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    Exam Review

    1. Exhibits Which assessment(s) should the nurse conduct? Select all that apply.
      (SATA)
      A)
      Muscle tone
      B)
      Level of consciousness
      C)
      Cranial nerves
      D)
      Brudzinski reflexes
      E)
      Pupil size
      F)
      Glasgow coma scale
      G)
      Romberg's test
    2. When assessing a client's range of motion, the nurse notes crepitation with movement of the left knee. Which information in the client's history is most likely related to this finding?
      A)
      Needle aspiration of the synovial space.
      B)
      Knee arthroplasty surgery.
      C)
      Degenerative disease.
      D)
      History of a fractured patella.
    3. While auscultating for bowel sounds in an adult client, the nurse notes a series of gurgles that last about 3 seconds and occur every 5 to 10 seconds in all quadrants. How should the nurse document this finding?
      A)
      Borborygmi sounds.
      B)
      Hypoactive bowel sounds.
      C)
      Normal bowel sounds.
      D)
      Hyperactive bowel sounds.
    4. The nurse is assessing a client with gallstones for jaundice. Which action should the nurse perform to confirm this information?
      A)
      Review recent serum bilirubin levels.
      B)
      Assess conjunctival sacs of lower lids for pallor.
      C)
      Observe the client's urine for dark orange color.
      D)
      Examine client's sclera for icterus.
    Page 1 of 14

    Exam Review

    1. A client asks the nurse to look at a mole located on the back. The client tells the nurse that the mole has changed from brown to black and enlarged in size. Which is the priority nursing action?
      A)
      Advise the client to see his healthcare provider for immediate evaluation.
      B)
      Offer to teach a family member how to monitor the skin around the mole.
      C)
      Encourage the client to keep checking the mole with a magnifying mirror.
      D)
      Ask the client if he often spends time outside in the sun without a shirt.
    2. The nurse is obtaining a health history for a client being admitted for new onset seizures. Which action should the nurse implement to accurately record the health history findings?
      A)
      Enter the information in the electronic medical record at the client's bedside.
      B)
      Document the assessment findings on the computer at the nursing station.
      C)
      Document the client's history that is directly related to current admission diagnoses.
      D)
      Enter subjective data in the note section of the client's electronic medical record.
    3. The nurse assesses a young adult female who was brought to the emergency department (ED) by her boyfriend because she has not been feeling well all day and he believes she is getting worse. Which finding supports the nurse's suspicion that the client is experiencing appendicitis?
      A)
      Sudden onset of severe anxiety, fear, and concern.
      B)
      Periumbilical pain localizing to right lower quadrant.
      C)
      Anorexia progressing to nausea, vomiting, and fever.
      D)
      Diffuse abdominal pain with elevated neutrophil count.
    4. To assess for the presence of egophony, which instruction should the nurse give the client who has a lung abscess?
      A)
      Repeat the number "99" during a systematic auscultation of the thorax
      B)
      Whisper "one, two, three" in sequence during auscultation of the thorax.
      C)
      Repeat vocalizing the letter "E" while the thorax is auscultated.
      D)
      Breathe in and out while all lobes of both lungs are auscultated.
    Page 2 of 14

    Exam Review

    1. Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.
      ✓Auscultate the lungs for adventitious breath sounds
      ✓Inspect the chest for lag on the affected side
      ✓Lobar pneumonia
      ✓Respiratory rate and pulse
      ✓Crackles
      Actions to take
      ✓Auscultate the lungs for adventitious breath sounds
      ✕Assess for tactile fremitus
      ✕Assess for muffled heart sounds
      ✕Assess for prolonged expiration
      ✓Inspect the chest for lag on the affected side
      Potential Condition
      ✕Pleural effusion
      ✕Atelectasis
      ✕Acute bronchitis
      ✓Lobar pneumonia
      Parameters to monitor
      ✕Loud bronchial breathing
      ✕Cyanosis
      ✕Wheezing
      ✓Respiratory rate and pulse
      ✓Crackles
    2. When assessing an older adult client with a history of cardiovascular disease, dyspnea, and peripheral edema, which method is best for the nurse to use to assess the client's pulse rate?
      A)
      Palpate the radial pulses in both arms for a deficit.
      B)
      Feel the volume of the dorsalis pedis and posterior tibialis pulses.
      C)
      Use the stethoscope to listen over the carotid artery.
      D)
      Auscultate the apical pulse at the point of maximal impulse.
    3. The nurse is doing a health assessment of a client who smoked three packs of cigarettes every day for the last twenty years before quitting two years ago. How should the nurse document the client's pack-years? (Enter the numerical value only.)
    4. When assessing an older adult client, which finding is most indicative of dehydration?
      A)
      A Loss of skin elasticity in the hand
      B)
      Thinning hair in the lower extremities
      C)
      Skin is warm and dry.
      D)
      Tenting noted in subclavicular area.
    Page 3 of 14

    Exam Review

    1. A 16-year-old client with a history of chronic ear infections when younger comes to the clinic for a health exam. No ear pain, vertigo or hearing loss is reported during history taking. Inspection of the tympanic membranes (TM) reveals the presence of dense white patches on the TMs in both ears. Both TMs are a translucent gray with a light reflex at 5:00. All landmarks are visible. Based on these findings, which action should the nurse take next?
      A)
      Referral to an audiologist for a hearing evaluation.
      B)
      Culture the white patches for possible fungal growth.
      C)
      Record the findings in the client's record.
      D)
      Clean the ears to remove excess wax build up.
    2. The nurse plans to assess a client's ability to think abstractly. Which question or statement is likely to provide the best information about the client's abstract thinking?
      A)
      "Has anyone come to visit you today?"
      B)
      "In what year were you born?"
      C)
      "What does, "The early bird catches the worm," mean
      D)
      "Count backwards by 7, starting with 100."
    3. The nurse is performing oral inspection of a client with dark pigmented skin. The nurse observes a patchy discoloration of the buccal mucosa- Which action should the nurse take?
      A)
      Document this finding in the medical record.
      B)
      Ask the client about use of irritating chemical agents.
      C)
      Schedule an appointment with a dermatologist
      D)
      Ask if the client recently received any antibiotics.
    4. When assessing heart sounds of a client with rheumatic valvular heart disease, where should the nurse place the stethoscope to auscultate the tricuspid valve?
      A)
      Left fourth intercostal space next to left sternal border.
      B)
      Second right intercostal space.
      C)
      Third left intercostal space.
      D)
      Left fifth intercostal space, midclavicular line.
    Page 4 of 14

    Exam Review

    1. While assessing a client who is obese, the nurse is unable to locate the gallbladder when palpating below the liver margin at the lateral border of the rectus abdominal muscle. Which is the most likely explanation for failure to locate the gallbladder by palpation?
      A)
      Palpating in the wrong abdominal quadrant.
      B)
      Deeper palpation technique is needed.
      C)
      The gallbladder is normal.
      D)
      The client is too obese.
    2. The nurse assesses that a client has nailbed clubbing. Which additional information is consistent with this finding?
      A)
      Absent deep tendon reflexes.
      B)
      Capillary refill less than 3 seconds.
      C)
      3+ peripheral dependent edema.
      D)
      Oxygen saturation of 85%.
    3. The nurse begins a client's musculoskeletal assessment. While using the technique of inspection, the nurse assesses for which possible findings? Select all that apply.
      A)
      Contracture.
      B)
      Kyphosis.
      C)
      Osteopenia.
      D)
      Atrophy.
      E)
      Crepitus.
    4. While conducting a physical assessment, the nurse shines a pen light into a client's right eye and moves the light source to check the client's left eye. Which finding indicates the need for further evaluation?
      A)
      Bilateral pupil size changes as the distance of the light source varies.
      B)
      The right pupil constricts and the left consensually responds.
      C)
      The left iris is "notched" and the pupil size changes minimally.
      D)
      Both pupils are equal in size and constrict readily to the light source.
    Page 5 of 14

    Exam Review

    1. The school nurse is interviewing a 13-year-old girl who wants to go home from school because of "back pain." Which question should the nurse ask the adolescent first?
      A)
      "Have you taken any medications to relieve the pain?"
      B)
      "Does changing your position make the pain worse?"
      C)
      "What were you doing when you first noticed the problem?"
      D)
      "Do you remember ever having this type of pain in the past?"
    2. During a health assessment, the client reports being treated for osteoarthritis. The nurse examines a client's hands and finds Heberden's nodes- Which finding should the nurse document in the client's medical record?
      A)
      Proximal inter-tarsal joint swelling of big toe.
      B)
      Non-painful enlarged interphalangeal joints.
      C)
      Distal interphalangeal joint nodules that deviate.
      D)
      Frozen, non-movable phalangeal joints.
    3. The nurse observes that the lower legs of a client with diabetes mellitus are shiny, and with no hair growth. To obtain additional data to support these findings, which assessment should the nurse perform?
      A)
      Palpate the client's dorsalis pedis pulses.
      B)
      Compare the range of motion of both legs.
      C)
      Ask if the client often feels weak or hungry.
      D)
      Measure the client's capillary glucose.
    4. The nurse reviews a client's laboratory results for a client admitted with gastrointestinal (Gl) bleeding who has no visible hemorrhoids on inspection of the anal area. Which laboratory test indicates that the client's bleeding is not yet resolved? Reference Range: Hematocrit (Hct) [42% to 52% (0.42 to 0.52 volume fraction)] Prothrombin time (PT) [11.0 to 12.5 seconds (8596-10096)] Glycosylated hemoglobin (AIC) [4% to 5.996]
      A)
      Hemoglobin AIC changes from 10% to 8%.
      B)
      Hematocrit changes from 36% to 32%.
      C)
      Guaiac test changes from positive to negative.
      D)
      Prothrombin time (PT) changes from 12 seconds to 18 seconds.
    Page 6 of 14