Kaplan Health Assessment A Practice Exam
1. The nurse identifies which volume is a typical daily urinary output in the normal adult?
a. 500 ml
b. 1,500
... [Show More] ml
c. 2,500 ml
d. 3,00 ml
2. The nurse assesses capillary refill time on a middle-aged client. Which result is considered to be within the normal range?
a. 1-3 seconds
b. 4-6 seconds
c. 6-8 seconds
d. 8-10 seconds
3. When assessing the client for tactile fremitus, which part of the hand does the nurse use?
a. Fingertips and finer pads
b. Dorsal surface of hand
c. Ulnar and palmar surface of hand
d. Dorsiflexed surface of wrist
4. Which assessment finding in the young adult client indicates to the nurse that there is a problem with fluid deficit?
a. Taut, shiny skin
b. Perspiration in the axillae
c. Warm, smooth, elastic skin
d. Tenting of the skin
5. The nurse identifies the correct area to assess the apical pulse is which location?
a. 2nd intercostal space to the right of the sternum
b. 3rd intercostal space to the left of the sternum
c. 5th intercostal space to the left midclavicular line
d. 5th intercostal space to the left of the sternum
6. After demographic data is collected by the nurse about a client during an initial health history interview, which should be the next focal area of assessment?
a. Overview of past health history
b. Reason for seeking healthcare now
c. Support system in past and present
d. Patterns of sleep, diet, exercise, stress management
7. When assessing the abdomen, the nurse should place the patient in which of the following positions?
a. Supine
b. Supine with knees flexed
c. Side lateral
d. Sims’
8. The nurse tests the pH of the child’s urine? The nurse expects which result?
a. pH 3.4
b. pH 6.0
c. pH 8.2
d. pH 8.5
9. The nurse auscultates the client’s breath sounds. The nurse knows the vesicular sounds will have which characteristics?
a. Loud, coarse, blowing sound heard over the trachea
b. Musical sounds or vibrations commonly heard on expiration
c. Harsh sounds heard over the mainstem bronchi
d. Soft and low-pitched breezy sounds heard over most of the peripheral lung fields
10. A child’s urine is tested for specific gravity, color, and clarity. Which of the following reports would the nurse consider normal?
a. 1.020, yellow, clear
b. 1.005, deep orange, clear
c. 1.035, deep orange, cloudy
d. 1.001, yellow, cloudy
11. The nurse assesses the cardiac status of the client and identifies an increased pulse pressure. Pulse pressure can best be described by which definition?
a. The difference between systolic and diastolic blood pressure readings
b. The intensity of peripheral pulses
c. The differences between the apical pulse and the radial pulse
d. The volume of the stroke and the heart rate
12. The nurse identifies that which set of vital signs is within the normal range for an adult?
a. BP 80/50 mm Hg, P 110 beat/minute, R 32 breaths/minute
b. BP 110/80 mm Hg, P 56 beats/minute, R 20 breaths/minute
c. BP 120/70 mm Hg, P 68 beats/minute, R 16 breaths/minute
d. BP 130/90 mm Hg, P 72 beats/minute, R 24 breaths/minute
13. When performing a physical assessment, the home health nurse notes that the eyes of the client involuntarily move rapidly from side to side. Which of the following term should the nurse in charting to describe this observation?
a. Strabismus
b. Nystagmus
c. Photophobia
d. Ptosis
14. The nurse prepares to assess a client’s ears and hearing. The nurse gathers which pieces of equipment?
a. A tuning fork and an otoscope
b. A tonometer and an ophthalmoscope
c. An otoscope and a sphygmomanometer
d. A percussion hammer and a stethoscope
15. After receiving report, the nurse assesses the client who is having Cheyne-Stokes respirations. Which is the BEST description of the breathing pattern the nurse expects to see?
a. Marked increased rate and depth of respirations
b. Irregular patterns of shallow breathing alternating with periods of apnea
c. Regular rapid and shallow breathing
d. Irregular patterns of rapid waxing, and waning breathing alternating with periods of apnea.
16. The client’s visual acuity is tested with a Snellen chart and reported to be 20/60. The nurse knows the number 60 indicates which measurement?
a. The distance at which the client stood from the chart
b. The distance at which the client with normal vision can read the chart
c. The client’s vision is 60% less than that of the client with normal vision.
d. The client has three times poorer vision in the right eye than in the left eye
17. The nurse prepares to conduct a physical assessment on the new client in the assisted living facility. The nurse determines which observation will have the most impact on the nursing assessment?
a. Presence of assistive devices for vision and hearing
b. Indications of anxiety
c. Appearance and appropriateness of clothing and grooming
d. Posture, height, and weight
18. The nurse recognizes the physical assessment should be completed in what order?
a. Inspection, palpation, percussion, and auscultation
b. Inspection, auscultation, percussion, and palpation
c. Auscultation, inspection, palpation, and percussion
d. Percussion, auscultation, inspection, and palpation
19. The nurse in the outpatient clinic receives a phone call from a patient complaining of a rash. Which of the following actions could the nurse take FIRST?
a. Make an appointment for the patient to see the physician
b. Determine if the patient is taking any new medications
c. Aske the patient how he is feeling
d. Instruct the patient to apply a cream to the rash
20. The clinic nurse performs a neurological assessment on a new patient. When the right leg is tapped for the patellar reflex, there is no movement. Which of the following actions should the nurse take FIRST?
a. Ask the patient what is causing the lack of reaction
b. Tell the patient to take several quick breaths and then tap the tendon again
c. Tap the tendon again while the patient is pulling against interlaced, locked fingers.
d. Tap the tendon again using more force with the pointed end of the reflex hammer.
21. Which is the average pulse range the nurse ANTICIPATES when conducting a physical examination for an adult client?
a. 40 to 60 beats/minute
b. 60 to 80 beats/minute
c. 60 to 100 beats/minute
d. 70 to 110 beats/minute
22. After completing the data collection process of the client’s health history interview, which action should the nurse take FIRST?
a. Inform the client about what to expect during the physical examination
b. Summarize the highlights of the interview and permit the client to add or clarify information
c. Thank the client and contact the physician to report the findings.
d. Document the history in the client’s record of the client including normal and abnormal findings.
23. The nurse auscultates the client’s lung fields and identifies a pleural friction rub. Which is the BEST description of a pleural friction rub?
a. Gurgling sounds commonly heard on inspiration
b. Squeaky sounds heard during inspiration and expiration
c. Grating sound or vibration heard during inspiration and expiration
d. Loud transmission of voice sounds caused by consolidation of lung
24. The client is diagnosed with emphysema. Which sound does the nurse expect to hear when percussing the lungs?
a. Dullness
b. Tympany
c. Hyperresonance
d. Flatness
25. In the mental status examination, the nurse asks the client to compare and contrast similar objects and to interpret proverbs. Which client ability is the nurse assessing?
a. Abstract reasoning
b. Judgement
c. Insight
d. Orientation
26. To assess the pedal pulse, the nurse palpates in which location?
a. The region in the back of the knee
b. The top of the foot
c. The groin area
d. The inner side of the ankle below the medial malleolus
27. The nurse places a pulse oximetry probe on the client newly admitted for evaluation of a seizure disorder. The client asks, “why do I have to have this thing on me?” which response by the nurse is BEST?
a. “it enables your IV fluids to run at a nice steady rate”
b. “It monitors your pulse rate on an ongoing basis”
c. “it tells us if you blood pressure stays within normal limits”
d. “it measures the amount of oxygen circulating in your blood”
28. Which of these methods should the nurse use to test the gag reflex?
a. Request that the patient speak
b. Ask the patient stick out the tongue and move it side to side
c. Touch the back of the throat with a cotton-tipped applicator.
d. Instruct the patient to drink a small amount of water
29. Which statement describes the CORRECT procedure for the nurse to use to examine a client’s pupils?
a. Compare the size of both pupils and check the reaction of light
b. Look for red spots around the pupil’s circumference
c. Examine the pupils with an ophthalmoscope
d. Examine the right eye with the light at the left side of the head, and the left eye with the light at the right side of the head.
30. The nurse identifies that which risk factor is MOST likely to contribute to an elevation of the client’s blood pressure?
a. A high pressure job
b. Daily vitamins
c. One glass of wine per day
d. Daily exercise [Show Less]