FUNDAMENTALS OF NURSING
Final Coaching NLE 2017
Practice Test 4
Physical Assessment
1. The nurse is assessing a postoperative patient for signs of haemorrhage. Which adaptation is most indicative of shock?
a. Hyperemia c. Irregular pulse
b. Hypotension d. Slow respiration
2. The nurse is monitoring the vital signs of a group of patient. When reviewing these results, the nurse must remember that the
body temperature usually is at its highest at:
a. 12 AM – 2 AM c. 4 PM – 6 PM
b. 6 AM – 10 AM d. 8 PM – 10 PM
3. When assessing bogborygmi, which physical examination method should the nurse use?
a. Auscultation c. Inspection
b. Percussion d. Palpation
4. The nurse plans to take a patient’s radial pulse. Which method of examination should be used by the nurse?
a. Palpation c. Percussion
b. Inspection d. Ausculration
5. Which nursing action is common to all instruments when taking a temperature?
a. Identify the reading is below 35 ◦C before c. Place a disposable sheath over the probe
insertion d. Ensure that the instrument is clean
b. Wash with cool soap and water after use
6. The nurse concludes that a patient is experiencing hyperthermia. Which assessment precipitated this conclusion?
a. Mental confusion c. Decrease heart rate
b. Increase appetite d. Rectal temperature of 38.8 ◦C
7. The nurse in the emergency department is engaging in an initial assessment of a patient. Which assessment of a patient. Which
assessment takes priority?
a. Blood pressure c. Breathing pattern
b. Airway clearance d. Circulatory status
8. The nurse is obtaining a patient’s blood pressure. Which information is most important for the nurse to document?
a. Staff member who took the blood pressure
b. Patient’s tolerance to having the blood pressure taken
c. Position of the patient if the patient is not in a sitting position
d. Difference between the palpated and auscultated systolic readings
9. The nurse is teaching a cancer prevention community health class. Which recommended cancer screening guideline for
asymptomatic non risk people should the nurse include?
a. Pap smear annually for female 13 years of age and older
b. Mammograms annually for women 30 years of age and older
c. Prostate-specific antigens yearly for men 30 years of age and older
d. Sigmoidoscopies every 5 years for patients 50 years and older
10. The nurse understands that the body heat production is increased by:
a. Vasodilation c. Shivering
b. Evaporation d. Radiation
11. The nurse is assessing a patient’s bilateral pulses for symmetry. However the nurse should not assess which pulse sites on both
sides of the body at the same time?
a. Radial c. Femoral
b. Carotid d. Brachial
12. The nurse is caring for a patient who is experiencing an increase I n symptoms associated with multiple sclerosis. Which term
best describes a recurrence of symptoms associated with chronic disease?
a. Variance c. Adaptation
b. Remission d. Exacerbation
13. The nurse in the clinic must obtain the vital signs of each patient before each patient is assessed by the practitioner. The nurse
should obtain a temperature via the rectal route for a patient:
, a. Who is a mouth breather c. With an intelligence of a seven-year-old child
b. With a history of vomiting d. Who cannot tolerate a semi-Fowler’s position
14. A patient with hypertension is given discharge instructions to take the blood pressure every day. The nurse is evaluating a family
member taking the patient’s blood pressure as part of the patient’s discharge teaching plan. The nurse identifies that further
teaching is necessary when the family member:
a. Place then diaphragm of the stethoscope over the brachial artery
b. Applies the center of the bladder of the cuff directly over an artery
c. Releases the valve on the manometer so that the gauge drops 10 mm Hg per heartbeat
d. Inserts the 2 earpieces of the stethoscope into the ears so that they tilt slightly forward
15. A patient has a serious vitamin K deficiency. For which adaptation should the nurse assess this patient?
a. Skin lesion c. Night blindness
b. Bleeding gums d. Muscle weakness
16. The nurse identifies that a patient with a fever has warm skin. An additional adaptation that confirms the defervescence (flush)
phase of a fever is:
a. Sweating c. Cyanotic nail beds
b. Shivering d. Goosebumps on the skin
17. When evaluating a patient’s temperature, the nurse recalls that people usually have the lowest body temperature at:
a. 4 AM -6 AM c. 4 PM – 6 PM
b. 8 AM – 10 PM d. 8 PM- 10 PM
18. Which method of examination is being used to assess the temperature of a patient’s skin?
a. Palpation c. Percussion
b. Inspection d. Observation
19. The nurse must assess for the presence of bowel sounds in a postoperative patient. The nurse should auscultate the patient’s
abdomen:
a. Prior to palpation c. Starting at the left lower quadrant
b. Using a warmed stethoscope d. For at least three minutes in each quadrant
20. Which assessment requires the nurse to assess the patient further?
a. 18-year-old woman with a pulse rate of 140 after riding 2 miles on an exercise bike
b. 50-year-old man with a BP of 112/60 upon awakening in the morning
c. 65-year-old man with a respiratory rate of 10
d. 40-year-old woman with a pulse of 88
21. The nurse is caring for a group of hospitalized patients. What should the nurse do first to prevent infection?
a. Provide small bedside bags to dispose of used tissues
b. Encourage staff to avoid coughing near patients
c. Administer antibiotics as ordered
d. Identify patients at risk
22. The nurse identify that the patient has inflammatory response. Which local patient adaptation supports this conclusion?
a. Fever c. Bradypnea
b. Erythema d. Tachycardia
23. A patient has a wound that is healing by secondary intention.to best support healing of the wound, the nurse should expect the
practitioner’s order to state, “Clean wound with:
a. Betadine and apply a dry sterile gauze.”
b. Normal saline and cover with a gauze dressing.”
c. Normal saline and apply a wet-to-damp dressing.”
d. Half peroxide and half normal saline and apply a wet to dry dressing.”
24. The nurse identifies that the greatest risk for a wound infection exists for a patient with a:
a. Surgical creation of a colostomy c. Puncture of the foot by a nail
b. First-degree burn on the back d. Paper cut on the finger
25. The nurse understands that the skin protects the body from infections because the:
a. Cells of the skin constantly being replaced, thereby eliminating external pathogen
b. Epithelial cells are loosely compacted on skin, providing a barrier against pathogen
c. Moisture on the skin surface prevents colonization of pathogen
d. Alkalinity of the skin limits the growth of pathogens
26. The nurse must collect the following specimens. Which specimen collection does not require the use of surgical aseptic
technique?
Final Coaching NLE 2017
Practice Test 4
Physical Assessment
1. The nurse is assessing a postoperative patient for signs of haemorrhage. Which adaptation is most indicative of shock?
a. Hyperemia c. Irregular pulse
b. Hypotension d. Slow respiration
2. The nurse is monitoring the vital signs of a group of patient. When reviewing these results, the nurse must remember that the
body temperature usually is at its highest at:
a. 12 AM – 2 AM c. 4 PM – 6 PM
b. 6 AM – 10 AM d. 8 PM – 10 PM
3. When assessing bogborygmi, which physical examination method should the nurse use?
a. Auscultation c. Inspection
b. Percussion d. Palpation
4. The nurse plans to take a patient’s radial pulse. Which method of examination should be used by the nurse?
a. Palpation c. Percussion
b. Inspection d. Ausculration
5. Which nursing action is common to all instruments when taking a temperature?
a. Identify the reading is below 35 ◦C before c. Place a disposable sheath over the probe
insertion d. Ensure that the instrument is clean
b. Wash with cool soap and water after use
6. The nurse concludes that a patient is experiencing hyperthermia. Which assessment precipitated this conclusion?
a. Mental confusion c. Decrease heart rate
b. Increase appetite d. Rectal temperature of 38.8 ◦C
7. The nurse in the emergency department is engaging in an initial assessment of a patient. Which assessment of a patient. Which
assessment takes priority?
a. Blood pressure c. Breathing pattern
b. Airway clearance d. Circulatory status
8. The nurse is obtaining a patient’s blood pressure. Which information is most important for the nurse to document?
a. Staff member who took the blood pressure
b. Patient’s tolerance to having the blood pressure taken
c. Position of the patient if the patient is not in a sitting position
d. Difference between the palpated and auscultated systolic readings
9. The nurse is teaching a cancer prevention community health class. Which recommended cancer screening guideline for
asymptomatic non risk people should the nurse include?
a. Pap smear annually for female 13 years of age and older
b. Mammograms annually for women 30 years of age and older
c. Prostate-specific antigens yearly for men 30 years of age and older
d. Sigmoidoscopies every 5 years for patients 50 years and older
10. The nurse understands that the body heat production is increased by:
a. Vasodilation c. Shivering
b. Evaporation d. Radiation
11. The nurse is assessing a patient’s bilateral pulses for symmetry. However the nurse should not assess which pulse sites on both
sides of the body at the same time?
a. Radial c. Femoral
b. Carotid d. Brachial
12. The nurse is caring for a patient who is experiencing an increase I n symptoms associated with multiple sclerosis. Which term
best describes a recurrence of symptoms associated with chronic disease?
a. Variance c. Adaptation
b. Remission d. Exacerbation
13. The nurse in the clinic must obtain the vital signs of each patient before each patient is assessed by the practitioner. The nurse
should obtain a temperature via the rectal route for a patient:
, a. Who is a mouth breather c. With an intelligence of a seven-year-old child
b. With a history of vomiting d. Who cannot tolerate a semi-Fowler’s position
14. A patient with hypertension is given discharge instructions to take the blood pressure every day. The nurse is evaluating a family
member taking the patient’s blood pressure as part of the patient’s discharge teaching plan. The nurse identifies that further
teaching is necessary when the family member:
a. Place then diaphragm of the stethoscope over the brachial artery
b. Applies the center of the bladder of the cuff directly over an artery
c. Releases the valve on the manometer so that the gauge drops 10 mm Hg per heartbeat
d. Inserts the 2 earpieces of the stethoscope into the ears so that they tilt slightly forward
15. A patient has a serious vitamin K deficiency. For which adaptation should the nurse assess this patient?
a. Skin lesion c. Night blindness
b. Bleeding gums d. Muscle weakness
16. The nurse identifies that a patient with a fever has warm skin. An additional adaptation that confirms the defervescence (flush)
phase of a fever is:
a. Sweating c. Cyanotic nail beds
b. Shivering d. Goosebumps on the skin
17. When evaluating a patient’s temperature, the nurse recalls that people usually have the lowest body temperature at:
a. 4 AM -6 AM c. 4 PM – 6 PM
b. 8 AM – 10 PM d. 8 PM- 10 PM
18. Which method of examination is being used to assess the temperature of a patient’s skin?
a. Palpation c. Percussion
b. Inspection d. Observation
19. The nurse must assess for the presence of bowel sounds in a postoperative patient. The nurse should auscultate the patient’s
abdomen:
a. Prior to palpation c. Starting at the left lower quadrant
b. Using a warmed stethoscope d. For at least three minutes in each quadrant
20. Which assessment requires the nurse to assess the patient further?
a. 18-year-old woman with a pulse rate of 140 after riding 2 miles on an exercise bike
b. 50-year-old man with a BP of 112/60 upon awakening in the morning
c. 65-year-old man with a respiratory rate of 10
d. 40-year-old woman with a pulse of 88
21. The nurse is caring for a group of hospitalized patients. What should the nurse do first to prevent infection?
a. Provide small bedside bags to dispose of used tissues
b. Encourage staff to avoid coughing near patients
c. Administer antibiotics as ordered
d. Identify patients at risk
22. The nurse identify that the patient has inflammatory response. Which local patient adaptation supports this conclusion?
a. Fever c. Bradypnea
b. Erythema d. Tachycardia
23. A patient has a wound that is healing by secondary intention.to best support healing of the wound, the nurse should expect the
practitioner’s order to state, “Clean wound with:
a. Betadine and apply a dry sterile gauze.”
b. Normal saline and cover with a gauze dressing.”
c. Normal saline and apply a wet-to-damp dressing.”
d. Half peroxide and half normal saline and apply a wet to dry dressing.”
24. The nurse identifies that the greatest risk for a wound infection exists for a patient with a:
a. Surgical creation of a colostomy c. Puncture of the foot by a nail
b. First-degree burn on the back d. Paper cut on the finger
25. The nurse understands that the skin protects the body from infections because the:
a. Cells of the skin constantly being replaced, thereby eliminating external pathogen
b. Epithelial cells are loosely compacted on skin, providing a barrier against pathogen
c. Moisture on the skin surface prevents colonization of pathogen
d. Alkalinity of the skin limits the growth of pathogens
26. The nurse must collect the following specimens. Which specimen collection does not require the use of surgical aseptic
technique?
