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Basic Physical Assessment NCLEX Questions With Complete Solutions
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Basic Physical Assessment NCLEX Questions With Complete Solutions
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Basic Physical Assessment NCLEX QuestionsWith Complete Solutions
A 35-year-old client is admitted to the hospital for routine
outpatient surgery. Before surgery, the nurse auscultates the
client's chest for breath sounds. Identify the area where the nurse
should expect to hear bronchovesicular breath sounds. Correct
Answers Bronchovesicular breath sounds are best heard next to
the upper third of the sternum and between the scapulae. These
breath sounds are equal in length during inspiration and
expiration.
A 40-year-old client is admitted with a diagnosis of new-onset
atrial fibrillation. To obtain an accurate pulse count, the nurse
counts the apical heart rate. Identify the area where the nurse
should place the stethoscope to best hear the apical rate. Correct
Answers The apical heart rate is best heard at the point of
maximal impulse, which is generally in the fifth intercostal
space at the midclavicular line.
A 60-year-old client comes to the clinic seeking medical
attention for a rash. The nurse assesses the rash and finds that
the client's back and right side are covered with vesicles
(elevated, round, blisterlike lesions that are filled with clear
fluid). A vesicular rash may be associated with which
conditions? Correct Answers 1. Contact dermatitis, 2. Herpes
zoster, 3. Smallpox
A 76-year-old client with no debilitating conditions belongs to
which geriatric population? Correct Answers 2. Middle-old
,A child with rheumatic fever must have his heart rate measured
while awake and while sleeping. Why are two readings
necessary? Correct Answers 4. To compensate for the effects
of activity on the heart rate
A client comes to the clinic complaining of a sore throat and
fever. To obtain a throat culture, the nurse asks the client to tilt
his head back, open his mouth, and close his eyes. What should
the nurse do next to obtain the specimen? Correct Answers 3.
Swab the tonsillar areas from side to side, avoiding contact with
the tongue, cheeks, and teeth.
A client comes to the clinic for a routine checkup. To check the
client's gag reflex, the nurse should use which method? Correct
Answers 2. Place a tongue blade lightly on the posterior aspect
of the tongue.
A client comes to the clinic for diagnostic allergy testing. Why
is an intradermal injection used for such testing? Correct
Answers 4. Intradermal drugs diffuse slowly.
A client complains of abdominal pain. To elicit as much
information about the pain as possible, the nurse should ask:
Correct Answers 4. "What does the pain feel like?"
A client complains of lower abdominal pressure. The nurse
notes a firm mass extending above the symphysis pubis. Which
condition is the most likely cause of these findings? Correct
Answers 4. Distended bladder
, A client has been admitted to the hospital with signs of
dehydration. Which action would be least beneficial in
increasing the client's fluid intake? Correct Answers 3. Serving
fluids in large amounts
A client has just undergone a bronchoscopy. Which nursing
intervention is most important at this time? Correct Answers 2.
Checking airway patency
A client has lymphedema in both arms and the nurse must
measure blood pressure using a thigh cuff. In reference to the
client's baseline arm blood pressure, the nurse should expect the
thigh to have a: Correct Answers 1. higher systolic blood
pressure reading.
A client is being discharged from the hospital after a total hip
replacement. The physician has ordered home health services for
the client. What's the most appropriate action for the nurse to
take? Correct Answers 1. Contact the home health agency and
provide a report of the client's condition and needs.
A client reports abdominal pain. Which action would aid the
nurse's investigation of this complaint? Correct Answers 2.
Palpating the painful area last
A client requests something to treat his constipation. The client's
medication administration record contains an order for a laxative
to be administered every other day as needed. Which assessment
finding by the licensed practical nurse indicates the need to
notify the registered nurse (RN) before administering the
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