NUR 3270/NUR3270 Exam 2 V3 | Comp
Health Assessment Q&A with Rationale |
William Paterson University
1. When assessing the lungs of a patient with suspected pneumonia, the nurse hears low-
pitched, bubbling, and gurgling sounds that decrease with coughing. How should the nurse
document this?
A. Coarse crackles
B. Wheezes
C. Fine crackles
D. Pleural friction rub
Correct Answer: A
Expert Explanation: Coarse crackles are described as low-pitched, moist, bubbling sounds
that occur when air meets secretions in the large airways. They are common in conditions
like pneumonia or pulmonary edema and may partially clear with coughing. Identifying
these sounds correctly is vital for determining the appropriate respiratory intervention.
2. In what order should the nurse perform an abdominal assessment?
A. Inspection, Auscultation, Percussion, Palpation
B. Inspection, Palpation, Percussion, Auscultation
C. Auscultation, Inspection, Percussion, Palpation
,D. Percussion, Palpation, Inspection, Auscultation
Correct Answer: A
Expert Explanation: The abdominal assessment follows a specific sequence of inspection,
auscultation, percussion, and then palpation. This order is unique to the abdomen because
percussion and palpation can stimulate peristalsis and alter bowel sounds. By auscultating
early, the nurse ensures a more accurate assessment of the patient’s natural GI activity.
3. The nurse is assessing the carotid arteries. Which technique is most appropriate to avoid
stimulating a carotid sinus reflex?
A. Palpate both carotid arteries simultaneously to compare pulse volume.
B. Ask the patient to take deep breaths during palpation.
C. Use the bell of the stethoscope to listen for bruits first.
D. Palpate only one carotid artery at a time.
Correct Answer: D
Expert Explanation: Palpating one carotid artery at a time is crucial to prevent the
stimulation of the carotid sinus, which could cause a sudden drop in heart rate or blood
pressure. Simultaneous palpation also carries the risk of compromising blood flow to the
brain. This technique ensures patient safety while accurately assessing pulse strength and
rhythm.
, 4. Which heart sound is caused by the closure of the atrioventricular (mitral and tricuspid)
valves?
A. S1
B. S2
C. S3
D. S4
Correct Answer: A
Expert Explanation: The S1 heart sound, often described as ‘lub,’ marks the beginning of
systole and is produced by the closure of the AV valves. It is usually loudest at the apex of
the heart. Understanding the origin of S1 helps the nurse differentiate it from S2 and other
abnormal heart sounds.
5. While assessing the lower extremities, the nurse notes that the patient’s skin is thin, shiny,
and hairless with cool temperatures. These findings are most indicative of:
A. Venous insufficiency
B. Lymphedema
C. Chronic arterial insufficiency
D. Deep vein thrombosis
Correct Answer: C
Health Assessment Q&A with Rationale |
William Paterson University
1. When assessing the lungs of a patient with suspected pneumonia, the nurse hears low-
pitched, bubbling, and gurgling sounds that decrease with coughing. How should the nurse
document this?
A. Coarse crackles
B. Wheezes
C. Fine crackles
D. Pleural friction rub
Correct Answer: A
Expert Explanation: Coarse crackles are described as low-pitched, moist, bubbling sounds
that occur when air meets secretions in the large airways. They are common in conditions
like pneumonia or pulmonary edema and may partially clear with coughing. Identifying
these sounds correctly is vital for determining the appropriate respiratory intervention.
2. In what order should the nurse perform an abdominal assessment?
A. Inspection, Auscultation, Percussion, Palpation
B. Inspection, Palpation, Percussion, Auscultation
C. Auscultation, Inspection, Percussion, Palpation
,D. Percussion, Palpation, Inspection, Auscultation
Correct Answer: A
Expert Explanation: The abdominal assessment follows a specific sequence of inspection,
auscultation, percussion, and then palpation. This order is unique to the abdomen because
percussion and palpation can stimulate peristalsis and alter bowel sounds. By auscultating
early, the nurse ensures a more accurate assessment of the patient’s natural GI activity.
3. The nurse is assessing the carotid arteries. Which technique is most appropriate to avoid
stimulating a carotid sinus reflex?
A. Palpate both carotid arteries simultaneously to compare pulse volume.
B. Ask the patient to take deep breaths during palpation.
C. Use the bell of the stethoscope to listen for bruits first.
D. Palpate only one carotid artery at a time.
Correct Answer: D
Expert Explanation: Palpating one carotid artery at a time is crucial to prevent the
stimulation of the carotid sinus, which could cause a sudden drop in heart rate or blood
pressure. Simultaneous palpation also carries the risk of compromising blood flow to the
brain. This technique ensures patient safety while accurately assessing pulse strength and
rhythm.
, 4. Which heart sound is caused by the closure of the atrioventricular (mitral and tricuspid)
valves?
A. S1
B. S2
C. S3
D. S4
Correct Answer: A
Expert Explanation: The S1 heart sound, often described as ‘lub,’ marks the beginning of
systole and is produced by the closure of the AV valves. It is usually loudest at the apex of
the heart. Understanding the origin of S1 helps the nurse differentiate it from S2 and other
abnormal heart sounds.
5. While assessing the lower extremities, the nurse notes that the patient’s skin is thin, shiny,
and hairless with cool temperatures. These findings are most indicative of:
A. Venous insufficiency
B. Lymphedema
C. Chronic arterial insufficiency
D. Deep vein thrombosis
Correct Answer: C
