NU650 | NU650 Health Assessment / Nursing Exam
2 Version 3 Questions with Correct Answers and
Expert Explanation for Each Question
1. During a cardiovascular assessment, the nurse notes a blowing, swishing sound with
the bell of the stethoscope over the carotid artery. How should this be documented?
A. A carotid bruit.
B. A normal find for an older adult.
C. A Grade II murmur.
D. S3 heart sound.
Correct Answer: A
Expert Explanation: A blowing, swishing sound indicates turbulent blood flow,
which is documented as a bruit. This finding suggests potential narrowing of the
vessel due to atherosclerosis. The nurse should use the bell of the stethoscope to
detect these low-pitched sounds while the patient holds their breath.
2. When palpating the abdomen, the nurse notes tenderness in the right upper
quadrant (RUQ). Which organ is most likely involved?
A. Spleen
B. Sigmoid colon
C. Liver
,D. Appendix
Correct Answer: C
Expert Explanation: The liver is the primary organ located in the right upper
quadrant of the abdomen. Tenderness in this area can indicate hepatitis,
cholecystitis, or hepatomegaly. Other RUQ structures include the gallbladder and
the head of the pancreas.
3. Which technique is correct when the nurse is percussing the posterior thorax for
diaphragmatic excursion?
A. Percuss from the area of resonance to the area of dullness during inspiration and
expiration.
B. Ask the patient to take a deep breath and hold it while percussing down the mid-
spinal line.
C. Percuss along the midaxillary line from the axilla down to the iliac crest.
D. Have the patient breathe shallowly while percussing over the scapula.
Correct Answer: A
Expert Explanation: Diaphragmatic excursion measures the distance the
diaphragm moves between inspiration and expiration. The nurse percusses down
the posterior chest wall until the sound changes from resonant to dull. A normal
excursion distance is typically 3 to 5 centimeters in a healthy adult.
,4. The nurse is assessing a patient for tactile fremitus. Which condition would cause an
increase in tactile fremitus?
A. Pneumothorax
B. Pleural effusion
C. Pneumonia with consolidation
D. Bronchial obstruction
Correct Answer: C
Expert Explanation: Tactile fremitus increases when there is consolidation of lung
tissue, such as in pneumonia. Solid or fluid-filled tissue conducts vibrations better
than air-filled tissue. Conversely, conditions that put air or fluid in the pleural space,
like pneumothorax or effusion, will decrease fremitus.
5. When auscultating the heart, where is the mitral valve area located?
A. Fifth intercostal space at the left midclavicular line
B. Second left intercostal space
C. Second right intercostal space
D. Fourth intercostal space at the left sternal border
Correct Answer: A
, Expert Explanation: The mitral valve is best heard at the apex of the heart, which is
located at the fifth intercostal space at the left midclavicular line. This is also the
location where the apical pulse is measured. Auscultating this area allows for the
clear detection of S1 and mitral murmurs.
6. A nurse is performing a breast exam and finds a firm, non-tender, fixed mass with
irregular borders in the upper outer quadrant. What is the priority action?
A. Advise the patient it is likely a benign cyst.
B. Refer the patient for further diagnostic testing, such as a mammogram or biopsy.
C. Document the finding and schedule a follow-up in six months.
D. Tell the patient to stop caffeine intake to see if the mass resolves.
Correct Answer: B
Expert Explanation: A firm, fixed, and irregular mass is a highly suspicious finding
for breast malignancy. The upper outer quadrant, including the tail of Spence, is the
most common site for breast cancer. Immediate referral for diagnostic imaging is
the standard of care to ensure early detection and treatment.
7. During an abdominal assessment, the nurse performs the Blumberg sign (rebound
tenderness). What does a positive result indicate?
A. Cholecystitis
B. Kidney stones
2 Version 3 Questions with Correct Answers and
Expert Explanation for Each Question
1. During a cardiovascular assessment, the nurse notes a blowing, swishing sound with
the bell of the stethoscope over the carotid artery. How should this be documented?
A. A carotid bruit.
B. A normal find for an older adult.
C. A Grade II murmur.
D. S3 heart sound.
Correct Answer: A
Expert Explanation: A blowing, swishing sound indicates turbulent blood flow,
which is documented as a bruit. This finding suggests potential narrowing of the
vessel due to atherosclerosis. The nurse should use the bell of the stethoscope to
detect these low-pitched sounds while the patient holds their breath.
2. When palpating the abdomen, the nurse notes tenderness in the right upper
quadrant (RUQ). Which organ is most likely involved?
A. Spleen
B. Sigmoid colon
C. Liver
,D. Appendix
Correct Answer: C
Expert Explanation: The liver is the primary organ located in the right upper
quadrant of the abdomen. Tenderness in this area can indicate hepatitis,
cholecystitis, or hepatomegaly. Other RUQ structures include the gallbladder and
the head of the pancreas.
3. Which technique is correct when the nurse is percussing the posterior thorax for
diaphragmatic excursion?
A. Percuss from the area of resonance to the area of dullness during inspiration and
expiration.
B. Ask the patient to take a deep breath and hold it while percussing down the mid-
spinal line.
C. Percuss along the midaxillary line from the axilla down to the iliac crest.
D. Have the patient breathe shallowly while percussing over the scapula.
Correct Answer: A
Expert Explanation: Diaphragmatic excursion measures the distance the
diaphragm moves between inspiration and expiration. The nurse percusses down
the posterior chest wall until the sound changes from resonant to dull. A normal
excursion distance is typically 3 to 5 centimeters in a healthy adult.
,4. The nurse is assessing a patient for tactile fremitus. Which condition would cause an
increase in tactile fremitus?
A. Pneumothorax
B. Pleural effusion
C. Pneumonia with consolidation
D. Bronchial obstruction
Correct Answer: C
Expert Explanation: Tactile fremitus increases when there is consolidation of lung
tissue, such as in pneumonia. Solid or fluid-filled tissue conducts vibrations better
than air-filled tissue. Conversely, conditions that put air or fluid in the pleural space,
like pneumothorax or effusion, will decrease fremitus.
5. When auscultating the heart, where is the mitral valve area located?
A. Fifth intercostal space at the left midclavicular line
B. Second left intercostal space
C. Second right intercostal space
D. Fourth intercostal space at the left sternal border
Correct Answer: A
, Expert Explanation: The mitral valve is best heard at the apex of the heart, which is
located at the fifth intercostal space at the left midclavicular line. This is also the
location where the apical pulse is measured. Auscultating this area allows for the
clear detection of S1 and mitral murmurs.
6. A nurse is performing a breast exam and finds a firm, non-tender, fixed mass with
irregular borders in the upper outer quadrant. What is the priority action?
A. Advise the patient it is likely a benign cyst.
B. Refer the patient for further diagnostic testing, such as a mammogram or biopsy.
C. Document the finding and schedule a follow-up in six months.
D. Tell the patient to stop caffeine intake to see if the mass resolves.
Correct Answer: B
Expert Explanation: A firm, fixed, and irregular mass is a highly suspicious finding
for breast malignancy. The upper outer quadrant, including the tail of Spence, is the
most common site for breast cancer. Immediate referral for diagnostic imaging is
the standard of care to ensure early detection and treatment.
7. During an abdominal assessment, the nurse performs the Blumberg sign (rebound
tenderness). What does a positive result indicate?
A. Cholecystitis
B. Kidney stones
