Health Assessment Exam 1 questions and
answers 2025/2026 latest update
A nurse is taking an adult client's temperature rectally. Which of the following actions should the nurse
take?
- Rotate the probe if any resistance is met as the thermometer is inserted.
- Insert the probe to aim at the client's pelvic area.
- Dip the probe about 0.58 cm (2in) into a tube of lubricant.
- Insert the probe about 2.5 cm (1in) into the clients anus. - answerInsert the probe about 2.5 cm (1in)
into the clients anus.
An insertion depth of 2.5 to 3.5 cm (1 to 1.5 in) for an adult ensures sufficient exposure of the probe to
the blood vessels in the rectal wall. Positioning the probe against the blood vessels enables it to
measure heat maximally and accurately.
A nurse is obtaining a client's blood pressure and notices the pressure reading on the manometer when
listening to the fourth Korotkoff sound. Which of the following factors does this pressure reading
correlate to?
- It corresponds to the client's systolic pressure.
- It is the second diastolic pressure to record.
- It is the loudest of the Korotkoff sounds.
- It might not follow with a fifth Korotkoff sound. - answerIt might not follow with a fifth Korotkoff
sound.
Most clinicians consider the fifth Korotkoff sound, which is actually the disappearance of sound, as an
adult client's diastolic blood pressure. However, with some clients, there is no distinct fifth sound. You
hear sounds all the way to 0 mm Hg. For these clients, the nurse should record the fourth Korotkoff
sound as the diastolic blood pressure.
A nurse is preparing to auscultate a clients apical pulse at the point of maximal impulse (PMI). In which
of the following locations should,d the nurse position the stethoscope?
,- Over the right midclavicular line
- Over the angle of Louis
- Overt the fifth intercostal space at the left midclavicular line
- Over the suprasternal notch - answerOvert the fifth intercostal space at the left midclavicular line
To locate the PMI, the nurse should first locate the angle of Louis, a bony prominence just below the
suprasternal notch. The nurse should then slide their fingers down each side of the angle of Louis to
locate the second intercostal space. Next, the nurse should gently move their fingers down the left side
of the sternum to the fifth intercostal space and laterally to the left midclavicular line. This is the PMI.
A nurse is obtaining a client's vital signs. The client has a new onset of a temperature of 39C (102F).
Which of the following other vital signs should the nurse inspect?
- An elevated pulse rate
- A decreased blood pressure
- An elevated blood pressure
- A decreased pulse rate - answerAn elevated pulse rate.
A fever increases metabolic rate and peripheral vasodilation, resulting in an increased pulse rate.
A nurse is collecting data about a clients respiratory condition. Which of the following actions should the
nurse take to determine the depth of the client's respiration?
- Observe the degree of chest-wall movement during inspiration and expiration.
- Count how many breathing cycles are observed per minute.
- Notice whether or not expiration takes longer than inspiration.
- Measure the precise amount of air the client takes in and breathes out. - answerObserve the degree of
chest-wall movement during inspiration and expiration.
, The nurse can determine the depth of respiration subjectively by evaluating how much chest-wall
movement is observed. The movement is generated by the movements of the diaphragm and
intercostal muscles as the client breathes. With shallow respiration, the nurse will observe very little
movement. Deep respiration involves full expansion of the lungs, which is usually quite visible.
A nurse is obtaining vital signs from a client. Which of the following findings is the priority for the nurse
to report to the provider?
- Oral temperature 37.8° C (100° F)
- Respirations 30/min
- BP 148/88 mm Hg
- Radial pulse rate 45 beats/30 seconds - answerRespirations 30/min
Respirations of 30/min is above the expected reference range of 12 to 20/min and indicates the need for
immediate attention. An adult client who has respirations of 30/min is experiencing shortness of breath,
or dyspnea. Without intervention, this can become a life-threatening situation.
A nurse is preparing to record the difference between a client's systolic and diastolic blood pressure.
Which of the following terms define this information when documenting?
- Auscultatory gap
- Pulse pressure
- Orthostatic hypotension
- Pulse deficit - answerPulse pressure
The difference between the systolic and diastolic pressures is the pulse pressure. If the client's blood
pressure is 130/85 mm Hg, the pulse pressure is 45 mm Hg. Pulse pressure can be a predictor of heart
conditions, especially in older adults. For example, an elevated pulse pressure usually reflects stiffness
and reduced elasticity of the aorta, most often due to hypertension or atherosclerosis.
A nurse is auscultating a client's apical pulse to loosens to the S1 and S2 hearts sounds. S2 heart sounds
are heard when which of the following occurs?
answers 2025/2026 latest update
A nurse is taking an adult client's temperature rectally. Which of the following actions should the nurse
take?
- Rotate the probe if any resistance is met as the thermometer is inserted.
- Insert the probe to aim at the client's pelvic area.
- Dip the probe about 0.58 cm (2in) into a tube of lubricant.
- Insert the probe about 2.5 cm (1in) into the clients anus. - answerInsert the probe about 2.5 cm (1in)
into the clients anus.
An insertion depth of 2.5 to 3.5 cm (1 to 1.5 in) for an adult ensures sufficient exposure of the probe to
the blood vessels in the rectal wall. Positioning the probe against the blood vessels enables it to
measure heat maximally and accurately.
A nurse is obtaining a client's blood pressure and notices the pressure reading on the manometer when
listening to the fourth Korotkoff sound. Which of the following factors does this pressure reading
correlate to?
- It corresponds to the client's systolic pressure.
- It is the second diastolic pressure to record.
- It is the loudest of the Korotkoff sounds.
- It might not follow with a fifth Korotkoff sound. - answerIt might not follow with a fifth Korotkoff
sound.
Most clinicians consider the fifth Korotkoff sound, which is actually the disappearance of sound, as an
adult client's diastolic blood pressure. However, with some clients, there is no distinct fifth sound. You
hear sounds all the way to 0 mm Hg. For these clients, the nurse should record the fourth Korotkoff
sound as the diastolic blood pressure.
A nurse is preparing to auscultate a clients apical pulse at the point of maximal impulse (PMI). In which
of the following locations should,d the nurse position the stethoscope?
,- Over the right midclavicular line
- Over the angle of Louis
- Overt the fifth intercostal space at the left midclavicular line
- Over the suprasternal notch - answerOvert the fifth intercostal space at the left midclavicular line
To locate the PMI, the nurse should first locate the angle of Louis, a bony prominence just below the
suprasternal notch. The nurse should then slide their fingers down each side of the angle of Louis to
locate the second intercostal space. Next, the nurse should gently move their fingers down the left side
of the sternum to the fifth intercostal space and laterally to the left midclavicular line. This is the PMI.
A nurse is obtaining a client's vital signs. The client has a new onset of a temperature of 39C (102F).
Which of the following other vital signs should the nurse inspect?
- An elevated pulse rate
- A decreased blood pressure
- An elevated blood pressure
- A decreased pulse rate - answerAn elevated pulse rate.
A fever increases metabolic rate and peripheral vasodilation, resulting in an increased pulse rate.
A nurse is collecting data about a clients respiratory condition. Which of the following actions should the
nurse take to determine the depth of the client's respiration?
- Observe the degree of chest-wall movement during inspiration and expiration.
- Count how many breathing cycles are observed per minute.
- Notice whether or not expiration takes longer than inspiration.
- Measure the precise amount of air the client takes in and breathes out. - answerObserve the degree of
chest-wall movement during inspiration and expiration.
, The nurse can determine the depth of respiration subjectively by evaluating how much chest-wall
movement is observed. The movement is generated by the movements of the diaphragm and
intercostal muscles as the client breathes. With shallow respiration, the nurse will observe very little
movement. Deep respiration involves full expansion of the lungs, which is usually quite visible.
A nurse is obtaining vital signs from a client. Which of the following findings is the priority for the nurse
to report to the provider?
- Oral temperature 37.8° C (100° F)
- Respirations 30/min
- BP 148/88 mm Hg
- Radial pulse rate 45 beats/30 seconds - answerRespirations 30/min
Respirations of 30/min is above the expected reference range of 12 to 20/min and indicates the need for
immediate attention. An adult client who has respirations of 30/min is experiencing shortness of breath,
or dyspnea. Without intervention, this can become a life-threatening situation.
A nurse is preparing to record the difference between a client's systolic and diastolic blood pressure.
Which of the following terms define this information when documenting?
- Auscultatory gap
- Pulse pressure
- Orthostatic hypotension
- Pulse deficit - answerPulse pressure
The difference between the systolic and diastolic pressures is the pulse pressure. If the client's blood
pressure is 130/85 mm Hg, the pulse pressure is 45 mm Hg. Pulse pressure can be a predictor of heart
conditions, especially in older adults. For example, an elevated pulse pressure usually reflects stiffness
and reduced elasticity of the aorta, most often due to hypertension or atherosclerosis.
A nurse is auscultating a client's apical pulse to loosens to the S1 and S2 hearts sounds. S2 heart sounds
are heard when which of the following occurs?
