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NUR 256 - EXAM 1 QUESTIONS WITH VERIFIED ANSWERS |
LATEST 2025/2026 UPDATE| 100% CORRECT.
A nurse has just received report on a newly admitted client who reports abdominal tenderness
in the lower right quadrant which of the following is the first step the nurse should perform
during the abdominal assessment?
A. Palpation
B. Percussion
C. Auscultation
D. Inspection - ANSWER-Inspection
A nurse is completing documentation in a client's medical record. Which of the following entries
display proper documentation by the nurse?
A. The client is feeling better
B. The client's abdomen is soft and distended
C. The client's status is unchanged
D. The client appears in pain - ANSWER-The client's abdomen is soft and distended
A nurse has just received report on a newly admitted client who speaks a different language
than the nurse. Which of the following actions should the nurse take to assist with effective
communication with the client during the initial assessment process?
A. Enlist the aid of the client's school-aged child to interpret for the nurse and the client
B. Ask the client's best friend to interpret for the nurse and client
C. Use jokes and laughter to make the client feel more at ease
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D. Request assistance from an interpreter during the assessment - ANSWER-Request assistance
from an interpreter during the assessment
A nurse is assessing a client's respiration and notes they are shallow and at a rate of 24/min.
The nurse should identify this as which of the following unexpected findings?
A. Tachypnea
B. Bradypnea
C. Apnea
D. Hypervenilation - ANSWER-Tachypnea
When conducting a general survey of a client, the nurse should assess ___, ___, and ___.
Respiratory rate
Speech
Temperature
Gait
Pain
Pupils
Level of consciousness
Skin turgor - ANSWER-Level of consciousness, speech, and gait
A nurse is documenting information in a client's medical record during an initial assessment.
Which of the following information did the nurse collect during the general survey?
Height and weight
Use of assistive devices
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Behavior and mood
Past medical history
Current medication list - ANSWER-Height and weight
Use of assistive device
Behavior and mood
A nurse is caring for a client who is comatose. Which of the following alternative routes should
the nurse use to obtain the most accurate core temp of the client?
A. Axillary
B. Temporal
C. Tympanic
D. Rectal - ANSWER-Rectal
A nurse is planning on obtaining an orthostatic blood pressure from a client who has syncope. In
what order should the nurse take the following steps?
Take the client's BP in the supine position
Keep the cuff in place and assist the client to a seated position
Assist the client to stand and then obtain their BP
Place the client in a supine position and allow them to rest
Take the client's BP in a seated position - ANSWER-Place the client in a supine position and allow
them to rest.
Take the client's BP in supine position
Keep the cuff in place and assist the client to a seated position.
Take the client's BP in a seated position.
Assist the client to stand and obtain their BP.
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A nurse is preparing to obtain a client's height during a general survey. Which of the following
actions should the nurse take?
A. Deduct the client's shoe height from the measurement
B. Have the client gently life their chin and look toward the ceiling
C. Ensure the client's feet are in contact with the wall or measuring pole
D. Pull up the measuring pole and extend the headpiece after the client steps on the scale -
ANSWER-Ensure the client's feet are in contact with the wall or measuring pole
A nurse is preparing to conduct an initial survey and assessment on a newly admitted client.
Which of the following actions should the nurse plan to take?
A. Have an informal conversation with the client before beginning the observation of the client
B. Complete all focused assessments prior to formulating thoughts regarding the client's general
health status
C. Sit on the client's bedside with them to have close contact and maintain eye contact
whenever possible
D. Engage in active listening with the client and allow the client to express concerns early in the
assessment process - ANSWER-Engage in active listening with the client and allow the client to
express concerns early in the assessment process
A nurse assess a client's respiratory rate and notes that it is below the expected reference
range. The nurse should identify that which of the following findings can cause a decreased
respiratory rate?
A. The client has been a chronic smoker for 10 years
B. The client takes a narcotic pain medication for chronic pain
C. The client reports anxiety due to being in a hospital
NUR 256 - EXAM 1 QUESTIONS WITH VERIFIED ANSWERS |
LATEST 2025/2026 UPDATE| 100% CORRECT.
A nurse has just received report on a newly admitted client who reports abdominal tenderness
in the lower right quadrant which of the following is the first step the nurse should perform
during the abdominal assessment?
A. Palpation
B. Percussion
C. Auscultation
D. Inspection - ANSWER-Inspection
A nurse is completing documentation in a client's medical record. Which of the following entries
display proper documentation by the nurse?
A. The client is feeling better
B. The client's abdomen is soft and distended
C. The client's status is unchanged
D. The client appears in pain - ANSWER-The client's abdomen is soft and distended
A nurse has just received report on a newly admitted client who speaks a different language
than the nurse. Which of the following actions should the nurse take to assist with effective
communication with the client during the initial assessment process?
A. Enlist the aid of the client's school-aged child to interpret for the nurse and the client
B. Ask the client's best friend to interpret for the nurse and client
C. Use jokes and laughter to make the client feel more at ease
,2|Page
D. Request assistance from an interpreter during the assessment - ANSWER-Request assistance
from an interpreter during the assessment
A nurse is assessing a client's respiration and notes they are shallow and at a rate of 24/min.
The nurse should identify this as which of the following unexpected findings?
A. Tachypnea
B. Bradypnea
C. Apnea
D. Hypervenilation - ANSWER-Tachypnea
When conducting a general survey of a client, the nurse should assess ___, ___, and ___.
Respiratory rate
Speech
Temperature
Gait
Pain
Pupils
Level of consciousness
Skin turgor - ANSWER-Level of consciousness, speech, and gait
A nurse is documenting information in a client's medical record during an initial assessment.
Which of the following information did the nurse collect during the general survey?
Height and weight
Use of assistive devices
,3|Page
Behavior and mood
Past medical history
Current medication list - ANSWER-Height and weight
Use of assistive device
Behavior and mood
A nurse is caring for a client who is comatose. Which of the following alternative routes should
the nurse use to obtain the most accurate core temp of the client?
A. Axillary
B. Temporal
C. Tympanic
D. Rectal - ANSWER-Rectal
A nurse is planning on obtaining an orthostatic blood pressure from a client who has syncope. In
what order should the nurse take the following steps?
Take the client's BP in the supine position
Keep the cuff in place and assist the client to a seated position
Assist the client to stand and then obtain their BP
Place the client in a supine position and allow them to rest
Take the client's BP in a seated position - ANSWER-Place the client in a supine position and allow
them to rest.
Take the client's BP in supine position
Keep the cuff in place and assist the client to a seated position.
Take the client's BP in a seated position.
Assist the client to stand and obtain their BP.
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A nurse is preparing to obtain a client's height during a general survey. Which of the following
actions should the nurse take?
A. Deduct the client's shoe height from the measurement
B. Have the client gently life their chin and look toward the ceiling
C. Ensure the client's feet are in contact with the wall or measuring pole
D. Pull up the measuring pole and extend the headpiece after the client steps on the scale -
ANSWER-Ensure the client's feet are in contact with the wall or measuring pole
A nurse is preparing to conduct an initial survey and assessment on a newly admitted client.
Which of the following actions should the nurse plan to take?
A. Have an informal conversation with the client before beginning the observation of the client
B. Complete all focused assessments prior to formulating thoughts regarding the client's general
health status
C. Sit on the client's bedside with them to have close contact and maintain eye contact
whenever possible
D. Engage in active listening with the client and allow the client to express concerns early in the
assessment process - ANSWER-Engage in active listening with the client and allow the client to
express concerns early in the assessment process
A nurse assess a client's respiratory rate and notes that it is below the expected reference
range. The nurse should identify that which of the following findings can cause a decreased
respiratory rate?
A. The client has been a chronic smoker for 10 years
B. The client takes a narcotic pain medication for chronic pain
C. The client reports anxiety due to being in a hospital
