Basic Physical Assessment NCLEX 3000
The nurse plans to obtain client information from a primary source. Which of the following is a primary information source?
3. The client
An adolescent client seeks medical attention because of a sore throat and probable mononucleosis. The nurse palpates the client’s submandibular lymph nodes for enlargement. Identify the area where the nurse should palpate to best feel these nodes.
The submandibular lymph nodes are located beneath the mandible, or lower jaw, halfway to the chin. These nodes may be enlarged in a client with a throat infection or mononucleosis.
To help assess a client’s cerebral function, the nurse should ask:
1. “Have you noticed a change in your memory?”
The nurse is assessing an elderly client. When performing the assessment, the nurse should consider that one normal age-related change is:
3. diminished reflexes.
A client complains of lower abdominal pressure. The nurse notes a firm mass extending above the symphysis pubis. Which condition is the most likely cause of these findings?
4. Distended bladder
Which reaction is a normal response to a corneal sensitivity test?
To evaluate a client’s posterior tibial pulse, where should the nurse palpate?
3. On the inner aspect of the ankle, below the medial malleolus
When an emergency department nurse enters the room, the client complains that she’s spitting up blood when she coughs. The nurse performs a quick review of the client’s pertinent health history, which should include:
2. the history of the present problem, allergies, medications, and recent major operations.
A newly hired licensed practical nurse (LPN) is helping the charge nurse admit a client. The charge nurse asks the LPN if she understands the facility’s rules of ethical conduct. Which statement by the LPN indicates the need for further teaching?
4. “I don’t discuss advance directives unless the client initiates the conversation.”
An elderly client who is 5′ 4″ and weighs 145 lb is admitted to the long-term care facility. The admitting nurse takes this report: The client sits for long periods in his wheelchair and has bowel and bladder incontinence. He is able to feed himself and has a fair appetite, eating best at breakfast and poorly thereafter. He doesn’t have family members living near by and is often noted to be crying and depressed. He also frequently requires large doses of sedatives. Which factors place the client at risk for developing a pressure ulcer?
2. Incontinence, 3. Sitting for long periods of time, 4. Sedation
Which statement regarding heart sounds is correct?
4. S1 is loudest at the apex, and S2 is loudest at the base.
The nurse-manager asks the staff to decrease costs on the unit. Which practice would be the most beneficial in reducing costs?
1. Taking only necessary supplies into the clients’ rooms
The nurse is helping a client ambulate for the first time after 3 days of bed rest. Which observation by the nurse suggests that the client tolerated the activity without distress?
4. The client’s pulse and respiratory rates increased moderately during ambulation.
A 76-year-old client with no debilitating conditions belongs to which geriatric population?
The physician states that he’ll refer his client to a home health agency after discharge from the hospital. When is the most appropriate time for a referral to be initiated for a hospitalized client?
2. As soon as the need is identified
A client comes to the clinic for diagnostic allergy testing. Why is an intradermal injection used for such testing?
4. Intradermal drugs diffuse slowly.
A client states that he has 20/40 vision. Which statement about this client’s vision is true?
2. The client can read from 20′ (6 m) what a person with normal vision can read from 40′.
The nurse is monitoring a client for adverse reactions during barbiturate therapy. What is the major disadvantage of barbiturate use?
3. Potential for drug dependence
A client comes to the clinic for a routine checkup. To check the client’s gag reflex, the nurse should use which method?
2. Place a tongue blade lightly on the posterior aspect of the tongue.
The physician orders contact precautions for a client with a draining wound. Which action should the nurse take to initiate these precautions?
3. Place an isolation cart containing gloves and gowns outside the client’s room.
An elderly client comes to the clinic complaining of hearing loss. The nurse performs Weber’s test to assess the client’s ability to hear. Identify the location where the nurse should place the tuning fork to perform this test.
To perform Weber’s test, the tuning fork should be struck and then placed on the midline of the head. Weber’s test determines if sound is heard equally in both ears. If the client hears the sound louder in one ear, he probably has unequal hearing loss that requires further intervention.
Which statement about crackles is true?
4. They may be fine, medium, or coarse.
Two days after undergoing a total abdominal hysterectomy, a client complains of left calf pain, and venography reveals deep vein thrombosis (DVT). When checking this client, the nurse is most likely to detect:
4. left calf circumference 1″ (2.5 cm) larger than the right.
A client has been admitted to the hospital with signs of dehydration. Which action would be least beneficial in increasing the client’s fluid intake?
3. Serving fluids in large amounts
Which pulse should the nurse palpate during rapid data collection of an unconscious adult?
The physician teaches a client about the need to increase her intake of calcium. At a follow-up appointment, the nurse asks the client which foods she has been consuming to increase her calcium intake. Which answer suggests that teaching about calcium-rich foods was effective?
2. Yogurt and kale
A client undergoes a total abdominal hysterectomy. When checking the client 10 hours later, the nurse identifies which finding as an early sign of shock?
When collecting data on a geriatric client, the nurse expects to find various aging-related physiologic changes. These changes include:
4. delayed gastric emptying.
An adolescent boy comes to the emergency department seeking medical attention for severe pain located in the area of the appendix. Identify the area where the nurse would expect the pain to localize.
Pain and tenderness during an acute attack of appendicitis localizes in the right lower quadrant, midway between the umbilicus and the crest of the ilium.
A client reports abdominal pain. Which action would aid the nurse’s investigation of this complaint?
2. Palpating the painful area last
The nurse is obtaining a client’s pulse rate. Which pulse feature should the nurse document?
When examining a client with abdominal pain, the nurse should collect data on:
3. the symptomatic quadrant last.
The nursing staff is devising methods to improve continuity of care. Which practice should they change to promote continuity of care?
4. Recorded shift report
Why shouldn’t the nurse palpate both carotid arteries at the same time?
3. It may impair cerebral circulation
A child with rheumatic fever must have his heart rate measured while awake and while sleeping. Why are two readings necessary?
4. To compensate for the effects of activity on the heart rate
The ear canal of an adult:
2. slants downward.
To avoid recording an erroneously low systolic blood pressure because of failure to recognize an auscultatory gap, the nurse should:
4. inflate the cuff at least another 30 mm Hg after the radial pulse becomes impalpable.
The nurse is examining a client with suspected peritonitis. How does the nurse elicit rebound tenderness?
1. Pressing the affected area firmly with one hand, releasing pressure quickly, and noting any tenderness on release
The nurse is collecting data on a client before surgery. Which statement by the client would alert the nurse to the presence of risk factors for postoperative complications?
4. “I’ve cut my smoking down from two packs to one pack per day.”
A client has lymphedema in both arms and the nurse must measure blood pressure using a thigh cuff. In reference to the client’s baseline arm blood pressure, the nurse should expect the thigh to have a:
1. higher systolic blood pressure reading.
An elderly client is admitted to the hospital for a fractured hip. He has a history of aortic stenosis. Identify the area where the nurse should place the stethoscope to best hear the murmur.
The murmur of aortic stenosis is low-pitched, rough, and rasping. It’s loudest in the second intercostal space, to the right of the sternum.
The nurse is preparing a client for surgery that’s scheduled in 1 hour. During preparation, the client states that he doesn’t understand the surgical procedure and wishes not to proceed with surgery. What action should the nurse take?
3. Ask the surgeon to speak with the client about his concerns before surgery.
The nurse prepares to measure a client’s blood pressure. What is the correct procedure for measuring blood pressure?
3. Wrapping the cuff around the limb, with the uninflated bladder covering about three-fourths of the limb circumference
When evaluating a client’s body for warmth, the nurse should use which part of the hand?
3. Dorsal surface
A client with a recent history of a stroke has been discharged from the rehabilitation facility with a walker. During the client’s return visit to the physician’s office, the nurse assesses his gait. Which finding indicates the need for further teaching about walker use?
3. The client’s arms are fully extended when using the walker.
A client comes to the clinic complaining of a sore throat and fever. To obtain a throat culture, the nurse asks the client to tilt his head back, open his mouth, and close his eyes. What should the nurse do next to obtain the specimen?
3. Swab the tonsillar areas from side to side, avoiding contact with the tongue, cheeks, and teeth.
The nurse measures a client’s temperature at 102° F. What is the equivalent Centigrade temperature?
3. 38.9° C
To evaluate a client’s chief complaint, the nurse performs deep palpation. The purpose of deep palpation is to assess which of the following?
An 80-year-old client comes to the clinic complaining of shortness of breath. When listening to the client’s lungs, the nurse hears crackles (intermittent, high- and low-pitched popping sounds in the lower bases of the lungs) during inspiration. In which conditions might the nurse auscultate crackles?
2. Acute respiratory distress syndrome, 3. Pneumonia, 4. Pulmonary edema
The nurse uses a stethoscope to auscultate a client’s chest. Which statement about a stethoscope with a bell and diaphragm is true?
2. The diaphragm detects high-pitched sounds best.
When palpating the bladder of an adult client, the nurse should identify which finding as normal?
3. A nonpalpable bladder
When auscultating a client’s abdomen, the nurse detects high-pitched gurgles over the lower right quadrant. Based on this finding, the nurse suspects:
3. nothing abnormal.
The nurse is collecting data on a 47-year-old client who has come to the physician’s office for his annual physical. The nurse should keep in mind that one of the first physical signs of aging is:
2. failing eyesight, especially close vision.
Which trait is the most important for ensuring that a nurse-manager is effective?
1. Communication skills
The nurse has just received the shift report. Which client should the nurse assess first?
2. A 60-year-old client admitted with chronic obstructive pulmonary disease (COPD) whose oxygen saturation level is 84%
Why should the nurse inspect first and then auscultate when collecting data on a pediatric client?
2. Because the child may cry as data collection proceeds, making auscultation difficult
The nurse correctly identifies which of the following as belonging to the dorsal cavity?
3. Vertebral canal
While collecting data on a newly admitted client, the nurse notes clear, thin nasal discharge. This type of nasal discharge may indicate:
2. cerebrospinal fluid leak.
When performing an abdominal assessment, the nurse should follow which examination sequence?
1. Inspection, auscultation, percussion, and palpation
A diabetic client comes to the clinic for medical attention because of numbness and tingling in his lower extremities. The nurse obtains the client’s vital signs and palpates the dorsalis pedis pulse. Identify the area where the nurse places her fingers to palpate the pedal pulse.
The pedal pulse is located on the top portion of the foot. Because clients with diabetes have complications related to circulation in the lower extremities, health care providers should palpate pedal pulses and check capillary refill.
What should the nurse do before auscultating the lungs of a male client with chest hair?
4. Lightly wet the client’s chest hair.
The nurse can auscultate for heart sounds more easily if the client is:
4. leaning forward.
After suctioning a tracheostomy, the nurse evaluates the client to determine the effectiveness of the suctioning. Which findings indicate that the airway is now patent?
2. Clear breath sounds and non-labored respirations
An 82-year-old client is admitted to the hospital with a diagnosis of pneumonia. The nurse learns that the client lives alone and hasn’t been eating or drinking. When collecting data, the nurse would expect to find:
The nurse is collecting data on a postoperative client. Which of the following should the nurse document as subjective data?
3. Client’s description of pain
A client requests something to treat his constipation. The client’s medication administration record contains an order for a laxative to be administered every other day as needed. Which assessment finding by the licensed practical nurse indicates the need to notify the registered nurse (RN) before administering the laxative?
3. Presence of blood in the client’s stool
An elderly client tells the nurse that he doesn’t want to take a bath. Which action by the nurse is most appropriate?
4. Explaining why a bath is important to overall health, and telling the client that she’ll return in 30 minutes to help him bathe
A mother comes to the clinic with her 5-year-old son who’s complaining of a fever and sore throat. The nurse documents the client’s tonsils as 3+. This means they’re:
3. touching the uvula.
A 40-year-old client is admitted with a diagnosis of new-onset atrial fibrillation. To obtain an accurate pulse count, the nurse counts the apical heart rate. Identify the area where the nurse should place the stethoscope to best hear the apical rate.
The apical heart rate is best heard at the point of maximal impulse, which is generally in the fifth intercostal space at the midclavicular line.
When auscultating a client’s chest, the nurse assesses a second heart sound (S2). This sound results from:
1. opening of the mitral and tricuspid valves.
The emergency department nurse obtains laboratory test results for a newly admitted client. Which result should she report to the physician immediately?
1. Cardiac troponin I level of 3.0 mcg/L
A licensed practical nurse (LPN) is planning client assignments in a long-term care facility. Which task should she assign to another LPN?
3. Performing dressing changes
When is the best time for the nurse to check a client for rebound tenderness?
4. At the end of the examination
The nurse is auscultating a client’s chest. How can the nurse differentiate a pleural friction rub from other abnormal breath sounds?
3. A rub occurs during both inspiration and expiration and produces a squeaking or grating sound.
The nurse is teaching a client who will be discharged soon how to change a sterile dressing on the right leg. During the teaching session, the nurse notices redness, swelling, and induration at the wound site. What do these signs suggest?
The nurse is caring for a client who has suffered a severe stroke. During data collection, the nurse notices Cheyne-Stokes respirations. Cheyne-Stokes respirations are:
1. progressively deeper breaths followed by shallower breaths with apneic periods.
The nurse is helping to plan a teaching session for a client who will be discharged with a colostomy. When describing a healthy stoma, which statement should the nurse be sure to include?
2. “At first, the stoma may bleed slightly when touched.”
To assess the effectiveness of cardiac compressions during adult cardiopulmonary resuscitation (CPR), the nurse should palpate which pulse site?
The nurse is collecting data on a client who has a rash on his chest and upper arms. Which questions should the nurse ask in order to obtain more information about the client’s rash?
1. “When did the rash start?”, 2. “Are you allergic to any medications, foods, or pollen?”, 4. “What have you been using to treat the rash?”, 5. “Have you traveled outside of the country?”
A client complains of abdominal pain. To elicit as much information about the pain as possible, the nurse should ask:
4. “What does the pain feel like?”
When checking the facial lacerations of a middle-aged client admitted to the facility 1 week ago, the nurse observes scabs around the lacerations. Scabs indicate which phase of wound healing?
Which of the following correctly describes the anatomic position?
3. Palms are turned forward
Tachycardia can result from:
3. fear, pain, or anger.
To evaluate a client’s cerebellar function, the nurse should ask:
1. “Do you have any problems with balance?”
A client has just undergone a bronchoscopy. Which nursing intervention is most important at this time?
2. Checking airway patency
When testing a client’s pupils for accommodation, the nurse should interpret which findings as normal?
3. Constriction and convergence
Before a transesophageal echocardiogram, a client is given an oral topical anesthetic spray. Upon return from the procedure, the nurse observes that the client has no active gag reflex. In response, the nurse should:
2. withhold food and fluids.
The nurse is obtaining the health history of a client whose background differs from the nurse’s. To develop culturally acceptable strategies for nursing care, the nurse should recognize which client factor?
2. Cultural influences
The nurse finds a client lying on the floor of the hospital corridor. After determining unconsciousness and breathlessness, and providing two ventilations, the nurse checks the client’s carotid artery for a pulse. Identify the area where the nurse can best palpate the carotid pulse.
The carotid artery is located in the neck in the groove between the trachea and the sternocleidomastoid muscle. It’s the artery of choice for determining a pulse in this situation because it’s usually the most accessible.
Which of the following is the most common source of airway obstruction in an unconscious victim?
3. The tongue
The nurse-manager has posted shift assignments on the unit. Which duty should the licensed practical nurse (LPN) refuse?
2. Conducting the admission assessment on a new client
An elderly client is scheduled for discharge from the hospital. Which statement by the client indicates that further teaching is needed?
3. “My daughter just recently waxed my hardwood floors.”
The nurse must check a client’s splinted extremity for neurovascular damage. What should she do?
3. Compare the capillary refill of each extremity, making sure it’s the same bilaterally.
When routinely evaluating a client for any atypical signs or symptoms, the nurse should remember that:
1. aging can reduce the body’s ability to regulate body temperature.
Vasodilation or vasoconstriction produced by an external cause will interfere with an accurate assessment of a client with peripheral vascular disease (PVD). Therefore, the nurse should:
1. keep the client warm.
All of the following components may be part of a client’s medical record. Which one is the major source of subjective data about the client’s health status?
1. Health history
When inspecting a client’s skin, the nurse finds a vesicle on the client’s arm. Which description applies to a vesicle?
3. Circumscribed, elevated, and filled with serous fluid
Why should an infant be quiet and seated upright when the nurse checks his fontanels?
4. Lying down and crying can cause the fontanels to bulge.
A client, age 75, is admitted to the facility. Because of the client’s age, the nurse should modify data collection by:
4. allowing extra time for this task.
A 60-year-old client comes to the clinic seeking medical attention for a rash. The nurse assesses the rash and finds that the client’s back and right side are covered with vesicles (elevated, round, blisterlike lesions that are filled with clear fluid). A vesicular rash may be associated with which conditions?
1. Contact dermatitis, 2. Herpes zoster, 3. Smallpox
A client is being discharged from the hospital after a total hip replacement. The physician has ordered home health services for the client. What’s the most appropriate action for the nurse to take?
1. Contact the home health agency and provide a report of the client’s condition and needs.
The nurse is teaching a client about the safe use of an I.V. infusion pump that he’ll require at home after discharge. Which statement by the client indicates the need for further teaching?
3. “If it shocks me, I’ll wait 10 minutes before using it again.”
Which of the following planes divides the body longitudinally into anterior and posterior regions?
1. Frontal plane
The nurse is collecting data on a client who may be in the early stages of dehydration. Early manifestations of dehydration include:
4. thirst or confusion
At 8 a.m., the nurse collects data on a client who’s scheduled for surgery at 10 a.m. During data collection, the nurse detects dyspnea, a nonproductive cough, and back pain. What should the nurse do next?
3. Notify the physician immediately of these findings.
The nurse must evaluate skin turgor of an elderly client. While doing so, the nurse should remember that:
3. inelastic skin turgor is a normal part of aging.
A 35-year-old client is admitted to the hospital for routine outpatient surgery. Before surgery, the nurse auscultates the client’s chest for breath sounds. Identify the area where the nurse should expect to hear bronchovesicular breath sounds.
Bronchovesicular breath sounds are best heard next to the upper third of the sternum and between the scapulae. These breath sounds are equal in length during inspiration and expiration.