Nurse Practice Act

Question 2

Nurse Practice Act. A nurse is performing an assessment within the legal parameters of assessment and diagnosis as defined by the board of nursing. These legal guidelines would be specified in which of the following?

The nurse’s terms of license
The institution’s policies and procedures guidelines
The client’s informed consent documents
The state’s Nurse Practice Act

Question 3

When preparing to do a comprehensive health assessment, the nurse obtains the client’s permission based on an understanding of what principle?

The client’s level of comfort will be increased by granting explicit consent.
The client has the right to refuse the assessment.
Obtaining permission enhances therapeutic rapport.
The client will be more willing to disclose after giving permission.

Question 4

What statement made by the client should be documented in the past health history component of the assessment?

“I drink three or four beers each week.”
“I have shortness of breath when I walk.”
“I have been having some pain when I urinate for the last several days.”
“I had surgery five years ago to repair an inguinal hernia.”

Question 6

The nurse is taking an initial blood pressure on a 72-year-old client with a history of hypertension. How should the nurse proceed?

Look at the client’s past blood pressure readings and inflate the cuff 30 mmHg above the highest systolic reading recorded.
Inflate the cuff to 200 mmHg in an attempt to obtain the most accurate systolic reading.
Inflate the blood pressure cuff 30 mmHg above the point at which the palpated pulse reappeared.
Place the cuff on the client’s arm and inflate it 50 mmHg above the client’s pulse rate.

Question 7

A nurse is preparing to complete a comprehensive assessment on a client. When collecting objective data which of the following should the nurse do first?

Inspect the client’s head for size, shape and contour.
Obtain the client’s standing weight.
Assess the client’s vital signs.
Observe the client’s overall appearance.

Question 8

The nurse is providing care for a client with cerebellar ataxia. What safety precautions would be important for the nurse to implement related to this finding?

Fall precautions
Aspiration precautions
Seizure precautions
Bleeding precautions

Question 9

The nurse is assessing a client for circulatory compromise. Where would the nurse inspect to identify peripheral cyanosis?

Nail beds
Oral mucosa
Palms of the hands
Sclera

Question 10

The nurse observes a raised, circumscribed area that is 3 millimeters. Serous fluid is also noted within the lesion. How would the nurse document this finding?

Bulla
Pustule
Vesicle
Papule

Question 11

A nurse is assessing an older adult client’s risk for pressure injury using the Braden Scale for Predicting Pressure Sore Risk. Which aspect of the client’s current health status would have the greatest impact on their risk for developing a pressure injury?

The client requires a full-time caregiver.
The client is often incontinent of urine.
The client is at risk for falling.
The client adheres to a vegetarian diet.

Question 12

An elderly woman is brought to the emergency department after being found lying on the kitchen floor for 2 days. She did not have access to food or fluid during that time. What would the nurse expect to find during their assessme¹nt?

Radial pulse $2+/4+$.
Skin turgor that recoils immediately.
Pale, yellow urine.
Sunken eyes with dark circles. Nurse Practice Act

Question 13

A nurse is assessing a client with chronic hypoxia related to chronic obstructive pulmonary disease. What finding below might the nurse expect?

Nail angle of 180 degrees or greater.
Longitudinal ridges and pitting of the nails.
Ratio of the anteroposterior (AP) to transverse diameter is 1:2.
Tenting of the skin under the clavicle.

Question 14

The nurse is preparing to auscultate breath sounds in a client who has severe dyspnea. What action should the nurse include in their assessment plan?

Auscultate the client’s inspiratory breath sounds only.
Administer a bronchodilator prior to assessing the client.
Avoid auscultating the breath sounds until the end of the assessment.
Provide rest breaks as needed while auscultating the breath sounds.

Question 15

The nurse notes the following findings during their assessment (see table below):

Vital Signs: $98.9^\circ F$; 94% oxygen saturation on 4 liters nasal cannula; 120/78; 22 breaths per minute; 100 beats per minute.
Respiratory Assessment: Productive cough with yellow sputum; AP to transverse ratio 1:2; Labored breathing at rest; Course crackles in bilateral lower lobes.

These signs and symptoms are consistent with which medical diagnosis?

Chronic obstructive pulmonary disease
Croup
Pneumonia
Congestive heart failure

Question 16

The following clients are assigned to the emergency department nurse. After receiving report, which client should the nurse see first?

A 28 year-old with stridor and intercostal retractions.
A 48 year-old with shortness of breath and heart rate of 108 after ambulating to the bathroom.
A 63 year-old with pectus excavatum and a respiratory rate of 20 breaths per minute.
A 78 year-old client with a productive cough and Glasgow Coma Scale of 14.

Question 18

A client has sought care with complaints of increasing swelling in their feet and ankles. The nurse’s assessment confirms the presence of bilateral edema. What health problem is the nurse concerned about?

Arterial insufficiency
Congestive heart failure
Myocardial infarction
Deep vein thrombosis

Question 19

After teaching a group of students about the areas of auscultation for heart sounds, the instructor determines that the teaching was successful when the students auscultate the apical pulse at which location?

Second intercostal space at the right sternal border
Third intercostal space at the left sternal border
Fifth intercostal space at the left midclavicular line
Lateral aspect of the wrist

Question 20

The nurse is auscultating a client’s heart using the diaphragm of the stethoscope. When listening at the pulmonic area, the nurse notes that the S2 sound is louder than the S1 sound. What is the nurses priority action regarding this finding?

Notify the provider of the findings.
Listen again as the S1 sound should be louder at this location.
Recognize this as a normal finding.
Ask the client about their cardiovascular medical history.

Question 21

A client has edema in the legs and feet bilaterally to such an extent that their shoes no longer fit. When the nurse presses the skin on the ankles, the indentation is approximately 2 centimeter deep and remains for nearly 30 seconds. How should the nurse document this finding?

+1 pitting edema present in bilateral ankles.
Signs and symptoms of venous insufficiency present in bilateral ankles.
4+ pitting edema present in bilateral ankles.
4+ non-pitting edema present in bilateral legs.

Question 22

The nurse is evaluating a client recently diagnosed with a deep vein thrombosis in the right lower leg. What complaint from the client would cause the nurse the most concern related to this diagnosis?

Pain in the right calf
Unilateral edema in the right leg
Paresthesia in the right foot
Sudden shortness of breath

Question 23

A client comes into the clinic with complaints of cramping leg pain when walking. The nurse also notes a one pack per day smoking history, hypertension, and diabetes mellitus type two controlled with diet. What peripheral vascular assessment should the nurse perform next?

Palpate for edema
Inspect skin color on legs
Palpate for dorsalis pedis pulses
Perform the Allen Test

Question 28

The nurse is assessing a client who is in liver failure and who has developed ascites. When measuring the client’s abdominal girth, the nurse should place the client in which ideal position?

Supine
Standing
Semi-fowlers
Sitting

Question 29

A new client is admitted for chest pain. The client has no history of abdominal or cardiovascular issues. During the comprehensive assessment the nurse is palpating the client’s abdomen and feels a prominent, nontender, pulsating 6-cm mass above the umbilicus. What action should the nurse take?

Counsel the client regarding hernia repair.
Refer the client to a cardiologist.
Continue palpating to get an in-depth assessment.
Stop palpating and get medical assistance.

Question 30

The nursing student is completing an abdominal assessment. The student notes that the abdomen is distended with no pulsations, bowel sounds are absent after listening for one minute, all quadrants are tender to palpation and rebound tenderness was noted while palpating the right lower quadrant. The student reports the findings to the primary nurse. What action should the nurse take?

Provide education about appendicitis to the client. Nurse Practice Act
Call the provider to report the findings.
Auscultate for bowel sounds for five minutes.
Test for referred tenderness in the left lower quadrant.

Question 31

The nurse is providing discharge education for a client recently diagnosed with epilepsy. What safety information would be important for the nurse to provide to the client?

“Do you take medications for the seizures?”
“It is recommended that you wear a medical bracelet to alert others that you have seizures.”
“Avoid going out in public as you may be at higher risk of falling.”
“You will always have an aura with a seizure so you will have time to get to a safe place.”

Question 32

The nurse is assessing a patient for a possible cerebrovascular accident (CVA) in the emergency room. The charge nurse and physician have asked for a complete cranial nerve assessment. How will the nurse test the function of Cranial Nerve XII (12)?

Test hearing acuity by asking the client to repeat one or two whispered words.
Palpate the temporal and masseter muscles as the person clenches the teeth.
Ask the client to protrude the tongue and move it side to side against resistance.
Ask the client to rotate the head forcibly against resistance applied to the chin.

Question 33

A client is being assessed in the neurological intensive care unit. The client has had a stroke 3 days prior and the family is at the bedside. When answering the family why the nurses provide neurological checks every hour, the nurse would be sharing the correct information if they verbalize that the earliest and most sensitive indication of altered cerebral function is

a change in vital signs.
change in level of consciousness.
loss of central reflexes.
inability to open the eyes.

Question 34

You are doing an assessment on a 29-year-old woman who reports “I feel so uncoordinated and clumsy lately.” While testing rapid alternating movements you notice she is unable to perform rapid alternating movements when tapping her thighs. Her response is very slow and she misses frequently. What might you suspect?

Impaired kinesthetic sensation
Impairment of the spinal accessory nerve (CN XI)
Cerebellar dysfunction
Impaired tactile discrimination

Question 35

A client comes to the emergency department because they noticed paralysis of part of their lower face. Upon assessment, the client is able to wrinkle the forehead and close both eyes. Which diagnosis would the nurse expect?

Amyotrophic lateral sclerosis
Cerebellar ataxia
Cerebrovascular accident
Bell’s palsy

Question 36

A student nurse is assessing for the client’s equilibrium with the Romberg test. What should the student nurse include in their instructions to the client?

“Place your arms out in front of you with your eyes closed.”
“Walk naturally across the room.”
“Put your feet together and stand with your eyes closed.”
“Stand with your feet apart and eyes closed for one minute.”

Question 37

While performing the comprehensive assessment, the nurse has exposed the client’s chest to complete the cardiovascular portion of the examination. What should the nurse do next?

Have the client stand up to assess the musculoskeletal system.
Place the client in a supine position to assess the abdomen.
Replace the client’s gown to provide privacy before moving to the next part of the exam.
Document the findings in the electronic health record (EHR).

Question 38

The nurse is caring for the following clients on the neurological unit. Which client should be seen first?

Client with Glasgow Coma Scale of 10 per nursing report.
Client with flat facial expression and not making eye contact.
Client who has been forgetful lately per their family.
Client who states, “I am afraid I’m losing my mind.”

Question 39

A novice nurse is practicing how to complete a comprehensive assessment to gain confidence and skill. Which of the following would be most important for the nurse to remember?

Establish a routine for the assessment.
Always allow the client a break between the two parts of the history/exam.
Intersperse the physical exam with the history.
Always gather objective data before subjective data.

Question 40

The nurse is reviewing a client’s health history and the results of the most recent physical examination. What statement in the chart would the nurse identify as subjective data? Nurse Practice Act

“Client grimaces with abdominal palpation.”
“Client reports weakness with ambulation and strength was noted to be 3+/5+ bilaterally.”
“Client states, ‘I get so short of breath and wheezy when I walk.'”
“Pupils are equal, round, react to light and accommodate.”

Question 41

The nurse is preparing to assess the client’s mouth and throat. A penlight and tongue blade are at hand. Which of the following would be most important for the nurse to do first?

Palpate the lips, tongue and buccal mucosa
Test the gag reflex
Assist the client to a prone position
Implement standard precautions

Question 42

The nurse is caring for the following client’s. Which client would the nurse prioritize as needing emergency assessment and treatment?

79 year-old with a visibly fractured radius and 10/10 pain.
51 year-old with a laceration across the thigh with moderate amount of bleeding.
82 year-old with cold extremities and pulses 1+/3+ in all extremities.
47 year-old in a tripod position with pursed lip breathing.

Question 43

The purpose and result of the nursing assessment is which of the following?

Prescription for treatment
Documentation of the client’s physiological status
Documentation of the need for referral
Formulation of a nursing diagnosis

Question 44

The comprehensive assessment was done on admission to the med/surg unit. The frequency of ongoing nursing assessments should be primarily determined by what variable?

The nurse’s potential for liability
The client’s acuity
The unit’s protocols
The client’s age

Question 45

The nurse is using the COLDSPA mnemonic during the client’s head-to-toe assessment. This tool will allow the nurse to address what component of assessment?

Personal health history
Review of body systems.
Health practices profile.
History of present health concern.

Question 47

The nurse is performing a comprehensive assessment. What information would be documented in the review of body systems?

Reports she has used over-the-counter antacids for many years to treat occasional heartburn.
Vaginal delivery of twin children in 1999 without complications.
States that she wears dentures; denies problems with eating, chewing, swallowing.
Father died at age 66 of a stroke.

Question 48

The nurse is preparing to perform a physical examination on a client who has been admitted to the emergency room with some complaints of a headache and nausea. The nurse should begin the collection of objective data with which of the following assessments?

Ask how long the nausea has been occurring.
Vital signs
Palpation of lymph nodes
Auscultation of bowel sounds

Question 49

A 30-year-old woman is seen in the clinic and reports a history of mitral valve problems. During the assessment the nurse palpates a thrill at the fifth left intercostal space midclavicular line. In the same area the nurse also auscultates a blowing, swishing sound right after S1. What diagnosis are these findings consistent with?

Heart failure.
Myocardial infarction.
A friction rub.
A heart murmur.

Question 50

You are the nurse caring for a 70-year-old female who fractured her right femur after a fall. On assessment you are unable to palpate the right posterior tibial pulse. What should your next action be?

Check for pretibial edema
Immediately report this finding to the physician
Palpate the right radial pulse
Palpate the right dorsalis pedis pulse Nurse Practice Act

Question 51

A nurse is preparing to perform the physical examination of an adult client who has presented to the clinic for the first time. When the nurse is preparing to auscultate the abdomen to assess for a suspected abdominal aneurysm which of the following statements should guide the nurse’s use of a stethoscope during this phase of assessment?

Use of the bell is reserved for advanced practice nurses.
The diaphragm should be held firmly against the body part.
The bell of the stethoscope can best detect low pitched bruits.
Auscultation through clothing.

Nurse Practice Act, Nursing

Isaura K

View All Posts >