The nurse is performing an assessment of the patient's thorax and lungs. In which order
will the nurse perform the following assessment techniques? 1. Percussion 2.
Auscultation 3. Inspection 4. Palpation
A.3, 1, 4, 2
B. 3, 4, 1, 2
C.2, 4, 3, 1
D.2, 3, 4, 1
E.3, 2, 4, 1 - CORRECT ANSWER-B. 3, 4, 1, 2
Which of the following are normal breath sounds? Select all that apply.
A. Vesicular
B. Brochovesicular
C. Bronchial
D. Vestibular
E. Crackles - CORRECT ANSWER-A. Vesicular
B. Brochovesicular
C. Bronchial
When auscultating the heart, a nurse knows that the "lub-dub" heart sounds heard are
caused by:
A. Contraction of the heart muscle.
B. Closure of the heart valves.
C. Blood moving from the heart into the aorta.
D. Blood moving from one chamber to another. - CORRECT ANSWER-B. Closure of
the heart valves.
While reading a physician's progress notes, a student notes that an assigned patient is
having hypoxia. What abnormal assessments would the student expect to find?
A. Abdominal pain, hyperthermia, dry skin.
B. Diarrhea, flatulence, decreased skin turgor.
C. Hypotension, reddened skin, edema.
D. Dyspnea, tachycardia, cyanosis. - CORRECT ANSWER-D. Dyspnea, tachycardia,
cyanosis.
A nurse is assessing level of awareness (LOA). Which of the following are used to
determine LOA? Select all that apply.
, A. Person
B. Place
C. Time
D. Lethargy
E. Things - CORRECT ANSWER-A. Person
B. Place
C. Time
A nurse palpates the pulse of a client and documents the following: Apical pulse 85 and
regular. Pulses +2/3, and equal in radial, popliteal, and dorsalis pedis. What does the
number +2 represent?
A. Pulse amplitude
B. Pulse rate
C. Pulse rhythm
D. Pulse deficit - CORRECT ANSWER-A. Pulse amplitude
A student visits the campus health clinic. The student tells the nurse, "I have had a lot of
pain in my abdomen." The nurse performs an abdominal assessment. This is a/an
_____ assessment. This type of assessment is based on a/an _____ framework.
A. Ongoing partial, medical
B. Comprehensive, body system
C. Focused, body system
D. Focused, hierarchy of needs - CORRECT ANSWER-C. Focused, body system
Standard precautions apply to which items? (Select all that apply.)
A. Sweat
B. Nonintact skin
C. Mucous membranes
D. Blood
E. Intact skin
F. Body fluid secretions - CORRECT ANSWER-B. Nonintact skin
C. Mucous membranes
D. Blood
F. Body fluid secretions
Which of the following are transmission-based precautions defined by the Centers for
Disease Control and Prevention? (Select all that apply.)
A. Contact precautions
B. Airborne precautions
C. Droplet precautions
D. Body fluid precautions
E. Microbial precautions - CORRECT ANSWER-A. Contact precautions