Nightingale College BSN 246 RN Health Assessment Final
Exam Practice Test (2025–2027) Complete: Original
NCLEX-Style Questions with Verified Answers and Detailed
Rationale
Question 1
A registered nurse begins a comprehensive health assessment on a newly admitted adult
patient. Which action should the nurse perform first to establish a therapeutic relationship
and obtain accurate assessment data?
A. Perform the physical examination immediately.
B. Explain the purpose of the assessment, introduce themselves, and ensure privacy.
C. Review laboratory results before speaking with the patient.
D. Ask the patient to change into a hospital gown before asking questions.
Answer: B
Rationale: Establishing rapport is the first step of a successful health assessment.
Introducing yourself, explaining the assessment, obtaining consent, and ensuring privacy
promote trust and encourage honest communication before collecting subjective and
objective data.
Question 2
,During a health history interview, a patient repeatedly provides vague answers. Which
communication technique should the nurse use to encourage the patient to provide
additional information?
A. Asking leading questions
B. Using open-ended questions
C. Interrupting to clarify every response
D. Asking multiple questions simultaneously
Answer: B
Rationale: Open-ended questions encourage patients to describe symptoms and concerns
in their own words, resulting in more complete and accurate assessment information.
Question 3
A nurse is assessing an adult patient's temperature using the tympanic route. Which finding
would most likely require confirmation using another assessment method?
A. Temperature of 98.6°F (37°C)
B. Temperature of 100.4°F (38°C) after exercise
C. Temperature of 95.4°F (35.2°C) in a patient wearing hearing aids
D. Temperature of 99.1°F (37.3°C)
Answer: C
Rationale: Tympanic temperatures may be inaccurate if the probe is improperly positioned
or if ear anatomy interferes with measurement. Unexpected hypothermia should always be
confirmed using another reliable route.
,Question 4
While obtaining a patient's blood pressure manually, the nurse notices repetitive tapping
sounds after the cuff pressure is released. The appearance of the first tapping sound
represents which measurement?
A. Mean arterial pressure
B. Pulse pressure
C. Systolic blood pressure
D. Diastolic blood pressure
Answer: C
Rationale: The first Korotkoff sound indicates systolic blood pressure, while the
disappearance of the sounds represents diastolic blood pressure.
Question 5
A patient reports chest discomfort during the health history interview. Which assessment
framework should the nurse use to comprehensively evaluate the symptom?
A. Glasgow Coma Scale
B. OLDCARTS assessment
C. Braden Scale
D. Morse Fall Scale
Answer: B
, Rationale: OLDCARTS (Onset, Location, Duration, Characteristics, Aggravating factors,
Relieving factors, Timing, Severity) provides a systematic method for assessing symptoms.
Question 6
Which assessment finding should the nurse identify as a normal age-related change in an
older adult?
A. Complete loss of peripheral pulses
B. Decreased skin elasticity and increased wrinkling
C. Bilateral crackles in the lungs
D. Fixed dilated pupils
Answer: B
Rationale: Aging naturally decreases collagen and elastin, causing thinner skin, wrinkles,
and decreased elasticity.
Question 7
A nurse inspects a patient's skin and observes localized redness that does not blanch when
pressure is applied. How should this finding be documented?
A. Stage I pressure injury
B. Stage II pressure injury
C. Stage III pressure injury
D. Normal erythema
Exam Practice Test (2025–2027) Complete: Original
NCLEX-Style Questions with Verified Answers and Detailed
Rationale
Question 1
A registered nurse begins a comprehensive health assessment on a newly admitted adult
patient. Which action should the nurse perform first to establish a therapeutic relationship
and obtain accurate assessment data?
A. Perform the physical examination immediately.
B. Explain the purpose of the assessment, introduce themselves, and ensure privacy.
C. Review laboratory results before speaking with the patient.
D. Ask the patient to change into a hospital gown before asking questions.
Answer: B
Rationale: Establishing rapport is the first step of a successful health assessment.
Introducing yourself, explaining the assessment, obtaining consent, and ensuring privacy
promote trust and encourage honest communication before collecting subjective and
objective data.
Question 2
,During a health history interview, a patient repeatedly provides vague answers. Which
communication technique should the nurse use to encourage the patient to provide
additional information?
A. Asking leading questions
B. Using open-ended questions
C. Interrupting to clarify every response
D. Asking multiple questions simultaneously
Answer: B
Rationale: Open-ended questions encourage patients to describe symptoms and concerns
in their own words, resulting in more complete and accurate assessment information.
Question 3
A nurse is assessing an adult patient's temperature using the tympanic route. Which finding
would most likely require confirmation using another assessment method?
A. Temperature of 98.6°F (37°C)
B. Temperature of 100.4°F (38°C) after exercise
C. Temperature of 95.4°F (35.2°C) in a patient wearing hearing aids
D. Temperature of 99.1°F (37.3°C)
Answer: C
Rationale: Tympanic temperatures may be inaccurate if the probe is improperly positioned
or if ear anatomy interferes with measurement. Unexpected hypothermia should always be
confirmed using another reliable route.
,Question 4
While obtaining a patient's blood pressure manually, the nurse notices repetitive tapping
sounds after the cuff pressure is released. The appearance of the first tapping sound
represents which measurement?
A. Mean arterial pressure
B. Pulse pressure
C. Systolic blood pressure
D. Diastolic blood pressure
Answer: C
Rationale: The first Korotkoff sound indicates systolic blood pressure, while the
disappearance of the sounds represents diastolic blood pressure.
Question 5
A patient reports chest discomfort during the health history interview. Which assessment
framework should the nurse use to comprehensively evaluate the symptom?
A. Glasgow Coma Scale
B. OLDCARTS assessment
C. Braden Scale
D. Morse Fall Scale
Answer: B
, Rationale: OLDCARTS (Onset, Location, Duration, Characteristics, Aggravating factors,
Relieving factors, Timing, Severity) provides a systematic method for assessing symptoms.
Question 6
Which assessment finding should the nurse identify as a normal age-related change in an
older adult?
A. Complete loss of peripheral pulses
B. Decreased skin elasticity and increased wrinkling
C. Bilateral crackles in the lungs
D. Fixed dilated pupils
Answer: B
Rationale: Aging naturally decreases collagen and elastin, causing thinner skin, wrinkles,
and decreased elasticity.
Question 7
A nurse inspects a patient's skin and observes localized redness that does not blanch when
pressure is applied. How should this finding be documented?
A. Stage I pressure injury
B. Stage II pressure injury
C. Stage III pressure injury
D. Normal erythema
