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NUR 198 Exam QUESTIONS WITH VERIFIED
SOLUTIONS | 2026 UPDATE
A nurse conducts an initial comprehensive assessment for a client admitted with a fever of unknown origin. Which area of assessment is primarily the nurse's responsibility?
- Collect subjective data related to overall function
- Perform a musculoskeletal examination
- Take anthropometric measurements
- Obtain a 24-hour diet recall collect subjective data related to overall function An older adult client has been admitted to the hospital with failure to thrive resulting from complications of diabetes. What would the nurse implement in response to a collaborative problem? Measure the client's blood glucose four times daily. When performing the steps of the assessment phase of the nursing process, which of the following would the nurse do first? collect subjective data The nurse performs an assessment on a newly admitted client. Data analysis reveals temperature 100.9 F (38.3 C), BP 82/58 mm Hg, 02 Saturation 91% RA, productive cough, lethargy, diaphoresis, WBC 15,000 mm3, Hemoglobin 9 g/dL, Hematocrit 29%. What action should the nurse take next? develop diagnosis
A client admitted to the hospital with status asthmaticus suddenly develops the following signs and symptoms: increased heart rate (105 bpm), increased respiratory rate (24/min), O2 saturation 90% on 100% nonrebreather mask, and sudden absence of wheezing. What action should the nurse take? perform emergency assessment A nurse provides care for a client with an elevated temperature. The client is given the prescribed medication and the nurse checks the client's temperature at repeated intervals. What step of the nursing process is the nurse using to determine whether the client has achieved the outcome criteria of the treatment? evaluation A home health nurse is visiting a client who recently was hospitalized for repair of a fractured hip. The client tells the nurse, "I have had a lot of pain in my abdomen." What type of assessment would the nurse conduct? focused When planning a community program related to Healthy People 2030, the critical first step involves defining the community After assessment and documentation of the information obtained from the client, the nurse needs to analyze the data collected. Which nursing actions depend on accurate analysis of data during this phase of the nursing process?
During the working phase of an interview the nurse encourages the client to continue and expand on the health issues. What technique is the nurse using? active listening A nurse is preparing to assess a client who is new to the clinic. When beginning the collection of the client's data, what action should the nurse prioritize? establishing a trusting relationship During the review of systems, a client reports having difficulty with urination and with establishing an erection. Which additional information should the nurse recognize as the highest priority to assess at this time? sexual history The nurse would document driving with car seatbelt fastened, bicycling with properly- fitted helmet, and installing a smoke detector in a vacation home in the client's health history under which of the following? personal and social history A client scheduled for surgery tells the nurse that he is very anxious about the surgery. What is an appropriate action by the nurse when interacting with this client? Provide simple and organized information. A nurse is performing a health history on a new client. What biographical data should the nurse obtain?
date of birth religion occupation What does the COLDSPA mnemonic stand for? Character Onset Location Duration Severity Pattern Associated factors The nurse performs a comprehensive assessment on a new client. What is the next action of the nurse? validate problems and determine client's goals During which of the following phases of the interview process will the nurse assure the client that all personal data the client discusses with the nurse will be kept confidential? introductory The nurse selects a tuning fork to use when assessing a client. Which body system is the nurse most likely assessing? peripheral vascular What is the principle of percussion?
When is a stethoscope bell used? Diaphragm? low pitched sounds high pitched sounds The nurse is preparing to leave the unit for lunch. What type of communication method should the nurse use? verbal handoff A nurse is working on an acute neurological unit. Which assessment form would the nurse most likely use to document assessment data? focused assessment form advantages of using EHRs (Electronic Health Records) improvement in risk management prevention of provider liability improvement in public health and client outcomes reduction in errors When recording data regarding the client's health record, the nurse mentions the analysis of the subjective and objective data in addition to detailing the plan for care of the client. Which style of documentation is the nursing implementing? SOAP charting The nurse is reviewing a SOAPIE note in the client's medical record. The nurse recognizes that "States no longer nauseous and would like something to eat" is which part of the SOAP note.
subjective The nurse responds to a call light for a client rating their pain "ten out of ten." The nurse's initial inspection reveals the client is watching videos and appears to be at ease physically and emotionally. How should the nurse validate the client's subjective complaint of pain? Perform further assessments addressing various aspects of the client's pain. A nurse needs to measure the blood pressure of a client who has just undergone a bilateral mastectomy. How should the nurse measure the blood pressure? over client's thigh In which order should a nurse assess a client's vital signs? Temperature, pulse, respiration, and blood pressure A nurse measures a client's blood pressure at 174/102 mm Hg. The nurse recognizes this as what classification of blood pressure measurement? stage 2 hypertension A client's blood pressure is affected by cardiac output, distensibility of the arteries, blood volume, blood velocity and viscosity. A nurse reviews the vital signs of a 77-year-old client: temperature 99.2 F° (37.33° C), heart rate 90 beats/min, blood pressure 130/50 mm Hg, respiratory rate 22 breaths/min and shallow, and oxygen saturation rate 93% on room air. Which action should the nurse take next? assess for infection
Two nurses collaborate in assessing an apical-radial pulse on a client. The pulse deficit is 16 beats/min. What does this indicate? Not all of the heartbeats are reaching the periphery. The nurse is assessing an elderly client's blood pressure and finds it to be high. Which of the following characteristics should the nurse suspect to find in respect to this client's arteries? rigid A nurse assesses a newly admitted 43-year-old client and documents the vital signs as follows: temperature 98° F (36.7° C), pulse 93 beats/min regular rhythm and bounding, blood pressure 145/93 mm Hg, and respiratory rate 16 breaths/min. What is the first action of the nurse? Ask the client if they are experiencing any other symptoms 4 steps of nociception transduction, transmission, perception, modulation 6 types of pains visceral- abdominal organs somatic- tissues, bones, joints cutaneous- skin referred- feeling pain somewhere other than affected body part phantom- pain felt in missing limb neuropathic- constant stimulus
What is responsible for transmitting the sensations to the central nervous system? nocioceptors As a nurse is adjusting a client's hospital bed, the nurse accidentally pinches a finger between the bed and the wall. What components of the PNS is involved in the transduction of the pain the nurse feels? A-delta and C fibers A client is experiencing acute pain and has asked the nurse for medication. The client rates the pain as an 8 on a scale of 0 to 10. During assessment, a physiological response from the client that the nurse can expect is: Diaphoresis (excessive sweating or perspiration) When clients report pain, it is important to find the source. When clients describe pain as "burning, painful numbness, or tingling," the source is more than likely: neuropathic A nursing instructor is teaching students about the pain experience. The instructor informs the students that a client experiencing pain will have a stress response. The students are aware that this stress response causes the following: Release of epinephrine, cortisol, and norepinephrine A nurse is assessing the effect of a client's chronic back pain on his affective dimension. What question should the nurse ask for this assessment? How does the pain influence your overall mood?
The spouse of a client believed to be a victim of intimate partner violence refuses to leave the room for the nurse to complete an assessment. What should the nurse do first? ensure for personal safety The nurse notes that an adolescent male has ptosis of the left eye. What should the nurse suspect as the reason for this finding? nerve damage from several eye injuries A nurse suspects abuse on a client with a fractured forearm, who does not want to discuss how the fracture happened. What is something the nurse could do to let the client know the client is not alone? educate the client of the high prevalence of human violence What are the 11 domains of mental status? appearance, attitude, behavior, mood and affect, speech, thought process, thought content, perception, cognition, insight, and judgment. A nursing instructor is teaching a group of students about assessing a client's orientation. The instructor determines that the teaching was successful when the students state that the ability to identify which of the following usually is lost first? time A new nurse asks the charge nurse what the Mini-Mental Status Examination tests. What is the appropriate response by the charge nurse? "A quick tool that is useful to examine the orientation, memory, speech, and cognitive functions"
The nurse plans to administer the CAGE Self-Assessment tool on a client. The nurse explains to the client how and when the tool is used by stating which of the following? "It is a short tool used to identify people at risk for substance use disorder. It consists of four questions." What intervention will the nurse implement initially for a client who has reported experiencing unexplained, severe neck pain for more than 2 months? screen for depression A mother brought a child in to the Emergency Department stating that she thinks her child's appendix has ruptured. Before any diagnostic tests can be done, the father comes in and says, "I don't want anything done, we will take the child to our church where prayer will heal him." What is an appropriate action by the nurse at this time? Notify the ethics committee The nurse is caring for a married female client who defers to her husband to answer all assessment questions. The nurse understands that it is common in some cultures for the male to hold a dominant role in the relationship. What stage of cultural awareness does the nurse display? conscious competence The path one pursues in the search for life's meaning and purpose. spirituality
chronic middle ear infection Interventions for nose, throat, sinus, and mouth infections ĂProvide oral hygiene every 8 hours. ĂConsult with speech pathologist to evaluate swallowing. ĂEncourage fluid increase to 2 L daily to liquefy secretions. The nurse asks a client to say "ah" while depressing the tongue with a wooden tongue blade. What is the nurse assessing when performing this technique? vagal nerve function A child presents to the health care facility with new onset of a foul-smelling, purulent drainage from the right nare. The mother states that no other signs of an upper respiratory tract infection are present. What is an appropriate action by the nurse? inspect nostrils with an otoscope A decrease in tongue strength is noted on examination of a client. The nurse interprets this as indicating a problem with which cranial nerve? XII A client is found to have leukoplakia, and the nurse is teaching the client about measures to reduce the client's risk. Which of the following statements would the nurse include in the teaching? avoid things that will irritate the mouth Which area of the mouth should the nurse assess to inspect for the Wharton's ducts?
either side of the frenulum on the floor of the mouth How will you assess a client's sinuses who is experiencing frontal headache? To palpate the sinuses, the nurse will sit facing the client and press up on the frontal sinuses under the brow bone. Then, the nurse will palpate over the cheek bones to assess the maxillary sinuses. Afterward, the nurse will tap lightly over the sinus areas to assess for tenderness A client is noted to have a bifid uvula. The nurse understands that this finding is most common in which ethnic group? native americans A nurse is assessing a child who got lost on a camping trip in November and was exposed all night to the elements. Which finding about the lips would support a diagnosis of hypoxia in this client? cyanotic What is halitosis? Anosmia? epistaxis? bad breath loss of smell nosebleeds What is lugwig's angina? edema pushing tongue up and back Ă airway obstruction from infection of the mouth floor What is dyspnea? Bradypnea? Tachypnea? Hyperpnea? Orthopnea?
An adult client is brought to the ED by her daughter. The client is cyanotic; her pulse is 117 beats/min, respirations 36 breaths/min, blood pressure 110/64, and oxygen saturation 82%. What is the first nursing action? administer O When do we have patient's say 99? When he nurse is palpating for fremitus and when the nurse plans to auscultate for voice sounds (bronchophony) The nurse is preparing to auscultate the client's thorax. What action is the priority during this component of assessment? Listen at each site for at least one complete respiratory cycle. The nurse assesses shallow respirations of 28 breaths/minute in a client with pleurisy (inflammation of membrane that seperates the lungs from chest wall). The nurse interprets this finding as... The pattern is expected with this condition How many lobes does the left lung have? Right lung? 2 (superior and inferior) 3 (upper, middle, lower) The nurse has assessed the respiratory pattern of an adult client. The nurse determines that the client is exhibiting Kussmaul respirations with hyperventilation. The nurse should contact the client's physician because this type of respiratory pattern usually indicates
diabetic ketoacidosis A client is diagnosed with pulmonary edema. The nurse would most likely assess the sputum color as which of the following? pink A nurse is palpating a Caucasian client's chest as part of a routine assessment. Which of the following findings would the nurse expect in this client because of his race? larger thorax and lung capacity Which action by a nurse demonstrates proper technique for assessment of chest expansion? Place both hands on the posterior chest at T9, press thumbs together, and then ask client to take a deep breath The clavicles extend from the _______ of the scapula to the part of the sternum termed the _______. acromion manubrium The nurse is reviewing the client's health history and notes he has pectus excavatum. The nurse would assess the client for what? funnel chest vThe nurse caring for a patient diagnosed with a 2nd rib fracture should know the location of the sternal angle is also called as what? angle of louis
