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    Exam Review

    1. The nurse asks a female client about the proverb "Glass Houses," and she replies, "It will break the windows." Which conclusion should be documented about this client's response?
      A)
      Impaired memory
      B)
      Normal mental status for age
      C)
      Impaired concentration
      D)
      Impaired thinking
    2. When systematically auscultating a client's anterior breath sounds, the nurse should begin by placing the stethoscope over which location?
      A)
      Clavicle
      B)
      Lung apex
      C)
      Sternum
      D)
      Aortic site
    3. The nurse observes that a client is experiencing melena. Which serum laboratory test should the nurse monitor in response to this finding?
      A)
      Blood urea nitrogen (BUN)
      B)
      Glucose
      C)
      Hematocrit
      D)
      White blood cell count (WBC)
    4. To objectively confirm the presence of fever, before taking the client's temperature, which action should the nurse take?
      A)
      Place the dorsum of the hand on the client's forehead.
      B)
      Lightly pinch a fold of skin over the client's sternum.
      C)
      Ask the client to describe any other related symptoms.
      D)
      Use both hands to hold and palpate the client's hands.
    Page 1 of 16

    Exam Review

    1. While auscultating a client's abdomen, the nurse hears a low-pitched blowing sound in the upper midline area. Which is the likely indication of this finding?
      A)
      A minor variation
      B)
      Normal borborygmus sounds
      C)
      Possible renal artery stenosis
      D)
      Hyperactive bowel sounds
    2. While completing an admission assessment for a client with gastrointestinal bleeding, the nurse inspects the perianal area and anus. Which findings indicate a normal appearance of the anus?
      A)
      Flap of tissue at sphincter
      B)
      Hypotonic tone of the anal sphincter
      C)
      Dimpled area above anus
      D)
      Increased pigmentation and coarse skin
    3. The nurse is performing an admission assessment for a client with pyelonephritis who has urgency and burning while urinating. Which finding indicates an expected response when the nurse percusses the costovertebral angle?
      A)
      Rebound tenderness
      B)
      Sharp, severe pain
      C)
      Audible thud without pain
      D)
      Rigidity and firmness
    4. During an admission assessment, which approach should the nurse use to assess a client's speech patterns?
      A)
      Have the client repeat a phrase containing alliteration
      B)
      Note the client's responses during the initial interview
      C)
      Ask the client to complete a common proverb or saying
      D)
      Listen while the client reads items listed on the menu
    Page 2 of 16

    Exam Review

    1. When inspecting the client's skin, the nurse observes several areas of ecchymosis on the trunk and extremities. Which information in the client's history requires additional follow-up by the nurse?
      A)
      Recently had dental surgery
      B)
      Adheres to a gluten-free diet
      C)
      Takes an oral anticoagulant
      D)
      Works in a daycare center
    2. A male client arrives at the clinic for a follow-up health assessment after recent antibiotic treatment for pneumonia without hospitalization. Which technique should the nurse implement to assess for adventitious lung sounds?
      A)
      Have the client lay flat while listening to the anterior surface of the chest
      B)
      Press the stethoscope's diaphragm firmly on the skin over each lung field
      C)
      Shave all chest hair that may distort sounds heard through the diaphragm
      D)
      Use the bell of the stethoscope to listen to the lung fields over lower lobes
    3. While obtaining a client's health history related to smoking cigarettes, the nurse plans to determine the client's smoking pack years. What information should the nurse obtain for this calculation? Select all that apply.
      A)
      Packs of cigarettes smoked per day
      B)
      Age when the client started smoking
      C)
      Client's current age
      D)
      Number of attempts to quit smoking
      E)
      Number of years the client smoked
    4. During an abdominal assessment, a client with a temperature of 103° F (39.4° C) experiences pain and abruptly stops inhaling during deep palpation. Which prescription is most important for the nurse to implement?
      A)
      Monitor urinary output
      B)
      Obtain an electrocardiogram
      C)
      Restrict activity to bed rest
      D)
      Initiate NPO status
    Page 3 of 16

    Exam Review

    1. While performing a physical assessment, the nurse is unable to palpate the client's pedal pulses. Which action should the nurse take?
      A)
      Apply warm blankets to both feet.
      B)
      Use a doppler ultrasonic stethoscope.
      C)
      Notify the healthcare provider.
      D)
      Palpate pulse points with legs dependent.
    2. A client presents with itching and pain in the left ear that started several days after beginning swim lessons. The nurse observes a discharge coming from the ear with a musty odor. How should the nurse expect the ear to appear when performing an otoscopic examination?
      A)
      Thickened and bulging tympanic membrane.
      B)
      Retracted and non-mobile tympanic membrane.
      C)
      Red, edematous ear canal with no visualization of the tympanic membrane.
      D)
      Translucent, pearly gray and mobile tympanic membrane.
    3. The nurse examines a client's right great toe. The joint is red, edematous, and very painful with limited range of motion. The client's serum uric acid levels are elevated. Which action should the nurse tell the client to make?
      A)
      Encourage fluid intake.
      B)
      Increase intake of red meat.
      C)
      Measure urine output.
      D)
      Splint the affected joint.
    4. While performing a physical assessment, the nurse is unable to palpate the client's pedal pulses. Which action should the nurse take?
      A)
      Apply warm blankets to both feet.
      B)
      Use a doppler ultrasonic stethoscope.
      C)
      Notify the healthcare provider.
      D)
      Palpate pulse points with legs dependent.
    Page 4 of 16

    Exam Review

    1. In assessing tactile fremitus in the client with suspected pneumonia, the nurse should perform which action?
      A)
      Use the fingertips to compress tissue over the lungs for evidence of a crackling sensation.
      B)
      Use a stethoscope to listen to and compare breath sounds anteriorly and posteriorly.
      C)
      Looking at the client from the side, observe the size and shape of the chest wall.
      D)
      Place the palm of the hand on the chest wall to feel vibrations while the client speaks.
    2. A client who is admitted for an acute stroke reports the onset of a burning sensation in the hands and legs. Which action should the nurse implement to identify additional findings that are consistent with the client's paresthesia?
      A)
      Evaluate client's muscle strength and hand grips.
      B)
      Observe skin for erythema, edema, and warmth.
      C)
      Review the client's serum electrolytes.
      D)
      Check distal phalanges capillary refill.
    3. The nurse is assessing a young adult female who is 5 feet 5 inches (165 cm) and has a body mass index (BMI) score of 32 kg/m². Based on this BMI, what should the nurse deduce about this client's general health?
      A)
      Obese, serious threat to well-being.
      B)
      Undernutrition, at risk for malnutrition.
      C)
      Appropriate weight for height, good general health.
      D)
      Extreme obesity, at risk for multiple co-morbidities.
    4. The nurse is examining an older female client and suspects that she has a dysfunction in her hip region. Which procedure should the nurse perform to further assess for hip dysfunction?
      A)
      Flex the hip and knee while standing.
      B)
      Abduct each hip while the client is supine.
      C)
      Observe balance while the client stands.
      D)
      Inspect gluteal folds for symmetry.
    Page 5 of 16

    Exam Review

    1. An adult client presents with gnawing epigastric pain. The pain is worse when the client is hungry and abates after eating something. Which problem do these symptoms suggest?
      A)
      Gastroesophageal reflux (GERD).
      B)
      Esophagitis.
      C)
      Peptic ulcer disease (PUD).
      D)
      Chronic pancreatitis.
    2. Which assessment finding supports the client statement, "My feet swell all the time?"
      A)
      Positive Homan's sign bilaterally.
      B)
      2+ pitting edema of ankles bilaterally.
      C)
      Capillary refill both feet greater than 3 seconds.
      D)
      Pedal pulses weak and thready.
    3. To assess a client's pupillary reaction to accommodation, which action should the nurse take?
      A)
      Determine if dilation of the pupils occurs when the room is darkened.
      B)
      Note the speed of pupil constriction when a penlight is shined into the eye.
      C)
      Compare the shape of each of the pupils bilaterally with normal room light.
      D)
      Observe pupil size when focusing on a near object and then a far object.
    4. The nurse is examining an older female client and suspects that she has a dysfunction in her hip region. Which procedure should the nurse perform to further assess for hip dysfunction?
      A)
      Flex the hip and knee while standing.
      B)
      Abduct each hip while the client is supine.
      C)
      Observe balance while the client stands.
      D)
      Inspect gluteal folds for symmetry.
    Page 6 of 16