Nursing 110 Exam one Review
Questions and Answers
The nurse is visiting the patient for the first time this shift. She introduces herself and asks the patient
several questions related to his condition. While doing so, and without being obvious, she is looking at
the color of his eyes and is assessing his ears and nose for discharge and the symmetry of his mouth.
Which assessment technique is the nurse using?
A: palpation
B: percussion
C: inspection
D: auscultation - Answer-C: inspection
The patient is admitted with fever and acute lower abdominal pain. He has taken tylenol but says he still
feels feverish. Before taking the patient's temperature, the nurse may:
A: touch the patients skin with the dorsal of her hand
B: touch the patients skin with the pads of her finger
C: palpate the skin using the bimanual method
D: touch the patients skin with the palmar side of her hand - Answer-A: touch the patients skin with the
dorsal of her hand
,What should the nurse do when preparing to complete an assessment for a 16 year old patient?
A: focus on the illness behaviors
B: plan for a diminished energy level
C: treat the patient as an individual
D: have the parents present throughout - Answer-C: treat the patient as an individual
The general survey begins with a review of the patient's primary health problems and an evaluation of
the patient's vital signs, height and weight, general behavior, and appearance. It also provides
information about the patient's illness, hygiene, skin condition, body image, and emotional state. Which
of the following cannot be delegated to nursing assistive personnel?
A: reporting subjectives signs and symptoms
B: measuring the patients height and weight
C: monitoring I&O
D: obtaining initial vital signs - Answer-D: obtaining initial vital signs
The nurse is preparing to examine a patient who has chronic lung disease. She realizes that the patient
most likely will need to be in which position for the examination?
A: high fowlers
B: supine
C: side-lying
D: prone - Answer-A: High fowlers
Nursing diagnoses meet specific criteria so they accurately reflect both the celints problem and the
possible etiology involved. Of the following statements, which one is an example of an appropriately
written nursing diagnosis?
A: cardiac output decreased related to motor vehicle accidents
B: potential for injury related to improper teaching in the use of crutches
,C: ineffective airway clearance related to increased secretions
D: risk for change in body image related to cancer - Answer-C: ineffective airway clearance related to
increased secretions
Where is the pulmonic area for auscultation found?
A: second intercostal space on the right side
B: second intercostal space on the left side
C: third intercostal space
D: fourth intercostal space along the sternum - Answer-B: second intercostal space on the left side
While performing a cardiovascular assessment on a patient with suspected left-sided congestive heart
failure, the nurse is unable to palpate the PMI with the patient lying supine. What might her next step
be?
A: have the patient turn onto his left side
B: have the patient lean forward
C: have the patient move to a sitting position
D: palpate the PMI to the right of the midclavicular line - Answer-A: have the patient turn onto his left
side
Which of the following should the nurse implement for assessment of the carotid artery?
A: massaging the arteries briskly
B: using the diaphragm of the stethoscope
C: palpating each carotid artery separately
D: placing the patient in a supine position - Answer-C: Palpating each carotid artery separately
Which of the following is an unexpected finding after a cardiac assessment?
A: a pulse rate of 72 beats per minute.
, B: jugular vein pulsation with the patient supine.
C: PMI found at the midclavicular line.
D: a sustained swishing sound during systole or diastole. - Answer-D: a sustained swishing sound during
systole or diastole
How should the nurse document an exaggeration of the posterior curvature of the thoracic spine found
during the assessment of a 90 year old patient?
A: lordosis.
B: osteoporosis.
C: scoliosis.
D: kyphosis. - Answer-D: kyphosis
A nurse is documenting a patient's breath sounds. Crackles are heard as:
A: loud, low-pitched, coarse sounds.
B: high-pitched, musical squeaks.
C: dry, granting sounds on inspiration.
D: high-pitched, fine sounds at the end of inspiration - Answer-D: high-pitched, fine sounds at the end
of inspiration
A 53 year old client is seen at the clinic for a yearly physical examination. In evaluating the client's
weight, the nurse also considers the age and height. This is an example of:
A: defining the client problem.
B: recognizing gaps in data assessment.
C: comparing data with normal health patterns.
D: drawing conclusions about the client's response. - Answer-C: comparing data with normal health
patterns
Questions and Answers
The nurse is visiting the patient for the first time this shift. She introduces herself and asks the patient
several questions related to his condition. While doing so, and without being obvious, she is looking at
the color of his eyes and is assessing his ears and nose for discharge and the symmetry of his mouth.
Which assessment technique is the nurse using?
A: palpation
B: percussion
C: inspection
D: auscultation - Answer-C: inspection
The patient is admitted with fever and acute lower abdominal pain. He has taken tylenol but says he still
feels feverish. Before taking the patient's temperature, the nurse may:
A: touch the patients skin with the dorsal of her hand
B: touch the patients skin with the pads of her finger
C: palpate the skin using the bimanual method
D: touch the patients skin with the palmar side of her hand - Answer-A: touch the patients skin with the
dorsal of her hand
,What should the nurse do when preparing to complete an assessment for a 16 year old patient?
A: focus on the illness behaviors
B: plan for a diminished energy level
C: treat the patient as an individual
D: have the parents present throughout - Answer-C: treat the patient as an individual
The general survey begins with a review of the patient's primary health problems and an evaluation of
the patient's vital signs, height and weight, general behavior, and appearance. It also provides
information about the patient's illness, hygiene, skin condition, body image, and emotional state. Which
of the following cannot be delegated to nursing assistive personnel?
A: reporting subjectives signs and symptoms
B: measuring the patients height and weight
C: monitoring I&O
D: obtaining initial vital signs - Answer-D: obtaining initial vital signs
The nurse is preparing to examine a patient who has chronic lung disease. She realizes that the patient
most likely will need to be in which position for the examination?
A: high fowlers
B: supine
C: side-lying
D: prone - Answer-A: High fowlers
Nursing diagnoses meet specific criteria so they accurately reflect both the celints problem and the
possible etiology involved. Of the following statements, which one is an example of an appropriately
written nursing diagnosis?
A: cardiac output decreased related to motor vehicle accidents
B: potential for injury related to improper teaching in the use of crutches
,C: ineffective airway clearance related to increased secretions
D: risk for change in body image related to cancer - Answer-C: ineffective airway clearance related to
increased secretions
Where is the pulmonic area for auscultation found?
A: second intercostal space on the right side
B: second intercostal space on the left side
C: third intercostal space
D: fourth intercostal space along the sternum - Answer-B: second intercostal space on the left side
While performing a cardiovascular assessment on a patient with suspected left-sided congestive heart
failure, the nurse is unable to palpate the PMI with the patient lying supine. What might her next step
be?
A: have the patient turn onto his left side
B: have the patient lean forward
C: have the patient move to a sitting position
D: palpate the PMI to the right of the midclavicular line - Answer-A: have the patient turn onto his left
side
Which of the following should the nurse implement for assessment of the carotid artery?
A: massaging the arteries briskly
B: using the diaphragm of the stethoscope
C: palpating each carotid artery separately
D: placing the patient in a supine position - Answer-C: Palpating each carotid artery separately
Which of the following is an unexpected finding after a cardiac assessment?
A: a pulse rate of 72 beats per minute.
, B: jugular vein pulsation with the patient supine.
C: PMI found at the midclavicular line.
D: a sustained swishing sound during systole or diastole. - Answer-D: a sustained swishing sound during
systole or diastole
How should the nurse document an exaggeration of the posterior curvature of the thoracic spine found
during the assessment of a 90 year old patient?
A: lordosis.
B: osteoporosis.
C: scoliosis.
D: kyphosis. - Answer-D: kyphosis
A nurse is documenting a patient's breath sounds. Crackles are heard as:
A: loud, low-pitched, coarse sounds.
B: high-pitched, musical squeaks.
C: dry, granting sounds on inspiration.
D: high-pitched, fine sounds at the end of inspiration - Answer-D: high-pitched, fine sounds at the end
of inspiration
A 53 year old client is seen at the clinic for a yearly physical examination. In evaluating the client's
weight, the nurse also considers the age and height. This is an example of:
A: defining the client problem.
B: recognizing gaps in data assessment.
C: comparing data with normal health patterns.
D: drawing conclusions about the client's response. - Answer-C: comparing data with normal health
patterns
