NMNC 1135 Exam 2 Study (Terminology and Quiz Questions) With Solved Solutions.

NMNC 1135 Exam 2 Study
(Terminology and Quiz Questions)
With Solved Solutions.

A nurse is performing cardiac assessment on a patient. Where will the nurse place the
stethoscope to determine auscultation of Erb's point?

1) Third left intercostal space (3rd LICS)

2) Fourth left intercostal space (4th LICS)

3) Second left intercostal space (2nd LICS)

4) Second right intercostal space (2nd RICS) - Answer 1) Third left intercostal space (3rd LICS)



A nurse is assessing a patient's neck veins. Which finding would suggest that the patient may
have heart failure or fluid overload?

1) Distended neck veins when the patient's head is elevated at 180 degrees

2) Distended neck veins when the patient is 90 degrees

3) Flat neck veins when the patient is supine at 180 degrees

4) Flat neck veins when the patient's head is elevated at 30 degrees - Answer 2) Distended
neck veins when the patient is 90 degrees



When assessing the heart rate of a client, the nurse identifies a change in the rate from 88 to 56
beats per minute. Which should the nurse do first?

1) Wait a half hour to retake the pulse

2) Tell the nurse in charge

3) Obtain the other vital signs

4) Ask about recent activity - Answer 3) Obtain the other vital signs



Rationale: Decrease in heart rate (bpm) can cause a decrease in O2 sat., elevated blood
pressure and, eventually shock.

---> If other vital signs are taken, the nurse can better understand what stage the patient is at
and the next steps that should be taken.



The second heart sound ( S2) occurs when ;

1) The aortic and pulmonic valves close

2) Systole begins

3) The mitral and tricuspid valves close

4) There is rapid ventricular filling - Answer 1) The aortic and pulmonic valves close

, In assessing the patient who has come to the clinic for a physical exam, the nurse see that the
patient has pallor. What is this finding most indicative of?

1) Thrombophlebitis

2) Anemia

3) Stoke

4) Heart Disease - Answer 2) Anemia



Edema - Answer Excessive amount of fluid in the interstitial spaces



Point of Maximal Impulse (PMI) - Answer Point of the chest wall where the heartbeat can be
seen; Left mid-clavicular, 5th intercostal space



Clubbing - Answer Enlarged phalanx of the finger; usually cause by chronic hypoxemia



Murmur - Answer Abnormal sound when listening to the heart; can be heard in systole or
diastole

(Valve insufficiency)



Systole - Answer Contraction of the chambers of the heart



Diastole - Answer Cardiac muscle relaxation



The nurse needs to obtain a radial pulse from a patient. What must the nurse do to obtain a
correct measurement?

1) Place the thumb over the groove along the little finger side of the patient's wrist.

2) Place the tips of the first two fingers over the groove along the little finger side of the
patient's wrist.

3) Place the thumb over the groove along the thumb side of the patient's wrist.

4) Place the tips of the first two fingers over the groove along the thumb side of the patient's
wrist. - Answer 4) Place the tips of the first two fingers over the groove along the thumb side
of the patient's wrist.



The nurse is caring for a small child and needs to obtain vital signs. Which site choice from the
nursing assistive personnel (NAP) will cause the nurse to praise the NAP?

1) Brachial site

2) Femoral site