EXAM ACTUAL EXAM QUESTIONS AND
VERIFIED ANSWERS WITH RATIONALES
GRADED A+ LATEST
1.
A nurse is assessing an older adult’s skin. Which finding is most consistent with
normal aging?
A. Thickened epidermis
B. Decreased skin elasticity
C. Increased sebaceous gland activity
D. Increased capillary refill time
Correct Answer: B
Rationale: Aging causes decreased collagen and elastin, leading to reduced skin
elasticity. The epidermis thins, sebaceous activity decreases, and capillary refill
remains normal unless vascular disease is present.
2.
A patient reports sharp pain when the nurse palpates the right lower quadrant of the
abdomen, followed by increased pain when pressure is released. This finding
suggests:
A. Ascites
B. Guarding
C. Rebound tenderness
D. Rigidity
Correct Answer: C
Rationale: Rebound tenderness occurs when pain intensifies upon release of
pressure and may indicate peritoneal irritation such as appendicitis.
,3.
Which technique should the nurse use first when performing an abdominal
assessment?
A. Percussion
B. Palpation
C. Inspection
D. Auscultation
Correct Answer: C
Rationale: Inspection is always performed first. Auscultation follows before
percussion and palpation to avoid altering bowel sounds.
4.
During cardiac auscultation, the nurse hears a sound immediately following S2.
This sound is best described as:
A. S3 gallop
B. S4 gallop
C. Split S1
D. Murmur
Correct Answer: A
Rationale: An S3 occurs just after S2 during early ventricular filling and may be
normal in children but abnormal in adults.
5.
A nurse assesses a client’s blood pressure as 88/56 mm Hg. Which additional
assessment finding would most concern the nurse?
A. Warm, dry skin
B. Bounding peripheral pulses
C. Dizziness upon standing
D. Slow capillary refill
,Correct Answer: C
Rationale: Orthostatic dizziness combined with hypotension suggests inadequate
cerebral perfusion and possible hypovolemia.
6.
Which cranial nerve is assessed by asking the patient to shrug the shoulders against
resistance?
A. Cranial nerve VII
B. Cranial nerve IX
C. Cranial nerve XI
D. Cranial nerve XII
Correct Answer: C
Rationale: Cranial nerve XI (spinal accessory) controls the sternocleidomastoid
and trapezius muscles.
7.
A nurse notes clubbing of the fingernails. This finding is most commonly
associated with:
A. Acute dehydration
B. Chronic hypoxia
C. Iron-deficiency anemia
D. Peripheral neuropathy
Correct Answer: B
Rationale: Clubbing is linked to long-term hypoxia seen in chronic lung or cardiac
conditions.
, 8.
When assessing the lungs, the nurse hears low-pitched, continuous sounds over the
bronchi. These are best described as:
A. Crackles
B. Wheezes
C. Rhonchi
D. Pleural friction rub
Correct Answer: C
Rationale: Rhonchi are low-pitched sounds caused by secretions or obstruction in
large airways.
9.
Which assessment finding suggests left-sided heart failure?
A. Peripheral edema
B. Jugular vein distention
C. Pulmonary crackles
D. Hepatomegaly
Correct Answer: C
Rationale: Left-sided heart failure leads to pulmonary congestion, producing
crackles. The other findings are more typical of right-sided failure.
10.
The nurse is assessing pupillary response. Which finding is considered normal?
A. Pupils unequal but reactive
B. Pupils equal, round, reactive to light
C. Pupils fixed and dilated
D. Pupils constrict slowly and unevenly
Correct Answer: B
Rationale: Normal pupils are PERRL—equal, round, and reactive to light.