Week 1: Basic Physical Assessment
During assessment, a nurse auscultates for a client's breath sounds. Auscultation provides
which type of data? -correct answer_objective Physical examination techniques such as
auscultation provide objective data, which reflect findings without interpretation. The client
and client's family report subjective data to the nurse. The family and members of the
healthcare team provide secondary source information. The nurse obtains medical data from
the physician and medical record. When evaluating a client's preoperative
cognitive-perceptual pattern, which question should the nurse ask the client? -correct
answer_"Do you wear glasses?" The nurse would ask whether the client wears glasses to
evaluate the client's preoperative cognitive-perceptual pattern. Asking about the client's
swallowing pattern would evaluate the client's nutritional-metabolic pattern. Asking about the
client's need for special equipment to walk would evaluate the client's activity-exercise pattern.
Asking about the client's history of smoking would evaluate the client's health
perception-health management pattern A nurse is caring for a client who is exhibiting signs
and symptoms characteristic of a myocardial infarction (MI). Which statement describes
priorities the nurse should establish while performing the physical assessment? -correct
answer_Assess the client's level of pain, and administer prescribed analgesics. The cardinal
symptom of MI is persistent, crushing substernal pain or pressure. The nurse should first assess
the client's pain and prepare to administer nitroglycerin or morphine for pain control. The
client must be medically stabilized before pulmonary artery catheterization can be used as a
diagnostic procedure. Anxiety and a feeling of impending doom are characteristic of MI, but
the priority is to stabilize the client medically. Although the client and their family should be
kept informed at every step of the recovery process, this action isn't the priority when treating
a client with a suspected MI. An older adult client is admitted to the hospital with a diagnosis
of pneumonia. The nurse learns that the client lives alone and has not been eating or drinking
properly. Upon physical assessment, the nurse notes tachycardia, hypotension, and
hyperthermia. Which admission order would the nurse implement first? -correct
answer_intravenous fluid hydration Both the history and physical assessment support a client
who is dehydrated. I.V. fluids would assist with rehydration and liquifying secretions. Although
the pneumonia is important to treat aggressively, hydration is the priority. After a laminectomy,
a client has a palpable bladder and reports lower abdominal discomfort with voiding 60 to 80
mL of urine every 4 hours. The vital signs are BP 110/88 mm Hg, HR 86 bpm, and RR of 20
breaths/min. What is the best nursing intervention? -correct answer_Perform a bladder scan,
and obtain an order for urinary catheterization. The client has overflow retention. A catheter
relieves the discomfort by draining urine from the bladder. Permitting further distension could
injure the bladder. Although an analgesic may relieve the discomfort, it will not resolve the
primary cause. Nurses' self regulation practice can perform a bladder scan without an order.
Other answers are incorrect because the client may have neurologic impairment and
decreased sensation for voiding. The nurse is working with a licensed practical nurse (LPN) and
delegating the taking of vital signs for a preoperative client. Upon review of the chart as the
client is leaving for the operating room, the nurse notes that the temperature is 101.1°F (38.4°C)
and the pulse is 110 bpm. What are the nurse's initial actions? -correct answer_Notify the
surgeon and await the surgeon's decision; reinforce with the LPN the importance of reporting
abnormal preoperative vital signs. The purpose of a registered nurse's signing off the chart is
to ensure that the safety of the client has been assessed. Abnormal vital signs identify that
priority systems indicate that a stressor or infection is present. For which client is the nursing
assessment of pain most likely to result in undertreatment? -correct answer_an older adult who
grimaces and states no pain after a gastrostomy tube placement Clients at risk for insufficient
pain control are older adults and those of ethnic origins that hold the tradition of stoicism,
,such as many Asian and Hispanic cultures. The nurse must assess carefully to provide culturally
appropriate care. Clients who request medication, or are allowed to regulate their own
medications, are more likely to have their pain controlled. The nurse receives morning lab work
after shift hand-off. Based on the analysis of lab values, which client would the nurse assess
first? -correct answer_a client diagnosed with renal disease and a serum potassium level of 6.1
mEq/dL (6.1 mmol/L) who has limited output The client with the elevated potassium level and
poor renal elimination is the client to assess first as the condition could develop into cardiac
concerns of arrhythmias such a ventricular fibrillation. Due to the seriousness of the
complication, this assessment is the priority. Intense thirst and a low urine specific gravity
(1.001- 1.003) is expected when diagnosed with diabetes insipidus. The blood glucose level of
175mg/dL (9.71 mmol/L) is elevated and insulin is given with morning breakfast. The blood
glucose level is not at a critical level. The client with a serum calcium level of 8.2 mEq/dL (2.05
mmol/L) is low normal or slightly below normal (depending upon the source) and cramping
may be an issue. The nurse is caring for a client that had surgery this morning. What
assessment finding would the nurse notify the health care provider about? -correct
answer_urinary output of 20 mL/hr over 2 hours Urine output is maintained at a minimum of
30 mL/hr in adults. Less than this for 2 consecutive hours should be reported to the health care
provider. A low-grade fever is expected in healing and is the natural inflammatory response to
surgery. Moderate drainage can be observed, and the blood pressure is still within normal
parameters. A client who underwent a mastectomy has been admitted to the surgical care unit
after discharge from the postanesthesia care unit. What is the nurse's priority assessment?
-correct answer_Assess the vital signs and oxygen saturation levels. The correct response is
based on the principle of prioritizing assessment of airway, breathing, and circulation (ABC) for
every client. Assessing vital signs and oxygen saturation, therefore, is the priority. The return of
urinary function after anesthesia usually takes 6 or more hours, so this assessment is not a
priority upon return from the postanesthesia care unit. Checking the dressing and level of pain
are both important but not the priority. To assess the effectiveness of cardiac compressions
during adult cardiopulmonary resuscitation (CPR), a nurse should palpate which pulse site?
-correct answer_carotid During CPR, the carotid artery pulse is the most accessible and may
persist when the peripheral pulses (radial and brachial) are no longer palpable because of
decreases in cardiac output and peripheral perfusion. Chest compressions performed during
CPR preclude accurate assessment of the apical pulse. The nurse is observing a nursing student
palpating a client's maxillary sinuses. The nurse observes that the student has correctly
palpated the client's maxillary sinuses when the student palpates which area? -correct
answer_below the client's cheekbones To palpate the maxillary sinuses, the nurse would place
hands on either side of the client's nose, below the cheekbone (zygomatic bone). To palpate
the frontal sinuses, the nurse places their thumb just above the client's eye, under the bony
ridge of the orbit. No sinuses are located on the bridge of the nose or in the temporal area.
Students in a health class are discussing birth control and prevention of sexually transmitted
disease. The school nurse would know that teaching has been effective if the students make
which statement? -correct answer_"Responsible sex involves using condoms and spermicides
for protection and birth control." This comment indicates an understanding of ways to lessen
the incidence of sexually transmitted illnesses by condom use. It also indicates that use of a
spermicide and condom will help to prevent unwanted pregnancies. The other choices are not
accurate examples of safer sex. Which is a priority nursing assessment of a reddened heel in a
bed-ridden client? -correct answer_Test for blanching to the affected area. When a fingertip is
pressed over the reddened area and the area does not blanch but remains consistently
reddened, it is an indication of deep tissue injury. The other choices are not appropriate ways
to treat a reddened area. The nurse is assessing a client's respiratory status. Which assessment
data indicate a problem? -correct answer_28 breaths/min and audible Twenty-eight breaths
are outside the normal range of 14 to 20 breaths/min. Breathing should be without effort or
, adventitious sounds. Based on these abnormal assessment findings, this client may be
experiencing respiratory distress. The rest of the choices are all within normal parameters of
respiratory status. A client arrives at the emergency department with chest and stomach pain
and a report of black, tarry stools for several months. Which diagnostic testing would the nurse
anticipate? -correct answer_ECG (electrocardiogram), complete blood count, testing for occult
blood, and comprehensive serum metabolic panel Diagnostic testing is one source of
information leading to a medical diagnosis. It is correct to anticipate cardiac and
gastrointestinal studies due to the client's signs and symptoms. An ECG evaluates the report of
chest pain, laboratory tests determine anemia, and the test for occult blood determines blood
in the stool. Cardiac monitoring, oxygen, and creatine kinase, and LD levels are appropriate for
a primary cardiac problem. A basic metabolic panel and alkaline phosphatase and aspartate
aminotransferase levels assess liver function. PT, PTT, fibrinogen, and fibrin split products are
measured to verify bleeding dyscrasias. An EEG evaluates brain electrical activity. The nurse is
preparing to administer fentanyl 25 mcg I.V. The available dose is 100 mcg/2 ml vial. How
much medication will the nurse ask another nurse to witness as a waste? Record your answer
using one decimal place. -correct answer_1.5 Fentanyl is a Schedule II controlled substance.
Federal law requires close monitoring of this type of medication to prevent diversion and
misuse. 25 mcg x 2 ml/100 mcg = 0.5 ml to be given 2 ml - 0.5 ml = 1.5 ml to waste The nurse
would ask another nurse to witness the waste of 1.5 ml of medication either down the sink or
in the approved pharmaceutical waste container as per the facility policy. A nurse is observing
a unlicensed assistive personnel (UAP) measure a client's blood pressure. Which action by the
UAP would be evaluated as correct? -correct answer_wrapping the cuff around the limb, with
the bladder covering three-quarters of the limb circumference When measuring blood
pressure, the nurse either removes the client's clothing or moves it above where the cuff will
the placed. The nurse should wrap the cuff around the client's arm or leg with the bladder
uninflated; the bladder should cover approximately three-quarters of the limb circumference.
The nurse chooses bladder size according to the size of the extremity. Using the automatic
blood pressure cuff on all clients without cleaning would cause of spread of hospital-acquired
infections. A cloth chest restraint has been presecribed for a client who is restless and
combative due to alcohol intoxication. What is an appropriate nursing intervention for this
client? -correct answer_Check the extremities for circulation based on hospital protocols.
Assessment of extremities is essential for distal blood flow. Professional responsibility is to
follow policies and procedures by the hospital. Family presence can lessen confusion, tied
knots do not allow for quick release in an emergency situation, and documentation of a client
in this acute state needs to occur more often than once per shift. A nurse determines that a
client has 20/40 vision. Which action by the nurse is most appropriate? -correct answer_Refer
the client to a healthcare provider for possible corrective lenses. Visual acuity is usually
measured with a Snellen chart. A client with 20/40 vision is able to read the same sized letters
from 20 feet away as a person with "normal" vision would be able to read at 40 feet away. The
client with 20/40 vision would be referred to a healthcare provider for the possible need for
corrective lenses, as 20/20 vision is considered normal. The client would need to be evaluated
by a healthcare provider prior to suggesting the purchase of corrective lenses for reading. In
most jurisdictions, 20/40 vision qualifies for an unrestricted driver's license, so corrective lenses
may not be required. However, the client must first see the healthcare provider before that can
be determined. When assessing a dark-skinned client for cyanosis, what area of the body will
best reveal cyanosis? -correct answer_oral mucous membranes In dark-skinned clients,
cyanosis can best be detected by examining the conjunctiva, lips, and oral mucous membranes.
Examining the retinas, nail beds, or inner aspects of the wrists is not an appropriate assessment
for determining cyanosis in any client. A client is on complete bed rest. The nurse should
initiate measures to prevent which complication of bed rest? -correct answer_thrombophlebitis
Thrombophlebitis is an inflammation of a vein. The underlying etiology involves stasis of blood,
During assessment, a nurse auscultates for a client's breath sounds. Auscultation provides
which type of data? -correct answer_objective Physical examination techniques such as
auscultation provide objective data, which reflect findings without interpretation. The client
and client's family report subjective data to the nurse. The family and members of the
healthcare team provide secondary source information. The nurse obtains medical data from
the physician and medical record. When evaluating a client's preoperative
cognitive-perceptual pattern, which question should the nurse ask the client? -correct
answer_"Do you wear glasses?" The nurse would ask whether the client wears glasses to
evaluate the client's preoperative cognitive-perceptual pattern. Asking about the client's
swallowing pattern would evaluate the client's nutritional-metabolic pattern. Asking about the
client's need for special equipment to walk would evaluate the client's activity-exercise pattern.
Asking about the client's history of smoking would evaluate the client's health
perception-health management pattern A nurse is caring for a client who is exhibiting signs
and symptoms characteristic of a myocardial infarction (MI). Which statement describes
priorities the nurse should establish while performing the physical assessment? -correct
answer_Assess the client's level of pain, and administer prescribed analgesics. The cardinal
symptom of MI is persistent, crushing substernal pain or pressure. The nurse should first assess
the client's pain and prepare to administer nitroglycerin or morphine for pain control. The
client must be medically stabilized before pulmonary artery catheterization can be used as a
diagnostic procedure. Anxiety and a feeling of impending doom are characteristic of MI, but
the priority is to stabilize the client medically. Although the client and their family should be
kept informed at every step of the recovery process, this action isn't the priority when treating
a client with a suspected MI. An older adult client is admitted to the hospital with a diagnosis
of pneumonia. The nurse learns that the client lives alone and has not been eating or drinking
properly. Upon physical assessment, the nurse notes tachycardia, hypotension, and
hyperthermia. Which admission order would the nurse implement first? -correct
answer_intravenous fluid hydration Both the history and physical assessment support a client
who is dehydrated. I.V. fluids would assist with rehydration and liquifying secretions. Although
the pneumonia is important to treat aggressively, hydration is the priority. After a laminectomy,
a client has a palpable bladder and reports lower abdominal discomfort with voiding 60 to 80
mL of urine every 4 hours. The vital signs are BP 110/88 mm Hg, HR 86 bpm, and RR of 20
breaths/min. What is the best nursing intervention? -correct answer_Perform a bladder scan,
and obtain an order for urinary catheterization. The client has overflow retention. A catheter
relieves the discomfort by draining urine from the bladder. Permitting further distension could
injure the bladder. Although an analgesic may relieve the discomfort, it will not resolve the
primary cause. Nurses' self regulation practice can perform a bladder scan without an order.
Other answers are incorrect because the client may have neurologic impairment and
decreased sensation for voiding. The nurse is working with a licensed practical nurse (LPN) and
delegating the taking of vital signs for a preoperative client. Upon review of the chart as the
client is leaving for the operating room, the nurse notes that the temperature is 101.1°F (38.4°C)
and the pulse is 110 bpm. What are the nurse's initial actions? -correct answer_Notify the
surgeon and await the surgeon's decision; reinforce with the LPN the importance of reporting
abnormal preoperative vital signs. The purpose of a registered nurse's signing off the chart is
to ensure that the safety of the client has been assessed. Abnormal vital signs identify that
priority systems indicate that a stressor or infection is present. For which client is the nursing
assessment of pain most likely to result in undertreatment? -correct answer_an older adult who
grimaces and states no pain after a gastrostomy tube placement Clients at risk for insufficient
pain control are older adults and those of ethnic origins that hold the tradition of stoicism,
,such as many Asian and Hispanic cultures. The nurse must assess carefully to provide culturally
appropriate care. Clients who request medication, or are allowed to regulate their own
medications, are more likely to have their pain controlled. The nurse receives morning lab work
after shift hand-off. Based on the analysis of lab values, which client would the nurse assess
first? -correct answer_a client diagnosed with renal disease and a serum potassium level of 6.1
mEq/dL (6.1 mmol/L) who has limited output The client with the elevated potassium level and
poor renal elimination is the client to assess first as the condition could develop into cardiac
concerns of arrhythmias such a ventricular fibrillation. Due to the seriousness of the
complication, this assessment is the priority. Intense thirst and a low urine specific gravity
(1.001- 1.003) is expected when diagnosed with diabetes insipidus. The blood glucose level of
175mg/dL (9.71 mmol/L) is elevated and insulin is given with morning breakfast. The blood
glucose level is not at a critical level. The client with a serum calcium level of 8.2 mEq/dL (2.05
mmol/L) is low normal or slightly below normal (depending upon the source) and cramping
may be an issue. The nurse is caring for a client that had surgery this morning. What
assessment finding would the nurse notify the health care provider about? -correct
answer_urinary output of 20 mL/hr over 2 hours Urine output is maintained at a minimum of
30 mL/hr in adults. Less than this for 2 consecutive hours should be reported to the health care
provider. A low-grade fever is expected in healing and is the natural inflammatory response to
surgery. Moderate drainage can be observed, and the blood pressure is still within normal
parameters. A client who underwent a mastectomy has been admitted to the surgical care unit
after discharge from the postanesthesia care unit. What is the nurse's priority assessment?
-correct answer_Assess the vital signs and oxygen saturation levels. The correct response is
based on the principle of prioritizing assessment of airway, breathing, and circulation (ABC) for
every client. Assessing vital signs and oxygen saturation, therefore, is the priority. The return of
urinary function after anesthesia usually takes 6 or more hours, so this assessment is not a
priority upon return from the postanesthesia care unit. Checking the dressing and level of pain
are both important but not the priority. To assess the effectiveness of cardiac compressions
during adult cardiopulmonary resuscitation (CPR), a nurse should palpate which pulse site?
-correct answer_carotid During CPR, the carotid artery pulse is the most accessible and may
persist when the peripheral pulses (radial and brachial) are no longer palpable because of
decreases in cardiac output and peripheral perfusion. Chest compressions performed during
CPR preclude accurate assessment of the apical pulse. The nurse is observing a nursing student
palpating a client's maxillary sinuses. The nurse observes that the student has correctly
palpated the client's maxillary sinuses when the student palpates which area? -correct
answer_below the client's cheekbones To palpate the maxillary sinuses, the nurse would place
hands on either side of the client's nose, below the cheekbone (zygomatic bone). To palpate
the frontal sinuses, the nurse places their thumb just above the client's eye, under the bony
ridge of the orbit. No sinuses are located on the bridge of the nose or in the temporal area.
Students in a health class are discussing birth control and prevention of sexually transmitted
disease. The school nurse would know that teaching has been effective if the students make
which statement? -correct answer_"Responsible sex involves using condoms and spermicides
for protection and birth control." This comment indicates an understanding of ways to lessen
the incidence of sexually transmitted illnesses by condom use. It also indicates that use of a
spermicide and condom will help to prevent unwanted pregnancies. The other choices are not
accurate examples of safer sex. Which is a priority nursing assessment of a reddened heel in a
bed-ridden client? -correct answer_Test for blanching to the affected area. When a fingertip is
pressed over the reddened area and the area does not blanch but remains consistently
reddened, it is an indication of deep tissue injury. The other choices are not appropriate ways
to treat a reddened area. The nurse is assessing a client's respiratory status. Which assessment
data indicate a problem? -correct answer_28 breaths/min and audible Twenty-eight breaths
are outside the normal range of 14 to 20 breaths/min. Breathing should be without effort or
, adventitious sounds. Based on these abnormal assessment findings, this client may be
experiencing respiratory distress. The rest of the choices are all within normal parameters of
respiratory status. A client arrives at the emergency department with chest and stomach pain
and a report of black, tarry stools for several months. Which diagnostic testing would the nurse
anticipate? -correct answer_ECG (electrocardiogram), complete blood count, testing for occult
blood, and comprehensive serum metabolic panel Diagnostic testing is one source of
information leading to a medical diagnosis. It is correct to anticipate cardiac and
gastrointestinal studies due to the client's signs and symptoms. An ECG evaluates the report of
chest pain, laboratory tests determine anemia, and the test for occult blood determines blood
in the stool. Cardiac monitoring, oxygen, and creatine kinase, and LD levels are appropriate for
a primary cardiac problem. A basic metabolic panel and alkaline phosphatase and aspartate
aminotransferase levels assess liver function. PT, PTT, fibrinogen, and fibrin split products are
measured to verify bleeding dyscrasias. An EEG evaluates brain electrical activity. The nurse is
preparing to administer fentanyl 25 mcg I.V. The available dose is 100 mcg/2 ml vial. How
much medication will the nurse ask another nurse to witness as a waste? Record your answer
using one decimal place. -correct answer_1.5 Fentanyl is a Schedule II controlled substance.
Federal law requires close monitoring of this type of medication to prevent diversion and
misuse. 25 mcg x 2 ml/100 mcg = 0.5 ml to be given 2 ml - 0.5 ml = 1.5 ml to waste The nurse
would ask another nurse to witness the waste of 1.5 ml of medication either down the sink or
in the approved pharmaceutical waste container as per the facility policy. A nurse is observing
a unlicensed assistive personnel (UAP) measure a client's blood pressure. Which action by the
UAP would be evaluated as correct? -correct answer_wrapping the cuff around the limb, with
the bladder covering three-quarters of the limb circumference When measuring blood
pressure, the nurse either removes the client's clothing or moves it above where the cuff will
the placed. The nurse should wrap the cuff around the client's arm or leg with the bladder
uninflated; the bladder should cover approximately three-quarters of the limb circumference.
The nurse chooses bladder size according to the size of the extremity. Using the automatic
blood pressure cuff on all clients without cleaning would cause of spread of hospital-acquired
infections. A cloth chest restraint has been presecribed for a client who is restless and
combative due to alcohol intoxication. What is an appropriate nursing intervention for this
client? -correct answer_Check the extremities for circulation based on hospital protocols.
Assessment of extremities is essential for distal blood flow. Professional responsibility is to
follow policies and procedures by the hospital. Family presence can lessen confusion, tied
knots do not allow for quick release in an emergency situation, and documentation of a client
in this acute state needs to occur more often than once per shift. A nurse determines that a
client has 20/40 vision. Which action by the nurse is most appropriate? -correct answer_Refer
the client to a healthcare provider for possible corrective lenses. Visual acuity is usually
measured with a Snellen chart. A client with 20/40 vision is able to read the same sized letters
from 20 feet away as a person with "normal" vision would be able to read at 40 feet away. The
client with 20/40 vision would be referred to a healthcare provider for the possible need for
corrective lenses, as 20/20 vision is considered normal. The client would need to be evaluated
by a healthcare provider prior to suggesting the purchase of corrective lenses for reading. In
most jurisdictions, 20/40 vision qualifies for an unrestricted driver's license, so corrective lenses
may not be required. However, the client must first see the healthcare provider before that can
be determined. When assessing a dark-skinned client for cyanosis, what area of the body will
best reveal cyanosis? -correct answer_oral mucous membranes In dark-skinned clients,
cyanosis can best be detected by examining the conjunctiva, lips, and oral mucous membranes.
Examining the retinas, nail beds, or inner aspects of the wrists is not an appropriate assessment
for determining cyanosis in any client. A client is on complete bed rest. The nurse should
initiate measures to prevent which complication of bed rest? -correct answer_thrombophlebitis
Thrombophlebitis is an inflammation of a vein. The underlying etiology involves stasis of blood,
