NSE 203 (WEEKS 1-5 CONTENT) EXAM QUESTIONS ANSWERED CORRECTLY LATEST UPDATE 2026
What is involved in "A" of the primary survey - Answers Airway:
- is the airway patent (open/unobstructed airway)
What is involved in "B" of the primary survey - Answers Breathing:
- measure RR
- evaluate work of breathing
- measure O2sat
What is involved in "C" of the primary survey - Answers Circulation:
- palpate pulse (rate and rhythm)
- BP
- assess urine output
What is involved in "D" of the primary survey - Answers - Assess LOC
- Evaluate speech
- Assess pain
- Assess facial symmetry
- Assess sudden change in vision
What is involved in "E" of the primary survey - Answers Exposure:
- measure body temp
- inspect skin integrity
- inspect/palpate skin for signs of pressure injury
- observe any wounds, dressings, drains, invasive lines
- assess bowel movements
What is included in the physical assessment (body systems) - Answers 1. skin
2. cardiac
3. respiratory
4. abdomenal/gastrointestinal
Low O2 sat and low systolic BP are considered to be what in relation to the primary survery - Answers
signs associated with death
A 75 year old hospitalized patient with limited mobility, activity and nutrition scores a 7 on the braden
risk assessment scale. what does this indicate? - Answers The patient is at very high risk for skin tears,
skin breakdown and/or the development of pressure ulcers/sores
When completing a health assessment of an older adult with mobility problems, how should you set
up the assessment? - Answers arrange to minimize the number of position changes for the patient
What assessment should be performed last on a 4-week old infant?
1. Palpation of fontanelles and suture lines
2. Auscultation of breath sounds
3. Otoscopic examination of the tympanic membrane
4. Weight, length, and head circumference - Answers Otoscopic examination of tympanic membrane
(most invasive last)
What test would be used to screen a young child for hip stability? - Answers Ortolani manoeuvre
To gain the trust of a young child, what should the examiner do? - Answers First focus on the parent
while the child plays with a toy
Which approach to a complete physical assessment should be used for an adolescent? - Answers
Head to toe approach
When assessing the extraocular muscles. which of test would be inappropriate?
1. six cardinal positions of gaze
2. corneal light reflex
3. cranial nerves III, IV, VI testing
4. confrontation test - Answers Confrontation test (this assesses cranial nerve II and visual fields)
When should the examiner/nurse auscultate for carotid bruits - Answers if the patient is middle aged
or older
The nurse is completing a blood pressure (BP) assessment as part of the first complete physical
examination of a 25-year-old male patient. The nurse knows the protocol for accurately assessing a BP
baseline is to take the BP: (SATA)
1. in the left arm
2. three times with 2 minute intervals
, 3. two times with 3 minute intervals
4. in both arms - Answers three times with 2 minute intervals and in both arms
The hospitalized patient does not require a full neurological examination during every shift
assessment. Which of the following may be a way of assessing the neurological status of the
hospitalized patient?
1. Palpating the carotid pulse
2. Looking at the significant other throughout the examination
3. Depressing the nail bed and release
4. Offering the patient a glass of water - Answers offering the patient a glass of water
A 56-year-old male patient has cellulitis of the left lower extremity and no history of health problems.
Which of the following findings would need further evaluation?
1. Irregular pulse
2. Flat brown macules on the dorsa of his hands
3. 2+ pedal pulses bilaterally
4. Chest anteroposterior diameter to transverse diameter at a 1:2 ratio - Answers Irregular pulse
An 80-year-old patient admitted with chest pain is on a monitored unit. The hearing for this patient
should initially be assessed by: - Answers Normal conversation
Which of the following patients should the nurse assess first?
1. An 89-year-old patient who has urinary tract infection and is confused
2. A 48-year-old patient with shortness of breath and pulse oximeter reading of 88%
3. A 59-year-old patient with chest pain that increases with deep inspiration
4. A 52-year-old patient with a white blood cell count of 22 × 109 cells/L - Answers A 48-year-old
patient with shortness of breath and pulse oximeter reading of 88%
Which of the following would be included in an assessment of a patient's ability to perform
instrumental activities of daily living (IADLs)?
1. Dressing, toileting, and using stairs
2. Eating, bathing, and grooming
3. Balance, gait, and motor coordination
4. Taking medications, shopping, and meal preparation - Answers Taking medications, shopping, and
meal preparation
Alterations in cognition in older adults is commonly attributed to what? - Answers Dementia,
delirium, depression
short attention span is associated with what in older adults? - Answers delirium
Why is it dangerous for a cognitive change to be attributed to the normal aging process? - Answers it
may delay the diagnosis of an underlying disease process
True or False: falls are the most common cause for injury related to hospitalization for older adults -
Answers True: Falls are the number one cause of injury-related hospitalizations of older adults in
Canada. Older adults who fall spend an average of 3 weeks in hospital, whereas with non-fall-related
hospitalizations, the older person's length of hospital stay, on average, is 12 days.
Prevention and treatment of ____________ may be one of the most effective interventions aimed at
reducing functional decline in an older adult. - Answers depression
What are the 2 major signs of caregiver burnout? - Answers - headaches
- epigastric pain
When the airway is blocked or threatened what type of action is required? - Answers immediate
If the client has a blocked or partially blocked airway, what should you do? - Answers 1. check LOCs
(alert, responding to verbal compands, responding to pain, or unresponsive)
2. check if the mouth is empty
3. check for facial or neurological trauma
accessory muscle use is a sign of what? - Answers blocked airway
Inspiratory stridor is usually heard when the airway is partially blocked, if you dont hear it what is the
cause? - Answers 1. fully blocked airway
2. execessive work of breathing is caused by something other than blockage
what is the triple airway meneuver? - Answers chin lift and jaw thrust: then give oxygen
What is involved in "A" of the primary survey - Answers Airway:
- is the airway patent (open/unobstructed airway)
What is involved in "B" of the primary survey - Answers Breathing:
- measure RR
- evaluate work of breathing
- measure O2sat
What is involved in "C" of the primary survey - Answers Circulation:
- palpate pulse (rate and rhythm)
- BP
- assess urine output
What is involved in "D" of the primary survey - Answers - Assess LOC
- Evaluate speech
- Assess pain
- Assess facial symmetry
- Assess sudden change in vision
What is involved in "E" of the primary survey - Answers Exposure:
- measure body temp
- inspect skin integrity
- inspect/palpate skin for signs of pressure injury
- observe any wounds, dressings, drains, invasive lines
- assess bowel movements
What is included in the physical assessment (body systems) - Answers 1. skin
2. cardiac
3. respiratory
4. abdomenal/gastrointestinal
Low O2 sat and low systolic BP are considered to be what in relation to the primary survery - Answers
signs associated with death
A 75 year old hospitalized patient with limited mobility, activity and nutrition scores a 7 on the braden
risk assessment scale. what does this indicate? - Answers The patient is at very high risk for skin tears,
skin breakdown and/or the development of pressure ulcers/sores
When completing a health assessment of an older adult with mobility problems, how should you set
up the assessment? - Answers arrange to minimize the number of position changes for the patient
What assessment should be performed last on a 4-week old infant?
1. Palpation of fontanelles and suture lines
2. Auscultation of breath sounds
3. Otoscopic examination of the tympanic membrane
4. Weight, length, and head circumference - Answers Otoscopic examination of tympanic membrane
(most invasive last)
What test would be used to screen a young child for hip stability? - Answers Ortolani manoeuvre
To gain the trust of a young child, what should the examiner do? - Answers First focus on the parent
while the child plays with a toy
Which approach to a complete physical assessment should be used for an adolescent? - Answers
Head to toe approach
When assessing the extraocular muscles. which of test would be inappropriate?
1. six cardinal positions of gaze
2. corneal light reflex
3. cranial nerves III, IV, VI testing
4. confrontation test - Answers Confrontation test (this assesses cranial nerve II and visual fields)
When should the examiner/nurse auscultate for carotid bruits - Answers if the patient is middle aged
or older
The nurse is completing a blood pressure (BP) assessment as part of the first complete physical
examination of a 25-year-old male patient. The nurse knows the protocol for accurately assessing a BP
baseline is to take the BP: (SATA)
1. in the left arm
2. three times with 2 minute intervals
, 3. two times with 3 minute intervals
4. in both arms - Answers three times with 2 minute intervals and in both arms
The hospitalized patient does not require a full neurological examination during every shift
assessment. Which of the following may be a way of assessing the neurological status of the
hospitalized patient?
1. Palpating the carotid pulse
2. Looking at the significant other throughout the examination
3. Depressing the nail bed and release
4. Offering the patient a glass of water - Answers offering the patient a glass of water
A 56-year-old male patient has cellulitis of the left lower extremity and no history of health problems.
Which of the following findings would need further evaluation?
1. Irregular pulse
2. Flat brown macules on the dorsa of his hands
3. 2+ pedal pulses bilaterally
4. Chest anteroposterior diameter to transverse diameter at a 1:2 ratio - Answers Irregular pulse
An 80-year-old patient admitted with chest pain is on a monitored unit. The hearing for this patient
should initially be assessed by: - Answers Normal conversation
Which of the following patients should the nurse assess first?
1. An 89-year-old patient who has urinary tract infection and is confused
2. A 48-year-old patient with shortness of breath and pulse oximeter reading of 88%
3. A 59-year-old patient with chest pain that increases with deep inspiration
4. A 52-year-old patient with a white blood cell count of 22 × 109 cells/L - Answers A 48-year-old
patient with shortness of breath and pulse oximeter reading of 88%
Which of the following would be included in an assessment of a patient's ability to perform
instrumental activities of daily living (IADLs)?
1. Dressing, toileting, and using stairs
2. Eating, bathing, and grooming
3. Balance, gait, and motor coordination
4. Taking medications, shopping, and meal preparation - Answers Taking medications, shopping, and
meal preparation
Alterations in cognition in older adults is commonly attributed to what? - Answers Dementia,
delirium, depression
short attention span is associated with what in older adults? - Answers delirium
Why is it dangerous for a cognitive change to be attributed to the normal aging process? - Answers it
may delay the diagnosis of an underlying disease process
True or False: falls are the most common cause for injury related to hospitalization for older adults -
Answers True: Falls are the number one cause of injury-related hospitalizations of older adults in
Canada. Older adults who fall spend an average of 3 weeks in hospital, whereas with non-fall-related
hospitalizations, the older person's length of hospital stay, on average, is 12 days.
Prevention and treatment of ____________ may be one of the most effective interventions aimed at
reducing functional decline in an older adult. - Answers depression
What are the 2 major signs of caregiver burnout? - Answers - headaches
- epigastric pain
When the airway is blocked or threatened what type of action is required? - Answers immediate
If the client has a blocked or partially blocked airway, what should you do? - Answers 1. check LOCs
(alert, responding to verbal compands, responding to pain, or unresponsive)
2. check if the mouth is empty
3. check for facial or neurological trauma
accessory muscle use is a sign of what? - Answers blocked airway
Inspiratory stridor is usually heard when the airway is partially blocked, if you dont hear it what is the
cause? - Answers 1. fully blocked airway
2. execessive work of breathing is caused by something other than blockage
what is the triple airway meneuver? - Answers chin lift and jaw thrust: then give oxygen
