Sample Questions and Answers
A nurse is assessing a client who reports a headache. Which of the following questions should the nurse ask first?
A) Have you ever experienced headaches like this before?
B) How long have you been experiencing this headache?
C) Do you have a family history of headaches?
D) Have you been taking any medications for the pain?
Answer: B
The nurse is assessing a 45-year-old client for risk factors of cardiovascular disease. Which of the following is the most important question to ask?
A) Have you had any surgeries in the past?
B) Do you drink alcohol?
C) Do you have a family history of cardiovascular disease?
D) Are you experiencing shortness of breath?
Answer: C
During a routine physical examination, the nurse auscultates a heart murmur. What is the nurse’s next action?
A) Document the finding and report it to the healthcare provider.
B) Notify the family immediately.
C) Perform a neurological assessment.
D) Reassess the heart sounds after repositioning the client.
Answer: A
A client presents with complaints of chest pain. What should the nurse prioritize in the assessment?
A) Assessing vital signs
B) Asking about the duration and quality of the pain
C) Determining the client’s medical history
D) Checking for signs of anxiety or depression
Answer: B
The nurse is assessing a client with diabetes. Which of the following findings is most concerning?
A) Blood pressure of 130/85 mmHg
B) Blood glucose level of 160 mg/dL
C) Urine output of 50 mL per hour
D) Pedal pulses are faint but palpable
Answer: B
The nurse is assessing a client for risk factors associated with deep vein thrombosis (DVT). Which of the following should the nurse assess first?
A) Client’s level of activity
B) History of recent surgery or trauma
C) Family history of blood clotting disorders
D) Recent use of contraceptives
Answer: B
When performing a neurological assessment, the nurse notices that the client has difficulty following commands. What is the nurse’s first action?
A) Reassess the client’s motor function
B) Ask the client to perform simple tasks again
C) Check the client’s level of consciousness and orientation
D) Immediately notify the healthcare provider
Answer: C
The nurse is assessing a client with a history of asthma. Which of the following findings would require immediate intervention?
A) Respiratory rate of 18 breaths per minute
B) Oxygen saturation of 92% on room air
C) Use of accessory muscles during breathing
D) Wheezing heard only on expiration
Answer: C
A nurse is performing an abdominal assessment. Which of the following is the correct sequence for this assessment?
A) Inspection, percussion, palpation, auscultation
B) Inspection, auscultation, percussion, palpation
C) Palpation, auscultation, percussion, inspection
D) Percussion, palpation, inspection, auscultation
Answer: B
A client reports sudden, severe pain in the lower back. Which of the following actions should the nurse take first?
A) Assess the client’s vital signs
B) Palpate the affected area for tenderness
C) Ask the client to rate the pain on a scale of 0 to 10
D) Assist the client to a comfortable position
Answer: C
The nurse is assessing a client with a suspected urinary tract infection (UTI). Which symptom would be most indicative of this condition?
A) Dysuria and fever
B) Nausea and vomiting
C) Diarrhea and bloating
D) Weight loss and fatigue
Answer: A
During a health assessment, the nurse asks the client about their sleep patterns. The client reports difficulty staying asleep. Which of the following questions should the nurse ask next?
A) Have you been drinking caffeine before bedtime?
B) Do you wake up feeling refreshed?
C) How long have you had difficulty sleeping?
D) Do you snore or have breathing problems while sleeping?
Answer: B
The nurse is assessing a client’s skin turgor. Which of the following findings would indicate dehydration?
A) Tenting of the skin
B) Pink and warm skin
C) Full, elastic skin
D) Rapid capillary refill
Answer: A
The nurse is assessing a client for signs of dehydration. Which of the following findings would be most concerning?
A) Decreased skin turgor
B) Increased heart rate
C) Dry mucous membranes
D) Low-grade fever
Answer: B
The nurse is performing a cardiac assessment on a client. Which of the following findings should be reported to the healthcare provider immediately?
A) Heart rate of 80 bpm
B) S1 and S2 heart sounds
C) Heart murmur grade II/VI
D) Irregular rhythm with occasional skipped beats
Answer: C
The nurse is assessing a client’s respiratory status. Which of the following findings indicates a need for further evaluation?
A) Respiratory rate of 20 breaths per minute
B) Bilateral lung expansion on palpation
C) Adventitious breath sounds in both lungs
D) Oxygen saturation of 95% on room air
Answer: C
The nurse is assessing a client with a history of hypertension. Which of the following would be the most appropriate action?
A) Measure blood pressure in both arms
B) Ask the client about recent weight loss
C) Assess for signs of peripheral edema
D) Check the client’s pulse rate
Answer: A
The nurse is performing a musculoskeletal assessment. Which of the following should the nurse ask the client first?
A) Do you experience any pain or stiffness in your joints?
B) Do you have a family history of arthritis?
C) When did you last exercise?
D) Have you had any fractures or injuries in the past?
Answer: A
The nurse is assessing a 70-year-old client for risk factors for falls. Which of the following factors should be assessed first?
A) Cognitive function
B) Medications
C) History of previous falls
D) Home safety environment
Answer: C
The nurse is performing a mental health assessment on a client. Which of the following findings would require immediate action?
A) Client reports feeling sad but denies suicidal thoughts
B) Client expresses a desire to harm others
C) Client is tearful but engaged in conversation
D) Client reports difficulty concentrating at work
Answer: B
The nurse is assessing a client with an open fracture. Which of the following is the priority action?
A) Apply a sterile dressing to the wound
B) Assess the client’s pain level
C) Perform a neurovascular assessment of the affected limb
D) Immobilize the fractured area
Answer: D
The nurse is assessing a client with suspected hypoglycemia. Which of the following symptoms would be most indicative of this condition?
A) Shaking, sweating, and confusion
B) Increased thirst, urination, and fatigue
C) Blurred vision and headache
D) Nausea, vomiting, and abdominal pain
Answer: A
During a health assessment, the nurse finds that the client has a fever. Which of the following is the most important next step?
A) Obtain a complete blood count (CBC)
B) Assess the client’s temperature every hour
C) Determine the cause of the fever
D) Administer an antipyretic medication
Answer: C
The nurse is assessing a client who is obese. Which of the following is the most important question to ask regarding their weight management?
A) Have you been on any weight-loss programs?
B) Do you follow a specific diet plan?
C) Have you experienced any significant changes in appetite?
D) Do you exercise regularly?
Answer: C
A client has a history of chronic obstructive pulmonary disease (COPD). What should the nurse assess first?
A) Respiratory rate and lung sounds
B) Client’s ability to perform activities of daily living
C) Oxygen saturation and pulse rate
D) Capillary refill time and skin color
Answer: A
The nurse is assessing a client with a potential stroke. Which of the following findings is most suggestive of this condition?
A) Sudden, severe headache and nausea
B) Difficulty speaking and weakness on one side of the body
C) Fever and chills
D) Pain in the chest and shortness of breath
Answer: B
The nurse is conducting a head-to-toe assessment. Which of the following is the most appropriate action when assessing the client’s head and neck?
A) Palpate the skull for any abnormalities
B) Ask the client to turn their head to the left and right
C) Check the neck veins for distention
D) Inspect the mouth for sores or lesions
Answer: A
The nurse is performing a skin assessment. Which of the following findings should be documented as a potential skin cancer risk?
A) Symmetrical mole with uniform color
B) Asymmetrical mole with uneven borders
C) Mole with a smooth, even border
D) Mole with a smaller diameter than a pencil eraser
Answer: B
The nurse is assessing a client with a history of gastrointestinal reflux disease (GERD). Which of the following questions should the nurse ask first?
A) Have you been experiencing any heartburn?
B) Do you have difficulty swallowing?
C) Have you lost weight recently?
D) Do you have a history of ulcers?
Answer: A
The nurse is assessing a client for signs of anemia. Which of the following symptoms would be most indicative of this condition?
A) Pallor and fatigue
B) Elevated blood pressure and headache
C) Weight gain and dizziness
D) Abdominal pain and nausea
Answer: A
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