,NUR 2356 Exam 2 | Multidimensional Care I (2026)
Actual Q&A PDF | Rasmussen College
1. A nurse is performing a focused respiratory assessment on a client who reports
shortness of breath. Which technique should the nurse use to assess for tactile fremitus?
A) Place the palms of both hands on the client's chest wall and ask the client to repeat
"ninety-nine."
B) Use the ulnar surface of the hand to tap the chest wall while listening for sound changes.
C) Listen over the trachea and bronchial areas with the diaphragm of the stethoscope.
D) Ask the client to breathe deeply through the mouth while observing chest expansion.
Correct Answer: Place the palms of both hands on the client's chest wall and ask the
client to repeat "ninety-nine."
Rationale: Tactile fremitus is assessed by placing the palms or the ulnar surface of the
hands on the chest wall and having the client repeat a phrase such as "ninety-nine."
Increased fremitus suggests consolidation, while decreased fremitus suggests air or fluid in
the pleural space. Percussion assesses tone, and auscultation assesses breath sounds.
2. A nurse is assessing a client who has a new diagnosis of heart failure. Which finding
should the nurse expect when auscultating the client's lungs?
A) Wheezing in the upper airways
B) Fine crackles at the lung bases
C) Pleural friction rub at the left lower sternal border
D) Diminished breath sounds bilaterally
Correct Answer: Fine crackles at the lung bases
,Rationale: Left-sided heart failure causes pulmonary congestion, leading to fine crackles
at the lung bases as fluid accumulates in the alveoli. Wheezing suggests bronchospasm or
asthma. A pleural friction rub indicates pleural inflammation. Diminished breath sounds
suggest pleural effusion or pneumothorax.
3. While performing a cardiovascular assessment, the nurse auscultates a murmur at the
second intercostal space, right sternal border. Which valve is the nurse most likely
assessing?
A) Mitral valve
B) Tricuspid valve
C) Aortic valve
D) Pulmonic valve
Correct Answer: Aortic valve
Rationale: The aortic valve is best heard at the second intercostal space at the right
sternal border. The pulmonic valve is heard at the second intercostal space at the left
sternal border. The tricuspid valve is heard at the fourth intercostal space at the left sternal
border. The mitral valve is heard at the apex.
4. A nurse is assessing a client's peripheral vascular system. Which finding should the nurse
document as abnormal?
A) Radial pulses 2+ bilaterally
B) Capillary refill of 2 seconds
C) Unilateral dependent rubor that resolves with elevation
D) Bilateral 1+ pitting edema in the lower extremities
Correct Answer: Unilateral dependent rubor that resolves with elevation
, Rationale: Dependent rubor is a reddish-blue discoloration of the extremity when it is
dependent and can indicate arterial insufficiency. Unilateral dependent rubor that resolves
with elevation is an abnormal finding. Bilateral 1+ pitting edema is a common finding in
venous insufficiency or heart failure and is not as immediately concerning. Radial pulses of
2+ and capillary refill of 2 seconds are normal.
5. A nurse is preparing to perform an abdominal assessment. Which sequence should the
nurse use?
A) Inspection, palpation, percussion, auscultation
B) Inspection, auscultation, percussion, palpation
C) Auscultation, inspection, palpation, percussion
D) Palpation, percussion, inspection, auscultation
Correct Answer: Inspection, auscultation, percussion, palpation
Rationale: The correct sequence for abdominal assessment is inspection, auscultation,
percussion, and palpation. Auscultation is performed before percussion and palpation
because these techniques can alter bowel sounds. Palpation is last to avoid stimulating the
bowel and altering findings.
6. A nurse is assessing a client's cranial nerves. Which action should the nurse take to test
cranial nerve VII (facial nerve)?
A) Ask the client to smile, frown, and puff out the cheeks.
B) Ask the client to stick out the tongue and move it side to side.
C) Ask the client to shrug the shoulders against resistance.
D) Ask the client to identify a familiar scent with each nostril.
Correct Answer: Ask the client to smile, frown, and puff out the cheeks.
Actual Q&A PDF | Rasmussen College
1. A nurse is performing a focused respiratory assessment on a client who reports
shortness of breath. Which technique should the nurse use to assess for tactile fremitus?
A) Place the palms of both hands on the client's chest wall and ask the client to repeat
"ninety-nine."
B) Use the ulnar surface of the hand to tap the chest wall while listening for sound changes.
C) Listen over the trachea and bronchial areas with the diaphragm of the stethoscope.
D) Ask the client to breathe deeply through the mouth while observing chest expansion.
Correct Answer: Place the palms of both hands on the client's chest wall and ask the
client to repeat "ninety-nine."
Rationale: Tactile fremitus is assessed by placing the palms or the ulnar surface of the
hands on the chest wall and having the client repeat a phrase such as "ninety-nine."
Increased fremitus suggests consolidation, while decreased fremitus suggests air or fluid in
the pleural space. Percussion assesses tone, and auscultation assesses breath sounds.
2. A nurse is assessing a client who has a new diagnosis of heart failure. Which finding
should the nurse expect when auscultating the client's lungs?
A) Wheezing in the upper airways
B) Fine crackles at the lung bases
C) Pleural friction rub at the left lower sternal border
D) Diminished breath sounds bilaterally
Correct Answer: Fine crackles at the lung bases
,Rationale: Left-sided heart failure causes pulmonary congestion, leading to fine crackles
at the lung bases as fluid accumulates in the alveoli. Wheezing suggests bronchospasm or
asthma. A pleural friction rub indicates pleural inflammation. Diminished breath sounds
suggest pleural effusion or pneumothorax.
3. While performing a cardiovascular assessment, the nurse auscultates a murmur at the
second intercostal space, right sternal border. Which valve is the nurse most likely
assessing?
A) Mitral valve
B) Tricuspid valve
C) Aortic valve
D) Pulmonic valve
Correct Answer: Aortic valve
Rationale: The aortic valve is best heard at the second intercostal space at the right
sternal border. The pulmonic valve is heard at the second intercostal space at the left
sternal border. The tricuspid valve is heard at the fourth intercostal space at the left sternal
border. The mitral valve is heard at the apex.
4. A nurse is assessing a client's peripheral vascular system. Which finding should the nurse
document as abnormal?
A) Radial pulses 2+ bilaterally
B) Capillary refill of 2 seconds
C) Unilateral dependent rubor that resolves with elevation
D) Bilateral 1+ pitting edema in the lower extremities
Correct Answer: Unilateral dependent rubor that resolves with elevation
, Rationale: Dependent rubor is a reddish-blue discoloration of the extremity when it is
dependent and can indicate arterial insufficiency. Unilateral dependent rubor that resolves
with elevation is an abnormal finding. Bilateral 1+ pitting edema is a common finding in
venous insufficiency or heart failure and is not as immediately concerning. Radial pulses of
2+ and capillary refill of 2 seconds are normal.
5. A nurse is preparing to perform an abdominal assessment. Which sequence should the
nurse use?
A) Inspection, palpation, percussion, auscultation
B) Inspection, auscultation, percussion, palpation
C) Auscultation, inspection, palpation, percussion
D) Palpation, percussion, inspection, auscultation
Correct Answer: Inspection, auscultation, percussion, palpation
Rationale: The correct sequence for abdominal assessment is inspection, auscultation,
percussion, and palpation. Auscultation is performed before percussion and palpation
because these techniques can alter bowel sounds. Palpation is last to avoid stimulating the
bowel and altering findings.
6. A nurse is assessing a client's cranial nerves. Which action should the nurse take to test
cranial nerve VII (facial nerve)?
A) Ask the client to smile, frown, and puff out the cheeks.
B) Ask the client to stick out the tongue and move it side to side.
C) Ask the client to shrug the shoulders against resistance.
D) Ask the client to identify a familiar scent with each nostril.
Correct Answer: Ask the client to smile, frown, and puff out the cheeks.
