Phsical Assessment

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Sample questions from Phsical Assessment

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 medical unit with weakness and dizziness. Supine blood pressure is 132/76 mm Hg and standing blood pressure is 98/60 mm Hg; the client reports feeling faint when standing. Which action should the nurse take first?

   • A.Ask the client to walk a short distance to assess gait
   • B.Encourage the client to stand slowly without assistance
   • C.Obtain a standing blood pressure again in 30 minutes
   • D.Assist the client back to bed and implement fall precautions

   Rationale: The symptomatic blood pressure decrease creates an immediate risk of syncope and injury, so the nurse should return the client to bed and prevent falls. Walking or standing again could cause a fall, and waiting to repeat the measurement does not address the immediate danger. The exam takeaway is to prioritize safety when assessment findings indicate symptomatic orthostatic hypotension.

2. 2.A 54-year-old client with a history of hypertension is seen at a community clinic. The blood pressure is 184/112 mm Hg, and the client denies headache, chest pain, or vision changes. What should the nurse do first?

   • A.Document the reading as expected for a client with hypertension
   • B.Arrange emergency transport immediately
   • C.Repeat the blood pressure after the client rests quietly for 5 minutes
   • D.Ask the client to take an extra dose of the prescribed antihypertensive

   Rationale: A markedly elevated reading should be confirmed with correct technique after a brief period of rest, while the nurse assesses for symptoms of acute target-organ injury. Giving an extra dose without a prescription or assessment is unsafe, and emergency transport is not automatically indicated when the client is asymptomatic and the reading has not been confirmed. The exam takeaway is to validate an abnormal measurement and assess symptoms before escalating care.

3. 3.A 72-year-old client is admitted to a rehabilitation unit after a fall. The client has a new prescription for an opioid analgesic and reports pain of 7 on a 0-to-10 scale. Which assessment is most important before administering the medication?

   • A.Respiratory rate and level of alertness
   • B.Bowel sounds in all four quadrants
   • C.Ability to recall the date
   • D.Capillary refill in both hands

   Rationale: Opioids can suppress respirations and cause sedation, so respiratory status and alertness are essential safety assessments before administration. Bowel sounds, orientation, and capillary refill may be relevant to the broader assessment but do not best identify the immediate risk of opioid-related respiratory depression. The exam takeaway is to assess the vital function most affected by a medication before giving it.

4. 4.A 66-year-old client is admitted to a medical unit with fatigue and pallor. The client has a hemoglobin level of 8.2 g/dL and becomes dizzy when standing. Which nursing actions support a focused, safe assessment? Select all that apply.

   • A.Assess orthostatic vital signs with assistance
   • B.Have the client walk alone to evaluate endurance
   • C.Check skin and mucous membranes for pallor
   • D.Ask about chest discomfort and shortness of breath
   • E.Review the client's medication and bleeding history

   Answer and rationale are in the full material.

5. 5.A 74-year-old client is admitted with suspected pneumonia. The temperature is 38.4 C (101.1 F), respiratory rate is 26/min, oxygen saturation is 90% on room air, and the client is newly confused. Which assessment finding should the nurse report immediately?

   • A.History of a productive cough
   • B.New confusion with hypoxemia
   • C.Temperature of 38.4 C (101.1 F)
   • D.Age greater than 70 years

   Answer and rationale are in the full material.