpation, percussion, auscultation, inspection
B) Inspection, auscultation, percussion, palpation
C) Auscultation, inspection, palpation, percussion
D) Inspection, palpation, percussion, auscultation
Answer B: Inspection, auscultation, percussion, palpation
Rationale: Palpation and percussion can alter bowel sounds; perform them
after auscultation.
4. A patient tells the nurse that they have had a cough for three days. This
information would be documented as:
A) Subjective data
B) Objective data
,C) Medical diagnosis
D) Nursing diagnosis
Answer A: Subjective data
Rationale: The patient's statement about their cough is subjective data
reported by the patient.
5. The nurse notes that a patient has a temperature of 101.2°F (38.4°C). This
is an example of:
A) Subjective data
B) Objective data
C) Assessment data
D) Plan data
Answer B: Objective data
Rationale: Objective data is measurable and observable, such as vital signs.
6. The nurse is performing a health history on an older adult. Which question
best reflects the functional assessment?
A) "What medications are you currently taking?"
B) "Are you able to bathe and dress yourself independently?"
C) "What allergies do you have?"
D) "When was your last physical exam?"
, Answer B: "Are you able to bathe and dress yourself independently?"
Rationale: Functional assessment evaluates activities of daily living (ADLs).
7. A patient reports being of Hispanic descent and prefers to use herbal
remedies. What action should the nurse take?
A) Advise the patient to stop using herbal remedies
B) Assess the patient's beliefs and integrate them into the plan of care when
possible
C) Report the patient to the healthcare provider
D) Ignore the patient's cultural preferences
Answer B: Assess the patient's beliefs and integrate them into the plan of
care when possible
Rationale: Culturally competent care respects and integrates patient beliefs
into the care plan.
8. Which pulse site is most commonly used to assess heart rate in an adult?
A) Apical
B) Radial
C) Carotid
D) Femoral
Answer B: Radial