Questions And Answers Latest
2025/2026 fully Solutions
The nurse is performing a thoracic assessment on a client with chronic asthma and hyperinflation of the
lungs. Which finding should be expected for this client? - CORRECT - ANSWERS Barrel chest
The nurse is assessing bowel sounds for a hospitalized client. The nurse has heard bowel sounds in the
right upper quadrant. What action should the nurse take next? - CORRECT - ANSWERS Note the
character and frequency of bowel sounds
During inspection of a client's mouth and pharynx, the nurse places a tongue blade on the back of the
tongue which causes the client to gag. After removing the tongue blade, what action should the nurse
take? - CORRECT - ANSWERS Document an intact gag reflex.
When teaching a client how to perform a monthly breast self-assessment, the nurse should tell the
client that it is most important to assess which part of the breast more closely for changes? - CORRECT -
ANSWERS Upper outer quadrant.
The nurse is assessing a postmenopausal client who has a BMI of 32. The client has a chest
measurement of 42 inches, waist measurement of 45 inches, and hip measurement of 50 inches. What
important message should the nurse explain to the client to promote health promotion? - CORRECT -
ANSWERS A waist circumference is greater than 35 inches in women puts you at higher risk for type
2 diabetes and heart disease."
The nurse performs a physical assessment on an older female client. Which change from the prior exam
may be an indication of osteoporosis? - CORRECT - ANSWERS Height reduction of 1.5 inches.
While conducting an interview to obtain a health history, the nurse notices that the client pauses
frequently and looks at the nurse expectantly. Which response is best for the nurse to provide? -
CORRECT - ANSWERS Sit quietly to allow the client to respond comfortably.
,A client is in the clinical for a yearly physical examination. Which action should the nurse take when
preparing to examine the client's abdomen? - CORRECT - ANSWERS Ask the client to urinate before
beginning the examination.
Which respiratory condition should the nurse document after measuring a respiratory rate of 8
breaths/minute? - CORRECT - ANSWERS Bradypnea.
Which procedure should the nurse use to assessfor a pulse deficit? - CORRECT - ANSWERS Measure
the apical pulse and compare it to the peripheral pulse.
*A pulse deficit is a palpable difference between the apical pulse at the point of maximal impulse and
the radial pulse palpated at the wrist.
A client has been diagnosed with bilateral lower lobe atelectasis. What percussion sound should the
nurse expect to hear when percussing over the client's lower lobes? - CORRECT - ANSWERS Dull,
thud-like.
A client is being assessed upon admission to the medical-surgical unit. The nurse is preparing to
complete a head-to-toe assessment and will begin at the head of the client. Which technique should the
nurse use to begin the assessment? - CORRECT - ANSWERS Inspect the hair and skin.
The nurse is assessing a healthy young adult during an annual physical examination. Which assessment
technique should the nurse implement when palpating the abdominal aorta? - CORRECT - ANSWERS
Deep palpation above and to the left of the umbilicus.
The nurse is conducting a family history as part of the assessment interview. Which action should the
nurse take to ensure that sufficient information about the client's blood relatives is obtained? - CORRECT
- ANSWERS Document at least 3 generations of the client's family medical history.
The nurse is testing the client's shoulders for range of motion. What should the nurse document to
record normal internal rotation? - CORRECT - ANSWERS Range of 90 degrees when the hands are
placed at the small of the back.
, A client presents with a rash along the occipital area of the hairline and reports intense itching. How
should the nurse begin the objective part of the examination? - CORRECT - ANSWERS Inspect the
scalp looking for nits.
The nurse is assessing a client's range of motion as the client bends the right knee up to the chest while
keeping the left leg straight, but is unable to keep the left thigh on the table. The assessment is repeated
for the left knee, and the client is unable to keep the right thigh on the table. How should the nurse
document this finding? - CORRECT - ANSWERS A flexion deformity referred to as a positive Thomas
test.
During a skin asssessment, the nurse notes, round and discrete lesions that are dark red in color and will
not blanch. The lesions range from 1 to 3 mm in size. What is the first question the nurse should ask the
client? - CORRECT - ANSWERS Have you notice any irregular bleeding
A client with progressive hearing loss appears distressed when the registered nurse (RN) asks open-
ended questions about the client's health history. Which forms of communication should the RN use? -
CORRECT - ANSWERS Face the client so the client can see the RN's mouth.
Check if the client's hearing aides are working properly.
Reduce environmental noise surrounding the client.
A client states that she had a mastectomy of her left breast last year and now experiences lymphedema.
What should the nurse expect to find when examining the client? - CORRECT - ANSWERS Swelling of
the left arm and non-pitting edema.
A client has just returned from the recovery room and asks to get out of bed to go to the bathroom. The
nurse decides to obtain orthostatic vital signs first. How will the nurse position the client to begin this
procedure? - CORRECT - ANSWERS Lying.
A postmenopausal female client is undergoing a routine physical examination. She has reported nothing
out of the ordinary. When performing the examination of the genitourinary system, the nurse finds an
irregularly enlarged uterus with firm, mobile, painless nodules in the uterine wall. How should the nurse
explain this finding to the client? - CORRECT - ANSWERS You have benign fibroid tumors, a common
occurrence in women your age.