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    Exam Review

    1. A nurse cares for a client in the emergency department following a motor vehicle accident. Which assessment finding requires immediate follow-up by the nurse?
      A)
      Trachea deviated to the right
      B)
      Bruising across the chest and arms
      C)
      Complaints of headache and dizziness
      D)
      Superficial abrasions on the forearms
    2. The nurse is preparing to assess the client's ears. How should the pinna be positioned when using an otoscope to examine an adult's ear?
      A)
      Pulled forward and up
      B)
      Pulled up and back
      C)
      Pulled down and back
      D)
      Left in its natural position
    3. Name: Patricia Smithe Provider: M. Pike, MD Code Status: Full Code Allergies: None known Age: 74 years Weight: 66.48 kg Review the electronic health record. Which vital sign(s) should the nurse find concerning? Select all that apply. Blood Pressure 90/58 Oxygen Saturation 97% on room air Pain 1/10 right leg Temperature 98.9 F(37.1 C) Heart Rate 118
      (SATA)
      A)
      Respirations
      B)
      Blood pressure
      C)
      Pain
      D)
      Heart rate
      E)
      Temperature
      F)
      Oxygen saturation
    4. A nurse is assessing a client's lifestyle habits. Which of the following questions is most appropriate to identify risk factors affecting the mouth and throat?
      A)
      Do you wear a helmet when biking?
      B)
      Do you drink at least eight glasses of water per day?
      C)
      Do you wear a mouth guard while sleeping?
      D)
      Do you use any tobacco or vaping products?
    Page 1 of 15

    Exam Review

    1. The nurse is assessing the skin of a client diagnosed with anemia. Which of the following findings should the nurse expect?
      A)
      Jaundiced skin tone
      B)
      Cyanosis of the extremities
      C)
      Flushed, warm skin
      D)
      Generalized pallor
    2. Name: Betty Jo Farlow Provider. R. Schulze, MD Code Status: Full Code Allergies: NKA Age: 41 years Weight: 66.36 kg Review the electronic health record. The nurse is working with an unlicensed assistive personnel (UAP). The UAP reports the client's vital signs as charted in the electronic health record. Which action should the nurse take?
      A)
      The nurse should report the UAP's behavior to the manager.
      B)
      The nurse should ask the UAP to retake the client's vital signs.
      C)
      The nurse should prepare to administer oxygen therapy.
      D)
      The nurse should reassess the client's pulse oximetry.
    3. What is the priority assessment in the health history of the ears?
      A)
      New discharge from the auditory canal
      B)
      Noise exposure while at work
      C)
      Use of cotton swabs to clean ears
      D)
      Piercings of the lobe and helix
    4. The nurse assesses a newborn infant. Which assessment finding places the infant at greatest risk for fluid loss?
      A)
      Fine vellus hair replacing lanugo
      B)
      Presence of cradle cap
      C)
      Presence of vernix caseosa at birth
      D)
      Thin, smooth, and permeable skin
    Page 2 of 15

    Exam Review

    1. The nurse cares for a client with a history of cardiac dysrhythmias. Which vital sign should the nurse prioritize when conducting the assessment?
      A)
      Temperature
      B)
      Pulse Oximetry
      C)
      Pulse
      D)
      Respirations
    2. A nurse is evaluating a client's oxygen saturation reading of 97% on room air. How would the nurse interpret this result? Select all that apply
      (SATA)
      A)
      The client does not need further intervention.
      B)
      The client has an abnormal oxygen saturation.
      C)
      The client has a normal oxygen saturation.
      D)
      The client may have an inaccurate reading.
      E)
      The client may have chronic lung conditions.
    3. A nurse is assessing a client's blood pressure. The reading is 140/90 mmHg. What does the systolic pressure indicate?
      A)
      The difference between the systolic and diastolic pressures.
      B)
      The pressure in the arteries when the ventricles are relaxed and filling with blood.
      C)
      The pressure in the veins when the ventricles are contracting.
      D)
      The pressure in the arteries when the ventricles are contracting and pushing blood forward.
    4. A nurse will assess a client's temperature using a tympanic thermometer. Which action should the nurse include in the plan?
      A)
      Place the thermometer in the armpit
      B)
      Place the thermometer in the mouth
      C)
      Place the thermometer on the forehead
      D)
      Place the thermometer in the ear canal
    Page 3 of 15

    Exam Review

    1. The nurse is completing the health history of a client's head, face, neck, and mouth. For each assessment question, click to specify whether the question relates to the head and neck or the mouth of the health history.
      A)
      "Are you taking any medications that would cause xerostomia?"
      B)
      "How often do you go to the dentist?"
      C)
      "Do you have difficulty chewing or swallowing food?"
      D)
      "Have you had any unusual or frequent headaches?"
      E)
      "Do you have a history of traumatic brain injury?"
    2. The nurse is assessing the vital signs of an older adult. Which finding(s) should the nurse anticipate as age-related physiological changes? Select all that apply.
      A)
      Pulse oximetry readings of 90%
      B)
      Irregular heart rhythms or arrythmias
      C)
      A body temperature of 97°F (36.1°C)
      D)
      Shallow and increased respiratory rate
      E)
      Decreased systolic blood pressure
    3. What is a benefit of water consumption for the skin?
      A)
      Increases the production of oils
      B)
      Supports the detoxification process
      C)
      Permanently tightens pores
      D)
      Slows the production of melanin
    4. A nurse is caring for a client who reports having acute pain rated 6/10 following abdominal surgery. Which additional assessment finding should the nurse expect?
      A)
      Temperature 100.2 F
      B)
      Respirations 16 breaths per minute
      C)
      Blood pressure 118/82 mmHg
      D)
      Heart rate 118 beats per minute
    Page 4 of 15

    Exam Review

    1. A nurse is planning care for an infant with a bulging fontanel noted during an assessment. Which of the following actions should the nurse complete?
      A)
      Apply a warm compress to the area.
      B)
      Document the finding and continue routine care.
      C)
      Reassess the fontanelle in 24 hours.
      D)
      Notify the healthcare provider immediately.
    2. A nurse is assessing a client's finger pictured below. How should the nurse describe these lesions when documenting an assessment?
      A)
      Hives
      B)
      Fissures
      C)
      Petechiae
      D)
      Vesicles
    3. The nurse cares for a client with genetically high melanin density. What complication is the client at increased risk for developing?
      A)
      Acne
      B)
      Contact dermatitis
      C)
      Vitamin D deficiency
      D)
      Keloids
    4. Which of the following goals is most appropriate when caring for a client at risk for skin breakdown?
      A)
      The nurse will apply barrier cream to pressure areas.
      B)
      The nurse will assess the client's skin daily.
      C)
      The client will maintain intact skin.
      D)
      The client will be pain free.
    Page 5 of 15

    Exam Review

    1. The nurse assesses a client and notes tachypnea. Which respiratory rate reflects the nurse's assessment?
      A)
      Respiratory rate 20 breaths per minute
      B)
      Respiratory rate 14 breaths per minute
      C)
      Respiratory rate 26 breaths per minute
      D)
      Respiratory rate 8 breaths per minute
    2. What is considered a normal pupil diameter measured in millimeters?
      A)
      3 to 5 mm
      B)
      1 to 3 mm
      C)
      2 to 4 mm
      D)
      5 to 7 mm
    3. The nurse is assessing a client who came to the hospital with tonsilitis. Which finding should the nurse prioritize?
      A)
      Temperature of 102.6 F (39.2)
      B)
      Swollen lymph nodes
      C)
      Difficulty swallowing
      D)
      Tonsils are bright red
    4. A nurse has received bedside report on a group of clients. Which client is at the greatest risk for developing pressure injuries?
      A)
      A 60-year-old client with history of strokes and lower extremity paralysis
      B)
      A 30-year-old client recovering from a laparoscopic appendectomy
      C)
      A 45-year-old client with a fractured femur who ambulates as tolerated
      D)
      A 72-year-old client with type 2 diabetes and peripheral neuropathy
    Page 6 of 15