Nursing Exam Questions PDF

A nurse is calling a provider to report a patient’s change in condition using the SBAR communication framework. Using clinical judgment, which action demonstrates an effective approach to the “B” (Background) component to support accurate decision-making? A. Share the patient’s current vital signs a...

A nurse is calling a provider to report a patient’s change in condition using the SBAR communication framework. Using clinical judgment, which action demonstrates an effective approach to the “B” (Background) component to support accurate decision-making? A. Share the patient’s current vital signs and clinical assessment findings to provide real-time data. B. Summarize relevant medical history, key diagnoses, and recent treatments to establish context for the situation. C. Explain the specific circumstances and symptoms that prompted the need for immediate communication. D. Recommend specific interventions or clarify provider orders to guide the next steps. Correct Answer: B A patient from a cultural background that values stoicism reports no pain, but their vital signs indicate tachycardia and increased blood pressure. The nurse observes signs of discomfort. What is the most appropriate nursing intervention? A. Accept the patient’s self-report and do not intervene further. B. Use open-ended questions to explore the patient’s pain experience. C. Administer pain medication based on the vital sign changes. D. Document the findings and inform the provider. Correct Answer: B A nurse is educating a community group about risk factors for impaired cognition. Which of the following individuals demonstrates the highest risk for developing cognitive impairment? A. A 45-year-old with a family history of Alzheimer’s disease who exercises regularly and eats a healthy diet. B. A 67-year-old with poorly controlled diabetes and a history of smoking. C. A 70-year-old who is socially active but recently retired from work. D. A 55-year-old with no significant medical history who experiences occasional forgetfulness. Correct Answer: B. A 67-year-old with poorly controlled diabetes and a history of smoking. During a health history assessment, a 48-year-old female reports the following: Persistent headache occurring daily for the past month Blurred vision and occasional dizziness A family history of hypertension and stroke Increased stress at work and poor sleep quality Which of the following findings would be considered most abnormal and require immediate intervention? A. Poor sleep quality due to stress B. Family history of hypertension and stroke C. Persistent daily headache with blurred vision D. Increased stress at work Correct Answer: C. Persistent daily headache with blurred vision A new client comes into the office, they can only speak broken sentences but have no issue understanding. Which of the following should the nurse do? 1. Speak slowly 2. Use written materials with pictures 3. Call for an interpreter 4. Use a family member to translate Correct Answer: 3. A client comes into the office experience symptoms of hypertension, which of the following are expected findings. Select all that apply. 1. Severe Headaches 2. Dizziness 3. Difficulty Breathing 4. Fainting Correct Answer: 1,2,3 A nurse is assessing a 75 year old client during a routine physical examination. Upon assessing the client, which of the following findings should the nurse report as abnormal? A. Smooth pink skin with no visible lesions B. A small mole with symmetrical borders C. A new mole that looks irregularly shaped with variations in color D. Wrinkled skin with mild sagging on the arms Correct Answer: C A Nurse is caring for a 72 year old patient who has been admitted to the Emergency Room complaining about shortness of breath. Upon taking the client’s vital signs, the nurse notes that the client’s oxygen saturation is at 90%. The nurse is preparing to assess the client’s respiratory status. Which of the following actions should be a priority that the nurse should take? A. Encourage the client to deep breathe and cough to clear secretions. B. Administer supplemental oxygen via prescribed provider orders C. Perform a complete assessment, auscultating lung sounds D. Reassure the patient that the oxygen saturation is within normal limits Correct Answer: B The nurse is assessing a client’s cranial nerve function. Which of the following findings would be considered abnormal when testing cranial nerve II (optic nerve)? A. The client correctly identifies objects in each visual field B. The client’s pupils constrict in response to light C. The client reports partial loss of vision in one eye D. The client can read from a Snellen chart at 20/20 Correct Answer: C. The client reports partial loss of vision in one eye A nurse is caring for a group of clients in a medical-surgical unit. Which of the following clients is at the greatest risk for developing an infection? A 78-year-old client with a urinary catheter placed for 2 days B. A 45-year-old client who has a history of diabetes mellitus C. A 22-year-old client who is 2 days postoperative from an appendectomy D. A 30-year-old client receiving IV antibiotics for pneumonia Correct Answer: A. A 78-year-old client with a urinary catheter placed for 2 days The nurse is conducting a cardiovascular assessment on a 60-year-old patient. Which finding should the nurse identify as abnormal and require further investigation? A) Apical pulse rate of 76 beats per minute with regular rhythm. B) Capillary refill of less than 2 seconds in the fingers and toes. C) Blood pressure of 138/88 mmHg measured in the right arm. D) Jugular vein distention observed at 45 degrees. Correct Answer: D) Jugular vein distention observed at 45 degrees. The nurse is teaching a patient about the risk factors for insomnia. Which patient statement indicates a need for further teaching? A. "I will avoid drinking coffee or energy drinks in the evening." B. "I'll keep my bedroom dark and quiet to help me sleep better." C. "I'll go to bed early and use my phone until I feel sleepy." D. "I'll try to go to bed and wake up at the same time every day." Correct Answer: C) "I'll go to bed early and use my phone until I feel sleepy."  A nurse is promoting smoking cessation to a group of patient. Which statement by a participant indicates they are in the preparation stage of the Transtheoretical Model of Change? A. "I don’t think smoking is that bad for me." B. "I’ve cut down from two packs a day to one." C. "I’ve decided to quit and set a date for next week." D. "I’ve been smoke-free for six months now." Correct Answer: C. "I’ve decided to quit and set a date for next week." A nurse is assessing a patient’s respiratory status. Which of the following findings are abnormal? (Select all that apply.) A. Respiratory rate of 17 bpm B. Use of accessory muscle during inspiration C. Oxygen saturation of 97% on room air D. Crackles in the lung on auscultation E. Asymmetrical chest expansion during inspiration Correct: B,D,E A nurse is performing an abdominal assessment on a patient. Which of the following actions should the nurse take first when conducting the assessment? A) Palpate the abdomen to assess for tenderness or masses. B) Inspect the abdomen for any visible abnormalities or signs of distress. C) Percuss the abdomen to assess for fluid or gas accumulation. D) Auscultate the abdomen to listen for bowel sounds. Correct Answer: B) Inspect the abdomen for any visible abnormalities or signs of distress. A nurse educating a client about good sleep hygiene. Which of the following statements by the client indicates a need for further teaching? A. "I will avoid caffeine and alcohol in the evening" B. "I will use my bedroom for sleeping only" C. "I will try to take naps throughout the day if I feel tired" D. "I will maintain a regular sleep schedule, going to bed and waking up at the same time each day" Answer: C. Which of the following interventions should a nurse prioritize to limit the spread of Clostridioides difficile (C. diff) in a healthcare setting? A) Administering routine antibiotics for all patients B) Ensuring proper hand hygiene and the use of gloves when providing patient care C) Promoting the use of alcohol-based hand sanitizers for all staff D) Isolating all patients with gastrointestinal symptoms in a shared room Answer: B The nurse is performing a focused musculoskeletal assessment on a patient. Which of the following findings would the nurse identify as abnormal and require further evaluation? Select all that apply: A. A smooth, coordinated gait with a symmetric arm swing. B. Tenderness and swelling over the left knee joint. C. Full range of motion in all extremities without pain. D. Muscle strength of 2/5 in the right lower extremity. E. A slight curvature of the thoracic spine when viewed laterally. Correct Answer: B, D A nurse is caring for a patient who has been prescribed parenteral nutrition (PN) due to severe malnutrition. Which of the following nursing interventions is most important to ensure the safe administration of parenteral nutrition? A. Verify the patient's order and ensure the parenteral nutrition solution is at room temperature before administration. B. Monitor the patient for signs of hyperglycemia, including increased thirst and frequent urination. C. Administer the parenteral nutrition solution through a peripheral vein to prevent complications.  D. Check the patient's vital signs every 12 hours to assess for potential complications. Correct Answer: A A nurse is performing a peripheral neurological assessment on a patient with a history of diabetes mellitus. Which of the following findings is considered normal and should not raise concern? A. The patient reports occasional numbness in both feet, but it resolves quickly. B. The patient’s right foot is warm to the touch with a normal pulse in the dorsalis pedis artery. C. The patient exhibits bilateral loss of sensation to light touch and pain in both lower extremities. D. The patient has diminished ankle reflexes bilaterally, but normal deep tendon reflexes in the upper extremities. Correct Answer: A A nurse is caring for a patient diagnosed with Clostridium difficile (C. difficile) infection in the hospital. The patient is placed in an isolation room. The nurse is reviewing the infection control measures to prevent the transmission of the infection. Which of the following statements best describes the necessary precautions for this patient? A) The nurse should wear a gown and gloves for all patient contact, and the room door may remain open to allow for adequate airflow. B) The nurse must wear an N95 respirator and gloves for all patient contact due to the risk of airborne transmission. C) The nurse should wear a gown and gloves, use hand hygiene with soap and water after patient contact, and ensure the room door remains closed. D) The nurse should wear gloves and a surgical mask for all patient contact, and only visitors are required to wear gowns. The Answer: C A nurse is conducting a health history assessment on a 55-year-old patient who presents for a routine check-up. The patient reports feeling generally well but has experienced some occasional headaches, difficulty falling asleep, and mild shortness of breath during exercise. Which of the following findings from the health history assessment would be considered abnormal and require further investigation? (Select all that apply.) A) The patient reports a family history of hypertension, diabetes, and stroke. B) The patient has a history of smoking 10 cigarettes per day for the past 20 years but quit 5 years ago. C) The patient states that their blood pressure is normally 130/85 mm Hg. D) The patient has a mild but chronic cough that occurs mostly in the morning. E) The patient reports occasional headaches and difficulty falling asleep, but no other recent changes in health. F) The patient denies any significant weight changes or difficulty with appetite. Answer: A,B, D A nurse is caring for a patient diagnosed with Clostridium difficile (C. difficile) infection in the hospital. The patient is placed in an isolation room. The nurse is reviewing the infection control measures to prevent the transmission of the infection. Which of the following statements best describes the necessary precautions for this patient? A) The nurse should wear a gown and gloves for all patient contact, and the room door may remain open to allow for adequate airflow. B) The nurse must wear an N95 respirator and gloves for all patient contact due to the risk of airborne transmission. C) The nurse should wear a gown and gloves, use hand hygiene with soap and water after patient contact, and ensure the room door remains closed. D) The nurse should wear gloves and a surgical mask for all patient contact, and only visitors are required to wear gowns. The Answer: C A nurse is caring for a 68-year-old patient recently diagnosed with moderate cognitive impairment due to early-stage Alzheimer's disease. The nurse collaborates with the healthcare team to develop a plan of care aimed at minimizing symptoms and improving the patient's quality of life. Which of the following interventions is most appropriate for the nurse to implement as part of the care plan? A) Encourage the patient to perform activities independently, without assistance, to promote autonomy. B) Provide a quiet, distraction-free environment to reduce agitation and improve focus. C) Focus solely on medical treatments, excluding family involvement, to minimize confusion. D) Limit communication with the patient to avoid overwhelming them with too much information. Correct Answer: B  A nurse is assessing the vital signs of a 45-year-old patient who is admitted to the hospital. The following vital signs are recorded: Temperature: 37.0°C (98.6°F) Heart rate: 88 beats per minute Respiratory rate: 22 breaths per minute Blood pressure: 118/76 mmHg Oxygen saturation: 98% on room air Which of his vital signs are within the normal range for an adult? A) Heart rate: 88 beats per minute B) Respiratory rate: 14 breaths per minute C) Blood pressure: 140/92 mmHg D) Oxygen saturation: 94% on room air Correct Answer: A The nurse is performing a respiratory assessment on a 45-year-old client. Which of the following findings would the nurse recognize as abnormal? A. Respiratory rate of 16 breaths per minute with regular rhythm. B. Clear lung sounds bilaterally upon auscultation. C. Use of accessory muscles during inspiration. D. Symmetrical chest expansion during breathing. Correct Answer: C A nurse is conducting an initial assessment for a client newly admitted to a rehabilitation facility. Which statement best explains the importance of assessing the client’s functional ability in client-centered care? A. It helps the nurse determine the level of support the client requires to maintain independence. B. It ensures the client can perform all self-care tasks without assistance from others. C. It allows the nurse to identify the client’s knowledge about health conditions and disease processes. D. It focuses on identifying medical diagnoses to create an appropriate care plan. Correct Answer: A A nurse is educating a patient with type 2 diabetes about self-management strategies to improve health outcomes. The patient expresses concern about their ability to manage the condition long-term. Which of the following approaches is most likely to improve the patient's health perception and enhance their self-care behaviors? A) Focusing on restricting the patient's diet and exercise only when blood sugar levels are elevated B) Encouraging the patient to set small, achievable goals for diet, exercise, and blood sugar monitoring C) Emphasizing the use of medication as the primary method for controlling blood sugar levels without making lifestyle changes D) Providing the patient with a strict regimen to follow without offering flexibility for personal preferences or challenges Correct Answer: B Patient presents to the ED with complaints of hypertension. Which of the findings are abnormal? A. normal breathing B. Nausea and vomiting C. BP 120/80 D. RR 17 Correct answer:B A nurse is teaching a client about healthy eating habits. Which of the following dietary choices by the client indicates that the nurse's teaching has been effective? A. I will eat more fried chicken to increase my protein intake. B. I will switch from potato chips to veggie straws. C. I will eat lots of sodium when I am stressed. D. I can eat a large meal before bed. Correct answer: B A nurse is assessing a patients head and neck. Which of the following findings should the nurse report to the provider? A. Firm next muscles B. Symmetrical face movements C. Locking of jaw joint  D. Trachea is midline Correct answer:C A nurse is assessing a 55 year old client who reports recent feelings of stress and anxiety. The client states, “I have been feeling anxious and tired all the time due to my new job, but I do not know how to fix it,”. Which of the following nursing interventions would be the most appropriate for this client? A) Advise the client to take a leave of absence from work and look for a less stressful job. B) Encourage the client to engage in physical activities for at least 30 minutes everyday C) Suggest that the client takes a daily anxiety medication so that he does not feel this way anymore. D) Advise the client to not speak with family members about his recent feelings of anxiety, as it may lead to conflict. Correct answer: B A nurse is performing a health assessment on a 65 year old client who reports having occasional shortness of breath and chest discomfort, after walking up the stairs. The nurse notes that the client is a smoker of 25 years, with an oxygen saturation of 91% on room air. Which of the following actions should the nurse take next? A) Document the findings in the client’s chart as normal for a person of their age. B) Advise the client to avoid strenuous activities until further testing has been conducted. C) Perform a focused assessment of the client’s lungs to assess for COPD. D) Provide smoking cessation to the client Correct answer: C A nurse is assessing a client during a routine cardiovascular exam. The findings include: Blood Pressure: 160/98 mmHg Heart Rate: 102 bpm, regular Peripheral Pulses: 2+ bilaterally Capillary Refill: 4 seconds Auscultation: S1 and S2 present, with a high-pitched murmur at the apex Which of the following findings should the nurse identify as abnormal? A. Peripheral pulses 2+ bilaterally B. Capillary refill of 4 seconds C. Heart rate of 102 bpm D. Presence of S1 and S2 Correct answer: B A nurse is assessing a client who reports severe abdominal pain rated 8/10 on a numeric pain scale. The client is grimacing, holding their abdomen, and states, "It hurts so much, I can’t eat or sleep." Which of the following is the nurse’s priority intervention? A. Administer the prescribed PRN pain medication and reassess the pain level in 30 minutes. B. Notify the healthcare provider about the client’s pain and request further diagnostic testing. C. Perform a focused abdominal assessment to identify possible underlying causes of the pain. D. Encourage the client to use non-pharmacological pain management techniques, such as deep breathing or distraction. Correct answer: C A nurse is assessing a client who reports shortness of breath. The client's oxygen saturation is 88% on room air. Which of the following is the nurse's priority intervention? A. Notify the healthcare provider about the oxygen saturation level. B. Administer oxygen via nasal cannula as prescribed and monitor the client's response. C. Position the client supine to maximize perfusion. D. Encourage the client to take deep breaths and reassess oxygen saturation in 10 minutes. Correct answer: B A nurse is assessing a client who was admitted with a head injury sustained in a motor vehicle accident. The client is lethargic, responds to verbal stimuli but falls asleep quickly, and is disoriented to time and place. Which of the following is the nurse's priority intervention? A. Notify the healthcare provider and prepare the client for a head CT scan. B. Administer prescribed IV fluids to maintain hydration and perfusion. C. Perform a full neurological assessment, including Glasgow Coma Scale (GCS) scoring. D. Document the findings and reassess the client's LOC in one hour. Correct answer : C  A nurse is assessing a 65-year-old client during a routine examination and detects an irregular radial pulse. Which of the following actions should the nurse prioritize? A. Perform a full set of vital signs, including apical pulse assessment for one full minute. B. Notify the healthcare provider immediately about the irregular pulse findings. C. Document the findings and continue with the assessment. D. Encourage the client to increase their fluid intake to stabilize the pulse. Correct answer A A client arrives at the emergency department with signs of a stroke. Which of the following is the priority assessment for the nurse to perform? a. Level of consciousness b. Blood pressure c. Blood glucose d. Time of symptom onset Correct Answer: d A nurse is caring for a client with increased intracranial pressure (ICP). Which nursing intervention is appropriate to reduce ICP? a. Place the client in a supine position with the head flat. b. Administer stool softeners as prescribed. c. Perform frequent suctioning of the airway. d. Encourage coughing exercises. Correct Answer: b A nurse is caring for a client of Asian descent who recently gave birth. The client's family brings her warm soups and advises her to avoid cold foods. Which nursing action demonstrates culturally competent care? 1. Informing the family that cold foods will not harm the client. 2. Educating the client about balanced nutrition and encouraging her to eat a variety of foods. 3. Respecting the client’s cultural preference and ensuring warm meals are available. 4. Explaining the importance of a calorie-rich diet for postpartum recovery. Correct answer: 3 A nurse is performing a musculoskeletal assessment on a 55-year-old client. Which of the following findings should the nurse identify as abnormal? 1. Symmetrical muscle tone and strength bilaterally. 2. Slight lordosis observed in the lumbar spine. 3. Joint crepitus with movement but no pain or swelling.  4. Limited range of motion in the shoulder with pain during abduction. Correct Answer: 4 A nurse educates nursing students about the long-term health and psychosocial consequences of untreated sleep disorders. Which of the following long-term and psychosocial implications of untreated sleep disorders? Which of the following long- term effects should the nurse emphasize as being most significant A. Increased risk of obesity and metabolic syndrome B. Improved cognitive function and memory retention C. Enhance ability to cope with stress D. Decreased incidence of chronic illness Correct answer: A Tiffany, a student nurse, is performing a health assessment on a 62-year-old patient. During the skin assessment, the nurse notes several common findings associated with aging skin changes. Which of the following findings should the nurse identify as a normal age-related change? A. The presence of thin, shiny skin on the legs B. Development of multiple nodules on the scalp C. Report of intense itching and dry patches on the arms D. Appearance of irregularly shaped pigment lesions Correct answer: A A nurse is caring for an older adult client who reports that they wake up frequently during the night. The nurse should identify which characteristics of older adult sleep patterns might explain the client's frequent awakening. 1. Older adults tend to spend more time in stage 4 sleep 2. Older adults tend to spend more time in stage 3 3. Older adults tend to spend less time in stage 1 sleep 4. Older adults tend to spend more time in stage 2 sleep. Correct answer; 4 A nurse is caring for a client following an appendectomy who has a postoperative prescription that reads “discontinue NPO status; advance to clear liquid as tolerated”. Which of the following choices should the nurse offer the client? a. applesauce b. chicken broth c. sherbet d. wheat toast e. cranberry juice correct answer: B, E A nurse is caring for a client who is newly admitted to the unit. Which action should the nurse take to establish a helping relationship with the client? a. Make sure the communication is equally distributed between the nurse and the clients desires b. encourage the client to communicate their thoughts and feelings. c. give unlimited to the nurse-client communication d. allow communication to occur spontaneously throughout the nurse-client relationship. Correct answer: B A nurse is performing a general survey on a new patient admitted to the hospital. Which of the following findings is most important for the nurse to report to the healthcare provider immediately? a. The patient appears anxious when speaking with the nurse b. The patient has a body mass index (BMI) of 27 c. The patient is observed to have a sluggish response to verbal stimuli d. The patient has pale skin and appears tired Correct answer: C A nurse is assessing a client who reports insomnia. Which of the following findings can contribute to the client’s insomnia? (Select all that apply) a. Irregular schedule b. Stress c. Warm bath d. Alcohol intake e. Morning walk Correct answers: A, B, D A 45-year-old woman with a family history of breast cancer undergoes a mammogram as part of her annual screening. Which health promotion strategy is being employed? 1. A) Primary prevention, as it aims to reduce the risk of developing breast cancer. B) Secondary prevention, as it focuses on early detection of breast cancer through screening. C) Tertiary prevention, as it focuses on managing breast cancer after diagnosis. D) Primary prevention, as it seeks to improve overall health by reducing cancer-related risks. Correct Answer: B Which of the following is an example of the Assessment component in the SBAR communication method? A) "The patient's blood pressure has been 180/100 for the past hour." B) "I need a pain management order for this patient." C) "This patient's blood pressure is elevated and may require intervention." D) "The patient is stable and ready for discharge." Correct Answer: C A nurse is caring for a patient who has recently been diagnosed with terminal cancer. The patient expresses feelings of sadness and asks the nurse, "Why is this happening to me?" Which of the following responses by the nurse best demonstrates the use of therapeutic communication? A) "You shouldn't feel that way; you need to stay positive." B) "It's normal to feel sad, but you should focus on the good things in your life." C) "I can’t imagine how difficult this must be for you. Can you tell me more about what you’re feeling?" D) "Everything will be okay. The doctors are doing their best to help you." Correct Answer: C A nurse is preparing to communicate a patient's condition to a physician using the SBAR (Situation, Background, Assessment, Recommendation) format. Which of the following is the appropriate order and content of the SBAR communication?  A) Situation: "The patient is a 65-year-old male with a history of heart disease and hypertension. His blood pressure is 180/100 mmHg, and he is complaining of chest pain." B) Background: "The patient had a myocardial infarction two years ago and has been on antihypertensive medication since then." C) Assessment: "His blood pressure is elevated, and his heart rate is 110 bpm. He appears to be diaphoretic and anxious." D) Recommendation: "I recommend starting a new antihypertensive medication and monitoring him closely in the ICU." Correct Answer: C The nurse is assessing an older adult patient and recognizes that risk factors for impaired cognition in this patient may include _______ and _______. Answer Options: 1. Diabetes mellitus 2. Adequate sleep 3. History of stroke 4. Frequent intellectual stimulation Correct Answers: 1, 3 A 54-year-old patient with a history of hypertension and diabetes is admitted to the hospital following a stroke. The nurse is assessing the patient's cognitive function. Which of the following findings would the nurse recognize as manifestations of impaired cognition? (Select all that apply.) A. Inability to remember the names of common objects (e.g., a pen or a chair).B. Frequent agitation and restlessness. C. Difficulty following conversations or understanding speech. D. Expressing confusion about the time of day and location. E. Consistently completing tasks independently without assistance. F. Making poor decisions, such as attempting to leave the hospital without assistance. Correct answers: A, B, C, D, F  A nurse is providing an SBAR to the patient's provider. Which of the following information would the nurse include as part of the Recommendation component of SBAR? A. "Hello, Dr. Smith. My name is Student Nurse, and I am calling from ASU Hospital regarding your patient, Henry Chester. He is experiencing difficulty breathing and is complaining of chest pains." B. "Mr. Chester just had surgery yesterday and has no prior medical history." C. "Patient appears anxious, has tachycardia, and low O2 saturation." D. "I'd like to administer oxygen therapy and obtain lab tests along with CT of his chest." Correct answer D A nurse is caring for a client following a myocardial infarction. The client tells the nurse that she does not think she can remain on a low-cholesterol diet. Which of the following responses should the nurse make? A. "What is it about the low-cholesterol diet that concerns you?" B. "If you don't follow the diet, you will probably have another heart attack." C. "I've been on this diet for the last 5 years. You will learn to change your eating habits after a while." D. "I will have the dietician talk to you since she is an expert and can be very helpful." Correct answer: A A nurse is caring for a client who has a new diagnosis of breast cancer. The client becomes quiet and withdrawn and says to the nurse, "What do you think people will say about me when I'm gone?" Which of the following responses should the nurse make? A. "What are you worried they will say about you?" B. "The thought of having breast cancer must seem hopeless." C. "Maintaining a positive attitude can influence your recovery." D. "You will be remembered as a very nice person." Correct answer: B During a health assessment, a nurse is gathering a health history from a 45-year- old patient. Which of the following statements made by the patient should the nurse identify as a potential abnormal finding? A) "I occasionally feel anxious about work deadlines, but it usually goes away after I take a break."  B) "I have been feeling more tired than usual and sometimes have trouble getting out of bed in the morning." C) "I drink coffee every morning, but I have cut back to just two cups a day." D) "I exercise regularly, about three times a week, and try to eat a balanced diet." Answer: B A community health nurse is planning a health promotion program targeting various age groups within the community. Which of the following interventions is most appropriate as a primary health promotion strategy for the older adult population? A) Conducting regular blood pressure screenings at health fairs. B) Offering nutrition workshops focused on healthy eating habits. C) Establishing a cardiac rehabilitation program for recovering patients. D) Providing support groups for individuals with chronic illnesses. Answer: B Which of the following findings in a comprehensive physical exam are considered normal? Select all that apply. A) The patient’s pupils are equal, round, and reactive to light and accommodation (PERRLA). B) The patient has a heart rate of 120 beats per minute (bpm) at rest, with a regular rhythm. C) The patient's breath sounds are clear bilaterally without wheezing, crackles, or rhonchi. D) The patient’s abdominal inspection reveals visible peristalsis and a firm, distended abdomen. E) The patient’s blood pressure is 118/75 mmHg, which is within the normal range. F) The patient has a respiratory rate of 8 breaths per minute with shallow breathing. Correct Answers: A, C, E Which of the following statements accurately describes the process of sleep and its physiological benefits? Select all that apply. 1. A) The circadian rhythm regulates the sleep-wake cycle, synchronizing with environmental cues such as light and temperature.  B) Sleep-wake homeostasis helps the body maintain alertness and prevents sleep by controlling the release of melatonin. C) REM sleep is characterized by rapid eye movement, low muscle tone, and increased heart rate, making it the stage of sleep most associated with dreaming. D) During Stage 3 (NREM), the body undergoes tissue repair, and the immune system strengthens. E) Sleep spindles and K-complexes in Stage 2 (NREM) sleep are involved in memory consolidation and maintaining sleep. F) Delta waves are characteristic of Stage 1 (NREM) sleep, which is the deepest stage of sleep, necessary for immune function and muscle repair. Correct Answers: A, C, D, E The nurse is performing a general survey on a newly admitted patient. Which of the following combinations of findings should the nurse recognize as abnormal and requiring immediate follow-up? (Select all that apply) A) A patient with a respiratory rate of 18 breaths per minute, exhibiting no signs of distress, a body temperature of 98.6°F (37°C), and a steady gait. B) A patient with a BMI of 32, pale skin, a heart rate of 110 bpm, and reports feeling dizzy upon standing. The patient also has 2+ pitting edema in both lower extremities. C) A patient with a blood pressure of 110/70 mmHg, a heart rate of 62 bpm, normal capillary refill of 2 seconds, and difficulty recalling their name and the date. D) A patient with a BMI of 24, a temperature of 99.2°F (37.3°C), a respiratory rate of 22 breaths per minute, and visible bruising on the forearms and thighs in various stages of healing. Correct Answer: B, C, D The nurse is assessing a patient's coping strategies during a period of significant stress. Match the following coping responses with whether they are adaptive or maladaptive. Instructions: Drag the coping response to the appropriate column (Adaptive or Maladaptive). Coping Responses: 1. Avoidance coping 2. Attacking or bullying 3. Compartmentalizing 4. Denial 5. Displacement 6. Emotional outbursts 7. Excessive eating 8. Regression 9. Self-harm 10. Social isolation/withdrawal 11. Substance use 12. Art therapy 13. Counseling 14. Physical activity 15. Relaxation techniques Adaptive Coping Responses: Art therapy Counseling Physical activity Relaxation techniques Maladaptive Coping Responses: Avoidance coping Attacking or bullying Compartmentalizing Denial Displacement Emotional outbursts Excessive eating Regression Self-harm Social isolation/withdrawal Substance use The nurse is conducting a general survey during a routine health assessment of a 60-year-old client. Which of the following abnormal findings would require the nurse to initiate immediate follow-up actions? A) The client’s speech is slow and deliberate, and they report feeling cold despite the room being warm. B) The client exhibits labored breathing with accessory muscle use and a respiratory rate of 26 breaths per minute. C) The client reports mild fatigue and is observed with a slightly stooped posture while walking. D) The client has a blood pressure of 160/90 mmHg and denies symptoms of headache, dizziness, or vision changes. Correct Answer: B A nurse is assessing a client who recently lost their job. Which of the following findings indicates the client may be at risk for altered coping? A) The client states they have joined a community support group. B) The client reports increased alcohol use over the past month. C) The client is volunteering to stay active during unemployment. D) The client says, "I know things will get better soon." Correct Answer: B A nurse is performing a Romberg test on a patient who has been experiencing dizziness and balance issues. The patient stands with feet together, arms at their sides, and eyes closed. The patient begins to sway significantly and falls to one side. What is the most appropriate nursing action? A. Reassure the patient that this is a normal finding and continue the assessment. B. Stop the test immediately, assist the patient to a sitting position, and assess further for neurological deficits. C. Document the swaying as a positive Romberg sign and discontinue further testing. D. Ask the patient to try again with their eyes open and observe the results. Answer: B A nurse is caring for a Hispanic patient who prefers to use traditional herbal remedies in addition to prescribed medications. Which response by the nurse demonstrates cultural sensitivity A. "You should stop using herbal remedies because they may interfere with your prescribed medications." B. "Tell me more about the herbal remedies you use so we can ensure they are safe with your medications." C. "Herbal remedies aren’t scientifically proven, so relying solely on your  prescribed medications is better." D. "I’ll consult the healthcare provider to discontinue your current medications since you prefer herbal treatments." Answer: B A nurse is caring for a 45-year-old patient who was admitted for respiratory distress. The patient’s vital signs are as follows: Temperature: 99.0°F (37.2°C) Heart rate: 120 beats per minute Respiratory rate: 30 breaths per minute Blood pressure: 138/88 mmHg What is the most appropriate nursing action based on these findings? 1. A) Administer an antipyretic for the slightly elevated temperature. B) Monitor the patient for signs of dehydration and continue to assess vital signs. C) Administer oxygen via nasal cannula to address the elevated heart rate. D) Notify the healthcare provider immediately about the abnormal vital signs. Correct Answer: B A 70-year-old patient is recovering from a hip replacement surgery. The nurse notes the following vital signs: Temperature: 99.1°F (37.3°C) Heart rate: 52 beats per minute Respiratory rate: 16 breaths per minute Blood pressure: 120/72 mmHg Which of the following is the most appropriate action for the nurse? A) Notify the healthcare provider immediately about the bradycardia. B) Document the findings and continue routine post-operative monitoring. C) Administer IV fluids to address the patient's bradycardia. D) Increase the oxygen flow rate to 4L/min via nasal cannula. Correct Answer: B A nurse is assessing a 60-year-old male patient who is post-cardiac surgery. The following vital signs are recorded: Temperature: 100.2°F (37.9°C) Heart rate: 88 beats per minute  Respiratory rate: 18 breaths per minute Blood pressure: 110/68 mmHg What is the most appropriate next action by the nurse? A) Administer antipyretics for the elevated temperature. B) Continue to monitor vital signs and assess for signs of infection. C) Notify the healthcare provider immediately about the elevated temperature. D) Increase the oxygen flow rate to 4L/min via nasal cannula to support the patient’s condition. Correct Answer: B (Select All That Apply): A nurse is educating a pregnant patient on how to increase folate intake to prevent neural tube defects. Which of the following foods should the nurse recommend as the best sources of folate during pregnancy? A) Fortified breakfast cereals B) Fresh orange juice C) Lean meats D) Dark leafy greens E) Whole grain breads Correct Answers: A, D A nurse is providing dietary teaching to a patient with chronic kidney disease (CKD) who is on hemodialysis. The nurse explains that certain nutrients need to be restricted. Which of the following foods should the nurse instruct the patient to limit? A) Grilled salmon with a side of roasted asparagus B) Whole grain cereal with low-fat milk C) Fresh orange juice with a side of scrambled eggs D) Baked potato with a dollop of sour cream and a green salad Correct Answer: C (Matching): Match the following nutrition-related conditions with the appropriate dietary recommendation: 1. Iron-deficiency anemia 2. Chronic kidney disease (CKD) 3. Celiac disease 4. Type 2 diabetes  A) Follow a gluten-free diet B) Increase iron-rich foods, such as red meat, beans, and fortified cereals C) Limit protein intake to reduce kidney strain D) Focus on complex carbohydrates, such as whole grains and vegetables, and limit sugar intake Correct Answers: A. Iron-deficiency anemia → B) Increase iron-rich foods, such as red meat, beans, and fortified cereals B. Chronic kidney disease (CKD) → C) Limit protein intake to reduce kidney strain C. Celiac disease → A) Follow a gluten-free diet D. Type 2 diabetes → D) Focus on complex carbohydrates, such as whole grains and vegetables, and limit sugar intake A nurse helping to develop an in-service about cultural competence is reviewing a list of health beliefs provided by members of a local cultural group. The nurse should recognize that this list provides which of the following types of information? A. A: Health disparity data B. B: Emic knowledge C. C: Etic knowledge D. D: Objective data Answer: B Which expected breath sounds are heard over the largest portions of the lungs and are soft-sounding like wind blowing through trees? A: Tracheal B: Vesicular C: Wheeze D: Rales Answer: B A nurse is caring for a patient who has been undergoing chemotherapy for cancer. The patient reports experiencing numbness and tingling in their fingers and toes. Which of the following conditions is most likely contributing to these symptoms? A. Diabetic neuropathy B. Chemotherapy-induced peripheral neuropathy C. Stroke D. Carpal tunnel syndrome Correct Answer: B A nurse is preparing to conduct a cultural assessment of a patient. Which question best allows the nurse to assess the patient’s cultural health beliefs? A. “What kind of diet do you follow at home?” B. “Do you take any medications daily?” C. “What do you think caused your illness?” D. “Do you prefer a male or female provider?” Correct Answer: C A nurse is assessing a 35 year old female in the emergency department. The following vitals are recorded 15 minutes after administering IV morphine. Which of the following findings should the nurse be most concerned about and require immediate follow up? A: Temperature: 37.8 C (100F) B: Pulse: 100 bpm C: O2: 97% D: Respiratory rate: 9/min E: BP: 135/85 Correct answer: D A nurse is caring for a client who has been prescribed total parenteral nutrition (TPN) feedings. The nurse should ensure that the tubing should be changed every ___. A: 36 hours B: week C: 24 hours D: 72 hours  Correct answer: c A nurse is caring for a client with an increased cardiac afterload. Which of the following findings should the nurse expect? A) Increase in blood pressure B) Increase in respiratory rate C) Decrease in cardiac output D) Decrease in preload Correct answer: A A nurse is caring for a client who is diagnosed with anxiety disorder. Which of the following interventions should the nurse include in the client's care plan? (SATA) A: Encourage the client to engage in deep breathing exercises when having anxiety B: Taking medication as prescribed like Benzodiazepines C: Educate the client on relaxation techniques like relief of pain and muscle tension D: Allow the client to pace alone until physically tired when the client has anxiety Rationales: Correct: A,B,C A nurse is assessing a patient's abdomen. Which of the following findings requires further investigation? 1. A) High-pitched, gurgling, and cascading bowel sounds 2. B) Smooth, dry skin with no visible bulges or masses 3. C) Presence of visible masses and asymmetry of abdominal movements 4. D) No redness, discoloration, or bruising on the skin Correct Answer: C  A patient with anxiety disorder is prescribed lorazepam. Which statement by the patient indicates a need for further teaching? 1. A) "Lorazepam works quickly to relieve anxiety." 2. B) "I can use lorazepam daily because it has no risk of addiction." 3. C) "Lorazepam is only for short-term use due to the risk of dependence." 4. D) "Lorazepam can cause sedation, so I should avoid driving after taking it. Correct answer: B A nursing student is doing an assessment of the skin on a 20 year old female. Which of the following may the nurse expect during a skin assessment? (Select all that apply.) 1. Acne 2. Diaphoresis 3. Cyanosis 4. Capillary refill less than two seconds 5. Hyperpigmentation Answer- A, D A nursing student has been recently diagnosed with generalized anxiety disorder. What symptoms would you expect for a patient with moderate anxiety? (Select all that apply.) 1. Insomnia 2. Increased heart rate 3. Anorexia 4. Irritability 5. Edema Answer- A, B, D A nurse is assessing a client who presents with numbness, tingling, and weakness in the lower extremities. Upon further examination, the nurse notes decreased sensation to light touch, absent deep tendon reflexes in the legs, and diminished muscle strength in the lower limbs. Which of the following conditions is most likely contributing to these abnormal findings? A) Stroke B) Peripheral neuropathy C) Spinal cord injury D) Multiple sclerosis Answer: B A nurse is assessing a client for risk factors related to stress and coping. Which of the following factors is most likely to increase the client's risk for experiencing stress? A) regular physical exercise and balanced diet B) strong social support from family and friends C) chronic illness and lack of effective coping mechanisms D) positive outlook on life and effective time management Answer: C A nurse is performing an abdominal assessment of a client. Which of the following positions should the nurse tell the client to assume for this examination? A. Lithotomy B. Lateral C. Supine D. Sims' Answer: C. supine A nurse is developing a care plan for a 45-year-old patient who has recently been diagnosed with hypertension. The patient has expressed interest in improving their overall health and reducing the need for medication. The nurse decides to implement a health promotion strategy that addresses primary, secondary, and tertiary prevention measures. Which of the following interventions best demonstrates the nurse's use of health promotion across all three prevention levels? A. Encouraging the patient to begin a daily exercise routine to prevent the onset of chronic diseases, suggesting blood pressure monitoring at home, and referring the patient to a support group for those with hypertension. B. Administering an antihypertensive medication as prescribed, monitoring the patient’s blood pressure regularly, and encouraging the patient to attend routine follow-up appointments with their healthcare provider.  C. Providing educational materials on the importance of diet and exercise, recommending a smoking cessation program, and scheduling a blood pressure screening every 6 months. D. Teaching the patient about the effects of hypertension, discussing a low-salt diet, and advising the patient to follow up for a re-evaluation of their medication regimen in 3 months. Answer: A A nurse is assessing a client and notes an irregular pulse of 120 beats per minute. Which of the following should be the priority nursing intervention? 1. Administer prescribed beta-blocker medication. 2. Obtain a 12-lead electrocardiogram (ECG). 3. Notify the healthcare provider immediately. 4. Assess for associated symptoms such as dizziness or chest pain. Correct Answer: 4 A nurse is assessing a healthy adult client’s skin and notes a mole with irregular borders, varying colors, and a diameter of 8 mm. What is the nurse’s best action? 1. Document the findings as normal. 2. Reassess the mole in 3 months for changes. 3. Recommend the client use sunscreen daily. 4. Notify the healthcare provider immediately. Correct Answer: 4 A nurse is performing a skin assessment on a 50-year-old patient during a routine physical examination. The following findings are noted. Which of these findings should the nurse be concerned about and report for further evaluation? Select all that apply. A) A round, flat mole on the patient's upper back, measuring 4 mm in diameter, with a uniform tan color and no changes in shape or size over the past 5 years. B) A new lesion on the patient's left thigh, with irregular borders, multiple shades of brown, and a diameter of 8 mm. C) A raised, scaly patch on the patient’s elbow that has been present for several months and is slightly itchy. D) A flat, circular birthmark on the patient’s chest that has remained unchanged in size and color for the last 20 years.  E) A firm, non-tender nodule on the patient's scalp that is increasing in size over the past month. Correct Answers- B, E A nurse is caring for a 72-year-old patient who has been diagnosed with early- stage Alzheimer's disease. The patient’s spouse expresses concern about recent changes in the patient’s behavior and memory. Which of the following manifestations should the nurse recognize as an indication of impaired cognition in this patient? A) The patient forgets the name of a close family member but can still recognize them. B) The patient has difficulty recalling recent events, such as what they ate for breakfast. C) The patient regularly asks the same question, such as "Where are my keys?" but remembers the answer once told. D) The patient consistently remembers the name of their childhood friend but frequently forgets the name of their spouse. Correct answer: B A nurse is educating a 60-year-old client with newly diagnosed type 2 diabetes on self- management strategies. Which of the following statements by the client indicates the need for further teaching? A. “I will check my blood sugar levels before meals and at bedtime.” B. “I will eat my favorite sugary desserts occasionally in small portions as part of my meal plan.” C. “I will take my medication only when my blood sugar is over 200 mg/dL.” D. “I will incorporate daily physical activity, such as walking, into my routine to help manage my blood sugar.” Correct Answer: C A nurse is conducting a head, neck, and neurological assessment on a 45-year-old client. Which of the following findings should the nurse recognize as abnormal and report to the healthcare provider? A. Pupils are equal, round, and reactive to light and accommodation (PERRLA). B. The client reports occasional mild headaches relieved by over-the-counter pain medication. C. The trachea is deviated to the right. D. The client’s cranial nerve XI (spinal accessory) assessment reveals full strength in the shoulders bilaterally. Correct Answer: C A nurse is caring for a postoperative client who just had an appendectomy. The nurse understands there are several factors for the client to develop an infection. Which of the following factors most significantly increase the client's risk for developing an infection? A. The client is prescribed pain medication for the postoperative discomfort. B. The client is ambulating with assistance four hours post op. C. The client has a history of type II Diabetes Mellitus. D. The client is receiving intravenous fluids for hydration. Correct Answer: B A 70-year-old client with a history of hypertension and Type 2 diabetes presents to the emergency department with complaints of sudden-onset weakness on the right side of the body, difficulty speaking, and a severe headache. On assessment, the nurse notes that the client’s right-sided facial droop, slurred speech, and inability to lift the right arm are present. The client is alert but disoriented to time. The nurse suspects a stroke. Which of the following interventions is the nurse's priority? A) Administer aspirin to reduce blood clot formation. B) Perform a NIH Stroke Scale (NIHSS) assessment to determine the severity of the stroke. C) Place the client in a high Fowler's position to improve breathing. D) Obtain a blood glucose level to rule out hypoglycemia. Correct answer: B A 65-year-old patient presents for a routine health assessment. During the cardiovascular examination, the nurse notes the following findings: 1. Heart rate: 72 beats per minute, regular rhythm 2. Blood pressure: 128/76 mmHg 3. Peripheral pulses: 2+ and equal bilaterally in the upper and lower extremities 4. Auscultation of heart sounds reveals S1 and S2 with no audible murmurs or gallops. 5. The patient reports occasional "skipping" heartbeats. Which of the following findings is considered abnormal and requires further assessment? A) Heart rate of 72 beats per minute B) Blood pressure of 128/76 mmHg C) Peripheral pulses of 2+ and equal bilaterally D) Occasional "skipping" heartbeats reported by the patient Correct Answer: D A nurse is teaching a group of patients about self-management strategies related to chronic illness. Which of the following approaches to self-care should the nurse emphasize to improve health perception and health management? A) Relying solely on pharmacological treatments to manage symptoms. B) Engaging in regular physical activity and maintaining a balanced diet. C) Avoiding all forms of physical activity to prevent exacerbation of illness. D) Attending medical appointments infrequently to avoid the stress of healthcare settings. Correct Answer: B A nurse is teaching a patient with newly diagnosed Type 2 Diabetes Mellitus about self- management of their condition. Which statement by the patient indicates a need for further teaching? A. “I will check my blood sugar before meals and at bedtime as instructed.” B. “I should inspect my feet daily for cuts, blisters, or redness.” C. “If I feel dizzy or shaky, I should eat a Snickers candy bar immediately.” D. “I will keep a log of my blood sugar readings to share with my healthcare provider.” Correct Answer: C A nurse is assessing a 30-year-old patient’s cardiovascular system. Which of the following findings would the nurse identify as abnormal and requiring further investigation?  A. Capillary refill time of 2 seconds. B. Apical pulse rate of 60 beats per minute. C. S1 and S2 heart sounds audible without murmurs. D. Bulging and bounding jugular vein on one side of the neck Correct Answer: D. A nurse is assessing a patient’s approach to self-care as part of the health perception and health management pattern. Which of the following statements by the patient would indicate a positive approach to self-care? A. "I rarely exercise because I don't have time, but I try to eat healthy when I can." B. "I check my blood pressure every day, and I take my medication exactly as prescribed." C. "I usually wait until my symptoms get worse before I go to the doctor." D. "I’ve been trying to quit smoking for years, but I haven’t been able to." Answer: B During a routine health assessment, a nurse evaluates a patient's peripheral and neurological systems. Which of the following findings should the nurse consider abnormal and require further investigation? A. The patient exhibits a 2+ deep tendon reflex in both knees. B. The patient has an absent dorsalis pedis pulse on the right foot. C. The patient demonstrates normal sensation to light touch in all four limbs. D. The patient has a negative Romberg test. Correct Answer: B A nurse is conducting a cardiovascular assessment. Match the findings to the appropriate category: Normal or Abnormal. Finding Normal Abnormal Heart rate of 72 beats per minute Jugular vein distension (JVD) S1 and S2 heart sounds Capillary refill