Physical Assessment
A nurse is mentoring a newly licensed nurse who is performing a physical assessment on a hospitalized patient. The new graduate nurse begins explaining the reason for the assessment to the patient. Which statement made by the new graduate nurse requires the preceptor to intervene?
A. “This assessment helps us identify any new health problems early.”
B. “I’m just going through this checklist because it’s hospital policy.”
C. “The assessment allows us to monitor your ongoing health status.”
D. “Completing this exam helps your care team plan the best treatment for you.”
Answer: B. “I’m just going through this checklist because it’s hospital policy.”
Rationale:
This statement may cause the patient to feel that the assessment is impersonal or unnecessary, potentially reducing trust and cooperation. Patient education should emphasize the purpose and benefit of the assessment for the patient’s health, not simply that it is a routine policy. The other statements correctly explain the assessment’s purpose and benefit to the patient.
The nurse is providing health teaching at a community health fair. Which activity represents primary prevention?
A. Administering the influenza vaccine to older adults.
B. Teaching a client with heart failure how to weigh themselves daily.
C. Leading a stroke rehabilitation exercise group.
D. Screening middle-aged adults for hypertension.
Correct Answer:
A. Administering the influenza vaccine to older adults.
Rationale:
Primary prevention = interventions that prevent disease before it occurs (e.g., immunizations, health education, lifestyle modification).
Secondary prevention = early detection (screening).
Tertiary prevention = managing established disease to prevent complications (rehab, teaching for chronic conditions).
A nurse is performing a routine assessment on a 62-year-old patient who reports unintended weight loss over the past three months and poor appetite. Which assessment finding is most consistent with malnutrition?
A. Dry, flaky skin and brittle nails
B. Mild ankle swelling
C. Occasional headaches
D. Shortness of breath with exertion
Answer: A. Dry, flaky skin and brittle nails
Rationale:
Malnutrition often presents with physical signs such as dry, flaky skin, brittle nails, hair loss, and muscle wasting due to deficiencies in essential nutrients. Mild ankle swelling could indicate fluid retention, headaches are nonspecific, and shortness of breath with exertion may relate to cardiovascular or respiratory conditions rather than malnutrition.
A nurse is preparing to teach a newly diagnosed diabetic patient about carbohydrate counting and blood glucose monitoring. When is the most appropriate time for the nurse to provide this teaching?
A. During the patient’s evening rest period
B. Immediately after a stressful diagnostic procedure
C. When the patient is alert and receptive in the morning
D. While the patient is receiving pain medication and feeling drowsy
Answer: C. When the patient is alert and receptive in the morning
Rationale:
Patient education is most effective when the patient is alert, able to focus, and receptive. Teaching during periods of stress, drowsiness, or rest may reduce retention of information.
An older-adult patient requires an intramuscular (IM) injection of a prescribed antibiotic. Which site is the most appropriate for the nurse to use?
A. Deltoid
B. Dorsogluteal
C. Vastus lateralis
D. Abdomen
Answer: C. Vastus lateralis
Rationale:
For older adults, the vastus lateralis is preferred for IM injections because it has a well-developed muscle mass, fewer major nerves, and a lower risk of injury compared to the dorsogluteal or deltoid sites. The abdomen is not an IM site.
A nurse is preparing to examine a 72-year-old patient admitted with chronic obstructive pulmonary disease (COPD) exacerbation. The patient reports shortness of breath and has labored breathing. Which position should the nurse assist the patient into to facilitate breathing during the assessment?
A. Supine with pillows under the knees
B. High Fowler’s position
C. Lateral recumbent position
D. Trendelenburg position
Answer: B. High Fowler’s position
Rationale:
High Fowler’s position (sitting upright at 90 degrees) maximizes chest expansion and facilitates lung ventilation, which is particularly important for patients experiencing dyspnea or with respiratory conditions like COPD or pneumonia. Supine and Trendelenburg positions can impair breathing, while the lateral recumbent position is mainly used for comfort or specific exams, not for optimizing oxygenation.
The nurse cares for a client who recently had a cerebrovascular accident (CVA). Which nursing intervention is tertiary prevention?
A. Teaching stroke warning signs to high-risk clients
B. Leading a support group for stroke survivors
C. Administering annual flu vaccines
D. Conducting vision screenings in older adults
Correct Answer: B. Leading a support group for stroke survivors
Rationale: Tertiary prevention helps manage disease and prevent complications in those already affected.
A nurse is managing care for several stable patients receiving tube feedings on a medical-surgical unit. Which task is appropriate to delegate to the nursing assistive personnel (NAP)?
A. Assessing the patient’s tolerance to the tube feeding
B. Administering the prescribed tube feeding
C. Measuring and documenting the patient’s oral intake
D. Adjusting the tube feeding rate based on patient response
Answer: C. Measuring and documenting the patient’s oral intake
Rationale:
Delegation to NAP should involve tasks that do not require clinical judgment. Measuring and documenting intake is within the NAP’s scope. Assessment, administration of enteral nutrition, and adjusting rates require nursing knowledge and critical thinking and should be performed by the nurse.
A patient admitted with community-acquired pneumonia is preparing for discharge. When should the nurse begin discharge planning for this patient?
A. Only on the day of discharge
B. During the first shift after admission
C. After the patient’s cough has completely resolved
D. After all lab values return to normal
Answer: B. During the first shift after admission
Rationale:
Discharge planning should begin at admission to ensure a smooth transition, identify patient needs, arrange follow-up care, and prevent readmissions. Waiting until symptoms resolve or labs normalize may delay necessary education and planning.
A nurse is closely monitoring an older adult patient for signs of digoxin toxicity. Which age-related physiological change most contributes to this patient’s increased risk?
A. Increased gastric acid secretion
B. Decreased renal clearance
C. Increased cardiac output
D. Enhanced hepatic metabolism
Answer: B. Decreased renal clearance
Rationale:
Older adults often have decreased kidney function, which can reduce drug excretion and increase the risk of toxicity for medications like digoxin.
During a routine checkup at a community clinic, the nurse reviews the patient’s health history and notes a previous diagnosis of seasonal allergies. Which assessment finding would the nurse expect to observe in this patient?
A. Wheezing and shortness of breath
B. Runny nose, sneezing, and itchy eyes
C. Swelling of the ankles and feet
D. Persistent high fever and chills
Answer: B. Runny nose, sneezing, and itchy eyes
Rationale:
Allergic reactions commonly present with upper respiratory symptoms such as sneezing, runny nose, nasal congestion, and itchy, watery eyes. Wheezing may occur in severe allergic reactions but is more characteristic of asthma. Swelling of the ankles and feet suggests fluid retention, and persistent high fever and chills are indicative of infection, not allergies.
A nurse is working in a community clinic. Which client activity represents secondary prevention?
A. Receiving the HPV vaccine
B. Attending a stress management workshop
C. Participating in a colonoscopy screening
D. Enrolling in cardiac rehabilitation after a myocardial infarction
Correct Answer: C. Participating in a colonoscopy screening
Rationale: Screening = secondary prevention (detecting disease early).
A nurse is caring for a 68-year-old patient who had a recent right-sided stroke. The patient has left-sided weakness, drooling, and a decreased gag reflex. Which action should the nurse take when assisting with oral feeding?
A. Place the patient in a semi-Fowler’s position and feed small bites slowly
B. Encourage the patient to drink fluids quickly between bites
C. Feed the patient while they are lying flat in bed
D. Allow the patient to self-feed without supervision
Answer: A. Place the patient in a semi-Fowler’s position and feed small bites slowly
Rationale:
Patients with neurological deficits affecting swallowing are at high risk for aspiration. Feeding in a semi-Fowler’s position, offering small bites, and closely supervising reduces aspiration risk. Drinking quickly, lying flat, or unsupervised feeding increases the risk of choking and aspiration pneumonia.
A nurse is teaching a patient how to safely use a walker after hip replacement surgery. Which learning objective is most appropriate for inclusion in the teaching plan?
A. Patient will describe the anatomy of the hip joint.
B. Patient will demonstrate walking with a walker without losing balance.
C. Patient will verbalize the benefits of exercise for general health.
D. Patient will list potential complications of hip surgery.
Answer: B. Patient will demonstrate walking with a walker without losing balance
Rationale:
Learning objectives for skill-based teaching should focus on measurable performance. Demonstration of safe walker use ensures patient safety and independence.
A patient presents to the emergency department with a severe migraine headache and requests immediate relief. Which route of medication administration will provide the fastest absorption?
A. Oral tablet
B. Subcutaneous injection
C. Intravenous (IV) injection
D. Rectal suppository
Answer: C. Intravenous (IV) injection
Rationale:
IV administration bypasses absorption barriers, delivering the drug directly into the bloodstream, making it the fastest method for rapid pain relief. Oral and rectal routes take longer, and subcutaneous absorption is slower than IV.
A 68-year-old patient is admitted with congestive heart failure. On admission, the patient’s weight is 180 lb. On the third day of hospitalization, the patient’s weight is recorded as 187 lb. Which condition should the nurse assess for in this patient?
A. Dehydration
B. Fluid retention
C. Malnutrition
D. Hyperthyroidism
Answer: B. Fluid retention
Rationale:
A rapid weight gain over a few days, especially in a patient with congestive heart failure, often indicates fluid retention. This can occur due to worsening heart failure and may require adjustments in medications such as diuretics. Dehydration typically causes weight loss, malnutrition develops over weeks to months, and hyperthyroidism usually leads to weight loss, not gain.
A nurse is caring for four clients. Which client should the nurse see first, based on Maslow’s hierarchy of needs?
A. A client who is anxious about an upcoming surgery and requests emotional support.
B. A client who reports feeling lonely and is requesting a visit from family.
C. A client whose oxygen saturation is 84% on room air and is experiencing shortness of breath.
D. A client who states, “I don’t feel like I have a purpose anymore since retiring.”
C. A client whose oxygen saturation is 84% on room air and is experiencing shortness of breath.
Rationale:
Maslow’s hierarchy prioritizes physiological needs (airway, breathing, circulation) above safety, love/belonging, esteem, and self-actualization. Hypoxemia threatens survival and must be addressed first. The other needs (emotional support, social connection, and self-actualization) are important but not life-threatening.
A nurse is caring for a 76-year-old patient who was recently diagnosed with Parkinson’s disease. During the assessment, the patient reports coughing and choking while eating. Which complication is the patient at greatest risk for developing?
A. Gastroesophageal reflux
B. Neurogenic dysphagia
C. Oral candidiasis
D. Dental caries
Answer: B. Neurogenic dysphagia
Rationale:
Patients with Parkinson’s disease have impaired neurological control of the muscles involved in swallowing, placing them at risk for neurogenic dysphagia. Symptoms can include coughing, choking, and difficulty swallowing. Gastroesophageal reflux, oral candidiasis, and dental caries may occur independently but are not directly caused by neurological swallowing dysfunction.
A patient with a severe peanut allergy requires epinephrine at home. Which learning objective should the nurse prioritize when teaching this patient?
A. Demonstrate how to read food labels to identify allergens
B. Identify strategies to eat a balanced diet
C. Verbalize understanding of when to seek routine medical care
D. Demonstrate proper use of the epinephrine auto-injector
Answer: D. Demonstrate proper use of the epinephrine auto-injector
Rationale:
For a patient with life-threatening allergies, the highest priority is the ability to correctly administer epinephrine during an emergency to prevent fatal outcomes.
A nurse is caring for a patient with dysphagia who is at risk for aspiration. Which nursing action is the most appropriate to reduce this risk?
A. Offer thin liquids and large bites of food to encourage swallowing
B. Position the patient upright at 90 degrees during meals
C. Allow the patient to eat quickly to finish the meal sooner
D. Place the patient supine and elevate the head of the bed slightly
Answer: B. Position the patient upright at 90 degrees during meals
Rationale:
Proper positioning (high Fowler’s) facilitates swallowing and decreases aspiration risk. Thin liquids, supine positioning, and rapid eating increase aspiration risk.
The patient is an 80-year-old male visiting the clinic for a routine physical. He reports fatigue and weakness, skin is warm and dry, pulse is 116 beats/min, and urinary sodium is slightly elevated. Which of the following nursing instructions should the nurse provide? (Select all that apply.)
A. Encourage increased daily fluid intake, including water and other hydrating fluids
B. Monitor for signs of dizziness, confusion, or decreased urine output
C. Restrict sodium intake to prevent fluid retention
D. Check daily weight to monitor fluid status
E. Begin vigorous exercise immediately to improve cardiovascular endurance
Correct Answers:
A, B, D
Rationale:
A: Older adults are at higher risk for dehydration; increasing fluids is essential.
B: Monitoring for dizziness, confusion, or decreased urine output helps detect worsening dehydration.
D: Daily weights help track fluid status in older adults.
C: Sodium restriction is not indicated unless the patient has hypertension or fluid overload.
E: Vigorous exercise is not appropriate while dehydrated; hydration should be addressed first.
The public health nurse plans community education programs. Which of the following interventions are examples of primary prevention? (Select all that apply.)
A. Teaching new parents about safe sleep practices for infants
B. Providing mammogram referrals to women over age 40
C. Distributing bicycle helmets to school-aged children
D. Administering MMR vaccines at a pediatric clinic
E. Teaching a diabetic support group about proper foot care
Correct Answers: A, C, D
Rationale:
A = Primary (preventing SIDS before it occurs)
C = Primary (injury prevention)
D = Primary (vaccination prevents illness)
B = Secondary (screening/detection)
E = Tertiary (managing existing illness).
A nurse is planning care for a group of older adult patients on a medical-surgical unit. Which of the following findings or actions should the nurse address immediately? (Select all that apply.)
A. A patient with a stroke has drooling and coughs while eating.
B. A patient receiving tube feedings is repositioned to 30 degrees after the feeding.
C. A patient reports unintended weight loss over 2 months and has thinning hair.
D. A stable patient receiving tube feeding has NAP document the intake of water and juice.
E. A patient with COPD is sitting upright in a chair while eating a meal.
Answer: A, C
Rationale:
A: Drooling and coughing during meals indicate high aspiration risk.
C: Weight loss and thinning hair suggest malnutrition — requires intervention.
B: Proper positioning post-feeding is appropriate.
D: Appropriate delegation to NAP.
E: Proper positioning for eating — safe.
A nurse is teaching a group of newly licensed nurses about HIPAA and patient confidentiality. Which behaviors indicate correct understanding? (Select all that apply.)
A. Discussing patient information only with the healthcare team involved in the patient’s care
B. Accessing a patient’s medical record to verify billing information for a friend
C. Logging out of the computer terminal after charting patient care
D. Sending a patient’s lab results to a family member without the patient’s consent
E. Storing printed patient reports in a locked cabinet
Answer: A, C, E
Rationale:
HIPAA requires safeguarding patient information, accessing records only for legitimate care or billing purposes, and proper storage or disposal. Accessing records for personal reasons or sharing without consent violates confidentiality.
A nurse is following best practices to reduce the risk of needlestick injuries while administering medications. Which actions should the nurse take? (Select all that apply.)
A. Recap needles immediately after use using a two-handed technique
B. Dispose of used sharps in a puncture-resistant container
C. Use safety-engineered needles whenever available
D. Avoid reporting minor needlestick injuries
E. Keep sharps containers at eye level for easy access
Answer: B, C
Rationale:
Safe needle practices include disposing of sharps in puncture-resistant containers and using safety-engineered needles. Recapping needles using a two-handed technique is unsafe. All needlestick injuries should be reported, and sharps containers should not be overfilled or positioned in a way that increases risk.