NURS 240 HEALTH ASSESSMENT EXAM 1
CERTIFICATION QUESTIONS AND VERIFIED
ANSWERS 2026
⏺ A patient is being treated with an antibiotic. The nurse explains to the
patient that this medication is required for the reduction of inflammation at
the injury site because this medication:
A) will decrease the pain at the site.
B) helps to kill the infection causing the inflammation.
C) will reduce the patients fever.
D) inhibits cyclooxygenase.? Answer:B
Antimicrobials treat the underlying cause of the infection which leads to
inflammation. Analgesics and nonsteroidal antiinflammatory drugs
(NSAIDs) help to treat pain. NSAIDs and other antipyretics are
cyclooxygenase inhibitors. Antipyretics help to reduce fever.
⏺ The nurse is caring for a client with ulcerative colitis and severe diarrhea.
Which nursing assessment is the highest priority?
A) Skin integrity
B) Blood pressure
C) Heart rate and rhythm
D) Abdominal percussion? Answer:C
Although the client with severe diarrhea may experience skin irritation and
hypovolemia, the client is most at risk for cardiac dysrhythmias secondary
to potassium and magnesium loss from severe diarrhea. The client should
have her or his electrolyte levels monitored, and electrolyte replacement
may be necessary. Abdominal percussion is an important part of physical
assessment but has lower priority for this client than heart rate and rhythm.
⏺ The nurse assesses a client with pneumonia and notes decreased lung
sounds on the left side and decreased lung expansion. What is the nurse's
best action?
,A) Increase oxygen flow to 10 L/min.
B) Perform an arterial blood gas analysis.
C) Have the client cough and deep breathe.
D) Check oxygen saturation and notify the health care provider.? Answer:D
Decreased lung sounds and decreased lung expansion could indicate the
development of a complication such as empyema or pus in the pleural
space. The nurse should check the client's oxygen saturation and notify the
provider. Infection can also move into the bloodstream and result in sepsis,
so quick treatment is needed.
⏺ The nurse is assigned a group of patients. Which patient would the nurse
identify as being at increased risk for impaired gas exchange? A patient:
A) with a hemoglobin of 8.5 g/dL
B) with a blood glucose of 350 mg/dL
C) who has been on anticoagulants for 10 days
D) with a heart rate of 100 beats/min and blood pressure of 100/60?
Answer:A
The hemoglobin is low (anemia), therefore the ability of the blood to carry
oxygen is decreased. High blood glucose and/or anticoagulants do not alter
the oxygen carrying capacity of the blood. A heart rate of 100 beats/min
and blood pressure of 100/60 are not indicative of oxygen carrying capacity
of the blood.
⏺ The nurse is starting a client on digoxin (Lanoxin) therapy. What
intervention is essential to teach this client?
A) "Increase your intake of foods high in potassium."
B) "Avoid taking aspirin or aspirin-containing products."
C) "Hold this medication if your pulse rate is below 80 beats/min."
D) "Do not take this medication within 1 hour of taking an antacid."?
Answer:D
Gastrointestinal absorption of digoxin is erratic. Many medications,
especially antacids, interfere with its absorption. Clients are taught to hold
their digoxin for bradycardia; a heart rate of 80 is too high for this cutoff.
, ⏺ The nurse is caring for a client with Crohn's disease who has developed
a fistula. Which nursing intervention is the highest priority?
A) Position the client to allow gravity drainage of the fistula.
B) Check and record blood glucose levels every 6 hours.
C) Encourage the client to consume a diet high in protein and calories.
D) Monitor the client's hematocrit and hemoglobin.? Answer:C
The client with Crohn's disease is already at risk for malabsorption and
malnutrition. Malnutrition impairs healing of the fistula and immune
responses. Therefore, maintaining adequate nutrition is a priority for this
client. The client will require 3000 calories per day to promote healing of
the fistula. Monitoring the client's blood sugar and hemoglobin levels is
important, but less so than encouraging nutritional intake. The client need
not be positioned to facilitate gravity drainage of the fistula, because
fistulas often are found in the abdominal cavity.
⏺ The nurse is teaching a client who has recently given birth about
immunity that has been passed to the newborn. Which statement by the
client indicates that additional teaching is needed?
A) "My baby received some antibodies from me before birth, and I will give
him more when I breast-feed."
B) "I had the measles, so my baby will be protected against it until he is old
enough to receive the MMR vaccine."
C) "Only certain antibodies were able to cross the placenta to protect my
baby."
D) "I had chickenpox and am immune to it, so my baby will not need to
have the chickenpox vaccine."? Answer:D
The baby receives passive immunity from antibodies that are passed
through the placenta in utero. Maternal passive immunity is temporary and
will last for only a short time after birth.
⏺ The nurse notes a venous ulcer on the client's left ankle. What additional
assessment finding does the nurse expect in this client?
A) Absence of hair on the left lower extremity
B) Skin surrounding the ulcer mottled but blanchable
C) Brownish discoloration of the lower extremity
CERTIFICATION QUESTIONS AND VERIFIED
ANSWERS 2026
⏺ A patient is being treated with an antibiotic. The nurse explains to the
patient that this medication is required for the reduction of inflammation at
the injury site because this medication:
A) will decrease the pain at the site.
B) helps to kill the infection causing the inflammation.
C) will reduce the patients fever.
D) inhibits cyclooxygenase.? Answer:B
Antimicrobials treat the underlying cause of the infection which leads to
inflammation. Analgesics and nonsteroidal antiinflammatory drugs
(NSAIDs) help to treat pain. NSAIDs and other antipyretics are
cyclooxygenase inhibitors. Antipyretics help to reduce fever.
⏺ The nurse is caring for a client with ulcerative colitis and severe diarrhea.
Which nursing assessment is the highest priority?
A) Skin integrity
B) Blood pressure
C) Heart rate and rhythm
D) Abdominal percussion? Answer:C
Although the client with severe diarrhea may experience skin irritation and
hypovolemia, the client is most at risk for cardiac dysrhythmias secondary
to potassium and magnesium loss from severe diarrhea. The client should
have her or his electrolyte levels monitored, and electrolyte replacement
may be necessary. Abdominal percussion is an important part of physical
assessment but has lower priority for this client than heart rate and rhythm.
⏺ The nurse assesses a client with pneumonia and notes decreased lung
sounds on the left side and decreased lung expansion. What is the nurse's
best action?
,A) Increase oxygen flow to 10 L/min.
B) Perform an arterial blood gas analysis.
C) Have the client cough and deep breathe.
D) Check oxygen saturation and notify the health care provider.? Answer:D
Decreased lung sounds and decreased lung expansion could indicate the
development of a complication such as empyema or pus in the pleural
space. The nurse should check the client's oxygen saturation and notify the
provider. Infection can also move into the bloodstream and result in sepsis,
so quick treatment is needed.
⏺ The nurse is assigned a group of patients. Which patient would the nurse
identify as being at increased risk for impaired gas exchange? A patient:
A) with a hemoglobin of 8.5 g/dL
B) with a blood glucose of 350 mg/dL
C) who has been on anticoagulants for 10 days
D) with a heart rate of 100 beats/min and blood pressure of 100/60?
Answer:A
The hemoglobin is low (anemia), therefore the ability of the blood to carry
oxygen is decreased. High blood glucose and/or anticoagulants do not alter
the oxygen carrying capacity of the blood. A heart rate of 100 beats/min
and blood pressure of 100/60 are not indicative of oxygen carrying capacity
of the blood.
⏺ The nurse is starting a client on digoxin (Lanoxin) therapy. What
intervention is essential to teach this client?
A) "Increase your intake of foods high in potassium."
B) "Avoid taking aspirin or aspirin-containing products."
C) "Hold this medication if your pulse rate is below 80 beats/min."
D) "Do not take this medication within 1 hour of taking an antacid."?
Answer:D
Gastrointestinal absorption of digoxin is erratic. Many medications,
especially antacids, interfere with its absorption. Clients are taught to hold
their digoxin for bradycardia; a heart rate of 80 is too high for this cutoff.
, ⏺ The nurse is caring for a client with Crohn's disease who has developed
a fistula. Which nursing intervention is the highest priority?
A) Position the client to allow gravity drainage of the fistula.
B) Check and record blood glucose levels every 6 hours.
C) Encourage the client to consume a diet high in protein and calories.
D) Monitor the client's hematocrit and hemoglobin.? Answer:C
The client with Crohn's disease is already at risk for malabsorption and
malnutrition. Malnutrition impairs healing of the fistula and immune
responses. Therefore, maintaining adequate nutrition is a priority for this
client. The client will require 3000 calories per day to promote healing of
the fistula. Monitoring the client's blood sugar and hemoglobin levels is
important, but less so than encouraging nutritional intake. The client need
not be positioned to facilitate gravity drainage of the fistula, because
fistulas often are found in the abdominal cavity.
⏺ The nurse is teaching a client who has recently given birth about
immunity that has been passed to the newborn. Which statement by the
client indicates that additional teaching is needed?
A) "My baby received some antibodies from me before birth, and I will give
him more when I breast-feed."
B) "I had the measles, so my baby will be protected against it until he is old
enough to receive the MMR vaccine."
C) "Only certain antibodies were able to cross the placenta to protect my
baby."
D) "I had chickenpox and am immune to it, so my baby will not need to
have the chickenpox vaccine."? Answer:D
The baby receives passive immunity from antibodies that are passed
through the placenta in utero. Maternal passive immunity is temporary and
will last for only a short time after birth.
⏺ The nurse notes a venous ulcer on the client's left ankle. What additional
assessment finding does the nurse expect in this client?
A) Absence of hair on the left lower extremity
B) Skin surrounding the ulcer mottled but blanchable
C) Brownish discoloration of the lower extremity
