UPDATE 2026
A. Appearance and behavior
B. Measurement of vital signs.
C. Observing specific body systems.
D. Conducting a detailed health history.
(A) - Answers The nurse prepares to conduct a general survey on an adult patient. Which assessment
is performed first while the nurse initiates the nurse-patient relationship?
A. 4, 2, 3, 1
B. 1, 2, 3, 4
C. 3, 2, 4, 1
D. 2, 3, 4, 1
(D) - Answers The nurse is performing an abdominal assessment on a patient. In what order does the
nurse perform the steps?
1. Percussion
2. Inspection
3. Auscultation
4. Palpation
A. Rhonchi
B. Coarse crackles
C. Sibilant wheeze
D. Pleural friction rub
(B) - Answers While auscultating the adult patient's lungs, the nurse hears loud, bubbly sounds during
inspiration that did not disappear after the patient coughed. Which finding should the nurse
document from the lung assessment?
A. Nodule
B. Macule
C. Wheal
D. Pustule
(C) - Answers During assessment of the skin, the nurse assesses a lesion on the arm of the patient.
The lesion is irregularly shaped, elevated with edema, and about 3 cm. What type of lesion does the
patient have?
A. Auscultation of an apical heart rate of 76
B. Absence of bowel sounds on abdominal assessment
C. Respiratory rate of 8 breaths/min
D. Palpation of dorsalis pedis pulses with strength of +2
(C) - Answers The nurse is assessing a patient who returned 1 hour ago from surgery for an
abdominal hysterectomy. Which assessment finding would require immediate follow-up?
A. "I'll make sure to schedule my colonoscopy annually after the age of 60."
B. "I'll make sure to have a computer tomography (CT) colonoscopy every 5 years."
C. "I'll make sure to have a flexible sigmoidoscopy every year once I turn 55."
D. "I'll make sure to have a fecal occult blood test annually once I turn 50."
(D) - Answers Which statement made by the patient indicates an understanding about teaching
related to early detection of colorectal cancer?
A. Supine with both arms overhead with palms upward.
B. Sitting with hands clasped just above the umbilicus.
C. Supine with the right arm abducted and hand under the head an neck.
D. Lying on the right side, adducting the right arm on the side of the body. - Answers How should the
patient be positioned to best palpate for lumps or tumors during an examination of the right breast?
A. "I'll recognize abnormal lumps because they are very painful"
, B. "I'll start performing testicular self-examination monthly after I turn 15"
C. "I'll perform the self-examination in front of a mirror"
D. "I'll gently roll the testicle between my fingers"
(A) - Answers The nurse is teaching a patient how to perform a testicular self-examination. Which
statement made by the patient indicates a need for further teaching?
A. The student stands at a midline position behind the patient observing for position of the spine and
scapula.
B. The student palpates the thoracic muscles for masses, pulsations, or abnormal movements.
C. the student places the bell of the stethoscope on the anterior chest wall to auscultate breath
sounds.
D. The student places the palm of the hand over the intercostal spaces and asks the patient to say
"ninety-nine"
(C) - Answers The nurse is observing the student nurse perform a respiratory assessment on a
patient. Which action by the student nurse requires the nurse to intervene?
A. "Tell me where you are."
B. "What can you tell me about your illness?"
C. "Repeat these numbers back to me: 7...5...8."
D. "What does this mean: 'A stitch in time saves nine?"
(C) - Answers The nurse plans to assess the patient's memory. Which task should the nurse ask the
patient to perform?
1. B
2. C
3. E
4. D
5. A - Answers The nurse is assessing the cranial nerves. Match the cranial nerve with its related
function.
1. Motor innervation to the muscles of the jaw
2. Lateral movement of the eyeballs
3. Sensation of the pharynx
4. Downward, inward eye movements
5. Position of the tongue
A. XII Hypoglossal
B. V trigeminal
C. VI Adducens
D. IV Trochlear
E. X Vagus
A. Limit intake of cholesterol to less than 400 mg/day.
B. Talk with your health care provider about taking a daily low dose of aspirin.
C. Work with your health care provider to develop a regular exercise program.
D. Limit daily intake of fats to less than 25% to 35% of total calories.
E. Review strategies to encourage the patient to quit smoking.
(B, C, D, E) - Answers The nurse is teaching a patient to prevent heart disease. Which information
should the nurse include? (Select all that apply)
A. Place the fingers behind and below the medial malleolus.
B. Have the patient slightly flex the knee with the foot resting on the bed.
C. Have the patient relax the foot while lying supine.
D. Palpate the groove lateral to the flexor tendon of the wrist.
E. Palpate along the top of the foot in a line with the groove between extensor tendons of great and
first toes.