,Chapter 1: Assessment
Multiple-Choice Questions (100 Questions)
Question 1: A nurse is performing a general assessment on a newly admitted patient. Which of the
following should the nurse assess first?
A) Height and weight
B) Level of consciousness
C) Skin color
D) Respiratory rate
Correct Answer: B
Rationale: Level of consciousness is the most sensitive indicator of neurologic change and should be
assessed first during a general assessment.
Question 2: Which of the following is considered a normal adult oral temperature?
A) 96.8°F (36°C)
B) 98.6°F (37°C)
C) 100.4°F (38°C)
D) 101.2°F (38.4°C)
Correct Answer: B
Rationale: Normal adult oral temperature is approximately 98.6°F (37°C).
Question 3: A nurse is assessing a patient's radial pulse. Which technique is correct?
A) Using the thumb to palpate the pulse
B) Using two or three fingers to palpate the pulse
C) Using the palm of the hand to palpate the pulse
D) Using one finger to palpate the pulse
Correct Answer: B
Rationale: Two or three fingers should be used to palpate a pulse; the thumb should never be used
because it has its own pulse.
Question 4: What is the normal adult resting heart rate range?
A) 40–60 beats per minute
B) 60–100 beats per minute
C) 100–120 beats per minute
D) 120–140 beats per minute
Correct Answer: B
Rationale: Normal adult resting heart rate is 60–100 beats per minute.
Question 5: A nurse is assessing a patient's blood pressure. Which Korotkoff sound represents the
diastolic pressure?
A) First sound
B) Second sound
C) Third sound
D) Fifth sound
Correct Answer: D
Rationale: The fifth Korotkoff sound (disappearance of sound) represents diastolic pressure in adults.
,Question 6: Which of the following is the correct technique for measuring blood pressure?
A) Place the cuff over the clothing
B) Position the arm above heart level
C) Place the cuff 1 inch above the antecubital space
D) Inflate the cuff rapidly to 200 mmHg
Correct Answer: C
Rationale: The cuff should be placed 1 inch above the antecubital space, with the arm at heart level.
Question 7: A nurse is assessing a patient's respiratory rate. What is the normal adult range?
A) 8–16 breaths per minute
B) 12–20 breaths per minute
C) 20–28 breaths per minute
D) 28–36 breaths per minute
Correct Answer: B
Rationale: Normal adult respiratory rate is 12–20 breaths per minute.
Question 8: Which of the following is a normal oxygen saturation (SpO₂) level?
A) 85%–90%
B) 90%–94%
C) 95%–100%
D) 100%–105%
Correct Answer: C
Rationale: Normal oxygen saturation is 95%–100%.
Question 9: A nurse is assessing a patient's pain using the PQRST method. What does the "P" stand for?
A) Palliation
B) Position
C) Pulse
D) Palpation
Correct Answer: A
Rationale: PQRST stands for Palliation, Quality, Region, Severity, and Timing.
Question 10: Which of the following is a sign of inadequate oxygenation?
A) Pink mucous membranes
B) Confusion
C) Respiratory rate of 16
D) Oxygen saturation of 98%
Correct Answer: B
Rationale: Confusion can be a sign of inadequate oxygenation to the brain.
Question 11: A nurse is assessing a patient's skin. Which finding should be reported immediately?
A) Dry, warm skin
B) Moist, cool skin
C) Jaundice
D) Freckles
Correct Answer: C
Rationale: Jaundice (yellowing of the skin) indicates liver dysfunction and should be reported.
, Question 12: Which of the following is a normal finding when assessing the abdomen?
A) Distended, firm abdomen
B) Soft, non-tender abdomen
C) Board-like rigidity
D) Visible peristaltic waves
Correct Answer: B
Rationale: A soft, non-tender abdomen is a normal finding.
Question 13: A nurse is assessing a patient's neurological status. Which of the following is assessed using
the Glasgow Coma Scale?
A) Pupil size
B) Eye opening
C) Deep tendon reflexes
D) Babinski reflex
Correct Answer: B
Rationale: The Glasgow Coma Scale assesses eye opening, verbal response, and motor response.
Question 14: Which of the following is a normal finding when assessing the ears?
A) Discharge from the ear canal
B) Tender auricle
C) Intact tympanic membrane
D) Swollen mastoid area
Correct Answer: C
Rationale: An intact tympanic membrane is a normal finding.
Question 15: A nurse is assessing a patient's eyes. Which of the following is a normal finding?
A) Pupils equal, round, reactive to light
B) Unequal pupil size
C) Yellow sclera
D) Cloudy cornea
Correct Answer: A
Rationale: PERRLA (pupils equal, round, reactive to light, and accommodation) is a normal finding.
Question 16: Which of the following is a normal finding when assessing the mouth?
A) Bleeding gums
B) Pink, moist mucous membranes
C) White patches on the tongue
D) Foul odor
Correct Answer: B
Rationale: Pink, moist mucous membranes are a normal finding.
Question 17: A nurse is assessing a patient's peripheral vascular system. Which of the following is a
normal finding?
A) Absent pedal pulses
B) Capillary refill greater than 3 seconds
C) Capillary refill less than 3 seconds
D) Cool, clammy extremities
Multiple-Choice Questions (100 Questions)
Question 1: A nurse is performing a general assessment on a newly admitted patient. Which of the
following should the nurse assess first?
A) Height and weight
B) Level of consciousness
C) Skin color
D) Respiratory rate
Correct Answer: B
Rationale: Level of consciousness is the most sensitive indicator of neurologic change and should be
assessed first during a general assessment.
Question 2: Which of the following is considered a normal adult oral temperature?
A) 96.8°F (36°C)
B) 98.6°F (37°C)
C) 100.4°F (38°C)
D) 101.2°F (38.4°C)
Correct Answer: B
Rationale: Normal adult oral temperature is approximately 98.6°F (37°C).
Question 3: A nurse is assessing a patient's radial pulse. Which technique is correct?
A) Using the thumb to palpate the pulse
B) Using two or three fingers to palpate the pulse
C) Using the palm of the hand to palpate the pulse
D) Using one finger to palpate the pulse
Correct Answer: B
Rationale: Two or three fingers should be used to palpate a pulse; the thumb should never be used
because it has its own pulse.
Question 4: What is the normal adult resting heart rate range?
A) 40–60 beats per minute
B) 60–100 beats per minute
C) 100–120 beats per minute
D) 120–140 beats per minute
Correct Answer: B
Rationale: Normal adult resting heart rate is 60–100 beats per minute.
Question 5: A nurse is assessing a patient's blood pressure. Which Korotkoff sound represents the
diastolic pressure?
A) First sound
B) Second sound
C) Third sound
D) Fifth sound
Correct Answer: D
Rationale: The fifth Korotkoff sound (disappearance of sound) represents diastolic pressure in adults.
,Question 6: Which of the following is the correct technique for measuring blood pressure?
A) Place the cuff over the clothing
B) Position the arm above heart level
C) Place the cuff 1 inch above the antecubital space
D) Inflate the cuff rapidly to 200 mmHg
Correct Answer: C
Rationale: The cuff should be placed 1 inch above the antecubital space, with the arm at heart level.
Question 7: A nurse is assessing a patient's respiratory rate. What is the normal adult range?
A) 8–16 breaths per minute
B) 12–20 breaths per minute
C) 20–28 breaths per minute
D) 28–36 breaths per minute
Correct Answer: B
Rationale: Normal adult respiratory rate is 12–20 breaths per minute.
Question 8: Which of the following is a normal oxygen saturation (SpO₂) level?
A) 85%–90%
B) 90%–94%
C) 95%–100%
D) 100%–105%
Correct Answer: C
Rationale: Normal oxygen saturation is 95%–100%.
Question 9: A nurse is assessing a patient's pain using the PQRST method. What does the "P" stand for?
A) Palliation
B) Position
C) Pulse
D) Palpation
Correct Answer: A
Rationale: PQRST stands for Palliation, Quality, Region, Severity, and Timing.
Question 10: Which of the following is a sign of inadequate oxygenation?
A) Pink mucous membranes
B) Confusion
C) Respiratory rate of 16
D) Oxygen saturation of 98%
Correct Answer: B
Rationale: Confusion can be a sign of inadequate oxygenation to the brain.
Question 11: A nurse is assessing a patient's skin. Which finding should be reported immediately?
A) Dry, warm skin
B) Moist, cool skin
C) Jaundice
D) Freckles
Correct Answer: C
Rationale: Jaundice (yellowing of the skin) indicates liver dysfunction and should be reported.
, Question 12: Which of the following is a normal finding when assessing the abdomen?
A) Distended, firm abdomen
B) Soft, non-tender abdomen
C) Board-like rigidity
D) Visible peristaltic waves
Correct Answer: B
Rationale: A soft, non-tender abdomen is a normal finding.
Question 13: A nurse is assessing a patient's neurological status. Which of the following is assessed using
the Glasgow Coma Scale?
A) Pupil size
B) Eye opening
C) Deep tendon reflexes
D) Babinski reflex
Correct Answer: B
Rationale: The Glasgow Coma Scale assesses eye opening, verbal response, and motor response.
Question 14: Which of the following is a normal finding when assessing the ears?
A) Discharge from the ear canal
B) Tender auricle
C) Intact tympanic membrane
D) Swollen mastoid area
Correct Answer: C
Rationale: An intact tympanic membrane is a normal finding.
Question 15: A nurse is assessing a patient's eyes. Which of the following is a normal finding?
A) Pupils equal, round, reactive to light
B) Unequal pupil size
C) Yellow sclera
D) Cloudy cornea
Correct Answer: A
Rationale: PERRLA (pupils equal, round, reactive to light, and accommodation) is a normal finding.
Question 16: Which of the following is a normal finding when assessing the mouth?
A) Bleeding gums
B) Pink, moist mucous membranes
C) White patches on the tongue
D) Foul odor
Correct Answer: B
Rationale: Pink, moist mucous membranes are a normal finding.
Question 17: A nurse is assessing a patient's peripheral vascular system. Which of the following is a
normal finding?
A) Absent pedal pulses
B) Capillary refill greater than 3 seconds
C) Capillary refill less than 3 seconds
D) Cool, clammy extremities
