,Exam 3 NSG121/NSG 121 Health Assessment |
Herzing (2026/2027) Verified Actual (PDF)
1. A nurse is performing a cardiovascular assessment on an adult client. In which order should the
nurse perform the four basic assessment techniques for this system?
A) Inspection, palpation, percussion, auscultation
B) Auscultation, inspection, palpation, percussion
C) Inspection, palpation, auscultation, percussion
D) Palpation, auscultation, inspection, percussion
Correct Answer: A) Inspection, palpation, percussion, auscultation
Rationale: For the cardiovascular system, the assessment sequence is inspection, palpation,
percussion, then auscultation. This order allows the nurse to visually inspect the chest for
abnormalities, palpate for thrills or heaves, percuss to assess cardiac borders, and finally auscultate
heart sounds without altering them. The abdominal assessment is the only exception where
auscultation precedes palpation and percussion.
2. A nurse is assessing the carotid arteries of an older adult client. Which finding requires immediate
further evaluation?
A) A palpable, symmetric pulse with a regular rhythm
B) A bruit heard on auscultation over the carotid artery
C) A pulse that is 2+ in amplitude and easily palpable
D) A slight decrease in pulse amplitude compared to the radial pulse
Correct Answer: B) A bruit heard on auscultation over the carotid artery
Rationale: A bruit is a whooshing or blowing sound heard over an artery, indicating turbulent blood
flow. This finding suggests carotid artery stenosis or occlusive disease and requires immediate further
evaluation. A palpable, symmetric pulse, a 2+ amplitude, and a slightly decreased amplitude
compared to the radial pulse are normal findings in older adults.
,3. A nurse is palpating a client's peripheral pulses. Which finding would be documented as normal?
A) A 1+ pulse that is weak and thready
B) A 2+ pulse that is easily palpable and expected
C) A 3+ pulse that is full and bounding
D) A 4+ pulse that is strong and hyperdynamic
Correct Answer: B) A 2+ pulse that is easily palpable and expected
Rationale: Pulse amplitude is typically graded on a 0 to 4+ scale. A 2+ pulse is considered normal,
indicating a pulse that is easily palpable and of expected strength. A 1+ pulse is weak or thready, a 3+
pulse is full or increased, and a 4+ pulse is bounding or hyperdynamic, all of which are abnormal
findings.
4. A nurse is assessing the jugular venous pressure (JVP) in a client. Which position is most appropriate
for this assessment?
A) Supine with the head of the bed flat
B) Supine with the head elevated to 90 degrees
C) Supine with the head elevated to 30 to 45 degrees
D) Sitting upright with the legs dangling
Correct Answer: C) Supine with the head elevated to 30 to 45 degrees
Rationale: The most accurate assessment of JVP is performed with the client in a supine position with
the head of the bed elevated to 30 to 45 degrees. This positioning allows for visualization of the
jugular venous pulsations and estimation of central venous pressure. Flat or 90-degree positioning can
obscure or exaggerate the JVP.
5. A nurse is assessing a client for jugular venous distention (JVD). Which finding indicates an
abnormal elevation of JVP?
A) The jugular venous pulsation is visible 1 cm above the sternal angle
B) The jugular venous pulsation is visible 2 cm above the sternal angle
C) The jugular venous pulsation is visible 3 cm above the sternal angle
, D) The jugular venous pulsation is visible 4 cm above the sternal angle
Correct Answer: D) The jugular venous pulsation is visible 4 cm above the sternal angle
Rationale: A JVP greater than 3 cm above the sternal angle is considered elevated and indicates
increased central venous pressure, which can be a sign of right-sided heart failure or fluid overload. A
JVP of 1-3 cm above the sternal angle is within the normal range for most adults.
6. A nurse is auscultating a client's heart sounds. Which action is correct for identifying S1 and S2?
A) Palpate the carotid pulse while auscultating; S1 occurs just before the carotid upstroke
B) Palpate the radial pulse while auscultating; S1 occurs simultaneously with the radial pulse
C) Palpate the apical pulse while auscultating; S1 occurs just after the apical impulse
D) Palpate the femoral pulse while auscultating; S2 occurs simultaneously with the femoral pulse
Correct Answer: A) Palpate the carotid pulse while auscultating; S1 occurs just before the carotid
upstroke
Rationale: The carotid pulse is used to distinguish S1 from S2. S1 is heard just before the carotid
upstroke, as it corresponds to the closure of the atrioventricular valves at the onset of systole. S2
follows the carotid upstroke. This technique helps confirm the identification of heart sounds.
7. A nurse is assessing a client's heart sounds and notes a split S2 during inspiration that disappears
with expiration. This finding is:
A) A normal physiological finding
B) Indicative of right bundle branch block
C) A sign of pulmonic stenosis
D) Indicative of an atrial septal defect
Correct Answer: A) A normal physiological finding
Herzing (2026/2027) Verified Actual (PDF)
1. A nurse is performing a cardiovascular assessment on an adult client. In which order should the
nurse perform the four basic assessment techniques for this system?
A) Inspection, palpation, percussion, auscultation
B) Auscultation, inspection, palpation, percussion
C) Inspection, palpation, auscultation, percussion
D) Palpation, auscultation, inspection, percussion
Correct Answer: A) Inspection, palpation, percussion, auscultation
Rationale: For the cardiovascular system, the assessment sequence is inspection, palpation,
percussion, then auscultation. This order allows the nurse to visually inspect the chest for
abnormalities, palpate for thrills or heaves, percuss to assess cardiac borders, and finally auscultate
heart sounds without altering them. The abdominal assessment is the only exception where
auscultation precedes palpation and percussion.
2. A nurse is assessing the carotid arteries of an older adult client. Which finding requires immediate
further evaluation?
A) A palpable, symmetric pulse with a regular rhythm
B) A bruit heard on auscultation over the carotid artery
C) A pulse that is 2+ in amplitude and easily palpable
D) A slight decrease in pulse amplitude compared to the radial pulse
Correct Answer: B) A bruit heard on auscultation over the carotid artery
Rationale: A bruit is a whooshing or blowing sound heard over an artery, indicating turbulent blood
flow. This finding suggests carotid artery stenosis or occlusive disease and requires immediate further
evaluation. A palpable, symmetric pulse, a 2+ amplitude, and a slightly decreased amplitude
compared to the radial pulse are normal findings in older adults.
,3. A nurse is palpating a client's peripheral pulses. Which finding would be documented as normal?
A) A 1+ pulse that is weak and thready
B) A 2+ pulse that is easily palpable and expected
C) A 3+ pulse that is full and bounding
D) A 4+ pulse that is strong and hyperdynamic
Correct Answer: B) A 2+ pulse that is easily palpable and expected
Rationale: Pulse amplitude is typically graded on a 0 to 4+ scale. A 2+ pulse is considered normal,
indicating a pulse that is easily palpable and of expected strength. A 1+ pulse is weak or thready, a 3+
pulse is full or increased, and a 4+ pulse is bounding or hyperdynamic, all of which are abnormal
findings.
4. A nurse is assessing the jugular venous pressure (JVP) in a client. Which position is most appropriate
for this assessment?
A) Supine with the head of the bed flat
B) Supine with the head elevated to 90 degrees
C) Supine with the head elevated to 30 to 45 degrees
D) Sitting upright with the legs dangling
Correct Answer: C) Supine with the head elevated to 30 to 45 degrees
Rationale: The most accurate assessment of JVP is performed with the client in a supine position with
the head of the bed elevated to 30 to 45 degrees. This positioning allows for visualization of the
jugular venous pulsations and estimation of central venous pressure. Flat or 90-degree positioning can
obscure or exaggerate the JVP.
5. A nurse is assessing a client for jugular venous distention (JVD). Which finding indicates an
abnormal elevation of JVP?
A) The jugular venous pulsation is visible 1 cm above the sternal angle
B) The jugular venous pulsation is visible 2 cm above the sternal angle
C) The jugular venous pulsation is visible 3 cm above the sternal angle
, D) The jugular venous pulsation is visible 4 cm above the sternal angle
Correct Answer: D) The jugular venous pulsation is visible 4 cm above the sternal angle
Rationale: A JVP greater than 3 cm above the sternal angle is considered elevated and indicates
increased central venous pressure, which can be a sign of right-sided heart failure or fluid overload. A
JVP of 1-3 cm above the sternal angle is within the normal range for most adults.
6. A nurse is auscultating a client's heart sounds. Which action is correct for identifying S1 and S2?
A) Palpate the carotid pulse while auscultating; S1 occurs just before the carotid upstroke
B) Palpate the radial pulse while auscultating; S1 occurs simultaneously with the radial pulse
C) Palpate the apical pulse while auscultating; S1 occurs just after the apical impulse
D) Palpate the femoral pulse while auscultating; S2 occurs simultaneously with the femoral pulse
Correct Answer: A) Palpate the carotid pulse while auscultating; S1 occurs just before the carotid
upstroke
Rationale: The carotid pulse is used to distinguish S1 from S2. S1 is heard just before the carotid
upstroke, as it corresponds to the closure of the atrioventricular valves at the onset of systole. S2
follows the carotid upstroke. This technique helps confirm the identification of heart sounds.
7. A nurse is assessing a client's heart sounds and notes a split S2 during inspiration that disappears
with expiration. This finding is:
A) A normal physiological finding
B) Indicative of right bundle branch block
C) A sign of pulmonic stenosis
D) Indicative of an atrial septal defect
Correct Answer: A) A normal physiological finding
