Exam 3: NR302 / NR 302 (2026/2027 Updated) Health Assessment I |Review with Questions and Verified Answers| 100% Correct | A Grade -Chamberlain

Exam 3: NR302 / NR 302 (2026/2027 Updated) Health Assessment I |Review with Questions and Verified Answers| 100% Correct | A Grade -Chamberlain Q. Which of these statements is true regarding the vertebra prominens? The vertebra prominens is ANSWER The spinous process of C7 Q. When performing a respiratory assessment on a patient, the nurse notices a costal angle of approximately 90 degrees. The characteristic is: ANSWER a normal finding in a healthy adult Q. When assessing a patients lung, the nurse recalls that the left lung ANSWER Consists of two lobes Q. Which statement about the apices of the lung is true? The apices of the lungs ANSWER extend 3 to 4 cm above the inner third of the clavicle Q. During an examination of the anterior thorax, the nurse is aware that the trachea bifurcates anteriorly at the ANSWER Sternal Angle Q. During an assessment, the nurse knows that expected assessment findings in the normal adult lung include the presence of ANSWER Muffled voice sounds and symmetric tactile fremitus Q. The primary muscles of respiration include the ANSWER Diaphragm and intercostals Q. A 65 year old patient with a history of heart failure comes to the clinic with complaints of "being awakened from sleep with shortness of breath". Which action by the nurse is most appropriate? ANSWER Assessing the other signs and symptoms of paroxysmal nocturnal dyspnea Q. When assessing tactile fremitus the nurse recalls that it is normal to feel tactile fremitus most intensely over which location? ANSWER Between the scapulae Q. The nurse is reviewing the technique of palpating for tactile remits with a new graduate. Which statement by the graduate nurse reflects a correct understanding of tactile fremitus? Tactile fremitus ANSWER Is caused by sounds generated by eh larynx Q. During percussion, the nurse knows that a dull percussion note elicited over a lung lobe most likely results from ANSWER Increased density of lung tissue Q. The nurse is observing the auscultation technique of another nurse. The correct method to use the progressing from one auscultatory site on the thorax to another is ___ comparison. ANSWER Side to side Q. When auscultating the lungs of an adult patient, the nurse notes that low pitched, soft breath sounds are heard over the posterior lower lobes, with inspiration being longer than expiration. The nurse interprets these sounds ANSWER Vesicular breath sounds are normal in that location Q. The nurse is auscultating the chest is an adult. Which technique is correct? ANSWER Firmly holding the diaphragm of the stethoscope against the chest Q. The nurse is percussing over the lungs of a patient with pneumonia. The nurse knows that percussion over an area of atelectasis in the lungs will reveal: ANSWER Dullness Q. During auscultation of the lungs, the nurse expects decreased breath sounds to be heard in which situation? ANSWER When the bronchial tree is obstructed Q. The nurse knows that a normal finding when assessing the respiratory system of an older adult ANSWER Decreased mobility of the thorax Q. A mother brings her 3 month old infant to the clinic for evaluation of a cold. She tells the nurse that he has had a runny nose for a week. When performing the physical assessment the nurse notes that the child has nasal flaring and sternal and intercostal retractions. The nurse's next action should be to ANSWER Recognize that these are serious signs, and contact the physician. Q. When assessing the respiratory system of a 4 year old child, which findings would the nurse expect ANSWER Presence of bronchovesicular breath sounds in the peripheral lung fields Q. When inspecting the anterior chest of an adult, the nurse should include which assessment ANSWER Shape and configuration of the chest wall Q. The nurse knows that auscultation of fine crackles would most likely be noticed in ANSWER The immediate newborn period Q. During an assessment of an adult, the nurse has noted unequal chest expansion and recognizes that this occurs in which situation? ANSWER When part of the lung is obstructed or collapsed Q. During auscultation of the lungs of an adult patient, the nurse notices the presence of bronchophony. The nurse should asses for signs of which condition ANSWER Pulmonary Consolidation Q. The nurse is reviewing the characteristics of breath sounds. Which statement about bronchovesicular breath sounds is true? Bronchovesicular breath sounds ANSWER Expected near the major airways Q. The nurse is listening to the breath sounds of a patient with severe asthma. Air passing through narrowed bronchioles would proceed which of these adventitious sounds? ANSWER Wheezes Q. A patient has a long history of chronic obstructive pulmonary disease (COPD). During the assessment, the nurse will most likely observe which of these? ANSWER AP to transverse diameter ration of 1:1 Q. A teenage patient comes to the emergency department with complains of an inability to breathe and a sharp pain in the left side of his chest. The assessment findings include cyanosis, tachypnea, trachieal deviation to the right, decreased tactile fremitus on the left, hypersonance on the left and decreased breath sounds on the left. The nurse interprets that these assessment findings are consisted with ANSWER Pneumothorax Q. An adult patient with a history of wheezing and difficulty breathing when working in his yard. The assessment findings include tachypnea, the use of accessory neck muscles, prolonged expiration, intercostal retractions, decreased breath sounds, and expiration wheezes. The nurse interprets that these assessment findings are consistent with ANSWER Asthma Q. A nurse is assessing the lungs of an older adult. Which of these changes are normal in the respiratory system of the older adult? ANSWER Lungs are less elastic and distensible, which decreases their ability to collapse and recoil Q. A women in her 26th week of pregnancy states that she is not really short of breath but feels that she is aware of her breathing and the need to breathe. What is the nurse's best reply? ANSWER "what you are experiencing is normal. Some women may interpret this as shortness of breath, but it is a normal finding and nothing is wrong" Q. A 35 year old recent immigrant is being seen in the clinic for complains of a cough that is associated with rust colored sputum, low grade afternoon fevers, and night sweats for the past 2 months. The nurses preliminary analysis, based on this history is that this patient may be suffering from ANSWER Tuberculosis Q. A 70 year old patient is being seen in the clinic for severe exacerbation of his heart failure. Which of these findings is the nurse most likely to observe in this patient ANSWER Shortness of breath, orthopnea, paroxysmal nocturnal dyspnea and ankle edema. Q. A patient comes to the clinic complaining of a cough that is worse at night but not as bad during the day. The nurse recognizes that this cough may indicate ANSWER Post nasal drip or sinusitis Q. During a morning assessment, the nurse notices that the patients sputum is frothy pink. which condition could this finding indicate? ANSWER Pulmonary Edema Q. During ausculation of breath sounds, the nurse should correctly use the stethoscope in which of the following ways? ANSWER Listening to at least one full respiration in each location Q. A patient has been admitted to the emergency department with a possible medical diagnosis of pulmonary embolism. The nurse expects to see which assessment findings related to this condition? ANSWER Chest pain that is worse on deep inspiration and dyspnea Q. During palpation of the anterior chest wall, the nurse notices a coarse crackling sensations over the skin surface. On the basis of these findings the nurse suspects ANSWER crepitus The nurse is auscultating the lungs of a patient who had been sleeping and notices short, popping, crackling sounds that stop after a few breaths. The nurse recognizes that these breath sounds are Atelectatic crackles that do not have a pathological cause A patient had been admitted to the emergency department for a suspected drug overdose. His respirations are shallow, with an irregular pattern, with a rate of 12 respirations per minute. The nurse interprets that the respiration pattern as which of the following Hypoventilation A patient with pleuritic has been admitted to the hospital and complains of pain with breathing. What other key assessment finding would the nurse expect to find upon auscultation? Friction rub The nurse is assessing voice sounds during a respiratory assessment. Which of the following indicates a normal assessment? Voice sounds are faint, muffled and almost inaudible when the patient whispers 1 2 3 in a very soft voice; when the patient speaks in a normal voice the examiner can hear a sound but can not distinguish what is being said; as the patient says a long eeeee sound the examiner also hears a long eee sound. The sac that surrounds and protects the heart is called the pericardium The direction of blood flow through the heart is best described by which of these? Right atrium, right ventricle, pulmonary artery, lungs, pulmonary vein, left atrium, left ventricle The nurse reviewing the anatomy and physiologic functioning of the heart. Which statement best describes what is meant by atrial kick? The atria contact toward the end of diastole and push the remaining blood into the ventricles. When listening to heart sounds, the nurse knows the valve closure that can be heard best at the base of the heart are aortic and pulmonic Which of these statements describes the closure of the valves in a normal cardiac cycle? The tricuspid valve closes slightly later than the mitral valve The component of the conduction system referred to as the pacemaker of the heart is the SA node The electrical stimulus of the cardiac cycle follows which sequence? AV node, SA node, bundle of His, bundle branches The findings from an assessment of a 70 year old patient with swelling in her ankles include jugular venous pulsations 5 cm above the sternal angle when the head of his bed is elevated 45 degrees. The nurse knows that this finding indicates Elevated pressure related to heart failure When assessing a newborn infant who is 5 minutes old, the nurse knows which of these statements to be true? Blood can flow into the left side of the heart through an opening in the atrial septum. A 25 year old woman in her fifth month of pregnancy has a blood pressure of 100/70 mm Hg. In reviewing her previous examination the nurse notes that her blood pressure in her second month was 124/80 mm Hg. In evaluating this change what does the nurse know to be true? This decline in blood pressure is the result of peripheral vasodilation and is an expected change. In assessing a 70 year old man, the nurse finds the following: blood pressure 140/100 mm Hg. heart rate 104 deaths per minute and slightly irregular, and the split S2 heart sound. Which of these findings can be explained by expected hemodynamic changes related to age? Increased systolic blood pressure A 45 year old man is in the clinic for a routine physical examination. During the recording of his health history, the patient states that he has been having difficulty sleeping. Ill be sleeping great and then I wake up and feel like I can't get my breath. The nurses best response to this would be "Do you have a history with problems with your heart?" In assessing a patient's major risk factors for heart disease, which could the nurse want to include when taking a history? Smoking, hypertension, obesity, diabetes, and high cholesterol A mother of a 3 month old infant states that her baby has not been gaining weight. With further questioning the nurse finds that the infant falls asleep after nursing and wakes up after a short time hungry again. What other information would the nurse want to have? Presence of dyspnea or diaphoresis when sucking In assessing the carotid arteries of an older patient with cardiovascular disease, the nurse would Listen with the bell of the stethoscope to assess for bruits. During an assessment of a 68 year old man with a recent onset of right sided weakness the nurse hears a blowing swishing sound with the bell of the stethoscope over the left carotid artery. This finding would indicate Blood flow turbulence During an inspection of the precordium of an adult patient, the nurse notices the chest moving in a forceful manner along the sternal border. This finding most likely suggests Enlargement of the right ventricle During an assessment of a health adult, where would the nurse expect to palpate the apical impulse? 5th left intercostal space at the midclavicular line The nurse is examining a patient who has possible cardiac enlargement. Which statement about percussion of the heart is true? Studies show that percussed cardiac borders do not correlate will with the true cardiac border The nurse is preparing to auscultate for heart sounds. Which technique is correct? Listening by inching the stethoscope in a rough Z pattern, from the base of the heart across and down, then over to the apex While counting the apical pulse on a 16 year old patient, the nurse notices an irregular rhythm. His rate speeds up on inspiration and slows on expiration. What would the nurse's response be? No further response is needed because sinus arrhythmia can occur normally While listening to heart sounds, the nurse knows that the S1 Coincides with the carotid artery pulse During cardiac auscultation the nurse hears a sound immediately occurring after the S2 at the second left intercostal space. To further assess this sound, what should the nurse do? Watch the patients respirations while listening for the effect on the sound Which of these findings would the nurse expect to notice during a cardiac assessment on a 4 year old child? Murmur at the second left intercostal space when supine While auscultation heart sounds on a 7 year old child for routine physical examination, the nurse hears an S3, a soft murmur at the left midsternal border, and a venous hum when the child is standing. What would be a correct interpretation of these findings? These findings can all be normal in a child During the precordial assessment on a patient who is 8 months pregnant, the nurse palpates the apical impulse on the fourth left intercostal space lateral to the midclavicular line. This finding would indicate Displacement of the heart from elevation of the diaphragm. In assessing for an S4 heart sound with a stethoscope the nurse would listen with the Bell of the stethoscope at the apex with the patient in the left lateral position A 70 year old patient with a history of hypertension has a blood pressure of 180/100 mm Hg. and a heart rate of 90 beats per minute. The nurse hears an extra heart sound at the apex immediately before the S1. The sound is heard only with the bell of the stethoscope while the patient is in the left lateral position. With these findings and the patient's history the nurse knows that this extra heart sound is most likely atrial gallop The nurse is performing a cardiac assessment on a 65 year old patient, 3 days after her myocardial infraction. Heart sounds are normal when she is supine, but when she is sitting and leaning forward the nurse hears a high pitched, scratchy sound with the diaphragm of the stethoscope at the apex. It disappears on inspiration. The nurse suspects Inflammation of the precordium The mother of a 10 month old infant tells the nurse that sh has noticed that her son becomes blue when he is crying and that the frequency of this is increasing. He is also not yet crawling. During the examination the nurse palpates a thrill at the left lower sternal border and auscultates a loud systolic murmur in the same area. What would most likely cause these findings? Tetralogy of Fallot A 30 year old woman with a history of mitral valve problems states that she has been very tired. She has started waking up at night and feels like her heart is pounding. During the assessment the nurse palpates a thrill and life at the firth left intercostal space midclavicular line. IN the same area the nurse auscultates a blowing swishing sound right after the S1. These findings would be most consistent with Mitral Regurgitation During a cardiac assessment on a 38 year old patient in the hospital for "chest pain" the nurse finds the following, jugular vein pulsations 4 cm above the sternal angle when the patient is elevated at 45 degrees, blood pressure 98/60 mm Hg. heart rate 130 deaths per minute, angle edema, difficulty breathing when supine and an S3 on auscultation. Which of these conditions best explains the cause of these findings? Heart Failure The nurse knows that normal splitting of S2 is associated with Inspiration During a cardiovascular assessment, the nurse knows that a thrill is Vibration that is palpable During a cardiovascular assessment, the nurse knows that an S4 heart sound is Heard at the end of ventricular diastole During an assessment the nurse notes that the patients apical impulse is laterally displaced and is palpable over a wide area. This finding indicates Volume overload, as in heart failure When the nurse is auscultating the carotid artery for bruits, which of these statements reflects the correct technique? While lightly applying the bell of the stereoscope over the carotid artery and listening, the patient is asked to take a breath, exhale and briefly hold it The nurse is preparing for a class on risk factors for hypertension and reviews recent statistics. Which racial group has the highest prevalence of hypertension in the world? Blacks The nurse is assessing a patient with possible cardiomyopathy and assess the hepatojugular reflux. If heart failure is present, then the nurse should recognize which finding while pushing on the right upper quadrant of the patients abdomen, just below the rib cage The jugular veins will remain elevated as long as the pressure on the abdomen is maintained The nurse is assessing the apical pulse of a 3 month old infant and finds the heart rate is 135 beats per minute. The nurse interprets this result as Normal for this age The nurse is presenting a class on risk factors for cardiovascular disease. Which of theses are considered modifiable risk factors for MI? abnormal lipids, smoking, hypertension, diabetes 4 fxns supplying oxygen, removing C02, maintaining homeostasis, maintaining heat exchan control of respirations -Brainstem -Normal stimulus to breathe -Decrease in O2 in blood -Inspiration -Expiration brain stem pons and medulla normal stim to breathe hypercapnia decrease in O2 in blood hypoxemia inspiration active process expiration passive process lower resp tract bronchi, plueral membranes, muscles of respirations bronchi right main bronchus is shorter, wider, more verticle, aspirated objects. pleural membranes patietal lines diaphragm and thoracic wall, visceral lines outer surface of lung, pleural fluid, acts as lubrication. muscles of reps intercostal muscles, diaphragm. Accessory muscles (neck, abdomen, chest). eupnea reg, even, rhythmic pattern of breathing dyspnea change in this pattern producing shortness of breath or difficulty breathing anterior landmarks sternum and clavicle sternum (Angle of Louis, sternal angle, 2ICS), angle or louis, sternal angle, 2ICS clavicle uprasternal notch or jugular notch, U-shaped depression just above the sternum costal angle norm 90 degrees or less posterior land marks vertebra prominens, spinous processes vertebra prominens flex head, most prominent process is C7 spinous process T1-T4 associated with kidney prob CVA tenderness anterior ref lines sternal, midclavicular, anterior axillary lines posterior ref lines vertebral, scapular, posterior axillary lateral ref lines anterior axillary, midaxillary, posterior axillary right lung 3 lobes (upper, middle, lower) left lung 2 lobes (upper, lower) lung borders apex, base apex highest point base lower border ped lung considerations -abdominal breathing till 5 to 7 years of age -anteroposterior (AP)= transverse diameter (1:1 ratio) -lipid substance needed for sustained inflation of alveoli preg lung considerations -diaphragmatic breathing -shortness of breath (SOB) -costal angle widens -lordosis or swayback, "waddling" gait geriatric lung considerations -changes to respiratory rate and depth, vital capacity, alveoli -decrease in cough ability -kyphosis "hunchback acute cough lasts 2 or 3 weeks, continuous, respiratory infxn, afternoon/evening, night (postnasal drip). chronic cough lasts over 2 mo, early morning - chronic bronchial inflammation, smokers productive or non productive subjective data sputum a mixture of saliva and mucus coughed up from the respiratory tract hemoptysis blood in mucous coughed up from resp tract white or clear phlegm bronchitis, viral infections yellow or green phlegm bacterial infxns rusted colored phlegm TB, pneumonia pink, frothy color phlegm pulmonary edema, medications to treat hacking pneumonia dry early congestive heart failure barking croup cogested colds, bronchitis, pneumonia associated symptoms (cough) Activity? Position (lying)? Fever? Congestion? Talking? Anxiety? cough treatments -OTC medications -vaporizer -rest -position change SOB sub data with exertion or at rest? position? time of day? associated symptoms? (cough, diaphoresis, cyanosis, wheezing, allergan exposure) orthopnea difficult breathing when supine paroxysmal nocturnal dyspnea (PND) -sudden onset of SOB at night -awaken from sleep -CHF (left-sided) chest pain w breathing -muscle soreness with coughing -inflammation of pleura (pleuritis), pneumonia -respiratory, cardiac, GI origin self care -pneumonia vaccines - (healthy adults 65 years) -influenza immunization (annual) inspection -shape and configuration of chest wall (AP: transverse diameter ratio 1:2). barrel chest: equal AP-to-transverse diameter (1:1) -spinous process should be straight, midline, position should be upright -no cyanosis, no lesions tripod with COPD; pectus excavatum; pectus carinatum; tripod with COPD chronic obstructive pulmonary disease palpation -crepitus -tenderness -ribs, intercoastal spaces -symmetric chest expansion - tactile fremitus tech -"ninety-nine"; side-to-side, over lung tissue -palmar base of fingers or ulnar edge of hand -decreased with obstruction increased tactile fremitus consolidation, pneumonia decreased tactile fremitus obstructed bronchus: pleural effusion, neumothorax, emphysema percussion lungs, diaphragmatic excursion resonance predominant note over the lung fields normal lung sounds low-pitched, clear, hollow abnormal lung sounds -hyperrsonance (emphysema, pneumothorax) -dullness (pneumonia, pleural effusion, atelectasis, tumor) tech of diaphragmatic excursion ask pt "exhale and hold it" - lung resonant to diaphragmatic dullness, "take a deep breath and hold it" - percuss down from first mark till sound changes to dullness. Measure the difference. normal diaphragmatic excursion findings normal adult excursion is 3 to 5 cm auscultation tech -sitting, lean forward slightly, arms across lap -instruct to breathe through mouth, little bit deeper than usual, but stop if feels dizzy -diaphragm of stethoscope, firmly on chest wall -listen to one full respiratory cycle per location -side-to-side comparison auscultation normal breath sounds bronchial (tracheal), bronchovesicular, vesicular adventitious breath sounds bronchophony, egophony, whispered pectoriloquy "Ninety-nine" ; normal sound is muffled Abnormal clear "ninety-nine" with lung consolidation bronchophony -"ninety-nine" ; normal sound is muffled -abnormal clear "ninety-nine" with lung consolidation egophony -"E"; normal sound is "eeee" -abnormal "eeee" changes to "aaaa" with lung consolidation crackels fine, coarse rhonchi wheezes - sibilant or sonorous; stridor, friction rub normal breath sounds -bronchial (tracheal) -bronchovesicular - vesicular whispered pectoriloquy whispered "one-two-three" -normal sound is muffled -abnormal clear "one-two-three" with lung consolidation inspection- anterior chest -shape and configuration -symmetry -costal angle is within 90 degrees -facial expression (relaxed) -level of consciousness (alert) -skin color and condition -respirations -retraction or bulging of intercostal spaces -accessory neck muscles hypoventilation irregular, slow respiration's -rate 10 chyne-strokes periods of deep breathing with periods of apnea; irregular pattern biot's respirations shallow, deep respirations with periods of apnea; irreguar pattern sighing frequent sighing obstructive breathing prolonged expirations hyperventilation rapid, deep resp; rate 24 tachypnea rapid, shallow resp; rate 24 bradypnea slow, regular resp eupnea (normal) even depth, regular pattern, inspirations=expirations, occasional sigh palpation- anterior chest -symmetric chest expansion -tactile or vocal fremitus -tenderness -lumps, masses -ribs, intercostal spaces -skin -mobility and turgor (under clavicle) -temperature and moisture percussion-anterior chest -lungs, resonance predominant note over the lung fields. Low-pitched, hollow sound auscultation- anterior chest -sitting, lean forward slightly, arms across lap -instruct to breathe through mouth, little bit deeper than usual, but stop if feels dizzy -diaphragm of stethoscope, firmly on chest wall -listen to one full respiratory cycle per location -side-to-side comparison asthma chronic hyperreactive condition atelectasis obstruction of airflow bronchitis inflammation of trachebronchial tree emphysema obstruction of the alveoli pneumonia infection in the alveoli pleural effusion fluid in the pleural space pneumothorax collapse of the lung pulmonary embolus blood clot in the lung congestive heart failure edema around the alveoli conduction system of the heart -sinoatrial (SA) node: normal pacemaker of the heart; 60-100 BPM -intra-atrial pathways -AV node 40-60 BPM -bundle of His right and left bundle branches -purkinje fibers 20-40 BPM grade 1- murmur barely audible w stethoscope, often considered psychologic not pathologic. Requires concentration and a quiet environment grade 2- murmur very soft but distinctly audible grade 3- murmur moderately loud. No thrill motion. grade 4- murmur distinctly loud in addition to palpable thrill grade 5- murmur very loud, can actually hear w part og the diaphragm of stethoscope off the chest, palpable thrust and thrill present grade 6- murmur loudest, can hear w the diaphragm off chest, thrill and thrust present