1. A nurse is performing an initial assessment of a newly admitted
client. Which action should the nurse perform first?
A. Review the client's family history
B. Obtain a complete medication history
C. Determine the client's immediate physiologic stability
D. Ask the client about long-term health goals
Answer: C. Determine the client's immediate physiologic stability
Rationale: Initial assessment begins with identifying immediate
threats to airway, breathing, circulation, and overall physiologic
stability. Less urgent information can be obtained after immediate
safety concerns are addressed.
,2. Which finding is most concerning when assessing a client with
respiratory difficulty?
A. Respiratory rate of 22/min
B. Oxygen saturation of 89%
C. Productive cough
D. Mild nasal congestion
Answer: B. Oxygen saturation of 89%
Rationale: An oxygen saturation of 89% indicates impaired
oxygenation and requires prompt assessment and intervention,
particularly when accompanied by respiratory distress.
3. A nurse wants to obtain subjective data. Which question is most
appropriate?
A. "Your blood pressure is elevated, isn't it?"
B. "What pain level are you experiencing?"
C. "Your skin appears pale."
D. "Your temperature is 38.2°C."
Answer: B. "What pain level are you experiencing?"
Rationale: Subjective data are information reported by the client, such
as pain, symptoms, feelings, and perceptions.
,4. Which assessment technique should the nurse use first when
examining the abdomen?
A. Palpation
B. Percussion
C. Auscultation
D. Inspection
Answer: D. Inspection
Rationale: Abdominal assessment follows inspection, auscultation,
percussion, and palpation. Palpation and percussion can alter bowel
sounds, so auscultation occurs before them.
5. A client reports sudden severe chest pressure accompanied by
diaphoresis. What should the nurse do first?
A. Encourage the client to ambulate
B. Obtain a complete dietary history
C. Assess vital signs and overall stability
D. Ask about the client's childhood illnesses
Answer: C. Assess vital signs and overall stability
, Rationale: Sudden severe chest pressure may indicate an acute
cardiovascular emergency. Immediate assessment of physiologic
stability is a priority.
6. Which finding represents objective data?
A. "I feel dizzy."
B. "My stomach hurts."
C. Blood pressure of 168/94 mmHg
D. "I feel anxious."
Answer: C. Blood pressure of 168/94 mmHg
Rationale: Objective data are measurable or observable findings
obtained through physical examination, monitoring, or diagnostic
testing.
7. A nurse is assessing pain in an adult client. Which approach
provides the most reliable initial pain assessment?
A. Observe facial expression only
B. Ask the client to describe the pain
C. Ask the family to estimate the pain
D. Assume pain is mild if vital signs are normal
client. Which action should the nurse perform first?
A. Review the client's family history
B. Obtain a complete medication history
C. Determine the client's immediate physiologic stability
D. Ask the client about long-term health goals
Answer: C. Determine the client's immediate physiologic stability
Rationale: Initial assessment begins with identifying immediate
threats to airway, breathing, circulation, and overall physiologic
stability. Less urgent information can be obtained after immediate
safety concerns are addressed.
,2. Which finding is most concerning when assessing a client with
respiratory difficulty?
A. Respiratory rate of 22/min
B. Oxygen saturation of 89%
C. Productive cough
D. Mild nasal congestion
Answer: B. Oxygen saturation of 89%
Rationale: An oxygen saturation of 89% indicates impaired
oxygenation and requires prompt assessment and intervention,
particularly when accompanied by respiratory distress.
3. A nurse wants to obtain subjective data. Which question is most
appropriate?
A. "Your blood pressure is elevated, isn't it?"
B. "What pain level are you experiencing?"
C. "Your skin appears pale."
D. "Your temperature is 38.2°C."
Answer: B. "What pain level are you experiencing?"
Rationale: Subjective data are information reported by the client, such
as pain, symptoms, feelings, and perceptions.
,4. Which assessment technique should the nurse use first when
examining the abdomen?
A. Palpation
B. Percussion
C. Auscultation
D. Inspection
Answer: D. Inspection
Rationale: Abdominal assessment follows inspection, auscultation,
percussion, and palpation. Palpation and percussion can alter bowel
sounds, so auscultation occurs before them.
5. A client reports sudden severe chest pressure accompanied by
diaphoresis. What should the nurse do first?
A. Encourage the client to ambulate
B. Obtain a complete dietary history
C. Assess vital signs and overall stability
D. Ask about the client's childhood illnesses
Answer: C. Assess vital signs and overall stability
, Rationale: Sudden severe chest pressure may indicate an acute
cardiovascular emergency. Immediate assessment of physiologic
stability is a priority.
6. Which finding represents objective data?
A. "I feel dizzy."
B. "My stomach hurts."
C. Blood pressure of 168/94 mmHg
D. "I feel anxious."
Answer: C. Blood pressure of 168/94 mmHg
Rationale: Objective data are measurable or observable findings
obtained through physical examination, monitoring, or diagnostic
testing.
7. A nurse is assessing pain in an adult client. Which approach
provides the most reliable initial pain assessment?
A. Observe facial expression only
B. Ask the client to describe the pain
C. Ask the family to estimate the pain
D. Assume pain is mild if vital signs are normal
