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COCN practice questions

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Question 1Assessment and Patient Evaluation

A nurse is evaluating an older adult for orthostatic hypotension. Which measurement sequence best follows accepted practice?

  1. Two seated blood pressures taken 5 minutes apart with the arm supported at the level of the heart
  2. A supine blood pressure only, with the cuff kept at the level of the right atrium throughout
  3. Blood pressure and pulse supine, then repeated at 1 and 3 minutes of standing Correct answer.
  4. A single standing blood pressure obtained immediately after the patient rises from bed, with no pulse check

Explanation

Orthostatic vital signs compare supine readings with readings taken after standing for 1 and 3 minutes, because the nadir of the blood pressure drop often does not occur immediately. A fall of at least 20 mmHg systolic or 10 mmHg diastolic, or any symptomatic fall, meets the criteria, and the pulse is recorded with each pressure.

Question 2Assessment and Patient Evaluation

Which finding is the most reliable indicator of the intensity of a patient's pain?

  1. The nurse's estimate based on the patient's facial expression and guarding
  2. The patient's self-report on a validated pain scale Correct answer.
  3. The rise in heart rate and blood pressure observed during the assessment
  4. The family's description of how the patient usually behaves when in pain

Explanation

Pain is a subjective experience, and the patient's own report on a validated instrument is the accepted standard for measuring its intensity. Physiologic and behavioral signs are adjuncts for patients who cannot self-report, but they correlate poorly with severity and never replace the patient's account.

Question 3Assessment and Patient Evaluation

A nurse performs a physical examination of the abdomen. Which sequence of techniques is correct?

  1. Inspection, auscultation, percussion, palpation Correct answer.
  2. Palpation, auscultation, inspection, percussion
  3. Auscultation, inspection, percussion, palpation
  4. Inspection, palpation, percussion, auscultation

Explanation

In every other body system percussion and palpation precede auscultation, but the abdomen is the exception: auscultation follows inspection immediately because palpation and percussion can alter bowel motility and change the character of bowel sounds. Percussion follows, and deep palpation comes last so painful areas are not stimulated before the rest of the examination.

Question 4Assessment and Patient Evaluation

An adult is 1.70 m tall and weighs 92 kg. Into which body mass index category does this patient fall?

  1. Obesity class II
  2. Overweight
  3. Obesity class I Correct answer.
  4. Normal weight

Explanation

Body mass index is weight in kilograms divided by height in meters squared: 92 divided by 2.89 equals approximately 31.8. A BMI from 30.0 to 34.9 is class I obesity, whereas overweight is 25.0 to 29.9 and class II obesity begins at 35.0.

Question 5Assessment and Patient Evaluation

Which item in an older adult's history is the strongest single predictor of an injurious inpatient fall?

  1. A body mass index of 22
  2. Wearing corrective eyeglasses
  3. Male sex
  4. A fall within the past 12 months Correct answer.

Explanation

A previous fall is the most powerful historical risk factor for a subsequent fall and is weighted heavily in fall-risk instruments such as the Morse Fall Scale. Sensory, cognitive, medication, and gait factors are also assessed, but they add only incrementally to a documented prior fall.

Question 6Assessment and Patient Evaluation

Which set of parameters is assessed by the Braden Scale?

  1. Mobility, continence, mental status, body weight, skin perfusion, and core temperature
  2. Sensory perception, moisture, activity, mobility, nutrition, friction and shear Correct answer.
  3. Age, serum albumin, incontinence, immobility, cognition, and skin color
  4. Sensation, circulation, infection, nutrition, pain, and positioning

Explanation

The Braden Scale scores six subscales, each from 1 to 4 with friction and shear scored 1 to 3, and lower totals indicate higher pressure injury risk. Laboratory values and age are not part of the instrument, although they inform overall clinical judgment.

Question 7Assessment and Patient Evaluation

Which finding is the key feature that separates delirium from a stable dementia on the Confusion Assessment Method (CAM)?

  1. A gradual decline in memory and word finding extending over several years of stable attention
  2. Intact attention with stable, unchanging cognition
  3. Loss of expressive language as the first symptom
  4. Acute onset with a fluctuating course together with inattention Correct answer.

Explanation

The CAM algorithm requires an acute onset with fluctuating course plus inattention, and then either disorganized thinking or an altered level of consciousness. Fluctuation and inattention are the hallmarks that separate delirium from a chronic, stable dementia, although the two conditions often coexist.

Question 8Assessment and Patient Evaluation

Which serum potassium value falls within the adult reference range?

  1. 5.6 mEq/L
  2. 4.3 mEq/L Correct answer.
  3. 2.8 mEq/L
  4. 3.2 mEq/L

Explanation

The usual adult reference range for serum potassium is approximately 3.5 to 5.0 mEq/L, so 4.3 mEq/L is normal. Values below 3.5 indicate hypokalemia and values above 5.0 indicate hyperkalemia, both of which warrant evaluation for dysrhythmia risk.

Question 9Assessment and Patient Evaluation

A patient describes chest discomfort. Using the OPQRST mnemonic, which question addresses the R component?

  1. What were you doing when the discomfort began?
  2. How long does each episode last?
  3. Does the discomfort spread to your arm, shoulder, or jaw? Correct answer.
  4. How would you rate the discomfort on a scale from 0 to 10?

Explanation

In OPQRST, R stands for region and radiation, meaning where the pain is located and whether it travels. Onset is covered by O, provocation and palliation by P, quality by Q, severity by S, and timing by T.

Question 10Assessment and Patient Evaluation

During percussion of the posterior chest, a nurse finds dullness over the right lower lobe where resonance is expected. Which condition does this most suggest?

  1. Consolidation or pleural fluid in that region Correct answer.
  2. A pneumothorax on the right side
  3. A normal finding at the lung bases
  4. Hyperinflation from chronic obstructive pulmonary disease

Explanation

Percussion reflects the density of underlying tissue: air-filled lung is resonant, whereas fluid, solid tissue, or consolidation produces dullness. Hyperinflation and pneumothorax add air and produce hyperresonance, and normal lung bases remain resonant, though slightly less so than the apices.

Question 11Assessment and Patient Evaluation

A nurse uses a blood pressure cuff whose bladder is too small for an obese patient's upper arm. What effect does this have on the measurement?

  1. It falsely lowers both systolic and diastolic readings
  2. It falsely lowers systolic and falsely raises diastolic pressure
  3. It has no effect as long as the cuff is placed over a thin sleeve
  4. It falsely raises the blood pressure reading Correct answer.

Explanation

An undersized bladder requires excessive pressure to compress the artery, so both systolic and diastolic values are falsely elevated. The bladder should encircle about 80 percent of the arm circumference and cover roughly 40 percent of its length, while a cuff that is too large tends to read falsely low.

Question 12Assessment and Patient Evaluation

A patient in atrial fibrillation has an apical heart rate of 118/min and a radial pulse of 96/min. How should the nurse document this finding?

  1. Radial pulse 96 with a regular rhythm
  2. Pulse deficit of 118
  3. Apical pulse 96 after correcting for an irregular rhythm
  4. Apical rate 118, radial rate 96, pulse deficit of 22 Correct answer.

Explanation

The pulse deficit is the difference between the apical and radial rates counted simultaneously for a full minute, here 118 minus 96 equals 22. A deficit reflects beats that fail to generate a peripheral pulse, a common finding in atrial fibrillation and other dysrhythmias.

Question 13Assessment and Patient Evaluation

Which components make up the Mini-Cog cognitive screen?

  1. Three-item recall plus a clock-drawing test Correct answer.
  2. Trail Making Test part B plus verbal fluency
  3. The full MMSE plus a caregiver interview
  4. A clock-drawing test plus a 10-item word-list recall

Explanation

The Mini-Cog combines a three-word recall with a clock-drawing test and takes about three minutes to administer. A positive screen is recall of zero words, or recall of one to two words with an abnormal clock; the tool flags cognitive impairment but does not establish a diagnosis.

Question 14Assessment and Patient Evaluation

A patient's hemoglobin A1c is 8.2 percent. What does this value primarily reflect?

  1. Average glucose over the preceding 7 days
  2. The fasting plasma glucose on the morning the sample was drawn
  3. Average glucose over the preceding 24 to 48 hours
  4. Average glucose over the preceding 2 to 3 months Correct answer.

Explanation

A1c measures nonenzymatic glycation of hemoglobin, which accumulates over the lifespan of circulating red blood cells, roughly 120 days. It therefore reflects average glycemia over about two to three months, and conditions that alter red cell survival, such as hemolysis or recent transfusion, can make the result unreliable.

Question 15Assessment and Patient Evaluation

A patient with advanced dementia and limited verbal ability appears restless during repositioning. Which approach to pain assessment is most appropriate?

  1. Ask the family to assign a numeric pain score on the patient's behalf, based on their long knowledge of the patient's usual behavior
  2. Use heart rate and blood pressure as the sole indicators of pain, since behavior is unreliable in dementia
  3. Document the patient as having no pain until a self-report can be obtained
  4. Use an observational tool such as PAINAD, which scores breathing, vocalization, face, body language, and consolability Correct answer.

Explanation

Observational tools such as PAINAD, ABBE, and the Checklist of Nonverbal Pain Indicators are validated for patients who cannot self-report. They score behaviors together with physiologic cues, are repeated at intervals, and are repeated again after an intervention to judge its effect.

Question 16Assessment and Patient Evaluation

A patient who speaks only Mandarin requires a detailed admission assessment. Which approach best meets accepted standards?

  1. Speak loudly and slowly in English and use hand gestures to clarify the questions
  2. Arrange a qualified medical interpreter, in person or by video Correct answer.
  3. Ask the patient's 12-year-old child to interpret the questions during the assessment
  4. Ask a bilingual employee from another department to translate the questions and the consent discussion

Explanation

Standards of care require a qualified interpreter for patients with limited English proficiency. Ad hoc interpreters, including family members, minors, and untrained staff, increase the risk of error and breach confidentiality, and professional interpretation improves the accuracy of the history and of informed consent.

Question 17Assessment and Patient Evaluation

An S3 heart sound is auscultated in a 74-year-old with dyspnea and elevated jugular venous pressure. What does this finding most likely indicate?

  1. Aortic stenosis causing outflow obstruction and a systolic murmur
  2. A normal age-related finding that requires no further evaluation
  3. Ventricular volume overload from heart failure Correct answer.
  4. Pericardial effusion causing muffled heart sounds and tamponade

Explanation

An S3 is generated by rapid ventricular filling into an overloaded or noncompliant ventricle and, in an older adult with dyspnea and elevated venous pressure, points to volume overload and decompensated heart failure. It is heard best at the apex with the bell while the patient lies in the left lateral position.

Question 18Assessment and Patient Evaluation

While assessing hydration in an 80-year-old, a nurse finds that a pinched fold of skin over the sternum returns slowly. What is the most accurate interpretation?

  1. Slow recoil is a normal age-related change in dermal elasticity that can be disregarded during hydration assessment
  2. This finding reliably confirms severe dehydration and justifies immediate bolus fluid replacement
  3. Turgor is best checked over the sternum or forehead, but slow recoil is nonspecific and needs corroboration Correct answer.
  4. Slow recoil indicates fluid overload

Explanation

Aging reduces dermal elastin, so turgor over the back of the hand is unreliable; the sternum or forehead is preferred, but even there slow recoil occurs with age and weight loss. Turgor must be combined with mucous membranes, orthostatic vital signs, intake and output, daily weights, and laboratory data before any conclusion is drawn.

Question 19Assessment and Patient Evaluation

A patient two days after a stroke is alert and asks for water. What should the nurse do before allowing oral intake?

  1. Give small sips of water and monitor the patient closely for coughing or a wet voice quality
  2. Withhold all oral intake, including medications, for 72 hours as a precaution after stroke
  3. Start with thickened liquids, because thickening eliminates any risk of aspiration in stroke patients
  4. Complete a validated bedside swallow screen before any oral intake Correct answer.

Explanation

Dysphagia is common after stroke and aspiration may be silent, so a validated bedside swallow screen is completed before any oral intake, including medications and ice chips. Thickened liquids reduce but do not eliminate aspiration risk and must be ordered after a swallowing evaluation.

Question 20Assessment and Patient Evaluation

Which instrument is used to quantify the severity of alcohol withdrawal and guide symptom-triggered treatment?

  1. The PHQ-9
  2. The CAGE questionnaire
  3. The AUDIT-C
  4. The CIWA-Ar Correct answer.

Explanation

The Clinical Institute Withdrawal Assessment for Alcohol, revised, scores ten signs and symptoms of withdrawal and is repeated so that benzodiazepines can be titrated to symptoms rather than given in fixed doses. The CAGE and AUDIT-C screen for unhealthy alcohol use, and the PHQ-9 measures depression severity.

Question 21Assessment and Patient Evaluation

Which set of findings best distinguishes the internal jugular venous pulse from the carotid arterial pulse?

  1. The jugular pulse has a single brisk upstroke that is unaffected by respiration, while the carotid pulse has three separate waves
  2. The jugular pulse is impalpable and multiphasic and falls with inspiration, while the carotid is palpable and monophasic Correct answer.
  3. Both are best assessed with the patient standing, the neck extended, and the head turned toward the examiner
  4. The jugular pulse is palpable and rises with inspiration, whereas the carotid pulse is impalpable and falls with inspiration

Explanation

Venous pressure is low, so the jugular waveform is impalpable, multiphasic, descends with inspiration, and is obliterated by light pressure at the base of the neck, whereas arterial pulsation is palpable, monophasic, and unaffected by these maneuvers. The patient is examined with the trunk elevated 30 to 45 degrees and the head turned slightly away.

Question 22Assessment and Patient Evaluation

A screening test has 95 percent sensitivity and 60 percent specificity for a condition whose prevalence is 1 percent in the population being screened. What is the most likely consequence?

  1. Nearly all positive results will be true positives
  2. Specificity has no influence on the predictive value of a positive result
  3. The test will fail to detect most people who have the condition
  4. Most positive results will be false positives because prevalence is low Correct answer.

Explanation

Positive predictive value depends on both the test characteristics and the prevalence of the condition. When prevalence is low, a modest false-positive rate applied to a very large number of healthy people outnumbers the true positives: per 10,000 screened, about 95 true positives are accompanied by roughly 3,960 false positives, so the positive predictive value is close to 2 percent.

Question 23Assessment and Patient Evaluation

An arterial blood gas shows pH 7.28, PaCO2 30 mmHg, and bicarbonate 14 mEq/L. How should this be interpreted?

  1. Respiratory alkalosis with metabolic compensation
  2. Respiratory acidosis
  3. Metabolic acidosis with respiratory compensation Correct answer.
  4. Metabolic alkalosis

Explanation

The pH is acidemic and the bicarbonate is low, identifying a primary metabolic acidosis, while the low PaCO2 represents the expected respiratory compensation; Winter's formula predicts 1.5 times 14 plus 8, or 29 plus or minus 2 mmHg. A PaCO2 outside that range would indicate an additional, mixed disorder.

Question 24Assessment and Patient Evaluation

A nurse prepares to administer the Montreal Cognitive Assessment (MoCA) to a patient who left school after the sixth grade. Which statement should guide the nurse's interpretation of the result?

  1. One point is added for fewer than 12 years of schooling, and the score is read with history and function Correct answer.
  2. The MoCA score is unaffected by educational level, language of administration, or cultural familiarity with the test items
  3. A score below 26 establishes a diagnosis of Alzheimer disease without further evaluation
  4. A normal MoCA result excludes delirium in a patient with an acute change in mental status

Explanation

The MoCA is more sensitive to mild cognitive impairment than the MMSE but is also more education-dependent, so one point is added when formal schooling totals fewer than 12 years. Cognitive screens flag impairment and must be interpreted alongside the history, collateral report, and functional assessment.

Question 25Assessment and Patient Evaluation

A patient rescued from a house fire has an SpO2 of 99 percent on room air but is confused and has cherry-red skin. Which principle best explains this discrepancy?

  1. The reading is falsely low because carbon monoxide causes severe peripheral vasoconstriction and poor perfusion
  2. Pulse oximetry directly measures the arterial oxygen tension, so the saturation reflects alveolar ventilation
  3. Pulse oximetry is accurate in this setting and the confusion is most likely due to anxiety and smoke inhalation
  4. Standard pulse oximetry misreads carboxyhemoglobin as oxyhemoglobin, giving a falsely high saturation Correct answer.

Explanation

Two-wavelength pulse oximeters read carboxyhemoglobin as though it were oxyhemoglobin, so saturation appears normal or high despite severely impaired oxygen delivery. Carbon monoxide poisoning is suspected from the exposure history and confirmed with co-oximetry, because oximetry estimates saturation and never reports arterial oxygen tension.

Question 26Assessment and Patient Evaluation

In what order should a nurse perform the four core techniques when assessing a patient's abdomen?

  1. Auscultation, inspection, percussion, palpation
  2. Inspection, auscultation, percussion, palpation Correct answer.
  3. Palpation, percussion, auscultation, inspection
  4. Inspection, palpation, percussion, auscultation

Explanation

Inspection is always performed first, and auscultation is done before percussion and palpation because those maneuvers can alter bowel sound frequency. The accepted sequence is inspection, auscultation, percussion, then palpation.

Question 27Assessment and Patient Evaluation

What is the lowest possible Glasgow Coma Scale score for an adult?

  1. A score of 0
  2. A score of 15
  3. A score of 1
  4. A score of 3 Correct answer.

Explanation

The Glasgow Coma Scale sums eye, verbal, and motor scores. Each component has a minimum score of 1, so the lowest total is 3. A score of 15 is the maximum.

Question 28Assessment and Patient Evaluation

A nurse documents a pedal pulse as 3+. What does this grade indicate?

  1. An absent pulse
  2. A weak, thready pulse
  3. An increased or bounding pulse Correct answer.
  4. A normal pulse

Explanation

Peripheral pulses are graded on a 0 to 4+ scale: 0 is absent, 1+ is weak, 2+ is normal, and 3+ is increased or bounding. A 4+ pulse is also described as bounding or hyperactive.

Question 29Assessment and Patient Evaluation

Which capillary refill time is considered normal in a well-perfused adult?

  1. 5 to 8 seconds
  2. More than 8 seconds
  3. Less than 3 seconds Correct answer.
  4. 3 to 5 seconds

Explanation

Capillary refill is assessed by blanching a nail bed and timing how long color returns. A normal adult refill is generally less than 3 seconds. Prolonged refill suggests poor peripheral perfusion.

Question 30Assessment and Patient Evaluation

Which action best assesses cranial nerve VII?

  1. Ask the patient to smile, show the teeth, and puff out the cheeks Correct answer.
  2. Ask the patient to identify a familiar scent with the eyes closed
  3. Ask the patient to shrug the shoulders against resistance
  4. Ask the patient to stick out the tongue and move it side to side

Explanation

Cranial nerve VII is the facial nerve and controls muscles of facial expression. Asking the patient to smile, show teeth, and puff the cheeks tests those muscles. Smell is cranial nerve I, tongue movement is XII, and shoulder shrugging is XI.

Question 31Assessment and Patient Evaluation

Which Korotkoff phase corresponds to the first clear tapping sound heard as the blood pressure cuff deflates?

  1. Phase IV
  2. Phase II
  3. Phase I Correct answer.
  4. Phase III

Explanation

Korotkoff phase I is the first clear tapping sound heard as the cuff pressure falls; it corresponds to systolic pressure. Phase V, the disappearance of sound, corresponds to diastolic pressure in adults.

Question 32Assessment and Patient Evaluation

Which categories are scored by the FLACC pain scale?

  1. Face, legs, activity, cry, consolability Correct answer.
  2. Face, arms, crying, cooperation, sleep
  3. Facial expression, verbal report, activity, vital signs
  4. Grimace, mobility, feeding, sleep

Explanation

FLACC stands for face, legs, activity, cry, and consolability. It is a behavioral pain scale used for young children or patients who cannot self-report pain. Each category is scored from 0 to 2.

Question 33Assessment and Patient Evaluation

A patient's Snellen visual acuity is recorded as 20/40. What does this mean?

  1. The patient sees at 20 feet what a normal eye sees at 40 feet Correct answer.
  2. The patient needs a 20-diopter lens to read at 40 feet
  3. The patient sees at 40 feet what a normal eye sees at 20 feet
  4. The patient has 40 percent of normal vision in that eye

Explanation

Snellen acuity compares the patient's vision with that of a person with normal vision. A result of 20/40 means the patient must stand at 20 feet to see what a normal eye sees at 40 feet. The larger the second number, the poorer the acuity.

Question 34Assessment and Patient Evaluation

A nurse is measuring orthostatic vital signs. Which procedure best follows accepted technique?

  1. Measure only standing blood pressure because supine values add no information
  2. Measure blood pressure and pulse after 1 minute supine, then immediately on standing
  3. Measure blood pressure and pulse after 5 minutes supine, then at 1 and 3 minutes standing Correct answer.
  4. Measure blood pressure and pulse after 10 minutes sitting, then after 10 seconds standing

Explanation

Orthostatic vital signs are measured after the patient has rested supine for about 5 minutes, then repeated after standing for 1 and 3 minutes. This detects a clinically significant drop in blood pressure or rise in pulse with position change.

Question 35Assessment and Patient Evaluation

A deep tendon reflex is present but diminished compared with normal. Which grade should the nurse document?

  1. 2+
  2. 4+
  3. 1+ Correct answer.
  4. 0

Explanation

Deep tendon reflexes are graded as 0 absent, 1+ diminished, 2+ normal, 3+ increased, and 4+ hyperactive with clonus. A reflex that is present but weaker than normal is documented as 1+.

Question 36Assessment and Patient Evaluation

Which description matches 2+ pitting edema?

  1. An 8-mm depression that persists for more than 5 minutes
  2. A 6-mm depression that persists for 1 to 2 minutes
  3. A 2-mm depression that rebounds immediately
  4. A 4-mm depression that rebounds in 10 to 15 seconds Correct answer.

Explanation

Pitting edema is graded by depth and duration of the pit. A 2+ grade corresponds to a roughly 4-mm depression that rebounds in about 10 to 15 seconds. Larger, longer-lasting pits indicate higher grades.

Question 37Assessment and Patient Evaluation

The right pupil measures 2 mm and the left pupil measures 6 mm. Which term describes this finding?

  1. Mydriasis
  2. Miosis
  3. Anisocoria Correct answer.
  4. Nystagmus

Explanation

Anisocoria is unequal pupil size, which may be benign or may indicate neurologic or ocular disease. Miosis refers to constriction, mydriasis refers to dilation, and nystagmus is rhythmic eye movement.

Question 38Assessment and Patient Evaluation

A patient stands with feet together and eyes open steadily, but sways markedly when the eyes are closed. Which sign is this?

  1. Babinski sign
  2. Romberg sign Correct answer.
  3. Brudzinski sign
  4. Kernig sign

Explanation

The Romberg test assesses balance with eyes open and then closed. A marked increase in sway with eyes closed indicates a positive Romberg sign, suggesting impaired proprioception or vestibular function.

Question 39Assessment and Patient Evaluation

When the lateral sole of an adult's foot is stroked, the great toe dorsiflexes and the other toes fan outward. What does this finding indicate?

  1. An upper motor neuron lesion Correct answer.
  2. A lower motor neuron lesion
  3. A peripheral nerve injury only
  4. A normal adult plantar reflex

Explanation

A positive Babinski sign in an adult is dorsiflexion of the great toe with fanning of the other toes. This indicates upper motor neuron dysfunction, such as from stroke or spinal cord disease. The normal adult response is plantar flexion.

Question 40Assessment and Patient Evaluation

Which description best characterizes crackles heard on chest auscultation?

  1. Continuous low-pitched snoring sounds during expiration
  2. Harsh tubular sounds heard over the trachea
  3. Discontinuous popping sounds heard mainly during inspiration Correct answer.
  4. Continuous high-pitched musical sounds during expiration

Explanation

Crackles are discontinuous, popping or bubbling sounds caused by collapsed airways reopening or fluid in the alveoli. They are heard mainly during inspiration. Wheezes are continuous and musical, and rhonchi are continuous and low-pitched.

Question 41Assessment and Patient Evaluation

Which factor is most likely to produce a falsely low pulse oximetry reading?

  1. A warm, well-perfused finger
  2. Carbon monoxide exposure
  3. Dark nail polish on the finger being used Correct answer.
  4. Mild anemia

Explanation

Pulse oximetry relies on light transmission through tissue, so dark nail polish or artificial nails can block light and lower the reading. Carbon monoxide falsely elevates the reading, anemia does not directly lower oxygen saturation, and good perfusion improves accuracy.

Question 42Assessment and Patient Evaluation

A patient's blood pressure is 160/90 mmHg. What is the mean arterial pressure?

  1. 120 mmHg
  2. 110 mmHg
  3. 103 mmHg
  4. 113 mmHg Correct answer.

Explanation

Mean arterial pressure is calculated as diastolic pressure plus one-third of the pulse pressure. Here, 90 + (160 - 90)/3 = 90 + 23.3, which rounds to 113 mmHg.

Question 43Assessment and Patient Evaluation

What does the Timed Up and Go test primarily assess?

  1. Cognitive recall and orientation
  2. Visual acuity and peripheral vision
  3. Mobility and fall risk Correct answer.
  4. Upper extremity strength and grip

Explanation

The Timed Up and Go test measures the time a patient takes to stand from a chair, walk a short distance, turn, and sit back down. It is used to assess mobility and fall risk in older adults.

Question 44Assessment and Patient Evaluation

Which question is part of the CAGE screening tool for alcohol use?

  1. Have you ever had a blackout after drinking?
  2. How many drinks do you have in an average week?
  3. Have you ever felt you should cut down on your drinking? Correct answer.
  4. Do you drink alone at home?

Explanation

CAGE stands for Cut down, Annoyed, Guilty, and Eye-opener. Asking whether the patient has felt the need to cut down is the C in CAGE. The other questions may be useful clinically but are not part of the CAGE tool.

Question 45Assessment and Patient Evaluation

A patient has a shallow open ulcer with a red-pink wound bed and no visible subcutaneous fat. Which pressure injury stage is this?

  1. Stage 3
  2. Stage 2 Correct answer.
  3. Stage 1
  4. Stage 4

Explanation

A stage 2 pressure injury involves partial-thickness loss of skin with a shallow open ulcer or intact blister. Subcutaneous fat is not visible. Stage 3 extends into subcutaneous fat, and stage 4 extends to deeper structures.

Question 46Assessment and Patient Evaluation

A nurse performs the Rinne test and finds that bone conduction is greater than air conduction in the right ear. What does this indicate?

  1. Conductive hearing loss in the right ear Correct answer.
  2. Sensorineural hearing loss in the right ear
  3. Conductive hearing loss in the left ear
  4. Normal hearing in the right ear

Explanation

Normally, air conduction is greater than bone conduction. When bone conduction exceeds air conduction in one ear, it indicates conductive hearing loss in that ear. Sensorineural loss typically reduces both air and bone conduction while air conduction remains greater.

Question 47Assessment and Patient Evaluation

A nurse notes increased tactile fremitus over the right lower posterior chest. Which condition best explains this finding?

  1. Emphysema
  2. Lobar pneumonia Correct answer.
  3. Pneumothorax
  4. Pleural effusion

Explanation

Tactile fremitus is increased when solid or consolidated lung tissue transmits vibrations more effectively, as in lobar pneumonia. Air in the pleural space, pleural fluid, and hyperinflation all reduce transmission and decrease fremitus.

Question 48Assessment and Patient Evaluation

During egophony testing, the patient says "E" and the nurse hears "A" over the left lower lobe. What does this finding suggest?

  1. A pleural friction rub
  2. A pneumothorax
  3. Consolidation of lung tissue Correct answer.
  4. A normal lung finding

Explanation

Egophony is positive when the spoken "E" is heard as a nasal "A" over consolidated lung tissue. This occurs because solid tissue changes sound transmission. Normal lung transmits the "E" sound without this change.

Question 49Assessment and Patient Evaluation

An ankle-brachial index of 0.60 is obtained in a patient with exertional leg pain. How should this value be interpreted?

  1. Mild arterial insufficiency
  2. Normal arterial flow
  3. Moderate arterial insufficiency Correct answer.
  4. Venous insufficiency

Explanation

An ankle-brachial index between 0.50 and 0.70 indicates moderate arterial insufficiency. Values from 0.90 to 1.30 are generally normal, 0.70 to 0.90 suggest mild disease, and values below 0.50 suggest severe disease.

Question 50Assessment and Patient Evaluation

A nurse assesses for ascites using shifting dullness. Which finding is considered positive?

  1. Tympany over the flank becomes dull when the patient turns toward that side Correct answer.
  2. Tympany is heard over the liver during inspiration
  3. Dullness over the flank remains unchanged when the patient turns
  4. Dullness over the umbilicus increases with deep breathing

Explanation

With ascites, free fluid moves to the dependent side when the patient turns. Tympany from gas-filled bowel is replaced by dullness over that flank, which is a positive shifting dullness finding.