Signs, Pulse & Apical-Radial Correlation, Blood
Pressure Measurement, Cuff Size & Placement,
Respiratory Assessment, Lung Sounds,
Diaphragmatic Excursion, Oxygen Saturation, Skin
& Nail Bed Perfusion, Peripheral Pulses, Edema
Assessment, Abdominal Inspection, Auscultation &
Palpation, Neuromuscular Evaluation, Muscle
Strength Testing, Posture & Spine Alignment, Eye
& Pupil Assessment, Skin Lesion Identification,
Temperature Measurement, Intake & Output
Documentation, Pain Assessment, Fall Risk
Evaluation, Cardiopulmonary Monitoring Exam
Questions Verified and Complete with A+ Graded
Rationales Latest Updated 2026
1. The nurse admits the patient with mild chest pain from the emergency department. Which
should the nurse implement first to gain patient cooperation during a physical assessment?
a.Explain the procedure and its purpose.
b.Perform assessment in stages over the day.
c.Complete assessment within 3 to 5 minutes.
d.Assess painful areas before nontender areas.
a.Explain the procedure and its purpose.
First and foremost, the nurse should explain the procedure and its purpose.
The patient is more likely to cooperate during a physical assessment if he or she knows what to
expect and what the purpose of the procedure is. The nurse explains how the information is
used to plan individualized nursing care.
The information helps make the patient feel valued and important because the nurse engages
him or her in the plan of care. In addition, the nurse reassures the patient about maintaining
,privacy.
The nurse completes the assessment in as few stages as possible because he or she needs the
assessment data to plan care.
While the nurse will assesses painful and tender areas first because if pain is triggered, the
nurse would want to stop the assessment and provide pain management, explaining the
procedure should precede any assessment.
Assessment data are vital to manage pain successfully.
2. The nurse assesses a patient with light skin and observes normally shaped nail beds exhibiting
pallor and a slight bluish color. Which should the nurse implement?
a.Provide a warm heating pad.
b.Collaborate with the healthcare provider.
c.Assess patient oxygen saturation.
d.Check for restricted venous return.
c.Assess patient oxygen saturation.
Capillary refill less than 3 secs
Nail beds in a patient with light skin are a view of the patient's capillary bed at the periphery.
Pallor and a bluish color in the capillary bed indicate inadequate oxygenation because
oxygenated blood is dark red resulting in pink nail beds.
Generally application of heat and cold requires a prescription from a healthcare provider;
moreover, the nurse needs to assess the patient and gather related data before being able to
decide that warmth is indicated.
The nurse needs to complete the assessment first, as long as the patient is in no immediate
danger or experiencing distress, and to think critically before collaboration.
If collaboration with the provider becomes necessary, the nurse presents a complete patient
assessment.
, Restricted venous return usually leads to edema; severe peripheral edema leads to pallor; and
cyanosis potentially occurs but is not common.
3. The nurse is performing a neurological assessment. Which patient behaviors demonstrate a
level of consciousness within normal limits?
a.States name, age, and date but not location
b.Is lethargic; responds logically to questions
c.Responds verbally, but words are unintelligible
d.Responds to questions spontaneously; is alert and oriented
d.Responds to questions spontaneously; is alert and oriented
The patient who responds to questions spontaneously and is alert and oriented exhibits
neurological findings that are within normal limits.
*Orientated to
· 1: person
· 2: person, place
· 3: person, place, and time
· 4: person, place, time and purpose
The patient is conscious, responds to the environment, and has congruent thought processes.
The patient who does not know the location is disoriented to place.
Lethargy is not a normal finding despite correct responses.
Unintelligible speech is abnormal.
4. How often should the nurse perform a general assessment of the patient?
a.At least every 4 hours
b.As often as it is needed
c.When the patient requests it
d.At the rate set by agency policy
b.As often as it is needed
The nurse performs a general assessment at the beginning of the shift and as often as needed
afterward; however, the nurse frequently performs a focused assessment to make clinical