NSG 3160 Exam 2 V1 | NSG 3160 Health
Assessment | Actual Q&A with Rationale (NSG3160
Exam 2) | Galen
1. A nurse is performing a respiratory assessment on a patient with chronic obstructive
pulmonary disease (COPD). Which of the following findings would the nurse expect to
observe? (Select All That Apply)
A. Anteroposterior-to-transverse diameter ratio of 1:1
B. Use of accessory muscles during inspiration
C. Pursed-lip breathing
D. Unequal chest expansion
E. Tripod positioning
F. Vesicular breath sounds throughout all lung fields
Correct Answer: ABCE
Explanation: Patients with COPD often develop a ‘barrel chest’ where the AP-to-transverse
diameter becomes equal. They frequently utilize accessory muscles and tripod positioning
to facilitate easier breathing and increase thoracic capacity. Pursed-lip breathing is a
common compensatory mechanism to keep airways open longer during exhalation.
Unequal chest expansion and normal vesicular sounds are not characteristic findings for
uncomplicated COPD; rather, breath sounds are typically diminished.
,2. The nurse is auscultating the heart sounds of an adult patient. To best hear the S1 sound,
where should the nurse place the stethoscope?
A. Second intercostal space, right sternal border
B. Fifth intercostal space, left midclavicular line
C. Second intercostal space, left sternal border
D. Fourth intercostal space, left sternal border
Correct Answer: B
Explanation: The S1 heart sound, which represents the closure of the atrioventricular
valves, is loudest at the apex of the heart. This location is typically found at the fifth
intercostal space at the left midclavicular line. While S1 can be heard over the entire
precordium, its intensity is greatest at this specific landmark. The nurse should focus on
this area to differentiate S1 from S2 effectively.
3. When assessing a patient’s abdomen, in which order should the nurse perform the physical
examination techniques?
A. Inspection, Auscultation, Percussion, Palpation
B. Inspection, Palpation, Percussion, Auscultation
C. Auscultation, Inspection, Percussion, Palpation
D. Percussion, Palpation, Auscultation, Inspection
Correct Answer: A
,Explanation: The standard order for abdominal assessment is modified to ensure that
bowel sounds are not altered by physical manipulation. Auscultation must occur
immediately after inspection to provide an accurate representation of bowel activity.
Percussion and palpation are performed last because they can stimulate peristalsis or
cause pain that may interfere with the rest of the exam. This sequence is a critical standard
of care in gastrointestinal health assessments.
4. The nurse is palpating the apical pulse of a patient. Which of the following is considered a
normal finding for the apical pulse in a healthy adult?
A. Located in the 5th intercostal space, midaxillary line
B. Diameter of approximately 1 to 2 cm
C. Sustained through the entire duration of systole
D. Easily palpable in all patients regardless of body habitus
Correct Answer: B
Explanation: A normal apical pulse, or point of maximal impulse (PMI), should be about 1
cm to 2 cm in diameter and occupy only one intercostal space. It is typically located at the
4th or 5th intercostal space at the midclavicular line, not the midaxillary line. It is a short,
gentle tap that occurs only during the first half of systole. In many adults, particularly those
with a thick chest wall or obesity, the apical pulse may not be palpable at all, which can still
be a normal finding.
, 5. During a respiratory assessment, the nurse notes a coarse, low-pitched, snoring sound that
clears somewhat with coughing. How should the nurse document this sound?
A. Wheezes
B. Crackles
C. Pleural friction rub
D. Rhonchi
Correct Answer: D
Explanation: Rhonchi are low-pitched, continuous sounds that resemble snoring or
rattling and are caused by secretions in the larger airways. A defining characteristic of
rhonchi is that they often clear or change significantly after the patient coughs. This
distinguishes them from crackles, which are discontinuous and do not clear with coughing,
or wheezes, which are high-pitched and musical. Accurate documentation of adventitious
sounds is essential for tracking changes in respiratory status.
6. A patient presents with edema in the lower extremities. The nurse notes a deep pitting
that remains for a short time and the leg looks swollen. How should this be documented
using the grading scale?
A. 1+
B. 3+
C. 2+
D. 4+
Assessment | Actual Q&A with Rationale (NSG3160
Exam 2) | Galen
1. A nurse is performing a respiratory assessment on a patient with chronic obstructive
pulmonary disease (COPD). Which of the following findings would the nurse expect to
observe? (Select All That Apply)
A. Anteroposterior-to-transverse diameter ratio of 1:1
B. Use of accessory muscles during inspiration
C. Pursed-lip breathing
D. Unequal chest expansion
E. Tripod positioning
F. Vesicular breath sounds throughout all lung fields
Correct Answer: ABCE
Explanation: Patients with COPD often develop a ‘barrel chest’ where the AP-to-transverse
diameter becomes equal. They frequently utilize accessory muscles and tripod positioning
to facilitate easier breathing and increase thoracic capacity. Pursed-lip breathing is a
common compensatory mechanism to keep airways open longer during exhalation.
Unequal chest expansion and normal vesicular sounds are not characteristic findings for
uncomplicated COPD; rather, breath sounds are typically diminished.
,2. The nurse is auscultating the heart sounds of an adult patient. To best hear the S1 sound,
where should the nurse place the stethoscope?
A. Second intercostal space, right sternal border
B. Fifth intercostal space, left midclavicular line
C. Second intercostal space, left sternal border
D. Fourth intercostal space, left sternal border
Correct Answer: B
Explanation: The S1 heart sound, which represents the closure of the atrioventricular
valves, is loudest at the apex of the heart. This location is typically found at the fifth
intercostal space at the left midclavicular line. While S1 can be heard over the entire
precordium, its intensity is greatest at this specific landmark. The nurse should focus on
this area to differentiate S1 from S2 effectively.
3. When assessing a patient’s abdomen, in which order should the nurse perform the physical
examination techniques?
A. Inspection, Auscultation, Percussion, Palpation
B. Inspection, Palpation, Percussion, Auscultation
C. Auscultation, Inspection, Percussion, Palpation
D. Percussion, Palpation, Auscultation, Inspection
Correct Answer: A
,Explanation: The standard order for abdominal assessment is modified to ensure that
bowel sounds are not altered by physical manipulation. Auscultation must occur
immediately after inspection to provide an accurate representation of bowel activity.
Percussion and palpation are performed last because they can stimulate peristalsis or
cause pain that may interfere with the rest of the exam. This sequence is a critical standard
of care in gastrointestinal health assessments.
4. The nurse is palpating the apical pulse of a patient. Which of the following is considered a
normal finding for the apical pulse in a healthy adult?
A. Located in the 5th intercostal space, midaxillary line
B. Diameter of approximately 1 to 2 cm
C. Sustained through the entire duration of systole
D. Easily palpable in all patients regardless of body habitus
Correct Answer: B
Explanation: A normal apical pulse, or point of maximal impulse (PMI), should be about 1
cm to 2 cm in diameter and occupy only one intercostal space. It is typically located at the
4th or 5th intercostal space at the midclavicular line, not the midaxillary line. It is a short,
gentle tap that occurs only during the first half of systole. In many adults, particularly those
with a thick chest wall or obesity, the apical pulse may not be palpable at all, which can still
be a normal finding.
, 5. During a respiratory assessment, the nurse notes a coarse, low-pitched, snoring sound that
clears somewhat with coughing. How should the nurse document this sound?
A. Wheezes
B. Crackles
C. Pleural friction rub
D. Rhonchi
Correct Answer: D
Explanation: Rhonchi are low-pitched, continuous sounds that resemble snoring or
rattling and are caused by secretions in the larger airways. A defining characteristic of
rhonchi is that they often clear or change significantly after the patient coughs. This
distinguishes them from crackles, which are discontinuous and do not clear with coughing,
or wheezes, which are high-pitched and musical. Accurate documentation of adventitious
sounds is essential for tracking changes in respiratory status.
6. A patient presents with edema in the lower extremities. The nurse notes a deep pitting
that remains for a short time and the leg looks swollen. How should this be documented
using the grading scale?
A. 1+
B. 3+
C. 2+
D. 4+
