TNCC Physical Assessment Question And Answers
Updated 2024
The nurse is providing care for a patient scheduled for surgery to amputate gangrenous toes from the
left foot. During the shift assessment, the nurse checks pedal pulses, skin color and warmth, and the
level of pain. Which finding would prompt the nurse to perform an additional assessment?
The patient's right lower leg and ankle are swollen.
The nurse is caring for a patient who returned 2 hr ago following throat surgery. Which focused
assessment finding will cause the greatest concern for the nurse?
Frequent swallowing movements.
The nurse is reassessing a patient's abdomen. Which reason is correct as to why the nurse alters the
normal order of physical assessment techniques?
Palpation of the abdomen before auscultation will alter bowel sounds.
The licensed practical nurse/licensed vocational nurse (LPN/LVN) reviews the registered nurse's (RN's)
assessment notes on a newly admitted patient. For which assessment finding will the LPN/LVN need
in order to acquire clarification from the RN?
The level of pain voiced by the patient during abdominal palpation.
The licensed practical nurse/licensed vocational nurse (LPN/LVN) accompanies the health-care
provider who is physically assessing a patient. Which assessment information does the nurse
understand the health-care provider acquires with the use of percussion?
The location and size of organs within the body.
. The nurse is assigned to care for a patient who is hospitalized. Which patient finding did the nurse
most likely find with the use of a stethoscope?
Carotid bruit.
The nurse is reassessing a patient's apical pulse prior to the administration of cardiac medication.
Which action by the nurse is inappropriate?
Listening to the posterior aspect of the thoracic cavity
The nurse is working in a clinic that focuses on the care of patients with respiratory conditions. Which
adventitious breath sounds will the nurse recognize as causing the concern? Select all that apply.
.
Rhonchi that sounds like snoring and gurgling.
Stridor present in a toddler in the emergency room.
The nurse is working in a clinic that focuses on the care of patients with respiratory conditions. Which
adventitious breath sounds will the nurse recognize as causing the concern? Select all that apply.
, Stridor present in a toddler in the emergency room.
The nurse works in the newborn nursery. In which order will the nurse perform the task of obtaining a
newborn's weight and height? Place the options in the correct order. All options must be used.
1,5,4,2,3
Which of the following may cause cheilitis? Select all that apply
wind chapping
sun exposure
anaphlaxysis
The nurse is preparing to review the physical assessment performed on a newly admitted patient.
Which purpose of the physical assessment will the nurse identify as inaccurate?
It provides guidelines for decisions about medical treatment.
The new graduate nurse states, "I am always fearful that I will forget part of the physical assessment
process." Which assistance does the experienced nurse provide?
"Start at the top and move downward to the toes, then do the arms and legs."
. The nurse in an adult clinic is assessing a patient who just arrived. Which assessment of the patient's
general appearance indicates physical distress?
Breathing through the mouth
The nurse is reassessing a patient. The nurse begins assessment at the patient's head and neck. Which
action does the nurse perform first?
Checks the patient's skin color
The nurse enters a patient's room and discovers the patient sitting on the side of the bed and leaning
forward over the bedside table. Which condition does the nurse associate with the patient's position?
Orthopnea.
The nurse is reassessing a patient admitted to the hospital. When inspecting the patient's mouth, the
nurse notes that the patient has no teeth. The patient states, "I have dentures but they hurt my
mouth so I didn't even bring them." Which action should the nurse take?
Seek an order for a mechanically soft diet.
The nurse is preparing to reassess a patient's neurological status. Which reason is why the nurse
verbally explains the assessment process to a patient who is comatose?
The sense of hearing may still be present.
The nurse is performing a focused assessment at the beginning of the shift on a patient diagnosed
with pneumonia. Which patient assessment is least informative for the nurse?
Skin color and warmth.
Updated 2024
The nurse is providing care for a patient scheduled for surgery to amputate gangrenous toes from the
left foot. During the shift assessment, the nurse checks pedal pulses, skin color and warmth, and the
level of pain. Which finding would prompt the nurse to perform an additional assessment?
The patient's right lower leg and ankle are swollen.
The nurse is caring for a patient who returned 2 hr ago following throat surgery. Which focused
assessment finding will cause the greatest concern for the nurse?
Frequent swallowing movements.
The nurse is reassessing a patient's abdomen. Which reason is correct as to why the nurse alters the
normal order of physical assessment techniques?
Palpation of the abdomen before auscultation will alter bowel sounds.
The licensed practical nurse/licensed vocational nurse (LPN/LVN) reviews the registered nurse's (RN's)
assessment notes on a newly admitted patient. For which assessment finding will the LPN/LVN need
in order to acquire clarification from the RN?
The level of pain voiced by the patient during abdominal palpation.
The licensed practical nurse/licensed vocational nurse (LPN/LVN) accompanies the health-care
provider who is physically assessing a patient. Which assessment information does the nurse
understand the health-care provider acquires with the use of percussion?
The location and size of organs within the body.
. The nurse is assigned to care for a patient who is hospitalized. Which patient finding did the nurse
most likely find with the use of a stethoscope?
Carotid bruit.
The nurse is reassessing a patient's apical pulse prior to the administration of cardiac medication.
Which action by the nurse is inappropriate?
Listening to the posterior aspect of the thoracic cavity
The nurse is working in a clinic that focuses on the care of patients with respiratory conditions. Which
adventitious breath sounds will the nurse recognize as causing the concern? Select all that apply.
.
Rhonchi that sounds like snoring and gurgling.
Stridor present in a toddler in the emergency room.
The nurse is working in a clinic that focuses on the care of patients with respiratory conditions. Which
adventitious breath sounds will the nurse recognize as causing the concern? Select all that apply.
, Stridor present in a toddler in the emergency room.
The nurse works in the newborn nursery. In which order will the nurse perform the task of obtaining a
newborn's weight and height? Place the options in the correct order. All options must be used.
1,5,4,2,3
Which of the following may cause cheilitis? Select all that apply
wind chapping
sun exposure
anaphlaxysis
The nurse is preparing to review the physical assessment performed on a newly admitted patient.
Which purpose of the physical assessment will the nurse identify as inaccurate?
It provides guidelines for decisions about medical treatment.
The new graduate nurse states, "I am always fearful that I will forget part of the physical assessment
process." Which assistance does the experienced nurse provide?
"Start at the top and move downward to the toes, then do the arms and legs."
. The nurse in an adult clinic is assessing a patient who just arrived. Which assessment of the patient's
general appearance indicates physical distress?
Breathing through the mouth
The nurse is reassessing a patient. The nurse begins assessment at the patient's head and neck. Which
action does the nurse perform first?
Checks the patient's skin color
The nurse enters a patient's room and discovers the patient sitting on the side of the bed and leaning
forward over the bedside table. Which condition does the nurse associate with the patient's position?
Orthopnea.
The nurse is reassessing a patient admitted to the hospital. When inspecting the patient's mouth, the
nurse notes that the patient has no teeth. The patient states, "I have dentures but they hurt my
mouth so I didn't even bring them." Which action should the nurse take?
Seek an order for a mechanically soft diet.
The nurse is preparing to reassess a patient's neurological status. Which reason is why the nurse
verbally explains the assessment process to a patient who is comatose?
The sense of hearing may still be present.
The nurse is performing a focused assessment at the beginning of the shift on a patient diagnosed
with pneumonia. Which patient assessment is least informative for the nurse?
Skin color and warmth.
