NUR 155 Exam 2, 3 and 4 Combined | Questions
and Answers with Rationales | 2026 Update |
100% Correct
SECTION 1: Health Assessment & Vital Signs
1. A nurse is performing a head-to-toe assessment on a 68-year-old patient
admitted for pneumonia. When assessing the thorax, the nurse notes the
anteroposterior (AP) diameter appears equal to the lateral diameter. Which action
should the nurse take first?
A. Document this as a normal finding for the patient's age
B. Auscultate breath sounds in all lung fields
C. Notify the provider immediately of barrel chest deformity
D. Palpate for tactile fremitus
Correct Answer: B
Rationale: An AP diameter equal to the lateral diameter (1:1 ratio) indicates a
barrel chest, commonly seen in patients with COPD or chronic respiratory
conditions. While this is an abnormal finding, the nurse must first complete a
comprehensive respiratory assessment before determining the significance.
Auscultating breath sounds assesses the current status of air movement and
identifies adventitious sounds that would indicate active pathology requiring
intervention. Option A is incorrect because this is not a normal finding; the normal
AP:lateral ratio is 1:2. Option C is incorrect because immediate notification is
unnecessary without assessment of current respiratory status. Option D is
incorrect because tactile fremitus assessment follows inspection and auscultation
in the systematic respiratory examination sequence .
2. During a neurological assessment, the nurse asks the patient to close their eyes
and identify whether a cotton ball touched their arm or hand. Which cranial nerve
is the nurse assessing?
,A. Cranial nerve V (Trigeminal)
B. Cranial nerve VII (Facial)
C. Cranial nerve IX (Glossopharyngeal)
D. Cranial nerve X (Vagus)
Correct Answer: A
Rationale: The nurse is testing light touch sensation, which assesses the
sensory component of cranial nerve V (Trigeminal nerve). The trigeminal nerve
provides sensory innervation to the face and motor function for chewing. Light
touch discrimination tests the integrity of the sensory pathways. Option B is
incorrect because CN VII is tested by assessing facial symmetry, taste on the
anterior two-thirds of the tongue, and eyelid closure. Option C is incorrect
because CN IX is tested by gag reflex and taste on the posterior one-third of the
tongue. Option D is incorrect because CN X is assessed by observing palate
elevation and uvula deviation during phonation .
3. A nurse is assessing a patient's skin and notes a 2 cm raised, solid lesion that
extends into the dermis. How should the nurse document this finding?
A. Macule
B. Papule
C. Nodule
D. Vesicle
Correct Answer: C
Rationale: A nodule is a solid, elevated lesion larger than 1 cm that extends
deeper into the dermis or subcutaneous tissue. Nodules are palpable, firm, and
circumscribed. Option A is incorrect because a macule is a flat, non-palpable
discoloration less than 1 cm. Option B is incorrect because a papule is a solid,
elevated lesion less than 1 cm that does not extend as deeply as a nodule. Option
D is incorrect because a vesicle is a small, fluid-filled blister less than 1 cm .
4. When performing an abdominal assessment, the nurse should begin with which
technique?
,A. Palpation
B. Percussion
C. Auscultation
D. Inspection
Correct Answer: C
Rationale: The abdominal assessment sequence differs from other body
systems. Auscultation is performed before palpation and percussion because
manipulation of the abdomen can alter bowel sounds, potentially causing false
findings. The correct sequence is inspection, auscultation, percussion, then
palpation. Option A and B are incorrect because palpation and percussion can
increase peristalsis and alter bowel sound assessment. Option D is technically the
first step (inspection) but the question asks about technique after initial
inspection; auscultation is the critical answer that distinguishes abdominal
assessment from other systems .
5. A patient presents with dehydration. What urine specific gravity value would
the nurse expect to find?
A. Less than 1.005
B. Exactly 1.020
C. Between 1.005 and 1.010
D. Greater than 1.030
Correct Answer: D
Rationale: Dehydration results in concentrated urine, which has a higher
specific gravity. Normal urine specific gravity ranges from 1.005 to 1.030. Values
greater than 1.030 indicate highly concentrated urine, consistent with dehydration
or reduced fluid intake. Options A and C are incorrect because low specific gravity
indicates dilute urine, which would be expected with overhydration. Option B is
incorrect because 1.020 is within the normal range and does not specifically
indicate dehydration .
, 6. A patient is producing less than 400 mL of urine per day. What clinical condition
might this indicate?
A. Anuria
B. Normal urine output
C. Polyuria
D. Oliguria
Correct Answer: D
Rationale: Oliguria is defined as urine output less than 400 mL per 24 hours or
less than 30 mL per hour. This indicates inadequate kidney perfusion or renal
dysfunction. Option A is incorrect because anuria is the absence of urine output
(typically less than 50–100 mL per day). Option B is incorrect because normal
urine output is approximately 1,500 mL per day. Option C is incorrect because
polyuria is excessive urine production .
7. What is the normal range for carbon dioxide (bicarbonate) in the human body?
A. 3.5–4.9 mEq/L
B. 135–145 mEq/L
C. 97–110 mEq/L
D. 22–26 mEq/L
Correct Answer: D
Rationale: The normal range for carbon dioxide (measured as bicarbonate,
HCO₃⁻) is 22–26 mEq/L. This value reflects the body's acid-base balance and renal
compensation. Option A is incorrect; this range is closer to potassium levels.
Option B is incorrect; 135–145 mEq/L is the normal range for sodium. Option C is
incorrect; 97–110 mEq/L is not a standard electrolyte range .
8. Normal serum sodium levels are:
A. 135 to 145 mEq/L
B. 125 to 140 mEq/L
and Answers with Rationales | 2026 Update |
100% Correct
SECTION 1: Health Assessment & Vital Signs
1. A nurse is performing a head-to-toe assessment on a 68-year-old patient
admitted for pneumonia. When assessing the thorax, the nurse notes the
anteroposterior (AP) diameter appears equal to the lateral diameter. Which action
should the nurse take first?
A. Document this as a normal finding for the patient's age
B. Auscultate breath sounds in all lung fields
C. Notify the provider immediately of barrel chest deformity
D. Palpate for tactile fremitus
Correct Answer: B
Rationale: An AP diameter equal to the lateral diameter (1:1 ratio) indicates a
barrel chest, commonly seen in patients with COPD or chronic respiratory
conditions. While this is an abnormal finding, the nurse must first complete a
comprehensive respiratory assessment before determining the significance.
Auscultating breath sounds assesses the current status of air movement and
identifies adventitious sounds that would indicate active pathology requiring
intervention. Option A is incorrect because this is not a normal finding; the normal
AP:lateral ratio is 1:2. Option C is incorrect because immediate notification is
unnecessary without assessment of current respiratory status. Option D is
incorrect because tactile fremitus assessment follows inspection and auscultation
in the systematic respiratory examination sequence .
2. During a neurological assessment, the nurse asks the patient to close their eyes
and identify whether a cotton ball touched their arm or hand. Which cranial nerve
is the nurse assessing?
,A. Cranial nerve V (Trigeminal)
B. Cranial nerve VII (Facial)
C. Cranial nerve IX (Glossopharyngeal)
D. Cranial nerve X (Vagus)
Correct Answer: A
Rationale: The nurse is testing light touch sensation, which assesses the
sensory component of cranial nerve V (Trigeminal nerve). The trigeminal nerve
provides sensory innervation to the face and motor function for chewing. Light
touch discrimination tests the integrity of the sensory pathways. Option B is
incorrect because CN VII is tested by assessing facial symmetry, taste on the
anterior two-thirds of the tongue, and eyelid closure. Option C is incorrect
because CN IX is tested by gag reflex and taste on the posterior one-third of the
tongue. Option D is incorrect because CN X is assessed by observing palate
elevation and uvula deviation during phonation .
3. A nurse is assessing a patient's skin and notes a 2 cm raised, solid lesion that
extends into the dermis. How should the nurse document this finding?
A. Macule
B. Papule
C. Nodule
D. Vesicle
Correct Answer: C
Rationale: A nodule is a solid, elevated lesion larger than 1 cm that extends
deeper into the dermis or subcutaneous tissue. Nodules are palpable, firm, and
circumscribed. Option A is incorrect because a macule is a flat, non-palpable
discoloration less than 1 cm. Option B is incorrect because a papule is a solid,
elevated lesion less than 1 cm that does not extend as deeply as a nodule. Option
D is incorrect because a vesicle is a small, fluid-filled blister less than 1 cm .
4. When performing an abdominal assessment, the nurse should begin with which
technique?
,A. Palpation
B. Percussion
C. Auscultation
D. Inspection
Correct Answer: C
Rationale: The abdominal assessment sequence differs from other body
systems. Auscultation is performed before palpation and percussion because
manipulation of the abdomen can alter bowel sounds, potentially causing false
findings. The correct sequence is inspection, auscultation, percussion, then
palpation. Option A and B are incorrect because palpation and percussion can
increase peristalsis and alter bowel sound assessment. Option D is technically the
first step (inspection) but the question asks about technique after initial
inspection; auscultation is the critical answer that distinguishes abdominal
assessment from other systems .
5. A patient presents with dehydration. What urine specific gravity value would
the nurse expect to find?
A. Less than 1.005
B. Exactly 1.020
C. Between 1.005 and 1.010
D. Greater than 1.030
Correct Answer: D
Rationale: Dehydration results in concentrated urine, which has a higher
specific gravity. Normal urine specific gravity ranges from 1.005 to 1.030. Values
greater than 1.030 indicate highly concentrated urine, consistent with dehydration
or reduced fluid intake. Options A and C are incorrect because low specific gravity
indicates dilute urine, which would be expected with overhydration. Option B is
incorrect because 1.020 is within the normal range and does not specifically
indicate dehydration .
, 6. A patient is producing less than 400 mL of urine per day. What clinical condition
might this indicate?
A. Anuria
B. Normal urine output
C. Polyuria
D. Oliguria
Correct Answer: D
Rationale: Oliguria is defined as urine output less than 400 mL per 24 hours or
less than 30 mL per hour. This indicates inadequate kidney perfusion or renal
dysfunction. Option A is incorrect because anuria is the absence of urine output
(typically less than 50–100 mL per day). Option B is incorrect because normal
urine output is approximately 1,500 mL per day. Option C is incorrect because
polyuria is excessive urine production .
7. What is the normal range for carbon dioxide (bicarbonate) in the human body?
A. 3.5–4.9 mEq/L
B. 135–145 mEq/L
C. 97–110 mEq/L
D. 22–26 mEq/L
Correct Answer: D
Rationale: The normal range for carbon dioxide (measured as bicarbonate,
HCO₃⁻) is 22–26 mEq/L. This value reflects the body's acid-base balance and renal
compensation. Option A is incorrect; this range is closer to potassium levels.
Option B is incorrect; 135–145 mEq/L is the normal range for sodium. Option C is
incorrect; 97–110 mEq/L is not a standard electrolyte range .
8. Normal serum sodium levels are:
A. 135 to 145 mEq/L
B. 125 to 140 mEq/L
