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Questions 1–200
1. Which of the following is an example of subjective data?
A) Blood pressure 120/80 mmHg
B) Heart rate 72 bpm
C) Patient reports severe headache
D) Skin is warm and dry
Answer C: Patient reports severe headache
Rationale: Subjective data is information reported by the patient and cannot be directly measured.
2. The nurse is performing a physical assessment on a newly admitted patient. Which assessment
should be performed first?
A) Palpation
B) Percussion
C) Inspection
D) Auscultation
Answer C: Inspection
Rationale: Inspection is always performed first during a physical examination.
3. During an abdominal assessment, in which order should the nurse perform the techniques?
A) Palpation, percussion, auscultation, inspection
B) Inspection, auscultation, percussion, palpation
C) Auscultation, inspection, palpation, percussion
D) Inspection, palpation, percussion, auscultation
Answer B: Inspection, auscultation, percussion, palpation
Rationale: Palpation and percussion can alter bowel sounds; perform them after auscultation.
,4. A patient tells the nurse that they have had a cough for three days. This information would be
documented as:
A) Subjective data
B) Objective data
C) Medical diagnosis
D) Nursing diagnosis
Answer A: Subjective data
Rationale: The patient's statement about their cough is subjective data reported by the patient.
5. The nurse notes that a patient has a temperature of 101.2°F (38.4°C). This is an example of:
A) Subjective data
B) Objective data
C) Assessment data
D) Plan data
Answer B: Objective data
Rationale: Objective data is measurable and observable, such as vital signs.
6. The nurse is performing a health history on an older adult. Which question best reflects the
functional assessment?
A) "What medications are you currently taking?"
B) "Are you able to bathe and dress yourself independently?"
C) "What allergies do you have?"
D) "When was your last physical exam?"
Answer B: "Are you able to bathe and dress yourself independently?"
Rationale: Functional assessment evaluates activities of daily living (ADLs).
7. A patient reports being of Hispanic descent and prefers to use herbal remedies. What action should
the nurse take?
A) Advise the patient to stop using herbal remedies
B) Assess the patient's beliefs and integrate them into the plan of care when possible
C) Report the patient to the healthcare provider
D) Ignore the patient's cultural preferences
Answer B: Assess the patient's beliefs and integrate them into the plan of care when possible
,Rationale: Culturally competent care respects and integrates patient beliefs into the care plan.
8. Which pulse site is most commonly used to assess heart rate in an adult?
A) Apical
B) Radial
C) Carotid
D) Femoral
Answer B: Radial
Rationale: The radial pulse is easily accessible and the most common site for pulse assessment.
9. The nurse is assessing a patient's blood pressure. The first sound heard during deflation of the cuff
corresponds to:
A) Diastolic pressure
B) Systolic pressure
C) Mean arterial pressure
D) Pulse pressure
Answer B: Systolic pressure
Rationale: The first Korotkoff sound indicates systolic blood pressure.
10. The nurse should palpate which artery when assessing a patient's blood pressure?
A) Radial artery
B) Brachial artery
C) Carotid artery
D) Femoral artery
Answer B: Brachial artery
Rationale: The brachial artery is palpated in the antecubital fossa for blood pressure measurement.
11. During a cardiac assessment, the nurse places the stethoscope at the fifth intercostal space at the
midclavicular line. This is the location of the:
A) Aortic valve area
B) Pulmonic valve area
C) Mitral valve (apex)
, D) Tricuspid valve area
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Answer C: Mitral valve (apex)
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Rationale: The mitral valve area is auscultated at the apex (5th ICS, MCL).
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12. The nurse is assessing a patient's lungs. Which lung sound is normal over the peripheral lung
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A) Bronchial
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B) Bronchovesicular
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C) Vesicular
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D) Tracheal
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Answer C: Vesicular j0 j0
Rationale: Vesicular breath sounds are soft, low-pitched sounds heard over peripheral lung fields.
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13. Crackles heard on lung auscultation are most commonly associated with which condition?
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A) Asthma
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B) Emphysema
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C) Pneumonia or pulmonary edema
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D) Pleural effusion
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Answer C: Pneumonia or pulmonary edema
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Rationale: Crackles indicate fluid in the alveoli, as seen in pneumonia and pulmonary edema.
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14. The nurse is assessing a patient with a history of heart failure. Which finding is most consistent
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A) Crackles in the lungs
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B) Peripheral edema and jugular venous distension
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C) Paroxysmal nocturnal dyspnea
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D) Orthopnea
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Answer B: Peripheral edema and jugular venous distension
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Rationale: Right-sided heart failure causes fluid backup into the venous system.
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15. The nurse should assess capillary refill on a patient with suspected peripheral vascular disease.
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