Graded A+
1. The NP is palpating the apical pulse. Which is a normal-sized impulse?
Approximately 1x2 cm
< 1 cm
Varies depending on the size of the person
3 cm
2. Upon entering the examination room, an nurse observes that the patient is
leaning forward on the tray table with arms supporting their body weight. The
nurse would most likely suspect which of the following?
Heart Failure
Chronic Obstructive Pulmonary Disease
Diabetes Mellitus
Systemic Lupus Erythematosus
3. What anatomical structure is primarily associated with the carotid pulse?
Carotid artery
Aorta
Femoral artery
Jugular vein
4. What is the correct anatomical location for the cone of light during an
otoscopic exam of the right ear?
Posterior inferior quadrant
, Superior quadrant
Posterior superior quadrant
Anterior inferior quadrant
5. Describe the significance of the aortic area in cardiovascular assessments.
The aortic area is used to evaluate visual acuity.
The aortic area is where blood pressure is measured.
The aortic area is significant because it is where heart sounds
related to aortic valve closure can be auscultated.
The aortic area is important for assessing respiratory function.
6. Describe the significance of assessing the posterior tibial pulse in nursing
practice.
It indicates the presence of respiratory distress.
It is used to measure blood pressure in the leg.
Assessing the posterior tibial pulse helps evaluate blood flow to the
lower extremities.
It assesses the function of the renal system.
7. What does a pedal pulse rating of +2 signify in a nursing assessment?
+1 pulse strength
Absent pulse
+2 pulse strength
+3 pulse strength
,8. A patient presents with diplopia after a head injury. What should be the
immediate nursing assessment focus?
Cardiovascular evaluation
Respiratory rate monitoring
Visual acuity testing
Neurological assessment
9. While checking for peripheral edema on a patient, you note that there is a
deep indentation that takes 30 seconds to rebound. Which of the following
can be a cause for the pitting edema this patient is experiencing? Bonus: what
is the grade of this patient's pitting edema?
Congestive heart failure
Chronic kidney disease
Liver disease
Venous stasis
All of the above
10. What is the manubriosternal angle?
a hollow, U-shaped depression just above the sternum
the articulation of the manubrium and the body of the sternum
11. Why is it important for the nurse to ensure proper lighting before conducting
an eye examination with the Snellen chart?
Proper lighting is only important for color vision tests.
Proper lighting is crucial for accurate visual acuity assessment.
Proper lighting is necessary to reduce patient anxiety.
, Proper lighting helps the nurse see the client's eye color.
12. What is egophony?
A change in the quality of the patient's voice from "A" to "E".
A decrease in the patient's body temperature.
An increase in the intensity and clarity of the patient's spoken voice as
perceived transthoracically through the stethoscope.
A change in the quality of the patient's voice from "E" to "A".
13. Describe the physiological significance of cyanosis in a patient.
Cyanosis is a sign of dehydration.
Cyanosis suggests an allergic reaction.
Cyanosis is a normal finding in healthy individuals.
Cyanosis indicates inadequate oxygenation of the blood.
14. A patient has had poorly controlled HTN for more than 10 years. Indicate the
most likely position of his PMI:
8th ICS MCL
5th ICS MCL
5th ICS left of MCL
6th ICS of MCL
15. During a patient assessment, you hear low-pitched, dry, grating sounds.
What should your next step be in managing this finding?
Refer the patient for a chest X-ray without further assessment.
Administer bronchodilators immediately.