1
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Table of Contents
1. Assessment
2. Caring Interventions
3. Comfort
4. Elimination
5. Fluids and Electrolytes
6. Infection
7. Intracranial Regulation
8. Metabolism
9. Mobility
10. Nutrition
11. Oxygenation
12. Perfusion
13. Perioperative Care
14. Reproduction
15. Safety
16. Tissue Integrity
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Chapter 1: Assessment
Question 1
A nurse is conducting a comprehensive health assessment on a new patient. The
nurse’s primary focus during the health history should be:
A) Understanding the patient’s mental health history
B) Identifying the patient's risk factors for chronic diseases
C) Gathering information on the patient’s chief complaint
D) Assessing the patient’s physical appearance and body systems
✅ Correct Answer: C) Gathering information on the patient’s chief complaint
Rationale: The health history is primarily aimed at obtaining detailed information
about the patient's current health problem or chief complaint, which serves as the
foundation for identifying further problems and guiding the clinical assessment.
This information helps to formulate the nursing diagnosis. While understanding
mental health and risk factors is important, it is not the central focus of the health
history.
DIF: Applying
TOP: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity – Physiological
Adaptation
Question 2
During a physical assessment, a nurse asks a patient to describe a lump in the left
breast. Which of the following assessment techniques is the nurse using?
A) Inspection
B) Palpation
C) Auscultation
D) Percussion
✅ Correct Answer: B) Palpation
Rationale: Palpation is the process of using the hands to assess the size, shape, and
tenderness of an area, such as a lump. It is a critical technique for gathering tactile
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data during the physical assessment. Inspection refers to visually examining the
body, while auscultation is listening to body sounds, and percussion involves
tapping to detect abnormalities in underlying structures.
DIF: Remembering
TOP: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity – Basic Care and
Comfort
Question 3
Which of the following is the most accurate approach for a nurse to take when
conducting a cultural assessment with a patient from a different cultural
background?
A) Using an interpreter to translate the patient’s responses
B) Making assumptions about the patient’s preferences based on cultural
stereotypes
C) Asking the patient directly about their cultural practices and preferences
D) Relying on the family to provide information about the patient's culture
✅ Correct Answer: C) Asking the patient directly about their cultural
practices and preferences
Rationale: It is important to approach cultural assessment with an open and
nonjudgmental attitude. Asking the patient directly respects their autonomy and
ensures that the nurse gathers accurate and individualized information. Using an
interpreter can be helpful but does not replace direct communication. Avoiding
assumptions and stereotypes is crucial to prevent bias in care.
DIF: Applying
TOP: Cultural Assessment
MSC: NCLEX Client Needs Category: Psychosocial Integrity
Question 4
A nurse is conducting a mental health assessment. Which question would be most
appropriate to assess a patient’s level of orientation?
A) “Can you tell me where you are right now?”
B) “What was the reason for your visit today?”
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C) “Do you have a history of mental illness in your family?”
D) “Have you experienced any changes in your sleep patterns recently?”
✅ Correct Answer: A) “Can you tell me where you are right now?”
Rationale: Asking the patient about their location helps to assess their orientation
to time, place, and person, which are essential aspects of mental status. This
question directly evaluates the patient’s ability to recognize their environment. The
other questions focus on health history or symptoms, not orientation.
DIF: Applying
TOP: Assessment
MSC: NCLEX Client Needs Category: Psychosocial Integrity
Question 5
A nurse is performing a skin assessment and notices a new lesion that is
asymmetrical with irregular borders and multiple colors. Based on these findings,
the nurse should:
A) Document the lesion as a normal age-related finding
B) Monitor the lesion for a few weeks and report any changes
C) Perform a biopsy immediately to confirm the diagnosis
D) Refer the patient to a healthcare provider for further evaluation
✅ Correct Answer: D) Refer the patient to a healthcare provider for further
evaluation
Rationale: The described lesion exhibits characteristics that are concerning for
melanoma, such as asymmetry, irregular borders, and multiple colors. These
features require prompt referral to a healthcare provider for further evaluation and
potential biopsy. Monitoring or waiting for changes may delay necessary
intervention, which could be critical in diagnosing skin cancer.
DIF: Applying
TOP: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity – Reduction of
Risk Potential
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Question 6
During a nutritional assessment, a nurse identifies that the patient’s diet lacks
sufficient protein. What is the nurse’s next priority action?
A) Recommend a high-protein supplement without further assessment
B) Ask the patient about the frequency of their physical activity
C) Inquire about the patient’s food preferences and allergies
D) Provide written educational materials on the importance of protein
✅ Correct Answer: C)Inquire about the patient’s food preferences and
allergies
Rationale: It is essential to understand the patient’s food preferences and allergies
before recommending any changes to their diet. This ensures that the nurse
provides a culturally appropriate and safe plan for dietary improvement. Jumping
straight to supplements or education without fully assessing the patient's needs may
not be effective or feasible.
DIF: Applying
TOP: Nutrition Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity – Basic Care and
Comfort
Question 7
A nurse is assessing the respiratory rate of a patient with chronic obstructive
pulmonary disease (COPD). Which of the following findings would be considered
abnormal?
A) Respiratory rate of 18 breaths per minute
B) Respiratory rate of 26 breaths per minute
C) Respiratory rate of 12 breaths per minute
D) Respiratory rate of 14 breaths per minute
✅ Correct Answer: B) Respiratory rate of 26 breaths per minute
Rationale: A respiratory rate of 26 breaths per minute is considered tachypnea
(rapid breathing) and indicates possible respiratory distress or worsening COPD.
The normal respiratory rate for an adult is 12–20 breaths per minute. Rates higher
than 20 may indicate respiratory problems, while rates below 12 could suggest
inadequate breathing.
DIF: Analyzing
TOP: Assessment
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MSC: NCLEX Client Needs Category: Physiological Integrity – Physiological
Adaptation
Question 8
A nurse is assessing a patient’s level of consciousness using the Glasgow Coma
Scale (GCS). The patient responds with incomprehensible sounds, but they are not
able to follow commands or make meaningful speech. How should the nurse score
this patient on the GCS?
A) 5
B) 7
C) 9
D) 10
✅ Correct Answer: B) 7
Rationale: The GCS measures eye, verbal, and motor responses. A score of 7
indicates a severe impairment of consciousness. In this case, the patient has no
meaningful speech or response to commands, which suggests a GCS score in the
range of 6-8. The motor response would likely be localizing or abnormal flexion,
adding up to a score of 7.
DIF: Applying
TOP: Assessment
MSC: NCLEX Client Needs Category: Safe and Effective Care Environment –
Management of Care
Question 9
Which of the following actions is the nurse’s priority when performing an
abdominal assessment on a patient?
A) Inspect the abdomen for any visible masses
B) Auscultate the abdomen for bowel sounds before palpation
C) Palpate the abdomen lightly to identify areas of tenderness
D) Percuss the abdomen to check for fluid retention
✅ Correct Answer: B) Auscultate the abdomen for bowel sounds before
palpation
Rationale: The nurse should always auscultate before palpating or percussing the
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Table of Contents
1. Assessment
2. Caring Interventions
3. Comfort
4. Elimination
5. Fluids and Electrolytes
6. Infection
7. Intracranial Regulation
8. Metabolism
9. Mobility
10. Nutrition
11. Oxygenation
12. Perfusion
13. Perioperative Care
14. Reproduction
15. Safety
16. Tissue Integrity
, 3
Chapter 1: Assessment
Question 1
A nurse is conducting a comprehensive health assessment on a new patient. The
nurse’s primary focus during the health history should be:
A) Understanding the patient’s mental health history
B) Identifying the patient's risk factors for chronic diseases
C) Gathering information on the patient’s chief complaint
D) Assessing the patient’s physical appearance and body systems
✅ Correct Answer: C) Gathering information on the patient’s chief complaint
Rationale: The health history is primarily aimed at obtaining detailed information
about the patient's current health problem or chief complaint, which serves as the
foundation for identifying further problems and guiding the clinical assessment.
This information helps to formulate the nursing diagnosis. While understanding
mental health and risk factors is important, it is not the central focus of the health
history.
DIF: Applying
TOP: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity – Physiological
Adaptation
Question 2
During a physical assessment, a nurse asks a patient to describe a lump in the left
breast. Which of the following assessment techniques is the nurse using?
A) Inspection
B) Palpation
C) Auscultation
D) Percussion
✅ Correct Answer: B) Palpation
Rationale: Palpation is the process of using the hands to assess the size, shape, and
tenderness of an area, such as a lump. It is a critical technique for gathering tactile
, 4
data during the physical assessment. Inspection refers to visually examining the
body, while auscultation is listening to body sounds, and percussion involves
tapping to detect abnormalities in underlying structures.
DIF: Remembering
TOP: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity – Basic Care and
Comfort
Question 3
Which of the following is the most accurate approach for a nurse to take when
conducting a cultural assessment with a patient from a different cultural
background?
A) Using an interpreter to translate the patient’s responses
B) Making assumptions about the patient’s preferences based on cultural
stereotypes
C) Asking the patient directly about their cultural practices and preferences
D) Relying on the family to provide information about the patient's culture
✅ Correct Answer: C) Asking the patient directly about their cultural
practices and preferences
Rationale: It is important to approach cultural assessment with an open and
nonjudgmental attitude. Asking the patient directly respects their autonomy and
ensures that the nurse gathers accurate and individualized information. Using an
interpreter can be helpful but does not replace direct communication. Avoiding
assumptions and stereotypes is crucial to prevent bias in care.
DIF: Applying
TOP: Cultural Assessment
MSC: NCLEX Client Needs Category: Psychosocial Integrity
Question 4
A nurse is conducting a mental health assessment. Which question would be most
appropriate to assess a patient’s level of orientation?
A) “Can you tell me where you are right now?”
B) “What was the reason for your visit today?”
, 5
C) “Do you have a history of mental illness in your family?”
D) “Have you experienced any changes in your sleep patterns recently?”
✅ Correct Answer: A) “Can you tell me where you are right now?”
Rationale: Asking the patient about their location helps to assess their orientation
to time, place, and person, which are essential aspects of mental status. This
question directly evaluates the patient’s ability to recognize their environment. The
other questions focus on health history or symptoms, not orientation.
DIF: Applying
TOP: Assessment
MSC: NCLEX Client Needs Category: Psychosocial Integrity
Question 5
A nurse is performing a skin assessment and notices a new lesion that is
asymmetrical with irregular borders and multiple colors. Based on these findings,
the nurse should:
A) Document the lesion as a normal age-related finding
B) Monitor the lesion for a few weeks and report any changes
C) Perform a biopsy immediately to confirm the diagnosis
D) Refer the patient to a healthcare provider for further evaluation
✅ Correct Answer: D) Refer the patient to a healthcare provider for further
evaluation
Rationale: The described lesion exhibits characteristics that are concerning for
melanoma, such as asymmetry, irregular borders, and multiple colors. These
features require prompt referral to a healthcare provider for further evaluation and
potential biopsy. Monitoring or waiting for changes may delay necessary
intervention, which could be critical in diagnosing skin cancer.
DIF: Applying
TOP: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity – Reduction of
Risk Potential
, 6
Question 6
During a nutritional assessment, a nurse identifies that the patient’s diet lacks
sufficient protein. What is the nurse’s next priority action?
A) Recommend a high-protein supplement without further assessment
B) Ask the patient about the frequency of their physical activity
C) Inquire about the patient’s food preferences and allergies
D) Provide written educational materials on the importance of protein
✅ Correct Answer: C)Inquire about the patient’s food preferences and
allergies
Rationale: It is essential to understand the patient’s food preferences and allergies
before recommending any changes to their diet. This ensures that the nurse
provides a culturally appropriate and safe plan for dietary improvement. Jumping
straight to supplements or education without fully assessing the patient's needs may
not be effective or feasible.
DIF: Applying
TOP: Nutrition Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity – Basic Care and
Comfort
Question 7
A nurse is assessing the respiratory rate of a patient with chronic obstructive
pulmonary disease (COPD). Which of the following findings would be considered
abnormal?
A) Respiratory rate of 18 breaths per minute
B) Respiratory rate of 26 breaths per minute
C) Respiratory rate of 12 breaths per minute
D) Respiratory rate of 14 breaths per minute
✅ Correct Answer: B) Respiratory rate of 26 breaths per minute
Rationale: A respiratory rate of 26 breaths per minute is considered tachypnea
(rapid breathing) and indicates possible respiratory distress or worsening COPD.
The normal respiratory rate for an adult is 12–20 breaths per minute. Rates higher
than 20 may indicate respiratory problems, while rates below 12 could suggest
inadequate breathing.
DIF: Analyzing
TOP: Assessment
, 7
MSC: NCLEX Client Needs Category: Physiological Integrity – Physiological
Adaptation
Question 8
A nurse is assessing a patient’s level of consciousness using the Glasgow Coma
Scale (GCS). The patient responds with incomprehensible sounds, but they are not
able to follow commands or make meaningful speech. How should the nurse score
this patient on the GCS?
A) 5
B) 7
C) 9
D) 10
✅ Correct Answer: B) 7
Rationale: The GCS measures eye, verbal, and motor responses. A score of 7
indicates a severe impairment of consciousness. In this case, the patient has no
meaningful speech or response to commands, which suggests a GCS score in the
range of 6-8. The motor response would likely be localizing or abnormal flexion,
adding up to a score of 7.
DIF: Applying
TOP: Assessment
MSC: NCLEX Client Needs Category: Safe and Effective Care Environment –
Management of Care
Question 9
Which of the following actions is the nurse’s priority when performing an
abdominal assessment on a patient?
A) Inspect the abdomen for any visible masses
B) Auscultate the abdomen for bowel sounds before palpation
C) Palpate the abdomen lightly to identify areas of tenderness
D) Percuss the abdomen to check for fluid retention
✅ Correct Answer: B) Auscultate the abdomen for bowel sounds before
palpation
Rationale: The nurse should always auscultate before palpating or percussing the
