NUR 3270/NUR3270 Exam 2 V1 | Comp
Health Assessment Q&A with Rationale |
William Paterson University
1. When assessing the lungs, the nurse understands that the apex of the lungs is located at
which position?
A. At the level of the diaphragm
B. At the sixth rib in the midclavicular line
C. 3 to 4 cm above the inner third of the clavicles
D. Even with the second rib anteriorly
Correct Answer: C
Expert Explanation: The apex of the lung is the highest point of lung tissue and is located
3 to 4 cm above the inner third of the clavicles. In contrast, the base of the lungs rests on
the diaphragm at about the sixth rib in the midclavicular line. Understanding these
landmarks is essential for accurate auscultation and percussion of all lung lobes.
2. The nurse is performing a respiratory assessment and notices a patient has a costal angle of
approximately 90 degrees. How should the nurse interpret this finding?
A. This indicates the patient has chronic obstructive pulmonary disease.
B. This is a normal finding in a healthy adult.
C. This is a sign of pectus excavatum.
,D. This indicates the patient has a barrel chest.
Correct Answer: B
Expert Explanation: A costal angle of 90 degrees or less is considered a normal finding in
a healthy adult. When the rib cage is chronically overinflated, such as in emphysema, this
angle increases significantly. Finding a 90-degree angle suggests normal thoracic
configuration and respiratory health.
3. During an abdominal assessment, in which order should the nurse perform the physical
examination techniques?
A. Inspection, Palpation, Percussion, Auscultation
B. Auscultation, Inspection, Palpation, Percussion
C. Inspection, Auscultation, Percussion, Palpation
D. Percussion, Auscultation, Inspection, Palpation
Correct Answer: C
Expert Explanation: The abdomen is always assessed in the order of inspection,
auscultation, percussion, and then palpation. This specific sequence is used because
percussion and palpation can increase peristalsis, which would give a false interpretation
of bowel sounds. By listening first, the nurse captures the natural frequency and character
of the bowel sounds.
4. Which heart sound is caused by the closure of the semilunar valves?
A. S1
, B. S2
C. S3
D. S4
Correct Answer: B
Expert Explanation: The second heart sound, S2, occurs with the closure of the semilunar
valves, which include the aortic and pulmonic valves. This sound signals the end of systole
and the beginning of diastole. It is usually heard loudest at the base of the heart.
5. A nurse is assessing a patient for peripheral edema and finds a deep pitting indentation
that remains for a short time, with a leg that looks swollen. How should this be documented?
A. 1+ edema
B. 2+ edema
C. 3+ edema
D. 4+ edema
Correct Answer: C
Expert Explanation: A 3+ edema rating indicates a deep pitting indentation that remains
for a short time and the leg looks visibly swollen. The scale ranges from 1+ for mild pitting
to 4+ for very deep pitting that lasts a long time. Accurate documentation of edema helps
track changes in a patient’s fluid status or cardiovascular health.
Health Assessment Q&A with Rationale |
William Paterson University
1. When assessing the lungs, the nurse understands that the apex of the lungs is located at
which position?
A. At the level of the diaphragm
B. At the sixth rib in the midclavicular line
C. 3 to 4 cm above the inner third of the clavicles
D. Even with the second rib anteriorly
Correct Answer: C
Expert Explanation: The apex of the lung is the highest point of lung tissue and is located
3 to 4 cm above the inner third of the clavicles. In contrast, the base of the lungs rests on
the diaphragm at about the sixth rib in the midclavicular line. Understanding these
landmarks is essential for accurate auscultation and percussion of all lung lobes.
2. The nurse is performing a respiratory assessment and notices a patient has a costal angle of
approximately 90 degrees. How should the nurse interpret this finding?
A. This indicates the patient has chronic obstructive pulmonary disease.
B. This is a normal finding in a healthy adult.
C. This is a sign of pectus excavatum.
,D. This indicates the patient has a barrel chest.
Correct Answer: B
Expert Explanation: A costal angle of 90 degrees or less is considered a normal finding in
a healthy adult. When the rib cage is chronically overinflated, such as in emphysema, this
angle increases significantly. Finding a 90-degree angle suggests normal thoracic
configuration and respiratory health.
3. During an abdominal assessment, in which order should the nurse perform the physical
examination techniques?
A. Inspection, Palpation, Percussion, Auscultation
B. Auscultation, Inspection, Palpation, Percussion
C. Inspection, Auscultation, Percussion, Palpation
D. Percussion, Auscultation, Inspection, Palpation
Correct Answer: C
Expert Explanation: The abdomen is always assessed in the order of inspection,
auscultation, percussion, and then palpation. This specific sequence is used because
percussion and palpation can increase peristalsis, which would give a false interpretation
of bowel sounds. By listening first, the nurse captures the natural frequency and character
of the bowel sounds.
4. Which heart sound is caused by the closure of the semilunar valves?
A. S1
, B. S2
C. S3
D. S4
Correct Answer: B
Expert Explanation: The second heart sound, S2, occurs with the closure of the semilunar
valves, which include the aortic and pulmonic valves. This sound signals the end of systole
and the beginning of diastole. It is usually heard loudest at the base of the heart.
5. A nurse is assessing a patient for peripheral edema and finds a deep pitting indentation
that remains for a short time, with a leg that looks swollen. How should this be documented?
A. 1+ edema
B. 2+ edema
C. 3+ edema
D. 4+ edema
Correct Answer: C
Expert Explanation: A 3+ edema rating indicates a deep pitting indentation that remains
for a short time and the leg looks visibly swollen. The scale ranges from 1+ for mild pitting
to 4+ for very deep pitting that lasts a long time. Accurate documentation of edema helps
track changes in a patient’s fluid status or cardiovascular health.
