2026 NCSBN NCLEX RN EXAM 2 TEST
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The nurse is preparing to measure the apical pulse on an assigned client. The nurse places the
diaphragm of the stethoscope over which cardiac site?
1.Mitral area
2.Right atrium
A+ TEST BANK 1
, NCSBN NCLEX RN EXAM
3.Right ventricle
4.Pulmonic valve –
Correct Answer :Correct: 1
Rationale:
The diaphragm of the stethoscope is placed over the skin at the mitral area to listen to the
apical pulse. S1 (lub) and S2 (dub) should be distinguished. The pulse should be counted for a
full minute. The right atrium, right ventricle, and pulmonic valve areas will not provide clear
auscultation of the apical pulse.
A chest x-ray report states that the client has a left apical pneumothorax. The nurse caring for
the client monitors the status of breath sounds in that area by placing the stethoscope at
which location?
1.Near the lateral 12th rib
2.Just under the left clavicle
3.In the fifth intercostal space
4.Posteriorly under the left scapula –
Correct Answer :Correct: 2
A+ TEST BANK 2
, NCSBN NCLEX RN EXAM
Rationale:
The apex of the lung is the rounded, uppermost part of the lung. The nurse would place the
stethoscope just under the left clavicle. The other options are incorrect locations.
The nurse is assessing a client with a history of cardiac problems. Where should the nurse
place the stethoscope to hear the first heart sound (S1) the loudest?
1.Over the second intercostal space at the left sternal border
2.Over the fourth intercostal space at the right sternal border
3.Over the second intercostal space at the right sternal border
4.Over the fifth intercostal space in the left midclavicular line –
Correct Answer :Correct: 4
Rationale:
The first heart sound (S1) is heard loudest at the lower left sternal border or the apex of the
heart. The apex is located at the fifth intercostal space in the left midclavicular line. Therefore,
the locations in the remaining options are incorrect.
A+ TEST BANK 3
, NCSBN NCLEX RN EXAM
The nurse is preparing to perform a Weber test on a client who reports a loss of hearing in 1
ear. To perform the test, the nurse places the tuning fork in which area? Click on the image to
indicate your answer.
1. Top of head
2. Temporal area
3. Ear
4. Mandible –
Correct Answer :Correct: 4
Rationale:
The Weber test is a valuable assessment test when a client reports hearing that is better with
1 ear than the other. In this test, a vibrating tuning fork is placed on the client's head over the
midline of the client's skull. The client is then asked whether the tone sounds the same in
both ears or better in 1 ear. The client should hear the tone by bone conduction through the
skull, and it should sound equally loud in both ears.
The nurse performs a physical assessment on a client and gathers both subjective and
objective data. Which would the nurse document as subjective data?
1.Pedal pulses are present.
2.Temperature is 99.6º F (37.6º C).
A+ TEST BANK 4