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NUR 216 EXAM 4*** QUESTIONS AND ANSWERS
| VERIFIED AND WELL DETAILED ANSWERS
|DOWNLOAD AND PASS | LATEST EXAM
UPDATE 2026/2027
When performing CVA (costovertebral angle) assessment,
what is the nurse assessing?
A. Bladder distention
B. Kidney inflammation
C. Intestinal obstruction
D. Liver enlargement
❖B. Kidney inflammation
Rationale:B. Kidney inflammation: This is the correct
answer. The CVA, located at the angle between the 12th
rib and the spine, is assessed to check for kidney
inflammation or tenderness, which may indicate
conditions such as pyelonephritis (kidney infection),
hydronephrosis, or renal calculi. The nurse gently
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percusses the area; tenderness is a positive sign that
warrants further investigation.
A client has absent bowel sounds after surgery. How long
should the nurse auscultate before confirming the
absence?
A. 1 minute per quadrant
B. 2 minutes per quadrant
C. 3 minutes total
D. 5 minutes total
❖D. 5 minutes total
Rationale:D. 5 minutes total: This is the correct answer.
According to clinical guidelines, the nurse must auscultate
for a full 5 minutes (divided across all quadrants) before
determining that bowel sounds are absent. Absent bowel
sounds may indicate a serious condition, such as paralytic
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ileus or bowel obstruction, and require immediate
medical attention.
During deep palpation, the nurse feels a firm, irregular
mass in the LUQ. What should the nurse do next?
A. Document the findings as normal
B. Apply more pressure to confirm the size
C. Notify the provider immediately
D. Continue to palpate the remaining quadrants
❖C. Notify the provider immediately
Rationale:C. Notify the provider immediately: This is the
correct action. A firm, irregular mass in the LUQ warrants
prompt evaluation by the provider to determine its
nature. The mass could indicate a variety of conditions,
including an enlarged spleen, gastric tumor, or pancreatic
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pathology, some of which may require urgent
intervention.
During a breast self-exam, a client reports a dimpled area.
What is the nurse's priority action?
A. Teach the client that dimpling is common with aging
B. Instruct the client to monitor for changes over a month
C. Refer the client for further evaluation immediately
D. Advise the client to perform the exam again using a
different technique
❖C. Refer the client for further evaluation immediately
Rationale:C. Refer the client for further evaluation
immediately: Dimpling of the breast may indicate
retraction of breast tissue, often associated with an
underlying mass or malignancy. Immediate referral for a
clinical breast examination, imaging (e.g., mammogram,
NUR 216 EXAM 4*** QUESTIONS AND ANSWERS
| VERIFIED AND WELL DETAILED ANSWERS
|DOWNLOAD AND PASS | LATEST EXAM
UPDATE 2026/2027
When performing CVA (costovertebral angle) assessment,
what is the nurse assessing?
A. Bladder distention
B. Kidney inflammation
C. Intestinal obstruction
D. Liver enlargement
❖B. Kidney inflammation
Rationale:B. Kidney inflammation: This is the correct
answer. The CVA, located at the angle between the 12th
rib and the spine, is assessed to check for kidney
inflammation or tenderness, which may indicate
conditions such as pyelonephritis (kidney infection),
hydronephrosis, or renal calculi. The nurse gently
,Page 2 of 143
percusses the area; tenderness is a positive sign that
warrants further investigation.
A client has absent bowel sounds after surgery. How long
should the nurse auscultate before confirming the
absence?
A. 1 minute per quadrant
B. 2 minutes per quadrant
C. 3 minutes total
D. 5 minutes total
❖D. 5 minutes total
Rationale:D. 5 minutes total: This is the correct answer.
According to clinical guidelines, the nurse must auscultate
for a full 5 minutes (divided across all quadrants) before
determining that bowel sounds are absent. Absent bowel
sounds may indicate a serious condition, such as paralytic
,Page 3 of 143
ileus or bowel obstruction, and require immediate
medical attention.
During deep palpation, the nurse feels a firm, irregular
mass in the LUQ. What should the nurse do next?
A. Document the findings as normal
B. Apply more pressure to confirm the size
C. Notify the provider immediately
D. Continue to palpate the remaining quadrants
❖C. Notify the provider immediately
Rationale:C. Notify the provider immediately: This is the
correct action. A firm, irregular mass in the LUQ warrants
prompt evaluation by the provider to determine its
nature. The mass could indicate a variety of conditions,
including an enlarged spleen, gastric tumor, or pancreatic
, Page 4 of 143
pathology, some of which may require urgent
intervention.
During a breast self-exam, a client reports a dimpled area.
What is the nurse's priority action?
A. Teach the client that dimpling is common with aging
B. Instruct the client to monitor for changes over a month
C. Refer the client for further evaluation immediately
D. Advise the client to perform the exam again using a
different technique
❖C. Refer the client for further evaluation immediately
Rationale:C. Refer the client for further evaluation
immediately: Dimpling of the breast may indicate
retraction of breast tissue, often associated with an
underlying mass or malignancy. Immediate referral for a
clinical breast examination, imaging (e.g., mammogram,
