NSG 312 - NURSING ASSESSMENT FINAL EXAM QUESTIONS WITH CORRECT ANSWERS LATEST
UPDATE 2026
What are universal fall precautions? - Answers Universal fall precautions are called "universal"
because they apply to all patients regardless of fall risk. Universal fall precautions revolve around
keeping the patient's environment safe and comfortable.
-Familiarize the patient with the environment.
-Have the patient demonstrate call light use.
-Maintain call light within reach.
-Keep the patient's personal possessions within patient safe reach.
-Have sturdy handrails in patient bathrooms, room, and hallway.
-Place the hospital bed in low position when a patient is resting in bed; raise bed to a comfortable
height when the patient is transferring out of bed.
-Keep hospital bed brakes locked.
-Keep wheelchair wheel locks in "locked" position when stationary.
-Keep nonslip, comfortable, well-fitting footwear on the patient.
-Use night lights or supplemental lighting.
-Keep floor surfaces clean and dry. Clean up all spills promptly.
-Keep patient care areas uncluttered.
-Follow safe patient handling practices.
Possible causes of chest pain - Answers -Cardiac
-Aortic
-Musculoskeletal
-Pleural
-Gastrointestinal
-Pulmonary
-Psychoneurotic
-Rule out cardiac before other options
-Chest pain in children and adolescents is seldom due to a cardiac problem.
-In assessment of chest pain in adults - assume cardiac until proven otherwise
Where should you start counting intercostal spaces? - Answers The angle of Louis
(also called the sternal angle)
is a useful place to start counting ribs.
If you find the sternal notch,
walk your fingers down the manubrium
a few centimeters until you feel
a distinct bony ridge. This is the sternal angle.
The 2nd rib is continuous with the sternal angle;
slide your finger down to localize the 2nd intercostal space.
The angle of Louis also marks the site of bifurcation
of the trachea into the right and left main bronchi
and corresponds with the upper border of the atria of the heart
Where do you palpate on the chest? - Answers Palpate the base, left sternal border and apex
Mid-clavicular line, 5th intercostal space, palpate PMI with one finger (located under breast tissue in
women)
assess location of PMI
(point of maximal impulse or apical impulse)
Order of auscultation of the heart. - Answers A- aortic
P - pulmonic
T - tricuspid
E - erbs point
, M - mitral
22345
Second ICS R of sternum
Second ICS L of sternum
Third ICS L of sternum
Fourth ICS L of sternum
Fifth ICS mid clavicular
Use of the Stethoscope:
-diaphragm
-bell - Answers Diaphragm
-High pitched sounds
-Best for hearing S1 and S2
-(bowel, breath, normal cardiac)
Bell
-Low pitched sounds
-Use for hearing S3 and S4
-Use to assess for carotid bruits
-heart murmurs
Order of blood flow through the heart - Answers right atrium > tricuspid > right ventricle > pulmonary
semilunar valve > pulmonary veins > left atrium > mitral /bicuspid > left ventricle > aortic semilunar
valve
Cardiac Cycle sounds:
-S1
-S2 - Answers Systole
-Heart sound = S1 - lub
-Contraction and emptying of the atria and ventricles
-Aortic and pulmonic valves open
-mitral and tricuspid valves close
-S1 loudest at apex
Diastole
-Heart sound = S2 - dub
-Relaxation and filling of the atria and ventricles
-Aortic and pulmonic valves close
-Mitral and tricuspid valves open
-S2 loudest at base
Extra heart sounds:
S3 & S4 - Answers S3...
Due to Rapid ventricular filling: ventricular gallop
S1 -- S2-S3 (Ken--tuc-ky)
-Low frequency sound in early diastole
S4...
Due to slow ventricular contraction: atrial gallop
S4-S1 — S2 (Ten-nes—see)
-Low frequency sound in presystolic portion of diastole
S3 Heart Sound is resulted from what? - Answers Results from increased atrial pressure leading to
increased flow rates, as seen in congestive heart failure, which is the most common cause of a S3.
Associated dilated cardiomyopathy with dilated ventricles also contribute to the sound.
Less commonly, valvular regurgitation and left to right shunts may also result in a S3 due to increased
flow.
May be normal physiological finding in patients less than age 40
UPDATE 2026
What are universal fall precautions? - Answers Universal fall precautions are called "universal"
because they apply to all patients regardless of fall risk. Universal fall precautions revolve around
keeping the patient's environment safe and comfortable.
-Familiarize the patient with the environment.
-Have the patient demonstrate call light use.
-Maintain call light within reach.
-Keep the patient's personal possessions within patient safe reach.
-Have sturdy handrails in patient bathrooms, room, and hallway.
-Place the hospital bed in low position when a patient is resting in bed; raise bed to a comfortable
height when the patient is transferring out of bed.
-Keep hospital bed brakes locked.
-Keep wheelchair wheel locks in "locked" position when stationary.
-Keep nonslip, comfortable, well-fitting footwear on the patient.
-Use night lights or supplemental lighting.
-Keep floor surfaces clean and dry. Clean up all spills promptly.
-Keep patient care areas uncluttered.
-Follow safe patient handling practices.
Possible causes of chest pain - Answers -Cardiac
-Aortic
-Musculoskeletal
-Pleural
-Gastrointestinal
-Pulmonary
-Psychoneurotic
-Rule out cardiac before other options
-Chest pain in children and adolescents is seldom due to a cardiac problem.
-In assessment of chest pain in adults - assume cardiac until proven otherwise
Where should you start counting intercostal spaces? - Answers The angle of Louis
(also called the sternal angle)
is a useful place to start counting ribs.
If you find the sternal notch,
walk your fingers down the manubrium
a few centimeters until you feel
a distinct bony ridge. This is the sternal angle.
The 2nd rib is continuous with the sternal angle;
slide your finger down to localize the 2nd intercostal space.
The angle of Louis also marks the site of bifurcation
of the trachea into the right and left main bronchi
and corresponds with the upper border of the atria of the heart
Where do you palpate on the chest? - Answers Palpate the base, left sternal border and apex
Mid-clavicular line, 5th intercostal space, palpate PMI with one finger (located under breast tissue in
women)
assess location of PMI
(point of maximal impulse or apical impulse)
Order of auscultation of the heart. - Answers A- aortic
P - pulmonic
T - tricuspid
E - erbs point
, M - mitral
22345
Second ICS R of sternum
Second ICS L of sternum
Third ICS L of sternum
Fourth ICS L of sternum
Fifth ICS mid clavicular
Use of the Stethoscope:
-diaphragm
-bell - Answers Diaphragm
-High pitched sounds
-Best for hearing S1 and S2
-(bowel, breath, normal cardiac)
Bell
-Low pitched sounds
-Use for hearing S3 and S4
-Use to assess for carotid bruits
-heart murmurs
Order of blood flow through the heart - Answers right atrium > tricuspid > right ventricle > pulmonary
semilunar valve > pulmonary veins > left atrium > mitral /bicuspid > left ventricle > aortic semilunar
valve
Cardiac Cycle sounds:
-S1
-S2 - Answers Systole
-Heart sound = S1 - lub
-Contraction and emptying of the atria and ventricles
-Aortic and pulmonic valves open
-mitral and tricuspid valves close
-S1 loudest at apex
Diastole
-Heart sound = S2 - dub
-Relaxation and filling of the atria and ventricles
-Aortic and pulmonic valves close
-Mitral and tricuspid valves open
-S2 loudest at base
Extra heart sounds:
S3 & S4 - Answers S3...
Due to Rapid ventricular filling: ventricular gallop
S1 -- S2-S3 (Ken--tuc-ky)
-Low frequency sound in early diastole
S4...
Due to slow ventricular contraction: atrial gallop
S4-S1 — S2 (Ten-nes—see)
-Low frequency sound in presystolic portion of diastole
S3 Heart Sound is resulted from what? - Answers Results from increased atrial pressure leading to
increased flow rates, as seen in congestive heart failure, which is the most common cause of a S3.
Associated dilated cardiomyopathy with dilated ventricles also contribute to the sound.
Less commonly, valvular regurgitation and left to right shunts may also result in a S3 due to increased
flow.
May be normal physiological finding in patients less than age 40
