Physical Assessment EXAM1

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Sample questions from Physical Assessment EXAM1

This material has 90 questions with answers and rationales. Here are the first 5.

1. 1.A 68-year-old client is admitted to the emergency department with sudden shortness of breath. The nurse notes a respiratory rate of 32/min, oxygen saturation of 86% on room air, and new confusion. Which action should the nurse take first?

   • A.Obtain a detailed medication history
   • B.Notify the client's family
   • C.Complete a head-to-toe assessment
   • D.Assess airway patency and support oxygenation

   Rationale: The low oxygen saturation, tachypnea, and confusion suggest impaired oxygenation requiring immediate assessment and support. A medication history and complete assessment are important but should follow stabilization. Family notification does not address the immediate threat.

2. 2.A 74-year-old client is admitted to a medical unit with weakness and dizziness. The blood pressure is 118/72 mm Hg supine and 92/60 mm Hg after standing for 2 minutes; the client reports lightheadedness. Which nursing action is most appropriate?

   • A.Restrict oral fluids until the provider evaluates the client
   • B.Repeat the standing blood pressure after the client walks
   • C.Assist the client to sit or lie down and report the orthostatic change
   • D.Encourage the client to walk to improve circulation

   Rationale: The symptomatic blood pressure drop places the client at immediate risk for a fall, so the nurse should return the client to a safe position and communicate the finding. Walking could worsen dizziness and injury risk. Repeating the measurement after walking delays safety measures, and fluid restriction is not indicated by these findings.

3. 3.A 62-year-old client on a medical-surgical unit reports new chest pressure. The client is pale and diaphoretic, with a heart rate of 112/min and blood pressure of 94/58 mm Hg. Which actions should the nurse take first? Select all that apply.

   • A.Obtain a 12-lead ECG as soon as possible
   • B.Ask the client to walk to the treatment room
   • C.Offer a meal to reduce weakness
   • D.Stay with the client and assess airway, breathing, and circulation
   • E.Activate the facility's emergency response process

   Rationale: Staying with the client allows immediate reassessment of potentially unstable airway, breathing, and circulation. Activating the emergency response process is appropriate for new chest pressure with hypotension and diaphoresis. A prompt ECG helps identify an acute cardiac event. Walking could worsen instability, and food is not an appropriate response to possible acute coronary syndrome.

4. 4.A charge nurse is assigning care for a stable 80-year-old client who needs routine vital signs and help with bathing. Which task is appropriate to delegate to an experienced unlicensed assistive personnel (UAP)?

   • A.Obtain and report routine vital signs
   • B.Teach the client how to use a walker
   • C.Assess the client's dizziness when standing
   • D.Evaluate the client's response to a new antihypertensive

   Answer and rationale are in the full material.

5. 5.A 56-year-old client is being admitted to an outpatient clinic for a focused assessment of new abdominal pain. Which action should the nurse take before beginning the examination?

   • A.Begin palpation to locate the most painful area
   • B.Verify the client's identity using two approved identifiers
   • C.Ask the client to remove all clothing before explaining the exam
   • D.Ask the client to describe the pain while standing

   Answer and rationale are in the full material.