NSG3160 | NSG3160 Health Assessment Exam 2
Version 2 | Questions with Correct Answers and
Expert Explanation for Each Question | Galen
1. A nurse is performing a respiratory assessment on a patient with chronic
obstructive pulmonary disease (COPD). Which finding is most indicative of the
patient’s chronic condition?
A. Respiratory rate of 20 breaths per minute
B. An anteroposterior-to-transverse diameter ratio of 1:1
C. Occasional dry cough at night
D. Vesicular breath sounds heard over the lung periphery
Correct Answer: B
Expert Explanation: A 1:1 ratio indicates a barrel chest, which is a classic clinical
sign of chronic air trapping in COPD. Normal chest diameter ratio is typically
between 1:2 and 5:7 in healthy adults. This change occurs because the lungs remain
overinflated with air, pushing the rib cage outward over time. The nurse should
document this as a chronic finding rather than an acute change. Understanding this
anatomical shift helps the nurse distinguish between chronic pathology and acute
respiratory distress.
,2. While auscultating the lungs of a patient with pneumonia, the nurse hears low-
pitched, bubbling, and gurgling sounds that decrease after the patient coughs. How
should the nurse document these sounds?
A. Pleural friction rub
B. Fine crackles
C. Sibilant wheeze
D. Coarse crackles
Correct Answer: D
Expert Explanation: Coarse crackles are described as moist, low-pitched bubbling
sounds that often improve with coughing or suctioning. They are caused by air
colliding with secretions in the trachea and large bronchi during inspiration and
expiration. In contrast, fine crackles are high-pitched and do not change significantly
with coughing. A pleural friction rub would sound like leather rubbing together and
would be painful. Sibilant wheezes are high-pitched musical sounds indicating
narrowed small airways rather than fluid in large ones.
3. Which technique is most appropriate for a nurse to use when auscultating the lungs
of an adult patient?
A. Listening through the patient’s hospital gown to maintain privacy
B. Using the bell of the stethoscope to detect high-pitched breath sounds
,C. Moving the stethoscope from side to side in a symmetric sequence
D. Asking the patient to breathe quickly through the nose
Correct Answer: C
Expert Explanation: Side-to-side comparison is essential to detect localized
abnormalities and ensure both lungs are expanding equally. The nurse must place
the stethoscope directly on the skin because clothing can create friction sounds that
mimic crackles. The diaphragm of the stethoscope should be used because breath
sounds are generally high-pitched. The patient should breathe deeply through the
mouth to provide the clearest auscultation of air movement. Following a systematic
ladder-like pattern ensures that all lung fields are thoroughly evaluated.
4. During palpation, the nurse notes increased tactile fremitus over the right lower
lobe. This finding is most consistent with which condition?
A. Pneumothorax
B. Pleural effusion
C. Pneumonia with consolidation
D. Asthma attack
Correct Answer: C
, Expert Explanation: Increased tactile fremitus occurs when there is consolidation
of lung tissue, such as in pneumonia, which conducts vibrations more efficiently.
Liquid or solid mass acts as a better conductor of sound than the air-filled spaces of
a normal lung. Conversely, conditions like pneumothorax or pleural effusion
decrease fremitus because they create a barrier between the lung and the chest wall.
In asthma, fremitus is usually decreased due to air trapping and hyperinflation. The
nurse uses the ulnar surface of the hands to detect these vibrations while the patient
repeats ‘ninety-nine’.
5. A patient presents with a respiratory rate of 32 breaths per minute, use of
sternocleidomastoid muscles, and cyanosis of the lips. What is the nurse’s priority
action?
A. Document the findings in the electronic health record
B. Place the patient in a supine position
C. Initiate oxygen therapy and notify the rapid response team
D. Educate the patient on pursed-lip breathing techniques
Correct Answer: C
Expert Explanation: The patient is showing signs of acute respiratory distress and
hypoxia, which requires immediate intervention to maintain oxygenation. Oxygen
therapy addresses the physiological need for gas exchange while the rapid response
Version 2 | Questions with Correct Answers and
Expert Explanation for Each Question | Galen
1. A nurse is performing a respiratory assessment on a patient with chronic
obstructive pulmonary disease (COPD). Which finding is most indicative of the
patient’s chronic condition?
A. Respiratory rate of 20 breaths per minute
B. An anteroposterior-to-transverse diameter ratio of 1:1
C. Occasional dry cough at night
D. Vesicular breath sounds heard over the lung periphery
Correct Answer: B
Expert Explanation: A 1:1 ratio indicates a barrel chest, which is a classic clinical
sign of chronic air trapping in COPD. Normal chest diameter ratio is typically
between 1:2 and 5:7 in healthy adults. This change occurs because the lungs remain
overinflated with air, pushing the rib cage outward over time. The nurse should
document this as a chronic finding rather than an acute change. Understanding this
anatomical shift helps the nurse distinguish between chronic pathology and acute
respiratory distress.
,2. While auscultating the lungs of a patient with pneumonia, the nurse hears low-
pitched, bubbling, and gurgling sounds that decrease after the patient coughs. How
should the nurse document these sounds?
A. Pleural friction rub
B. Fine crackles
C. Sibilant wheeze
D. Coarse crackles
Correct Answer: D
Expert Explanation: Coarse crackles are described as moist, low-pitched bubbling
sounds that often improve with coughing or suctioning. They are caused by air
colliding with secretions in the trachea and large bronchi during inspiration and
expiration. In contrast, fine crackles are high-pitched and do not change significantly
with coughing. A pleural friction rub would sound like leather rubbing together and
would be painful. Sibilant wheezes are high-pitched musical sounds indicating
narrowed small airways rather than fluid in large ones.
3. Which technique is most appropriate for a nurse to use when auscultating the lungs
of an adult patient?
A. Listening through the patient’s hospital gown to maintain privacy
B. Using the bell of the stethoscope to detect high-pitched breath sounds
,C. Moving the stethoscope from side to side in a symmetric sequence
D. Asking the patient to breathe quickly through the nose
Correct Answer: C
Expert Explanation: Side-to-side comparison is essential to detect localized
abnormalities and ensure both lungs are expanding equally. The nurse must place
the stethoscope directly on the skin because clothing can create friction sounds that
mimic crackles. The diaphragm of the stethoscope should be used because breath
sounds are generally high-pitched. The patient should breathe deeply through the
mouth to provide the clearest auscultation of air movement. Following a systematic
ladder-like pattern ensures that all lung fields are thoroughly evaluated.
4. During palpation, the nurse notes increased tactile fremitus over the right lower
lobe. This finding is most consistent with which condition?
A. Pneumothorax
B. Pleural effusion
C. Pneumonia with consolidation
D. Asthma attack
Correct Answer: C
, Expert Explanation: Increased tactile fremitus occurs when there is consolidation
of lung tissue, such as in pneumonia, which conducts vibrations more efficiently.
Liquid or solid mass acts as a better conductor of sound than the air-filled spaces of
a normal lung. Conversely, conditions like pneumothorax or pleural effusion
decrease fremitus because they create a barrier between the lung and the chest wall.
In asthma, fremitus is usually decreased due to air trapping and hyperinflation. The
nurse uses the ulnar surface of the hands to detect these vibrations while the patient
repeats ‘ninety-nine’.
5. A patient presents with a respiratory rate of 32 breaths per minute, use of
sternocleidomastoid muscles, and cyanosis of the lips. What is the nurse’s priority
action?
A. Document the findings in the electronic health record
B. Place the patient in a supine position
C. Initiate oxygen therapy and notify the rapid response team
D. Educate the patient on pursed-lip breathing techniques
Correct Answer: C
Expert Explanation: The patient is showing signs of acute respiratory distress and
hypoxia, which requires immediate intervention to maintain oxygenation. Oxygen
therapy addresses the physiological need for gas exchange while the rapid response
