Practice Questions and Answers |
Latest Version | 2025/2026 | Correct &
Verified
A nurse is assessing a client’s vital signs. Which finding indicates a need for immediate
intervention?
A. Blood pressure 130/80 mmHg
B. Temperature 37.2°C
✔✔C. Respiratory rate 8/min
D. Heart rate 76 bpm
During a physical assessment, a nurse notices the client has jugular vein distention while sitting
at 45 degrees. What does this most likely indicate?
A. Dehydration
✔✔B. Right-sided heart failure
C. Hypotension
D. Pulmonary embolism
A nurse is performing a cardiovascular assessment. Which finding is considered abnormal?
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,A. Apical pulse rate 72 bpm
B. S1 and S2 heard clearly
✔✔C. Presence of S3
D. Peripheral pulses 2+
A nurse is assessing a client’s lungs. Which finding is expected in a healthy adult?
A. Wheezing
✔✔B. Vesicular breath sounds over the peripheral lung fields
C. Crackles at bases
D. Diminished breath sounds
A nurse is assessing a client’s abdomen. Which finding requires further investigation?
A. Bowel sounds present in all quadrants
B. Soft, non-tender abdomen
✔✔C. Distended abdomen with absent bowel sounds
D. Slight tympany on percussion
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,During a neurological assessment, a client cannot perform rapid alternating movements with
their hands. What does this suggest?
A. Cranial nerve II deficit
B. Sensory deficit
✔✔C. Cerebellar dysfunction
D. Peripheral neuropathy
A nurse is assessing a client’s skin. Which finding is normal in an older adult?
A. Moist and warm
B. Turgor returns immediately
C. Multiple vesicles
✔✔D. Dryness and decreased elasticity
A nurse is performing a head-to-toe assessment. Which cranial nerve is being tested when the
client shrugs their shoulders against resistance?
A. Cranial nerve V
B. Cranial nerve IX
✔✔C. Cranial nerve XI
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, D. Cranial nerve VII
A nurse is assessing a client’s eyes. Which is a normal pupillary response?
A. Pupils unequal, sluggish reaction
B. Constricted and fixed pupils
✔✔C. Pupils equal, round, and reactive to light and accommodation
D. Dilated and nonreactive pupils
A nurse is checking a client’s peripheral pulses. Which pulse is located behind the knee?
A. Radial
B. Femoral
✔✔C. Popliteal
D. Dorsalis pedis
During an assessment, a nurse hears a bruit over the carotid artery. What does this indicate?
A. Normal finding
✔✔B. Turbulent blood flow suggesting possible arterial narrowing
C. Venous congestion
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