NUR 265 Exam Questions and Correct Answers Practice In Depth Study Guide Exam Latest Update 2025

NUR 265 NUR 265 Exam Questions and Correct Answers Practice In Depth Study Guide Exam Latest Update 2025 A nurse is preparing to perform palpation on the patient during a physical assessment. Which of the following findings is the nurse assessing during the palpation? Skin temperature, moisture, or unexpected findings A nurse is preparing to irrigate a client's leg wound. Which of the following pieces of PPE should the nurse wear while performing the task (SATA) Gloves, Gown, Goggles The nurse is completing documentation in the client's medical records. Which of the following entries display proper documentation by the nurse? The client's abdomen is soft and nondistended A nurse in the ED has received a report on a child who has a laceration to the right calf. Which of the following steps of the nursing process should the nurse perform first? Analysis A nurse has just received a report on a newly admitted patient who speaks a different language than the nurse. Which of the following actions should the nurse take to assist with effective communication with the client during the initial assessment process? Request assistance from an interpreter during the assessment A nurse is caring for a client who is crying and appears to be upset after receiving news that they will need to have a surgical procedure. Which of the following actions should the nurse take to display empathy towards the client? Show interest in the client's feelings by acknowledging that they are upset A nurse is documenting their assessment and documents that the client states, "I have a dry cough every morning when I wake up." Which of the following types of data is the nurse documenting? Subjective NUR 265 NUR 265 A nurse is assisting a client with ambulating around the nurses' station. Which of the following steps of the nursing process is the nurse performing? Implementation A nurse has performed preoperative care on a client and is transferring the client to the surgical holding area when the client states, "I have changed my mind. I do not want to have this surgery." Which of the following ethical principles is the client using? Autonomy A nurse has just received a report on a newly admitted client who reports abdominal tenderness in the lower right quadrant. Which of the following is the first step the nurse should perform during the abdominal assessment? Inspection A nurse is performing auscultation during a client's physical assessment. Which of the following tools should the nurse use for this part of the assessment? Stethoscope A nurse is preparing to assess a newly admitted client. Which of the following pieces of equipment does the nurse need to begin the inspection part of the physical assessment (SATA) Penlight, Tongue depressor, Tape measure A nurse is performing a peradmission assessment on a client and employs the use of nonverbal communication. Which of the following actions demonstrates the use of a nonverbal communication technique by the nurse? Maintaining an arm's length between self and the client A nurse is preparing to perform a physical examination on a client. Which of the following interventions should the nurse perform to ensure client privacy? Do not expose any more of the client's body than required at the time A nurse is performing a physical assessment of a client who has reported abdominal tenderness. Which of the following actions should the nurse take? Palpate the tender areas of the client's abdomen last A nurse is caring for a client who is experiencing severe pain. Which of the following client statements indicates that the client is experiencing chronic pain (SATA) NUR 265 NUR 265 "I have had this pain for 9 months" , "The pain has been off and on for about a year now" A nurse is preparing to obtain a client's height during a general survey. Which of the following actions should the nurse take? Ensure the client's feet are in contact with the wall or measuring pole A nurse is providing teaching to a client who asks "What are things that can affect my blood pressure?" Which of the following information should the nurse include as factors that affect blood pressure (SATA) Diuretic medication, Smoking, Obesity, Time of day While conducting a general survey on a client who is being admitted to a long term care facility a nurse is assessing the client's emotional state. Which of the following findings should the nurse record as an unexpected finding? The client reports they feel sad and lonely most of the time A nurse is obtaining a client's pulse and notes a regular rhythm with a rate of 110/min. The nurse should identify this as which of the following unexpected findings? Tachycardia A nurse is documenting information in a client's medical record. Which of the following information did the nurse collect during the general survey (SATA)? Behavior and mood, Height and weight, Use of assistive devices A nurse is assessing a client's respirations and notes they are shallow and at a rate of 24/min. The nurse should identify this as which of the following unexpected findings? Tachypena A nurse is documenting a client's vital signs in the medical record following a general survey. Which of the following entries should the nurse place in the record? Oxygen saturation 96% on oxygen 2L/min via nasal cannula A nurse is having difficulty obtaining a pulse oximetry reading from a client. The nurse should identify which of the following factors as possibly interfering with obtaining a pulse oximetry reading? Recent scan with contrast dye NUR 265 NUR 265 A nurse is caring for an adult client who is comatose. Which of the following routes should the nurse use to obtain the most accurate core body temperature of the client? Rectal A nurse is conducting a general survey on a client and notes a continuous twitching movement of a muscle in the client's left arm. Which of the following terms should the nurse use to describe this involuntary movement? Fasciculation A nurse is preparing to conduct a general survey and assessment on a newly admitted patient. Which of the following actions should the nurse plan to take? Engage in active listening with the client and allow the client to express concerns early in the assessment process A nurse assesses a client's respiratory rate and notes that it is below the expected reference range. The nurse should identify that which of the following findings can decrease a client's respiratory rate? The client takes a narcotic pain medication for chronic pain A nurse is preparing an older adult client for a physical examination the provider is about to perform. Which of the following actions should the nurse take? Explain to the client what is about to happen A nurse is preparing a client for a hip arthroplasty. For which of the following reasons should the nurse assess the client's vital signs? To establish a baseline for postoperative assessment A nurse is assessing a client who has a fracture of the femur. The nurse obtains vital signs on admission and again in 2 hours. Which of the following changes in assessment should indicate to the nurse that the client could be developing a serious complication? Increased respiratory rate from 18 to 44/min. A nurse is teaching a client's partner about how to obtain a blood pressure reading. Which of the following actions by the partner indicates a need for further instruction? Places the client's arm above the level of the client's heart A nurse is measuring a client's oral temperature. The client informs the nurse that he has just eaten some ice chips. Which of the following actions should the nurse take? NUR 265 NUR 265 Wait 30 min and return to measure the oral temperature A nurse is obtaining vital signs from 2-month-old infant. The infant's heart rate is 190/min and his temperature is 40° C (104° F). The father asks the nurse why the infant's heart is beating so fast. Which of the following responses by the nurse is appropriate? "The fever is causing an increase in your baby's heart rate." A nurse is reviewing the documentation of a client's blood pressure by a newly licensed nurse. The documentation states, "Blood pressure 102/58 mm Hg, client sitting up in a chair." Which of the following information should the nurse clarify? Location of blood pressure cuff An assistive personnel (AP) reports a client's vital signs as tympanic temperature 37.1° C (98.8° F), pulse 92/min, respiratory rate 18/min, and BP 98/58 mm Hg. Which of the following vital signs should the nurse re-measure? BP A nurse is assessing a client's radial pulse and determines that the pulse is irregular. Which of the following actions should the nurse take? Assess the apical pulse for a full minute. A nurse is preparing to collect health history data during a client's admission. Which of the following questions should the nurse use to promote this discussion? "What brought you to the hospital?" A nurse is discussing a client's tobacco usage during a health history interview. Which of the following questions should the nurse ask to maintain nurse-client rapport? "Would you like any information on smoking cessation?" A nurse is collecting biographic data from a client who reports they are seeking health care due to a persistent cough. The client states they identify as transgender. Which of the following questions should the nurse ask? "What pronouns do you use?" A nurse is gathering information during a health history interview from a client who reports they have type 1 diabetes mellitus. What action should the nurse take? Ask the client for additional information regarding the management of their diabetes. NUR 265 NUR 265 A nurse is preparing to conduct a health history interview. Which of the following actions should the nurse plan to perform during the closing stage of the interview? Provide an opportunity for the client to ask questions. A nurse is conducting a health history interview. Which of the following type of information is the nursing gathering when using the acronym "OLD CARTS" Information about the client's presenting problem A nurse is planning to conduct a health history interview with a client. Which of the following actions should the nurse plan to take? (SATA) Ensure face to face contact is eye level, Gather supplies to take notes, Select a position that is approximately 2 to 4 feet from the client during the interview A nurse has collected biographical data from a client. Which of the following findings in the client's community is considered a social determinant of health that can negatively impact the client's health? Limited access to a pharmacy A nurse is conducting a review of systems with a client during a health history interview. Which of the following responses by the client requires additional investigation? "I have a cough." A nurse is conducting a health history interview and asks the client to describe the pain that they are experiencing. This is an example of what type of question? Open-ended question A nurse is collecting a health history from a client who does not speak the same language as the nurse. Which of the following actions should the nurse take? Speak directly to the client throughout the interview A nurse is gathering information about a client's personal lifestyle choices. Which of the following information should the nurse seek to gather while investigating substance use? (SATA) Prescription medications taken for recreational purposes, Determination of when the client last had an alcoholic drink A nurse is collecting information about a client's family history. The nurse should plan to collect information about the health of which of the following client relatives? (SATA) Parents, Siblings, Grandparents NUR 265 NUR 265 A nurse is collecting information about a client's spirituality using the FICA spiritual History Tool. Based on this tool, which of the following information should the nurse gather? (SATA) What impact do the client's spiritual or religious beliefs have on their health care decision making?, Does the client identify spiritual or religious beliefs that are of importance to them?, Are there any spiritual or religious practices that should be included when planning the client's care?, Is there a spiritual or religious group that the client identifies as having an importance in their life? A nurse is preparing to collect a health history from a client. Which of the following should the nurse plan to assess as a component of a functional assessment (SATA)? Client's ability to perform activities associated with daily living, If the client is experiencing abuse or human trafficking, The clients use of substances, The environment in which the client resides A nurse is conducting a health history interview with a client. Which of the following is true of a directive interview technique? This technique consists of mostly closed-ended questions. A nurse is preparing an in-service for a group of newly hired assistive personnel about body temperature. Which of the following information should the nurse include? A temporal probe thermometer uses infrared scanning to determine a client's temperature A charge nurse is teaching a group of assistive personnel about the importance of documenting accurate vital signs. Which of the following information should the charge nurse include in the teaching? Recording vital signs provides critical information regarding a client's condition A nurse is reviewing the vital signs for a group of clients to determine the effectiveness of interventions. Which of the following findings indicates an intervention was effective? An adult client who received medication for pain 30 min ago now has a respiratory rate of 18/min A nurse is planning care for a group of clients and is delegating to the AP to take the clients' vital signs. For which of the following clients should the nurse obtain the vital signs rather than the AP? NUR 265 NUR 265 A client who was recently admitted and reports chest pain A nurse is reviewing documentation of vital signs by a newly licensed nurse for an assigned client. Which of the following entries in the chart requires follow up by the nurse? Pulse rate 116/min, left radial, standing, immediately following 10 min of ambulating in hall A nurse is planning care for a client who has hypertension. Which of the following interventions should the nurse include in the plan (SATA) Provide the client with low-sodium meals and snacks, Encourage the client to participate in physical activity each day, Instruct the client in the use of relaxation techniques, Inform the client of the importance of abstaining from using products that contain nicotine. A nurse is preparing an in-service about vital signs for a group of newly hired AP. Which of the following information should the nurse include about measuring body temperature? Oral temperature is easily accessible despite a client's position A nurse is reviewing the vital signs obtained by an AP at 1200. For which of the following clients should the nurse plan to intervene? Toddler who has a respiratory rate of 44/min A charge nurse is discussing the physiology of the heart with a newly licensed nurse. Which of the following anatomical sites should the newly licensed nurse identify as the pacemaker of the heart? Sinoatrial (SA) node A charge nurse is reviewing orthostatic hypotension with a group of newly licensed nurses. Which of the following statements should the charge nurse make? "A decrease of 20 millimeters of mercury in the systolic pressure with a position change indicates orthostatic hypotension." A nurse is teaching a group of newly licensed nurses about vital sign measurements. Which of the following factors should the nurse include in the teaching? Body temperature is typically lower in older adults NUR 265 NUR 265 A charge nurse in a clinic is preparing an in-service about blood pressure measurements for a group of staff members. Which of the following information should the nurse include? A client who has a blood pressure of 128/86 mm Hg is considered as having stage I hypertension A nurse is providing teaching about thermoregulation to a group of newly licensed nurses. Which of the following statements should the nurse include in the teaching? "The body lowers body temperature through sweating." A nurse is planning care for a group of clients. For which of the following clients should the nurse direct and AP to obtain a rectal temperature? A client who is diaphoretic and frequently chewing ice to relieve dry mouth A nurse is reviewing the vital signs for a group of clients obtained by an AP. The nurse should identify which of the following clients requires a follow up assessment due to bradycardia? A young adult who has a radial pulse rate of 56/min A nurse is discussing the use of a client's thigh for blood pressure measurements which an AP. Which of the following information should the nurse include? Use the thigh to obtain blood pressure when a client has severe edema in their arms. A nurse is obtaining vital signs for a group of clients. Which of the following findings requires intervention? An 11-year-old child who has a respiratory rate of 34/min A nurse is caring for a client who has an increase in cardiac output. Which of the following findings should the nurse expect? Increase in blood pressure A charge nurse is discussing a client's respiratory data with a newly licensed nurse. Which of the following statements should the nurse include? "Count the respiratory rate for 1 minute for clients who have a respiratory infection." A nurse is evaluating the effectiveness of interventions provided to a client who was admitted for decreased circulation. Which of the following findings requires further intervention by the nurse? Left radial pulse is nonpalpable NUR 265 NUR 265 A nurse is providing care to a client who has an apical pulse rate of 54/min and is experiencing dizziness. Which of the following is the nurse's priority action? Inform the client to ask for assistance with getting out of bed A nurse is evaluating the effectiveness of interventions provided to four clients who have unexpected findings for vital signs. Which of the following findings requires follow up? A client has a radial pulse of +4 bilateral. A nurse is planning care for a group of clients and is reviewing the recent vital signs obtained by an AP. Which of the following clients should the nurse assess and recheck the vital signs prior to notifying the provider? 8-year-old male: respiratory rate 34/min, SaO2 97% A nurse is preparing an in-service about peripheral pulses for a group of staff nurses. Which of the following information should the nurse include? A pulse strength of +1 indicates that the pulse is weak or diminished upon palpation A nurse is preparing to obtain a young adult client's apical pulse. In which of the following locations should the nurse place their stethoscope to auscultate the client's pulse? Apex of the heart A nurse is evaluating the effectiveness of interventions used to address clients' vital signs that were outside of the expected reference ranges. Which of the following findings indicates the intervention was effective? A young adult who is experiencing an asthma attack and has a blood pressure of 116/72 mm Hg after using an inhaler A nurse working on a medical-surgical unit is caring for a group of clients. Which of the following clients' vital signs should the nurse identify is outside the expected reference range and notify the provider? A client who has an apical pulse rate of 120/min A nurse is caring for a client who has increased cardiac afterload. Which of the following findings should the nurse expect? Increase in blood pressure NUR 265 NUR 265 A nurse obtains a client's electronic blood pressure reading of 188/96 mmHg. Which of the following actions should the nurse take next? Obtain a manual blood pressure reading from the client A nurse is teaching a group of APs about techniques used to obtain BP. For which of the following clients should the nurse instruct the AP to obtain an electric BP measurement? A client who has stabilized BP measurements A nurse is evaluating the effectiveness of interventions used for clients who had alterations in vital signs. Which of the following clients' vital signs indicate that interventions were effective A preschooler who was exhibiting tachypnea 2 hr postoperative and now has a respiratory rate of 24/min, An older adult client who had bradycardia while sleeping and now has an apical pulse rate of 66/min, A young adult who had hypotension after receiving an opioid analgesic and now has a blood pressure of 98/68 mm Hg A nurse is caring for a client who has hypotension. Which of the following factors should the nurse identify as a contributing factor to the client's condition? Decrease in contractility A charge nurse is reviewing documentation of vital signs by a newly licensed nurse. Which of the following pieces of documentation is correct? SaO2 97% right index finger, room air A nurse is discussing oxygen saturation with a client. Which of the following information should the nurse include? Oxygen saturation reflects the amount of oxygen being delivered to body tissues A nurse is caring for a client who is experiencing tachypena due to an exacerbation of asthma. Which of the following medications should the nurse anticipate administering? A bronchodilator A nurse is caring for a client who has a heart rate of 120/min. Which of the following actions should the nurse take? Instruct the client to bear down like they are having a bowel movement. NUR 265 NUR 265 A nurse on a pediatric unit is reviewing the medical records for a group of clients. Which of the following clients has a vital sign outside the expected reference range that requires intervention? A 4-year-old preschooler who has an apical pulse rate of 144/min A nurse is observing an AP obtain vital signs from an adult client. Which of the following actions by the AP requires follow up by the nurse? The AP informs the client when they are counting the respirations. A charge nurse is discussing mechanisms of loss of body heat with a newly licensed nurse. Which of the following states shield the nurse include? "Radiation is the loss of body heat when a client is in close proximity to a cooler surface." A nurse planning care for a client who is experiencing tachycardia. Which of the following interventions should the nurse plan to include? Encourage the client to practice relaxation techniques each day. A nurse is caring for a group of clients. Which of the following clients is experiencing an alteration in their respiratory rate that requires intervention? A school-age child who has a respiratory rate of 14/min A nurse is assessing a client who has orthostatic hypotension. Which of the following should the nurse take? Encourage the client to change positions slowly. A charge nurse is reviewing the expected reference range of blood pressure in adult clients with a newly licensed nurse. Which of the following statements should the charge nurse include? "Hypertension is diagnosed with two elevated measurements on two separate occasions." A nurse is assessing a 3 month old infant during a well child visit. Which of the following actions should the nurse take when assessing the apical pulse Place the stethoscope over the 4th intercostal space to the left of the sternum. A nurse is caring for a client who asks about factors that could cause their pulse rate to increase. Which of the following factors should the nurse include in their response? NUR 265 NUR 265 Smoking A nurse is preparing an in-service about factors affecting respiratory rate for a group of AP. Which of the following information should the nurse include? Fever can increase a client's respiratory rate. A charge nurse is evaluating a newly licensed nurse's documentation of vital signs for several clients. Which of the following documentation should the charge nurse identify as being incomplete? BP 124/82 mm Hg, lying in bed A nurse is reviewing the vital signs of four clients. The nurse should identify which of the following clients has a vital sign outside of the expected reference range? A 23-year-old client who runs marathons and has a blood pressure of 82/54 mm Hg A nurse is observing an AP who is obtaining a blood pressure reading from a client. Which of the following actions by the AP requires follow up by the nurse? The AP loosens the valve to reduce pressure within the bladder cuff at a rate of 5 mm Hg per second. A nurse is reviewing the vital signs for a group of clients. Which of the following clients should the nurse identify as exhibiting tachycardia? A young adult who has an apical pulse rate of 104/min A charge nurse is providing an in-service for a group of nurses about cardiac output. Which of the following statements should the nurse include? "Cardiac output is the amount of blood flow through the heart in 1 minute." A nurse is reviewing blood flow through the heart with a group of APs. The nurse should identify that blood flows to which of the following parts of the heart as it leaves the right ventricle? Pulmonary artery A nurse is evaluating the effectiveness of interventions provided to a client who has an SaO2 below the expected reference range. Which of the following manifestations requires follow up by the nurse Dyspnea NUR 265 NUR 265 A nurse is caring for a recently admitted client and as part of the plan of care, two nurses obtained simultaneous pulse rates. The client's auscultated apical pulse was 106/min and the palpated pulse was 93/min. The nurse should document the findings as which of the following? Pulse deficit of 13/min A nurse is reviewing the recent vital signs of a group of clients. Which of the following clients should the nurse see first? A 52-year-old client who has an SaO2 of 92% A nurse is discussing the physiology of blood pressure with a group of APs. Which of the following information should the nurse include? Blood pressure is measured and documented in millimeters of mercury. A nurse is caring for a client who has a heart rate of 118/min. Which of the following actions should the nurse take to improve the client's heart rate? Encourage the client to reduce intake of caffeinated soft drinks. NUR 265